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Rocco N, Ghilli M, Curcio A, Bortul M, Burlizzi S, Cabula C, Cabula R, Ferrari A, Folli S, Fortunato L, Frittelli P, Gentilini O, Grendele S, Grassi MM, Grossi S, Magnoni F, Murgo R, Palli D, Rovera F, Sanguinetti A, Taffurelli M, Tazzioli G, Terribile DA, Caruso F, Galimberti V. Is routine axillary lymph node dissection needed to tailor systemic treatments for breast cancer patients in the era of molecular oncology? A position paper of the Italian National Association of Breast Surgeons (ANISC). EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107954. [PMID: 38217946 DOI: 10.1016/j.ejso.2024.107954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 12/17/2023] [Accepted: 01/05/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND De-escalation of axillary surgery in breast cancer (BC) management began when sentinel lymph node biopsy (SLNB) replaced axillary lymph node dissection (ALND) as standard of care in patients with node-negative BC. The second step consolidated ALND omission in selected subgroups of BC patients with up to two macrometastases and recognized BC molecular and genomic implication in predicting prognosis and planning adjuvant treatment. Outcomes from the recent RxPONDER and monarchE trials have come to challenge the previous cut-off of two SLN in order to inform decisions on systemic therapies for hormone receptor-positive (HR+), human epidermal growth factor receptor type-2 (HER2) negative BC, as the criteria included a cut-off of respectively three and four SLNs. In view of the controversy that this may lift in surgical practice, the Italian National Association of Breast Surgeons (Associazione Nazionale Italiana Senologi Chirurghi, ANISC) reviewed data regarding the latest trials on this topic and proposes an implementation in clinical practice. MATERIAL AND METHODS We reviewed the available literature offering data on the pathological nodal status of cN0 breast cancer patients. RESULTS The rates of pN2 status in cN0 patients ranges from 3.5 % to 16 %; pre-surgical diagnostic definition of axillary lymph node status in cN0 patients by ultrasound could be useful to inform about a possible involvement of ≥4 lymph nodes in this specific sub-groups of women. CONCLUSIONS The Italian National Association of Breast Surgeons (ANISC) considers that for HR + HER2-/cN0-pN1(sn) BC patients undergoing breast conserving treatment the preoperative workup should be optimized for a more detailed assessment of the axilla and the technique of SLNB should be optimized, if considered appropriate by the surgeon, not considering routine ALND always indicated to determine treatment recommendations according to criteria of eligibility to RxPONDER and monarch-E trials.
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Affiliation(s)
- Nicola Rocco
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy.
| | - Matteo Ghilli
- Breast Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Marina Bortul
- SSD Chirurgia Senologica e Breast Unit, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy Naples, Italy
| | - Stefano Burlizzi
- UOSD Chirurgia Senologica, Ospedale "A. Perrino", Brindisi, Italy
| | - Carlo Cabula
- Chirurgia Senologica Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Roberta Cabula
- Cagliari University Hospital, Surgery Unit, Cagliari, Italy
| | - Alberta Ferrari
- SSD Chirurgia Tumori eredo-famigliari, SC Chirurgia Generale 3, Senologia, Fondazione IRCCS Policlinico san Matteo, Pavia, Italy
| | - Secondo Folli
- SC di Chirurgia Oncologica-Senologia, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Lucio Fortunato
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Patrizia Frittelli
- UOC Chirurgia senologica, Ospedale Isola Tiberina Gemelli Isola, Rome, Italy
| | - Oreste Gentilini
- Breast Unit, IRCCS Ospedale San Raffaele di Milano, Milan, Italy
| | - Sara Grendele
- Breast Surgery, Department of Functional Oncology, Alto Vicentino Hospital, Santorso, Vicenza, Italy
| | | | | | - Francesca Magnoni
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Roberto Murgo
- Chirurgia Senologica, IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Dante Palli
- UOC di Chirurgia Generale ad Indirizzo Senologico-Breast Unit AUSL Piacenza, Italy
| | - Francesca Rovera
- S.S.D. Breast Unit - Ospedale Universitario, Varese, Italy; Dipartimento di Medicina e Innovazione Tecnologica, Università degli Studi dell'Insubria, Varese, Italy
| | - Alessandro Sanguinetti
- SSD Chirurgia della Mammella - Dipartimento di Chirurgia, Azienda Ospedaliera "S.Maria", Terni, Italy
| | - Mario Taffurelli
- Breast Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant'Orsola, Bologna, Italy
| | | | | | - Francesco Caruso
- Breast Unit, Humanitas Istituto Clinico Catanese, Misterbianco, (CT), Italy; National Association of Breast Surgeons (ANISC), Italy
| | - Viviana Galimberti
- Division of Senology, European Institute of Oncology, IRCCS, Milan, Italy
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2
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Wu SY, Li JW, Wu HL, Shao ZM, Liu GY, Hu N. Accuracy of ultrasound-guided targeted fine-needle aspiration in assessing nodal response in node-positive breast cancer after neoadjuvant chemotherapy: prospective feasibility study. Br J Surg 2022; 109:1194-1197. [PMID: 36018290 DOI: 10.1093/bjs/znac277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/19/2022] [Accepted: 07/16/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Si-Yu Wu
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jian-Wei Li
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Huai-Liang Wu
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhi-Ming Shao
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Guang-Yu Liu
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Centre, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Na Hu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Ultrasound, Fudan University Shanghai Cancer Centre, Shanghai, China
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3
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Mittendorf EA, King TA, Tolaney SM. Impact of RxPONDER and monarchE on the Surgical Management of the Axilla in Patients With Breast Cancer. J Clin Oncol 2022; 40:3361-3364. [PMID: 35675571 DOI: 10.1200/jco.22.00173] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA.,Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA.,Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
| | - Sara M Tolaney
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA.,Division of Cancer Medicine, Dana-Farber Cancer Institute, Boston, MA
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4
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Gibbons CE, Quinn CM, Gibbons D. Fine-Needle Aspiration Biopsy Management of the Axilla in Primary Breast Carcinoma. Acta Cytol 2019; 63:314-318. [PMID: 30893685 DOI: 10.1159/000496159] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 12/10/2018] [Indexed: 01/09/2023]
Abstract
CONTEXT Fine-needle aspiration biopsy (FNAB) is frequently used to stage the axilla preoperatively in patients with primary breast carcinoma. In the light of the ACOSOG-Z0011 and AMAROS trials that specified sentinel lymph node biopsy as an inclusion criterion, the role of FNAB in axillary staging is changing. OBJECTIVE This article will review the diagnostic accuracy of FNAB in staging of the axilla in patients with primary breast carcinoma. The efficacy of axillary FNAB compared with core-needle biopsy will be evaluated. The evolving approach to staging of the axilla, in the light of ACOSOG-Z0011 and AMAROS trials, will be discussed. DATA SOURCES Data were sourced from published peer-reviewed articles in PubMed (US National Library of Medicine) and published guidelines including the European Guidelines for Quality Assurance in Breast Cancer and those from the European Society of Medical Oncology (ESMO), Union for International Cancer (UICC), American Society of Clinical Oncology (ASCO), and the American Society of Breast Surgeons. CONCLUSIONS FNAB of the axilla is almost 100% specific with a sensitivity between 40 and 90%. A positive FNAB reduces the need for a second axillary procedure by up to 20% with reduced morbidity and cost. The recent ACOSOG-Z0011 and AMAROS trials have reduced the use of FNAB axilla in American protocols, but it remains the standard of care in Europe.
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Affiliation(s)
- Ciara Ellen Gibbons
- Medicine Department, Mater Misericordiae University Hospital, Dublin, Ireland,
| | - Cecily Mary Quinn
- Pathology Department, St. Vincent's University Hospital, Dublin, Ireland
| | - David Gibbons
- Pathology Department, St. Vincent's University Hospital, Dublin, Ireland
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5
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Preoperative Evaluation of Axillary Lymph Nodes in Malignant Breast Lesions with Ultrasonography and Histopathologic Correlation. J Belg Soc Radiol 2016; 100:58. [PMID: 30038983 PMCID: PMC5854458 DOI: 10.5334/jbr-btr.899] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose: Our aim is to define the sonographic criteria for assessing involved axillary nodes and to evaluate the accuracy of axillary ultrasound in the staging workup of individuals with breast cancer. Materials and Methods: Thirty-five patients with breast cancer were prospectively evaluated with preoperative ultrasonography (US) to determine the presence of axillary lymph node metastasis. We determined whether there was axillary lymph node metastasis after axillary lymph node dissection or sentinel lymph node biopsy. If metastasis was found, the number of metastatic lymph nodes was recorded and compared with preoperative axillary US findings using histopathological evaluation as a reference. Results: Metastatic lymph node detection in sonographic evaluation was associated with echogenic hilus obliteration, complete hypoechoic or anechoic appearance of lymph nodes, and asymmetric/nodal or diffuse cortical thickening greater than 3.8 mm. The overall sensitivity, specificity, positive predictive value, and negative predictive value of US were calculated as (20/22) 91 percent, (10/13) 77 percent, (20/23) 87 percent, and (10/12) 83 percent, respectively. Conclusion: Ultrasonography examination is a valuable method for evaluating the axilla in newly diagnosed breast cancer patients and provides valuable information for planning proper breast cancer management.
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Akıncı M, Bulut SP, Erözgen F, Gürbüzel M, Gülşen G, Kocakuşak A, Gülen M, Kaplan R. Predictive value of fine needle aspiration biopsy of axillary lymph nodes in preoperative breast cancer staging. ULUSAL CERRAHI DERGISI 2016; 32:191-6. [PMID: 27528822 DOI: 10.5152/ucd.2015.2913] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 03/28/2015] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Diagnosis of axillary nodal involvement is significant in the management of breast cancer as well as in predicting prognosis. In this prospective study, we evaluated the efficiency of US-guided fine needle aspiration biopsy (FNAB) in preoperative axillary staging of early breast cancer. MATERIAL AND METHODS Between January 2011 and July 2013, 46 women were prospectively enrolled in the study. Ultrasound guided-FNABs for axillary assessment were performed preoperatively. Cytology results were compared with histopathology reports to determine its sensitivity, specificity, negative and positive predictive value and accuracy. RESULTS Nineteen cases that had malignant cytology on FNAB also had axillary involvement in axillary lymph node dissection (ALND) without any false-positive results. The sensitivity and specificity of US-guided FNAB were 63.3% and 100%, respectively. US-guided FNAB was accurate in predicting the status of the axilla in 76.1% of patients. CONCLUSION Although this technique is favorable due to its minimally invasive nature, it is not as effective as sentinel lymph node biopsy (SLNB) in terms of detecting axillary metastasis preoperatively. The low sensitivity and low accuracy rates decrease the usefulness of the technique. Therefore, it seems that US-guided FNAB alone could not replace SLNB. Nevertheless, combining some other molecular studies may be useful in increasing the technique's sensitivity. These issues should be determined by comprehensive clinical trials.
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Affiliation(s)
- Muzaffer Akıncı
- Clinic of General Surgery, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Serap Pamak Bulut
- Clinic of General Surgery, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Fazilet Erözgen
- Clinic of General Surgery, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Mihriban Gürbüzel
- Clinic of Pathology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Gökçe Gülşen
- Clinic of Radiology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Ahmet Kocakuşak
- Clinic of General Surgery, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Mehmet Gülen
- Clinic of General Surgery, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Rafet Kaplan
- Clinic of General Surgery, Haseki Training and Research Hospital, İstanbul, Turkey
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7
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Pilewskie M, Jochelson M, Gooch JC, Patil S, Stempel M, Morrow M. Is Preoperative Axillary Imaging Beneficial in Identifying Clinically Node-Negative Patients Requiring Axillary Lymph Node Dissection? J Am Coll Surg 2015; 222:138-45. [PMID: 26711795 DOI: 10.1016/j.jamcollsurg.2015.11.013] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 11/03/2015] [Accepted: 11/03/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND American College of Surgeons Oncology Group (ACOSOG) Z0011 results support the omission of axillary lymph node dissection (ALND) in women with less than 3 positive sentinel lymph nodes (SLNs) undergoing breast-conserving surgery (BCS) and radiation therapy. We sought to determine if abnormal axillary imaging is predictive of the need for ALND in this population. STUDY DESIGN Patients with cT1-2N0 breast cancer by physical examination undergoing BCS were managed according to Z0011 criteria independent of axillary imaging. Patient characteristics and rates of ALND were compared among those with and without abnormal lymph nodes (LNs) detected by mammogram, ultrasound (US), or MRI. All available axillary imaging was reviewed by 1 breast radiologist. RESULTS Between August 2010 and December 2013, 3,253 breast cancer patients were treated with BCS and SLN biopsy; 425 patients met Z0011 criteria (cT1-2N0) and had nodal metastasis on SLN biopsy. Clinicopathologic features were median patient age, 58 years; median tumor size, 1.8 cm; 85% ductal histology; and 89% estrogen receptor positive. All women had a mammogram, 242 had axillary US, 172 had MRI. Abnormal LNs were seen on 7%, 25%, and 30% of mammograms, US, and MRIs, respectively. Although abnormal LNs on mammogram or US were associated with a significant increase in ALND and a non-significant trend was seen with MRI, 68% to 73% of women with abnormal axillary imaging did not require ALND. CONCLUSIONS Among clinically node-negative patients with abnormal axillary imaging, 71% did not meet criteria for ALND and were spared further surgical morbidity. Abnormal nodes on US, MRI, or mammogram in clinically node-negative patients are not reliable indicators of the need for ALND.
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Affiliation(s)
- Melissa Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Maxine Jochelson
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jessica C Gooch
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michelle Stempel
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
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8
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Abstract
The sentinel lymph node biopsy is a safe, accurate operation for the initial staging of breast cancer. Over the last decade, there has been increasing literature supporting its use, and it is now considered a standard of care for the initial evaluation of metastatic spread to the axillary lymph node chain.
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9
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Reyna C, Kiluk JV, Frelick A, Khakpour N, Laronga C, Lee MC. Impact of axillary ultrasound (AUS) on axillary dissection in breast conserving surgery (BCS). J Surg Oncol 2015; 111:813-8. [DOI: 10.1002/jso.23885] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 12/24/2014] [Indexed: 02/05/2023]
Affiliation(s)
- Chantal Reyna
- Comprehensive Breast Program; H. Lee Moffitt Cancer Center and Research Institute; Tampa Florida
| | - John V. Kiluk
- Comprehensive Breast Program; H. Lee Moffitt Cancer Center and Research Institute; Tampa Florida
| | - Anne Frelick
- University of South Florida; Morsani College of Medicine; Tampa Florida
| | - Nazanin Khakpour
- Comprehensive Breast Program; H. Lee Moffitt Cancer Center and Research Institute; Tampa Florida
| | - Christine Laronga
- Comprehensive Breast Program; H. Lee Moffitt Cancer Center and Research Institute; Tampa Florida
| | - Marie Catherine Lee
- Comprehensive Breast Program; H. Lee Moffitt Cancer Center and Research Institute; Tampa Florida
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10
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Boughey JC, Ballman KV, Hunt KK, McCall LM, Mittendorf EA, Ahrendt GM, Wilke LG, Le-Petross HT. Axillary Ultrasound After Neoadjuvant Chemotherapy and Its Impact on Sentinel Lymph Node Surgery: Results From the American College of Surgeons Oncology Group Z1071 Trial (Alliance). J Clin Oncol 2015; 33:3386-93. [PMID: 25646192 DOI: 10.1200/jco.2014.57.8401] [Citation(s) in RCA: 156] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The American College of Surgeons Oncology Group Z1071 trial reported a 12.6% false-negative rate (FNR) for sentinel lymph node (SLN) surgery after neoadjuvant chemotherapy (NAC) in cN1 disease. Patients were not selected for surgery based on response, but a secondary end point was to determine whether axillary ultrasound (AUS) after NAC after fine-needle aspiration cytology can identify abnormal nodes and guide patient selection for SLN surgery. PATIENTS AND METHODS Patients with T0-4, N1-2, M0 breast cancer underwent AUS after neoadjuvant chemotherapy. AUS images were centrally reviewed and classified as normal or suspicious lymph nodes. AUS findings were tested for association with pathologic nodal status and SLN FNR. The impact of AUS results to select patients for SLN surgery to reduce the FNR was assessed. RESULTS Postchemotherapy AUS images were reviewed for 611 patients. One hundred thirty (71.8%) of 181 AUS-suspicious patients were node positive at surgery compared with 243 (56.5%) of 430 AUS-normal patients (P < .001). Patients with AUS-suspicious nodes had a greater number of positive nodes and greater metastasis size (P < .001). The SLN FNR was not different based on AUS results; however, using a strategy where only patients with normal AUS undergo SLN surgery would potentially reduce the FNR in Z1071 patients with ≥ two SLNs removed from 12.6% to 9.8% when preoperative AUS results are considered as part of SLN surgery. CONCLUSION AUS is recommended after chemotherapy to guide axillary surgery. An FNR of 9.8% with the combination of AUS and SLN surgery would be acceptable for the adoption of SLN surgery for women with node-positive breast cancer treated with neoadjuvant chemotherapy.
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Affiliation(s)
- Judy C Boughey
- Judy C. Boughey, Mayo Clinic; Karla V. Ballman, Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN; Kelly K. Hunt, Elizabeth A. Mittendorf, and Huong T. Le-Petross, The University of Texas MD Anderson Cancer Center, Houston, TX; Linda M. McCall, Alliance Statistics and Data Center, Duke University, Durham, NC; Gretchen M. Ahrendt, University of Pittsburgh Cancer Institute, Pittsburgh, PA; and Lee G. Wilke, University of Wisconsin Hospital and Clinics, Madison, WI.
| | - Karla V Ballman
- Judy C. Boughey, Mayo Clinic; Karla V. Ballman, Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN; Kelly K. Hunt, Elizabeth A. Mittendorf, and Huong T. Le-Petross, The University of Texas MD Anderson Cancer Center, Houston, TX; Linda M. McCall, Alliance Statistics and Data Center, Duke University, Durham, NC; Gretchen M. Ahrendt, University of Pittsburgh Cancer Institute, Pittsburgh, PA; and Lee G. Wilke, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Kelly K Hunt
- Judy C. Boughey, Mayo Clinic; Karla V. Ballman, Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN; Kelly K. Hunt, Elizabeth A. Mittendorf, and Huong T. Le-Petross, The University of Texas MD Anderson Cancer Center, Houston, TX; Linda M. McCall, Alliance Statistics and Data Center, Duke University, Durham, NC; Gretchen M. Ahrendt, University of Pittsburgh Cancer Institute, Pittsburgh, PA; and Lee G. Wilke, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Linda M McCall
- Judy C. Boughey, Mayo Clinic; Karla V. Ballman, Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN; Kelly K. Hunt, Elizabeth A. Mittendorf, and Huong T. Le-Petross, The University of Texas MD Anderson Cancer Center, Houston, TX; Linda M. McCall, Alliance Statistics and Data Center, Duke University, Durham, NC; Gretchen M. Ahrendt, University of Pittsburgh Cancer Institute, Pittsburgh, PA; and Lee G. Wilke, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Elizabeth A Mittendorf
- Judy C. Boughey, Mayo Clinic; Karla V. Ballman, Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN; Kelly K. Hunt, Elizabeth A. Mittendorf, and Huong T. Le-Petross, The University of Texas MD Anderson Cancer Center, Houston, TX; Linda M. McCall, Alliance Statistics and Data Center, Duke University, Durham, NC; Gretchen M. Ahrendt, University of Pittsburgh Cancer Institute, Pittsburgh, PA; and Lee G. Wilke, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Gretchen M Ahrendt
- Judy C. Boughey, Mayo Clinic; Karla V. Ballman, Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN; Kelly K. Hunt, Elizabeth A. Mittendorf, and Huong T. Le-Petross, The University of Texas MD Anderson Cancer Center, Houston, TX; Linda M. McCall, Alliance Statistics and Data Center, Duke University, Durham, NC; Gretchen M. Ahrendt, University of Pittsburgh Cancer Institute, Pittsburgh, PA; and Lee G. Wilke, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Lee G Wilke
- Judy C. Boughey, Mayo Clinic; Karla V. Ballman, Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN; Kelly K. Hunt, Elizabeth A. Mittendorf, and Huong T. Le-Petross, The University of Texas MD Anderson Cancer Center, Houston, TX; Linda M. McCall, Alliance Statistics and Data Center, Duke University, Durham, NC; Gretchen M. Ahrendt, University of Pittsburgh Cancer Institute, Pittsburgh, PA; and Lee G. Wilke, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Huong T Le-Petross
- Judy C. Boughey, Mayo Clinic; Karla V. Ballman, Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN; Kelly K. Hunt, Elizabeth A. Mittendorf, and Huong T. Le-Petross, The University of Texas MD Anderson Cancer Center, Houston, TX; Linda M. McCall, Alliance Statistics and Data Center, Duke University, Durham, NC; Gretchen M. Ahrendt, University of Pittsburgh Cancer Institute, Pittsburgh, PA; and Lee G. Wilke, University of Wisconsin Hospital and Clinics, Madison, WI
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11
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Yu YH, Mo QG, Zhu X, Gao LQ, Liang C, Huang Z, Qin QH, Wei W, Jiang Y, Bu KP, Wei CY. Axillary fine needle aspiration cytology is a sensitive and highly specific technique for the detection of axillary lymph node metastasis: a meta-analysis and systematic review. Cytopathology 2014; 27:59-69. [DOI: 10.1111/cyt.12224] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Y.-H. Yu
- Department of Breast Surgery; Guangxi Cancer Hospital & Affiliated Cancer Hospital of Guangxi Medical University
| | - Q.-G. Mo
- Department of Breast Surgery; Guangxi Cancer Hospital & Affiliated Cancer Hospital of Guangxi Medical University
| | - X. Zhu
- Department of Breast Surgery; Guangxi Cancer Hospital & Affiliated Cancer Hospital of Guangxi Medical University
| | - L.-Q. Gao
- Department of Microbiology; Guangxi Medical University
| | - C. Liang
- Department of Surgery; The Third Affiliated Hospital of Guangxi Medical University
| | - Z. Huang
- Department of Breast Surgery; Guangxi Cancer Hospital & Affiliated Cancer Hospital of Guangxi Medical University
| | - Q.-H. Qin
- Department of Breast Surgery; Guangxi Cancer Hospital & Affiliated Cancer Hospital of Guangxi Medical University
| | - W. Wei
- Department of Breast Surgery; Guangxi Cancer Hospital & Affiliated Cancer Hospital of Guangxi Medical University
| | - Y. Jiang
- Department of Breast Surgery; Guangxi Cancer Hospital & Affiliated Cancer Hospital of Guangxi Medical University
| | - K.-P. Bu
- Department of Breast Surgery; Guangxi Cancer Hospital & Affiliated Cancer Hospital of Guangxi Medical University
| | - C.-Y. Wei
- Department of Breast Surgery; Guangxi Cancer Hospital & Affiliated Cancer Hospital of Guangxi Medical University
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12
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van Wely BJ, de Wilt JHW, Francissen C, Teerenstra S, Strobbe LJA. Meta-analysis of ultrasound-guided biopsy of suspicious axillary lymph nodes in the selection of patients with extensive axillary tumour burden in breast cancer. Br J Surg 2014; 102:159-68. [DOI: 10.1002/bjs.9663] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 04/15/2014] [Accepted: 09/01/2014] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Recent studies show that not all patients with breast cancer and positive axillary lymph nodes need additional axillary surgery. A systematic review and meta-analysis of the literature was performed to test the hypothesis that ultrasound-guided biopsy of suspicious nodes can be a useful tool to identify patients with extensive axillary tumour burden.
Methods
PubMed and Embase were searched to identify articles reporting on ultrasound-guided techniques to stage the axilla of patients with breast cancer. The emphasis was to study the number of positive nodes found after axillary lymph node dissection (ALND) following a positive ultrasound-guided biopsy or a positive sentinel lymph node biopsy (SLNB). Information regarding the number of positive nodes thus had to be available. Results were tested for heterogeneity and a meta-analysis was performed.
Results
A total of 894 articles were identified, and 115 were selected based on title and abstract information by two independent reviewers. After extensive review, 18 articles were eligible for analysis. Eight studies reported sufficient data to perform a meta-analysis comparing 532 patients with a positive ultrasound-guided biopsy with 248 patients with a negative ultrasound-guided biopsy but a positive SLNB. The number of involved nodes was significantly higher in patients in whom axillary metastasis was detected by ultrasound-guided biopsy (P < 0·001). No heterogeneity in the observed effect was found (I2 = 22 per cent, P = 0·26).
Conclusion
Patients with breast cancer in whom axillary metastases are detected by ultrasound-guided biopsy have significantly more involved nodes than SLNB-positive patients. This finding enables further preoperative tailoring of axillary treatment in breast cancer.
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Affiliation(s)
- B J van Wely
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - C Francissen
- Department of Surgery, Geldersche Vallei Hospital, Ede, The Netherlands
| | - S Teerenstra
- Section of Biostatistics, Department of Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - L J A Strobbe
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
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Houssami N, Turner RM. Staging the axilla in women with breast cancer: the utility of preoperative ultrasound-guided needle biopsy. Cancer Biol Med 2014; 11:69-77. [PMID: 25009748 PMCID: PMC4069800 DOI: 10.7497/j.issn.2095-3941.2014.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 03/26/2014] [Indexed: 02/05/2023] Open
Abstract
Preoperative staging of the axilla in women with invasive breast cancer using ultrasound-guided needle biopsy (UNB) identifies approximately 50% of patients with axillary nodal metastases prior to surgical intervention. Although moderately sensitive, it is a highly specific staging strategy that is rarely falsely-positive, hence a positive UNB allows patients to be triaged to axillary lymph-node dissection (ALND) avoiding potentially unnecessary sentinel node biopsy (SNB). In this review, we extend our previous work through an updated literature search, focusing on studies that report data on UNB utility. Based on data for 10,934 breast cancer patients, sourced from 35 studies, a positive UNB allowed triage of 1,745 cases (simple proportion 16%) to axillary surgical treatment: the utility of UNB was a median 19.8% [interquartile range (IQR) 11.6%-26.7%] across these studies. We also modelled data from a subgroup of studies, and estimated that amongst patients with metastases to axillary nodes, the odds ratio (OR) for high nodal disease burden for a positive UNB versus a negative UNB was 4.38 [95% confidence interval (95% CI): 3.13, 6.13], P<0.001. From this model, the estimated proportion with high nodal disease burden was 58.9% (95% CI: 50.2%, 67.0%) for a positive UNB, whereas the estimated proportion with high nodal disease burden was 24.6% (95% CI: 17.7%, 33.2%) if UNB was negative. Overall, axillary UNB has good clinical utility and a positive UNB can effectively triage to ALND. However, the evolving landscape of axillary surgical treatment means that UNB will have relatively less utility where surgeons have modified their practice to omission of ALND for minimal nodal metastatic disease.
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Affiliation(s)
- Nehmat Houssami
- Screening and Test Evaluation Program (STEP), School of Public Health, Sydney Medical School, University of Sydney, Sydney 2006, Australia
| | - Robin M Turner
- Screening and Test Evaluation Program (STEP), School of Public Health, Sydney Medical School, University of Sydney, Sydney 2006, Australia
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Cyr AE, Margenthaler JA. Axillary ultrasound and sentinel lymph node biopsy: an evolving paradigm for management of the axilla. BREAST CANCER MANAGEMENT 2014. [DOI: 10.2217/bmt.14.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Axillary lymph node dissection was used to treat and to provide staging information for women with invasive breast cancer. With the adoption of sentinel lymph node biopsy over the past two decades, evaluation and management of the axilla has become less invasive for many patients. However, as treatment decisions are more frequently based on tumor biology rather than anatomic staging information, the information obtained from even more minimal axillary surgery may be less clinically relevant, and any surgery may cause morbidity. Imaging technologies, such as axillary ultrasound, offer the capability of providing some staging information without the risks associated with surgery. In addition, the therapeutic need for axillary surgery is in question, and less invasive means of managing the axilla are under investigation.
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Affiliation(s)
- Amy E Cyr
- Department of Surgery, Washington University School of Medicine, 660 S Euclid Avenue, Campus box 8109, St Louis, MO 63110, USA
| | - Julie A Margenthaler
- Department of Surgery, Washington University School of Medicine, 660 S Euclid Avenue, Campus box 8109, St Louis, MO 63110, USA
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Fung AD, Collins JA, Campassi C, Ioffe OB, Staats PN. Performance characteristics of ultrasound-guided fine-needle aspiration of axillary lymph nodes for metastatic breast cancer employing rapid on-site evaluation of adequacy: analysis of 136 cases and review of the literature. Cancer Cytopathol 2013; 122:282-91. [PMID: 24353146 DOI: 10.1002/cncy.21384] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 10/31/2013] [Accepted: 11/04/2013] [Indexed: 01/27/2023]
Abstract
BACKGROUND It has been demonstrated that axillary ultrasound-guided fine-needle aspiration (US-FNA) has excellent positive predictive value for the axillary lymph node status of patients with breast cancer before surgery or neoadjuvant therapy and, thus, can obviate the need for sentinel lymph node biopsy in FNA-positive patients. However, US-FNA has only moderate sensitivity, in part because of the collection of nondiagnostic or equivocal specimens. Rapid on-site evaluation for adequacy (ROSE) can improve definitive diagnosis rates but has not been well characterized in this setting. METHODS One hundred thirty-three patients with breast carcinoma were identified who underwent 136 US-FNAs of axillary lymph nodes, all with ROSE, and the results were correlated with the diagnosis on a subsequent surgical procedure. RESULTS The adequacy rate was 95.6% (130 of 136 FNAs), and a definitive diagnosis was made in 91.2% (124 of 136 FNAs). Among definite diagnoses, sensitivity was 75%, specificity was 100%, the positive predictive value was 100%, and the negative predictive value was 79%. Sources of false-negative and potential false-positive diagnoses were evaluated among these cases and in the literature. CONCLUSIONS Small metastasis size is the most common cause of false-negative results, whereas interpretation errors by pathologists are quite rare. ROSE appears to improve adequacy and definitive diagnosis rates and, thus, can more accurately triage patients to appropriate care.
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Affiliation(s)
- Adele D Fung
- Department of Pathology, University of Maryland School of Medicine and University of Maryland Medical Center, Baltimore, Maryland
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Chang MC, Escallon JM, Colgan TJ. Prognostic significance of a positive axillary lymph node fine-needle aspirate in patients with invasive breast carcinoma. Cancer Cytopathol 2013; 122:138-44. [PMID: 24106096 DOI: 10.1002/cncy.21354] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 08/13/2013] [Accepted: 08/15/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND Image-guided axillary lymph node fine-needle aspirates (FNAs) correlate well with pathologic lymph node staging in cases of invasive breast carcinoma. The objective of this study was to determine the prognostic significance of a positive lymph node. METHODS Consecutive cases of nonmetastatic (M0) invasive breast carcinoma evaluated by image-guided FNA were identified (4-year period, median follow-up of 51 months). "Positive" and "nonpositive" groups were compared using Kaplan-Meier survival analysis. Multivariate Cox regression was used to correct for clinicopathologic and treatment factors. A total of 142 cases was included, 70 with positive axillary FNA and 72 with a nonpositive result. RESULTS FNA-positive and nonpositive cases did not differ in patient age, tumor subtype, or hormone receptor status. Positive FNA was significantly associated with advanced T and N pathologic stage, and with HER2 (human epidermal growth factor receptor 2) positivity. FNA-positive patients were more likely to undergo mastectomy and to receive chemotherapy. Kaplan-Meier analysis showed that positive FNA is associated with poor prognosis, both with respect to disease-free survival (89% nonpositive versus 73% positive at 5 years, P < .001) and overall survival (94% versus 81%, respectively, at 5 years, P = .01). Multivariate analysis showed that when correcting for other variables, FNA positivity was not independently significant. CONCLUSIONS Positive axillary lymph node FNA is associated with poor prognosis on univariate analysis. By contrast, overall nodal staging is independently significant on multivariate analysis. The prognostic significance of axillary FNA likely results from its ability to predict for nodal status. Axillary FNA has utility as a preoperative staging procedure.
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Affiliation(s)
- Martin C Chang
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
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Amoui M, Akbari ME, Tajeddini A, Nafisi N, Raziei G, Modares SM, Hashemi M. Value of sentinel lymph node biopsy in breast cancer surgery with simple pathology facilities--an Iranian local experience with a review of potential causes of false negative results. Asian Pac J Cancer Prev 2013; 13:5385-9. [PMID: 23317188 DOI: 10.7314/apjcp.2012.13.11.5385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Sentinel lymph node biopsy (SLNB) is a precise procedure for lymphatic staging in early breast cancer. In a valid SLNB procedure, axillary lymph node dissection (ALND) can be omitted in node- negative cases without compromising patient safety. In this study, detection rate, accuracy and false negative rate of SLNB for breast cancer was evaluated in a setting with simple modified conventional pathology facilities without any serial sectioning or immunohistochemistry. MATERIAL AND METHOD Patients with confirmed breast cancer were enrolled in the study. SLNB and ALND were performed in all cases. Lymph node metastasis was evaluated in SLN and in nodes removed by ALND to determine the false negative rate. Pathologic assessment was carried out only by modified conventional technique with only 3 sections. Detection rate was determined either by lymphoscintigraphy or during surgery. RESULTS 78 patients with 79 breast units were evaluated. SLN was detected in 75 of 79 cases (95%) in lymphoscintigraphy and 76 of 79 cases (96%) during surgery. SLN metastases was detected in 30 of 75 (40%) cases either in SLNB and ALND groups. Accuracy of SLNB method for detecting LN metastases was 92%. False negative rate was 3 of 30 of positive cases: 10%. In 7 of 10 cases with axillary lymphadenopathy, LN metastastates was detected. CONCLUSION SLNB is recommended for patients with various tumor sizes without palpable lymph nodes. In modified conventional pathologic examination of SLNs, at least macrometastases and some micrometastases could be detected similar to ALND. Consequently, ALND could be omitted in node-negative cases with removal of all palpable LNs. We conclude that SLNB, as one of the most important developments in breast cancer surgery, could be expanded even in areas without sophisticated pathology facilities.
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Affiliation(s)
- Mahasti Amoui
- Cancer Research Center, Shohadae Tajrish Hospital, Nuclear Medicine Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Balu-Maestro C, Ianessi A, Chapellier C, Marcotte C, Stolear S. Ultrasound-guided lymph node sampling in the initial management of breast cancer. Diagn Interv Imaging 2013; 94:389-94. [PMID: 23290786 DOI: 10.1016/j.diii.2012.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Ultrasound-guided fine needle sampling is proving very useful for avoiding surgical biopsy of the sentinel lymph node for N+breast cancer. Because of its high specificity, cytology is sufficient in most cases. Focal or diffuse cortical thickening or the absence of the echogenic hilum irrespective of the size and shape of the lymph node are ultrasound signs which should be taken into account. The status of the lymph nodes in axillary and extra-axillary sites has an impact on the later management of patients and reduces the length of time for secondary lymph node dissection and adjuvant therapy, as one third of sentinel ganglion procedures can be avoided. It should be possible to optimise identification of the sentinel lymph node by the intradermal injection of ultrasound contrast agent. The cost/effectiveness ratio is positive but unknown and should be assessed in the initial management of breast cancer.
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Affiliation(s)
- C Balu-Maestro
- Department of radiology, centre Antoine-Lacassagne, 33 avenue de Valombrose, Nice cedex 2, France.
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Al Ayyan M, Bu Ali O, Al Sharri S, Kassis A, Hussain S, Al-Bashir M. Negative axillary ultrasonography with biopsy may predict non-involvement of the non-sentinel lymph nodes in operable breast cancer patients. Asia Pac J Clin Oncol 2012; 10:e86-9. [DOI: 10.1111/ajco.12039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2012] [Indexed: 02/05/2023]
Affiliation(s)
- Muna Al Ayyan
- Department of Surgery; Tawam Hospital; Al-Ain United Arab Emirates
| | - Omaima Bu Ali
- Department of Surgery; Tawam Hospital; Al-Ain United Arab Emirates
| | | | - Adnan Kassis
- Department of Radiology; Tawam Hospital; Al-Ain United Arab Emirates
| | - Sabir Hussain
- Department of Oncology; Tawam Hospital; Al-Ain United Arab Emirates
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Lee MC, Joh JE, Chau A. Axillary Staging Prior to Neoadjuvant Chemotherapy: The Roles of Sentinel Lymph Node Biopsy and Axillary Ultrasonography. Cancer Control 2012; 19:277-285. [DOI: 10.1177/107327481201900404] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
- Marie Catherine Lee
- Comprehensive Breast Program at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Division of Oncologic Sciences at the University of South Florida, Tampa, Florida
| | - Jennifer E. Joh
- Comprehensive Breast Program at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Hoffberger Breast Center at Mercy, Mercy Medical Center, Baltimore, Maryland
| | - Alec Chau
- Diagnostic Imaging Program at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Division of Oncologic Sciences at the University of South Florida, Tampa, Florida
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Oz A, Demirkazik FB, Akpinar MG, Soygur I, Baykal A, Onder SC, Uner A. Efficiency of ultrasound and ultrasound-guided fine needle aspiration cytology in preoperative assessment of axillary lymph node metastases in breast cancer. J Breast Cancer 2012; 15:211-7. [PMID: 22807939 PMCID: PMC3395745 DOI: 10.4048/jbc.2012.15.2.211] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 04/24/2012] [Indexed: 02/05/2023] Open
Abstract
PURPOSE We performed this study to detect preoperative axillary metastases with ultrasound (US)-guided fine needle aspiration biopsy (FNAB), to eliminate the need for time-consuming and costly sentinel lymph node (SLN) scintigraphy and biopsy steps in the treatment of breast cancer patients, and in that of with suspicious US findings, and to evaluate the accuracy of preoperative US-guided FNAB for patients with suspicious lymph node metastases on US. METHODS Patients with a suspicious breast lump or histopathologically proven breast cancer underwent breast-axillary US. Increase in lymph node size, cortical thickening, non-hilar cortical flow, and hilar changes were evaluated with gray scale-color Doppler US. FNAB was performed if US results were suspicious for malignancy. RESULTS Thirty-eight axillary lymph nodes (ALN) underwent FNAB. ALN dissection, SLN scintigraphy, and biopsy steps were bypassed in 23 axillas with positive ALN FNAB (60.5%). The sensitivity of ALN FNAB was 88.46%; specificity and positive predictive value were 100%; and negative predictive value was 66.6% (inadequate cytology included; 76.7%, 100%, 100%, 53.3%, respectively). Asymmetrical cortical thickening, non-hilar cortical flow, and increase in hypoechogenity were only detected in metastatic nodes. Cortical thickening, and lymph node and breast mass size was higher in the metastatic group. CONCLUSION By performing FNAB on suspicious lymph nodes, the routine, high-cost SLN scintigraphy and intraoperative gamma probe steps may be skipped, and axilla dissection can be performed directly. This leads to the elimination of the need for SLN investigation in more than half of the patients. The assessment of ALN metastases with preoperative US-guided FNAB is a cost-effective method with high specificity, that eliminates the need for costly and time-consuming SLN scintigraphy and biopsy steps, and helps in preoperative staging.
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Affiliation(s)
- Aysegul Oz
- Department of Radiology, Hacettepe University, Ankara, Turkey
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22
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Iwuchukwu O, Wahed S, Wozniak A, Dordea M, Rich A. Recent advances in non-invasive axillary staging for breast cancer. Surg Oncol 2011; 20:253-8. [DOI: 10.1016/j.suronc.2010.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Revised: 03/21/2010] [Accepted: 05/31/2010] [Indexed: 01/17/2023]
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Consequences of Axillary Ultrasound in Patients with T2 or Greater Invasive Breast Cancers. Indian J Surg Oncol 2011. [DOI: 10.1007/s13193-011-0085-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Turaga KK, Chau A, Eatrides JM, Kiluk JV, Khakpour N, Laronga C, Lee MC. Selective application of routine preoperative axillary ultrasonography reduces costs for invasive breast cancers. Oncologist 2011; 16:942-8. [PMID: 21572122 DOI: 10.1634/theoncologist.2010-0373] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Preoperative axillary sonography with fine needle aspiration (FNA) in patients with invasive breast cancer identifies patients with nodal metastasis who can be spared further surgery. Indiscriminate use of the diagnostic modality can increase costs and yield inaccurate results. We evaluate the costs associated with the use of highly sensitive axillary ultrasonography in patients with stage ≥T2 tumors. PATIENTS AND METHODS We constructed a decision analysis tree using TreeAge Pro 2009 software comparing direct hospital charges between patients with and without routine use of axillary ultrasound. Base case estimates were derived from our institutional data and compared with those derived from the literature. One- and two-way sensitivity analyses were performed to check the validity of our inferences. RESULTS We found that, for the base case estimate with 35% lymph node positivity in stage ≥T2 tumors and sensitivity of the axillary ultrasound set at 86% with a specificity of 40%, the strategy to perform preoperative axillary ultrasound yielded rollback costs of $15,215, compared with $15,940 for surgery plus sentinel lymph node biopsy (cost difference, $725 per patient favoring axillary ultrasound). On two-way sensitivity analysis, the cost benefit for axillary ultrasound was not seen in patients with a low risk for nodal metastasis. CONCLUSION The adoption of routine preoperative axillary sonography with FNA is a lower-cost strategy than conventional strategies in patients with stage ≥T2 invasive breast cancer.
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Affiliation(s)
- Kiran K Turaga
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Ojeda-Fournier H, Nguyen JQ. Ultrasound Evaluation of Regional Breast Lymph Nodes. Semin Roentgenol 2011; 46:51-9. [DOI: 10.1053/j.ro.2010.06.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Lee MC, Eatrides J, Chau A, Han G, Kiluk JV, Khakpour N, Cox CE, Carter WB, Laronga C. Consequences of axillary ultrasound in patients with T2 or greater invasive breast cancers. Ann Surg Oncol 2010; 18:72-7. [PMID: 20585876 DOI: 10.1245/s10434-010-1171-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Indexed: 02/05/2023]
Abstract
BACKGROUND Axillary ultrasound (AUS) with needle biopsy is used to detect metastasis in patients with invasive breast cancers. Our hypothesis is that preoperative AUS significantly reduces sentinel node biopsy (SLNB) use in patients with invasive breast tumors >2 cm upon clinical examination. METHODS A single-institution database of patients with breast cancer and AUS was reviewed. Patients with incomplete records, clinical tumor <2 cm, or postoperative AUS were excluded. A control cohort of non-AUS patients with clinical T2 (cT2) or greater disease was identified. Clinicopathologic data were collected. Simple Kappa coefficient and chi-square statistical analyses were performed. RESULTS AUS was performed in 153 patients vs. 370 controls. Of AUS patients, 112 (73.2%) had cT2 disease vs. 272 (73.5%) controls. Median AUS patient age was 53.7 (range, 22.8-85.8) years vs. 53.8 (range, 26.7-91.6) years; median pathologic tumor was 3.8 (range, 1.0-20.0) cm in AUS patients vs. 2.5 (range, 0.1-11.0) cm. Among AUS patients, 78% had needle biopsy; 85 of 120 (70.8%) were positive. Sixty-eight patients had SLNB: 33 after negative AUS and 35 after negative needle biopsy. Twenty-three SLNB (37.3%) were positive; 15 of 33 after negative AUS and 8 of 35 after a negative needle biopsy. Axillary dissection was performed in 102 of 153 vs. 225 of 370 controls. Sensitivity and specificity of AUS was 86.2% and 40.5%. Sensitivity of AUS plus needle biopsy was 89.3% with 100% specificity. Neoadjuvant chemotherapy was given to 49.7% of AUS patients. AUS reduced costs by more than $4,000 per patient. CONCLUSIONS AUS reduces SLNB use and affects treatment in patients with cT2 or greater breast cancer. Routine AUS should be considered in this population.
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Affiliation(s)
- M Catherine Lee
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL, USA.
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Al Mushawah F, Tan MC, Margenthaler JA. Residual nodal disease in biopsy proven n1/n2 breast cancer following neoadjuvant systemic therapy. World J Surg 2010; 34:256-60. [PMID: 20012606 DOI: 10.1007/s00268-009-0328-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The purpose of this study was to determine the rate of complete pathologic response in axillary lymph nodes after neoadjuvant therapy and the clinicopathologic factors associated with a complete response. METHODS Clinical, demographic, and pathologic data from all patients with breast cancer treated at our institution are prospectively recorded in a database. We reviewed this database from 2000 to 2007 and identified 90 patients who were node-positive before neoadjuvant therapy based on image-guided fine needle aspiration biopsy; all 90 patients underwent axillary lymph node dissection (ALND) after neoadjuvant therapy. Data were compared using chi-square and Fisher's exact test. RESULTS Of 90 patients with breast cancer who were node-positive before neoadjuvant therapy, 71 (79%) had positive nodal disease on final ALND pathology and 19 (21%) had a complete nodal pathologic response. Age, race, tumor grade, clinical T and N stage, and estrogen/progesterone receptor and Her-2neu status were not predictive of a complete nodal response. The only factor predictive of a complete nodal response was the type of neoadjuvant therapy used; all 19 patients with a complete response received neoadjuvant chemotherapy and none received neoadjuvant endocrine therapy (P < 0.05). CONCLUSIONS Twenty-five percent of patients who underwent neoadjuvant chemotherapy had a complete pathologic response in the nodal basin, whereas no patient who underwent neoadjuvant endocrine therapy experienced a complete nodal response. Twenty-five percent of patients who underwent neoadjuvant chemotherapy had a complete pathological response in the nodal specimen, whereas no patient who underwent neoadjuvant endocrine therapy experienced a complete nodal response.
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Affiliation(s)
- Fatema Al Mushawah
- Department of Surgery, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8109, St. Louis, MO 63110, USA
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Aydogan F, Ozben V, Atasoy D, Yilmaz MH, Halaç M, Celik V. Excision of axillary lymph node recurrences in breast cancer patients with axillary ROLL (A-ROLL). J Surg Oncol 2010; 101:141-4. [PMID: 19937993 DOI: 10.1002/jso.21450] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Conventional surgical exploration to find clinically occult axillary lymph node recurrence of breast cancer can be challenging. The aim of this study was to determine the place of our alternative technique, axillary-ROLL (A-ROLL), in previously treated breast cancer patients with nonpalpable axillary lymph node recurrences. METHODS Between March 2005 and May 2009, included in this retrospective study were four women (age, 42-51 years) without clinical evidence of distant metastasis who had treatment for breast cancer and were subsequently found to have suspicious axillary lymph node(s) detected by control ultrasonography (US) examination during follow-up. A-ROLL was utilized for the identification of lymph nodes. 0.5-1 mCi (99m)Tc-human serum albumin makroaggregate was injected under US guidance. A gamma probe was then used to guide the excision of the lymph nodes. RESULTS The involved lymph nodes were successfully localized by A-ROLL technique and removed surgically. Of all four patients, postoperative histopathologic examination revealed nodal cancer metastases in three patients (75%) and lymphoid hyperplasia in one patient. No complications occurred. CONCLUSIONS A-ROLL technique has proved to be accurate and safe in the identification and excision of clinically occult axillary lymph node recurrence.
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Affiliation(s)
- Fatih Aydogan
- Department of General Surgery, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
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Krishnamurthy S. Current applications and future prospects of fine-needle aspiration biopsy of locoregional lymph nodes in the management of breast cancer. Cancer 2010; 117:451-62. [PMID: 19813277 DOI: 10.1002/cncy.20055] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Staging of disease is routine in the evaluation of patients newly diagnosed with breast cancer. Assessment of palpable and/or nonpalpable locoregional lymph nodes is an important component of the initial staging. Ultrasound (US) is the favored imaging modality for the initial investigation of lymph nodes and results in a significant increase in the specificity of the overall evaluation when used in conjunction with fine-needle aspiration (FNA). This review provides a concise summary, based on published literature, of the current applications and future prospects of FNA biopsy of locoregional lymph nodes in the initial staging and subsequent surgical management of patients with breast cancer. Patients undergo either sentinel lymph node (SLN) biopsy or complete axillary lymph node dissection, based on whether the axillary lymph node status is determined to be negative or positive in the initial staging process. The status of lymph nodes in the supraclavicular, infraclavicular, and internal mammary regions provides more accurate staging information and also impacts subsequent surgical management. The identification and evaluation of intramammary lymph nodes can add value in the overall assessment of patients with breast cancer. The feasibility of noninvasive imaging modalities for SLN mapping in animal models has indicated a good potential for FNA biopsy in the subsequent investigation of SLNs identified noninvasively in humans.
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Affiliation(s)
- Savitri Krishnamurthy
- Department of Pathology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Abstract
Surgeons retain the central role in the multidisciplinary care of the breast cancer patient. While technical details of the operations for these patients remain important, effective evidence-based decision making may be even more so. Advances in the methods of breast cancer diagnosis, localization techniques and surgical therapies, as well as the expanded role of the surgeon in breast cancer prevention, radiation therapy and the treatment of distant disease, requires surgeons to stay up to date with the available evidence. Herein, we present a review of the current surgical therapy of invasive breast cancer.
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Affiliation(s)
- Barbara A Pockaj
- Section of Surgical Oncology, Department of Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd., Phoenix, AZ 85054, USA.
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Dixon J, Mak C, Radhakrishna S, Kehoe T, Millar A, Wong D, Thomas J. Effectiveness of immediate preoperative injection of radiopharmaceutical and blue dye for sentinel node biopsy in patients with breast cancer. Eur J Cancer 2009; 45:795-9. [DOI: 10.1016/j.ejca.2008.11.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 11/04/2008] [Accepted: 11/07/2008] [Indexed: 11/25/2022]
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Holwitt DM, Swatske ME, Gillanders WE, Monsees BS, Gao F, Aft RL, Eberlein TJ, Margenthaler JA. Scientific Presentation Award: The combination of axillary ultrasound and ultrasound-guided biopsy is an accurate predictor of axillary stage in clinically node-negative breast cancer patients. Am J Surg 2008; 196:477-82. [PMID: 18723153 DOI: 10.1016/j.amjsurg.2008.06.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2008] [Revised: 06/01/2008] [Accepted: 06/01/2008] [Indexed: 02/05/2023]
Abstract
BACKGROUND The study aim was to determine the accuracy of axillary ultrasound (AUS) and fine-needle aspiration biopsy (FNAB)/needle core biopsy in axillary breast cancer staging. METHODS We reviewed 256 patients with clinically node-negative breast cancer who underwent AUS +/- FNAB/needle core biopsy. AUS-guided FNAB/needle core biopsy was compared with histopathology to determine sensitivity, specificity, negative predictive value, and positive predictive value. RESULTS AUS-guided FNAB/needle core biopsy and final pathology were positive in 72 of 256 patients (28%). In 125 of 256 cases (49%), the AUS and final pathology were negative. Two of 110 patients had a false-positive FNAB (1.8%); both received neoadjuvant chemotherapy. Nine patients (8%) had a false-negative FNAB/needle core biopsy; the median size of lymph node metastasis was 3 mm. The sensitivity and specificity of AUS-guided FNAB/needle core biopsy was 71% and 99%, respectively, with a negative predictive value of 84% and a positive predictive value of 97%. CONCLUSIONS AUS-guided FNAB/needle core biopsy is accurate in predicting the status of the axilla in 70% of clinically node-negative breast cancer patients. This technique is minimally invasive with a low complication rate and can obviate the need for staged lymph node procedures.
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Affiliation(s)
- Dana M Holwitt
- Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8109, St. Louis, MO 63110, USA
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