Axillary ultrasound and fine needle aspiration biopsy in the preoperative diagnosis of axillary metastases in early-stage breast cancer

Ultrasonography and ultrasound-guided fine-needle aspiration biopsy can predict a heavy nodal metastatic burden in early-stage breast cancer

PURPOSE

This study aimed to predict a heavy nodal burden (≥3 metastatic axillary lymph nodes [LNs]) using axillary ultrasonography (US) and US-guided fine-needle aspiration biopsy (FNAB) in patients with early-stage breast cancer.

METHODS

We retrospectively reviewed the medical records of 403 women (404 cancers) who underwent US-guided FNAB for axillary LN staging from January 2006 to December 2015. US findings and US-guided FNAB results were reviewed and compared using pathology results as the reference. Diagnostic performance was analyzed, and clinicopathological and radiological findings were compared between patients with <3 metastatic LNs and ≥3 metastatic LNs.

RESULTS

The final pathology results revealed that 20.5% of cancers had heavy nodal metastases. US-guided FNAB showed significantly higher sensitivity (79.0% vs. 63.0%, P=0.009) and specificity (84.8% vs. 79.3%, P=0.036) in predicting heavy nodal metastases than did US. The presence of a larger number of suspicious LNs (two or more) on axillary US and positive FNAB results were significantly correlated with a heavy nodal burden in the multivariate analysis. The odds ratios were 4.20 (95% confidence interval [CI], 1.90 to 9.39) for two suspicious LNs, 9.40 (95% CI, 2.99 to 29.54) for three or more suspicious LNs, and 14.22 (95% CI, 6.78 to 29.82) for positive FNAB results.

CONCLUSION

The number of suspicious LNs detected on axillary US and FNAB results can help predict a heavy axillary nodal burden in patients with early-stage breast cancer.

To Evaluate the Accuracy of Axillary Staging Using Ultrasound and Ultrasound-Guided Fine-Needle Aspiration Cytology (USG-FNAC) in Early Breast Cancer Patients-a Prospective Study

In breast cancer, axillary lymph node involvement directly impacts the patient survival and prognosis. Sentinel lymph node biopsy (SLNB) is a procedure of choice for axillary staging in early breast cancer. Currently, management options for axilla management are axillary lymph node dissection and sentinel node biopsy in node positive and in node negative respectively. Accuracy of current clinical methods for evaluating axilla is low. Hence, to select patients for appropriate procedure, ultrasound (USG) combined with fine-needle aspiration cytology (USG-FNAC) using vascular pedicle-based nodal mapping method is emerging as a good tool to address above issues. We evaluated the feasibility of ultrasound and needle aspiration cytology in a tertiary care center. All early breast cancer patients with clinically node-negative axilla and having palpable nodes with less than or equal to 5 cm tumor size in breast were screened by ultrasound of axilla to categorize the nodes as suspicious or non-suspicious based on radiological features and vascular pedicle-based nodal mapping method of axilla. Patients having suspicious nodes underwent ultrasound of axilla and needle aspiration; if found positive, patient underwent axillary node dissection. Sentinel node biopsy (SLNB) performed in all patients found negative on needle aspiration and in all patients having non-suspicious nodes on ultrasound axilla. Final histopathology was taken as gold standard. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for ultrasound (USG) and ultrasound-guided needle aspiration (USG-FNAC). A total of 100 patients were included in which 58 had non-suspicious and 42 had suspicious nodes on ultrasound of axilla. Among suspicious group, 24 were positive on ultrasound-guided needle aspiration cytology and 18 were negative. In non-suspicious nodes, sentinel node biopsy was performed. Sensitivity, specificity, positive predictive value, and negative predictive value for ultrasound were 61.5%, 75.6%, 69.5%, and 68.5% respectively. For ultrasound-guided needle aspiration (USG-FNAC), sensitivity, specificity, and positive and negative predictive value are 83%, 100%, 100%, and 72.6% respectively. The accuracy of ultrasound (USG) and ultrasound-guided needle aspiration (USG-FNAC) was 69% and 88.1%. The result of our study indicates the feasibility of USG and USG-FNAC in a high-volume center with good accuracy of around 70-80%. Approximately one-fourth (24%) of the total patients were taken up for axillary lymph node dissection (ALND) without performing SLNB.

A review on methods for diagnosis of breast cancer cells and tissues

Breast cancer has seriously been threatening physical and mental health of women in the world, and its morbidity and mortality also show clearly upward trend in China over time. Through inquiry, we find that survival rate of patients with early‐stage breast cancer is significantly higher than those with middle‐ and late‐stage breast cancer, hence, it is essential to conduct research to quickly diagnose breast cancer. Until now, many methods for diagnosing breast cancer have been developed, mainly based on imaging and molecular biotechnology examination. These methods have great contributions in screening and confirmation of breast cancer. In this review article, we introduce and elaborate the advances of these methods, and then conclude some gold standard diagnostic methods for certain breast cancer patients. We lastly discuss how to choose the most suitable diagnostic methods for breast cancer patients. In general, this article not only summarizes application and development of these diagnostic methods, but also provides the guidance for researchers who work on diagnosis of breast cancer.

Shortcomings of ultrasound-guided fine needle aspiration in the axillary management of women with breast cancer

Background

Ultrasound, along with ultrasound-guided fine needle aspiration, is currently used for the axillary evaluation of breast cancer patients in order to identify candidates for axillary lymph node dissection. The aim of this study is to evaluate the accuracy of this tool in correctly identifying patients who may or may not benefit from axillary clearance in light of the ACOSOG Z0011 trial recommendations.

Methods

One hundred one patients (65 with positive US-FNA with corresponding axillary lymph node dissection (ALND), and 36 with negative US-FNA with corresponding ALND/sentinel lymph node biopsy) were studied for the number of involved axillary lymph nodes, tumor clinicopathologic features, and axillary radiologic findings.

Results

From the positive US-FNA group, 43% of patients had two or fewer positive lymph nodes upon ALND pathologic examination. In the US-FNA negative group, the negative predictive value for detecting axillary disease was 72.7%. With both groups combined, the sensitivity, specificity, PPV, and NPV of US-FNA for selecting patients based on axillary disease burden were 86%, 51.7%, 57%, and 83.3%, respectively.

Conclusion

Based on Z0011 guidelines, US-FNA is not a reliable tool in triaging patients in need for ALND and leads to overtreatment of 43% patients when positive, while depriving a small but significant percentage of patients from necessary therapy, when negative.

Risk factors for axillary lymph node metastases in clinical stage T1-2N0M0 breast cancer patients

Axillary lymph node metastasis (ALNM) is commonly the earliest detectable clinical manifestation of breast cancer when distant metastasis emerges. This study aimed to explore the influencing factors of ALNM and develop models that can predict its occurrence preoperatively.Cases of sonographically visible clinical stage T1-2N0M0 breast cancers treated with breast and axillary surgery at West China Hospital were retrospectively reviewed. Univariate and multivariate logistic regression analyses were performed to evaluate associations between ALNM and variables. Decision tree analyses were performed to construct predictive models using the C5.0 packages.Of the 1671 tumors, 541 (32.9%) showed axillary lymph node positivity on final surgical histopathologic analysis. In multivariate logistic regression analysis, tumor size (P < .001), infiltration of subcutaneous adipose tissue (P < .001), infiltration of the interstitial adipose tissue (P = .031), and tumor quadrant locations (P < .001) were significantly correlated with ALNM. Furthermore, the accuracy in the decision tree model was 69.52%, and the false-negative rate (FNR) was 74.18%. By using the error-cost matrix algorithm, the FNR significantly decreased to 14.75%, particularly for nodes 5, 8, and 13 (FNR: 11.4%, 9.09%, and 14.29% in the training set and 18.1%,14.71%, and 20% in the test set, respectively).In summary, our study demonstrated that tumor lesion boundary, tumor size, and tumor quadrant locations were the most important factors affecting ALNM in cT1-2N0M0 stage breast cancer. The decision tree built using these variables reached a slightly higher FNR than sentinel lymph node dissection in predicting ALNM in some selected patients.