Role of axillary ultrasound examination in the selection of breast cancer patients for sentinel node biopsy

doi:10.1016/j.amjsurg.2006.02.021

The American Journal of Surgery

Volume 193, Issue 1, January 2007, Pages 16-20

https://doi.org/10.1016/j.amjsurg.2006.02.021 Get rights and content

Abstract

Background

Sentinel node biopsy (SNB) is a time-consuming procedure that can be avoided in presence of axillary metastases. The aim of this study was to assess the accuracy of ultrasound scan (US) in the prediction of axillary nodes status in patients scheduled for SNB.

Methods

Axillary US was performed and when feasible, a core biopsy of suspicious nodes was taken. The nodal status as assessed by US and/or core biopsy was compared with final histology.

Results

Of the 132 patients enrolled, 31 (23.5%) had suspicious axillary nodes according to US; 19 (61.3%) were true positive, whereas 12 cases (38.7%) were not. In 14 of 31 suspicious cases an US-guided core-biopsy was taken, which in 11 of 14 cases (78.5%) confirmed the neoplastic involvement. Overall, core biopsy of the nodes correctly predicted the final histology in 13 of 14 cases (92.8%).

Conclusions

The US of axillary nodes, possibly associated with core biopsy, improved the preoperative evaluation of breast cancer patients scheduled for SNB.

Section snippets

Methods

Between July 2001 and December 2003 we performed preoperative axillary US with detailed study of the lymph nodes in 147 women scheduled for conservative breast surgery for whom SNB had been planned. Fifteen patients were excluded from the study: 6 because they were found to have benign breast disease and 9 because they failed to meet the sonographic requirement of at least 4 visible axillary nodes. The US examinations were performed by a single radiologist (J.N.), using a Technos MP unit

US findings versus final histology

Axillary US was performed in 132 breast cancer patients in whom at least 4 lymph nodes were visualized. Metastases in 1 or more nodes were documented in 42 patients (31.8%) at final histology. Of the 132 patients, 101 (76.5%) had sonographically normal or nonsuspicious lymph nodes according to the previously mentioned US criteria. The definitive histologic examination of these 101 cases confirmed the negative results in 78 true-negative cases (77.2%), whereas in the remaining 23 false-negative

Comments

The sonographic study of the axilla may be used as a non-invasive and fast method for assessing lymph node status in the preoperative staging of breast cancer patients and in the subsequent planning of local and systemic treatment. In metastatic lymph nodes, the process mainly involves the entire subcortical or cortical region, which, being invaded by the neoplastic tissue, becomes dishomogeneously hypertrophic deforming or even cancels the hyperechogenicity of the hilum or lymphatic sinusoids

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Cited by (93)

The effectiveness of ultrasound-guided core needle biopsy in detecting lymph node metastases in the axilla in patients with breast cancer: systematic review and meta-analysis
2023, Clinics
This study aimed to perform a meta-analysis to investigate the diagnostic safety and accuracy of Ultrasound-Guided Core Needle Biopsy (US-CNB) Axillary Lymph Nodes (ALNs) region in patients with Breast Cancer (BC).
The authors searched the electronic databases PubMed, Scopus, Embase, and Web of Science for clinical trials about US-CNB for the detection of ALNs in breast cancer patients. The authors extracted and pooled raw data from the included studies and performed statistical analyses using Meta-DiSc 1.4 and Review Manager 5.3 software. A random effects model was used to calculate the data. At the same time, data from the Ultrasound-guided Fine-Needle Aspiration (US-FNA) were introduced for comparison with the US-CNB. In addition, the subgroup was performed to explore the causes of heterogeneity. (PROSPERO ID: CRD42022369491).
In total, 18 articles with 2521 patients were assessed as meeting the study criteria. The overall sensitivity was 0.90 (95% CI [Confidence Interval], 0.87‒0.91; p = 0.00), the overall specificity was 0.99 (95% CI 0.98‒1.00; p = 0.62), the overall area under the curve (AUC) was 0.98. Next, in the comparison of US-CNB and US-FNA, US-CNB is better than US-FNA in the diagnosis of ALNs metastases. The sensitivity was 0.88 (95% CI 0.84‒0.91; p = 0.12) vs. 0.73 (95% CI 0.69‒0.76; p = 0.91), the specificity was 1.00 (95% CI 0.99‒1.00; p = 1.00) vs. 0.99 (95% CI 0.67‒0.74; p = 0.92), and the AUC was 0.99 vs. 0.98. Subgroup analysis showed that heterogeneity may be related to preoperative Neoadjuvant Chemotherapy (NAC) treatment, region, size of tumor diameter, and the number of punctures.
US-CNB has a satisfactory diagnostic performance with good specificity and sensitivity in the preoperative diagnosis of ALNs in BC patients.
Characterizing Occult Nodal Disease Within a Clinically Node-Negative, Neoadjuvant Breast Cancer Population
2022, Clinical Breast Cancer
Neoadjuvant therapy aims to preoperatively downstage breast cancer patients. We evaluated nodal upstaging in clinically node-negative (cN0) patients receiving neoadjuvant chemotherapy (NAC) and neoadjuvant endocrine therapy (NET).
cN0 patients undergoing neoadjuvant therapy from 2009 to 2018 were reviewed. Univariate and multivariate analyses evaluated rates of nodal upstaging.
A total of 228 cN0 patients with a mean age of 55 years underwent neoadjuvant therapy for Stage I-III invasive carcinoma. Subtypes included ER+/HER2- = 93 (40%), HER2+ = 61 (27%), and triple negative (TNBC) = 74 (33%). Among ER+/HER2- patients, 65 (70%) underwent NET. Overall, 49 patients (21%) were upstaged due to occult nodal disease. Factors associated with higher rates of occult nodal disease included advanced stage on initial presentation (P = .008), larger presenting tumor size (P = .009), low/intermediate tumor grade (P = .025), and ER+/HER2- subtype (P < .001); incidence of occult nodal disease by subtype included: ER+/HER2- = 37%, HER2+ = 15%, TNBC = 8%. Patients experiencing a breast pCR had a significantly lower rate of nodal upstaging compared to those with residual tumor (4% vs. 96%, P < .001). On multivariate analysis, ER+/HER- patients exhibited higher risk of occult nodal disease when compared to patients with HER2+ (odds ratio [OR] = 3.4, 95% CI, 1.2-9.8, P = .003) and TNBC (OR = 5.7, 95% CI, 1.7-19.6, P = .003). Comparing NAC vs. NET in ER+/HER2- patients showed no difference in rates of occult nodal disease (39% vs. 35%, P = .13).
ER+/HER2- subtype carries higher risk for occult nodal disease after neoadjuvant therapy; NAC versus NET in these patients does not affect nodal upstaging.
Development and Validation of a Preoperative Scoring System to Distinguish Between Nonadvanced and Advanced Axillary Lymph Node Metastasis in Patients With Early-stage Breast Cancer
2021, Clinical Breast Cancer
It has been determined that axillary lymph node dissection after the detection of limited axillary lymph node metastasis does not improve the prognosis of patients with breast cancer. Thus, a need exists for less-invasive axillary surgery. However, it remains unclear whether a predictive model based on preoperative data would be sufficient to accurately predict the probability of pN2-N3 (> 3 lymph node metastases). We sought to develop an easy-to-use scoring system to distinguish between pN0-N1 (0-3 lymph node metastases) and pN2-N3 using only preoperative data and validate its predictive performance.
We retrospectively identified 2687 patients diagnosed with cT1-3cN0-N1 who had undergone surgery in our hospital from 2013 to 2019. We evaluated the risk factors associated with pN2-N3 by logistic regression analysis and developed a scoring system. Predictive performance was assessed by calculating the receiver operating characteristic area under the curve (AUC) and was validated using K-fold cross-validation.
We identified 1987 patients with stage pN0, 522 with pN1, and 178 with pN2-N3. Multivariate analysis revealed tumor size, number of suspicious lymph nodes on axillary ultrasound examination, histologic type, histologic grade, and receptor status were significant risk factors for pN2-N3. The AUC value was 0.87, and the mean AUC of the 10-fold cross-validation was 0.88. When the cutoff score was set at 6, the negative predictive value for excluding patients with pN2-N3 was 98.4%.
Our easy-to-use scoring system could be useful to preoperatively identify patients at lower risk of pN2-N3 and avoid unnecessary axillary lymph node dissection.
Effectiveness of ultrasound in the detection of axillary metastasis in patients with breast cancer without clinical evidence of axillary disease: Clinical impact
2021, Revista de Senologia y Patologia Mamaria
Preoperative ultrasound in patients with breast cancer without evidence of clinical axillary disease represents an attempt to reliably identify axillary lymph node metastasis. However, the usefulness of ultrasound for the detection of axillary disease should be evaluated.
The study included a retrospective cohort of 826 patients with diagnosed invasive breast cancer, treated at the National Cancer Institute of Mexico, from 2014 to 2018. All patients underwent ipsilateral axillary ultrasound for staging purposes. Besides the descriptive analysis of the preoperative ultrasound, findings of the cohort were compared with their corresponding cytology and histopathology reports.
Diagnostic index for axillary ultrasound was calculated as follows: 32.8% sensitivity, 82.5% specificity, 37.1% positive predictive value (PPV), 79.6% negative predictive value (NPV), 70.6% diagnostic accuracy, 1.86 positive likelihood ratio (LR+), and 0.81 negative likelihood ratio (LR−). Loss of fatty hilum was associated with a higher risk of axillary metastasis on the multivariate analysis (OR 3.645; 95% CI, 1.664–7.985, p < 0.001).
The utility of axillary ultrasound as a method of determining the nodal status prior to surgery in patients with breast cancer without clinical evidence of axillary disease was not demonstrated in this study.
La ecografía preoperatoria en pacientes con cáncer de mama sin evidencia de enfermedad clínica axilar representa un intento de identificar de manera confiable metástasis a ganglios linfáticos axilares. Sin embargo, se debe evaluar la utilidad de la ecografía para la detección de la enfermedad axilar.
El estudio incluyó una cohorte retrospectiva de 826 pacientes con cáncer de mama invasivo diagnosticado en el Instituto Nacional de Cancerología de México, de 2014 a 2018. Todos los pacientes se sometieron a una ecografía axilar ipsilateral con fines de estadificación. Además del análisis descriptivo de la ecografía preoperatoria, los resultados de la cohorte se compararon con sus correspondientes informes de citología e histopatología.
Los índices diagnósticos para la ecografía axilar fueron: 32,8% de sensibilidad, 82,5% de especificidad, 37,1% de valor predictivo positivo (VPP), 79,6% de valor predictivo negativo (VPN), 70,6% de precisión diagnóstica, 1,86 de razón de verosimilitud positiva (LR⁺) y 0,81 de razón de verosimilitud negativa (LR⁻). La pérdida de hilio graso se asoció con un mayor riesgo de metástasis axilares en el análisis multivariado (RM: 3.645; IC al 95%: 1.664-7.985; p < 0,001).
La utilidad de la ecografía axilar como método para determinar el estado ganglionar antes de la cirugía en pacientes con cáncer de mama sin evidencia clínica de enfermedad axilar no se demostró en este estudio.
Lymph Node Predictive Model with in Vitro Ultrasound Features for Breast Cancer Lymph Node Metastasis
2020, Ultrasound in Medicine and Biology
Ultrasound diagnosis of axillary lymph nodes has the advantages of ease, convenience and low cost; however, most previous studies evaluated lymph node metastasis of the entire axilla rather than the association between the ultrasound features of a single lymph node and its pathology. This prospective study was performed to explore the ultrasound features of lymph nodes observed in bionic medium in vitro and to develop a lymph node-specific model for prediction of metastasis based on analysis of the association between the ultrasound features and pathology of each lymph node. From November 1, 2017 to December 19, 2017, 373 nodes (54 patients) were enrolled into the modeling group; from December 20, 2017 to January 12, 2018, 139 lymph nodes (22 patients) were enrolled into the validation group. Lymph nodes from sentinel lymph node biopsy or axillary lymph node dissection were enrolled. Individual lymph nodes were placed in bionic medium and observed separately using ultrasound. Traditional ultrasound features of metastatic nodes (long axis, short axis, cortical thickness and hilum loss) were recorded, and the longitudinal-to-transverse axis ratio (L/T) and cortical proportion were calculated. Pathologic results specific to each lymph node were recorded. On the basis of two-level binary logistic regression, independent predictors of lymph node metastasis in the modeling group were lymph node long axis (p = 0.004), short axis (p < 0.001), L/T (p = 0.006), cortical thickness (p = 0.001) and hilum loss (p < 0.001). When analysis was done at the node level, the areas under the curve of the modeling and validation groups were 0.97 and 0.75, respectively. When validation was done at the patient level, the areas under the curve of the modeling and validation groups were 0.96 and 0.93, respectively. The model for prediction of metastasis based on the ultrasound features and pathology of each lymph node is of good predictive value for lymph node metastasis.
Value of Axillary Ultrasound after Negative Axillary MRI for Evaluating Nodal Status in High-Risk Breast Cancer
2019, Journal of the American College of Surgeons
It is assumed that axillary ultrasound (AxUS) is the best method for axillary nodal evaluation in newly diagnosed breast cancer patients. However, few have evaluated the efficacy of preoperative axillary MRI. We compared the statistical accuracy of AxUS and MRI in detecting nodal metastases among breast cancer patients who were selected for neoadjuvant chemotherapy.
We retrospectively analyzed 219 breast cancer patients undergoing neoadjuvant chemotherapy from 2007 to 2015, all of whom had AxUS and breast MRI before chemotherapy. Two breast radiologists, blinded to clinical, pathologic, and AxUS findings, re-reviewed all breast MRIs, specifically focusing on axillary nodal characteristics. We correlated clinico-pathologic characteristics, AxUS, and MRI findings, and quantified predictive values of both imaging modalities.
Overall, 101 of 219 (47%) patients had T2 tumors. The most common abnormal nodal finding was size >10 mm. Axillary ultrasound and MRI agreed on nodal status in 192 of 219 patients (87.6%). When correlated with pre-chemotherapy needle biopsy in 129 patients, AxUS and axillary MRI performed similarly (sensitivity of 99.1% vs 97.4% and specificity 15.4% vs 15.4%, respectively). Only 4 of 129 (3.1%) patients had a negative MRI and positive AxUS; 3 of 4 of these patients (75%) had a positive biopsy and 2 of 3 had positive lymph nodes on final pathology, therefore suggesting MRI missed clinically significant disease in only 2 of 129 (1.5%) patients.
In a high-risk patient population, AxUS and MRI have similar statistical profiles in evaluating axillary nodal status. Routine use of AxUS after a normal axillary MRI is not warranted.

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Clinical surgery–internationalRole of axillary ultrasound examination in the selection of breast cancer patients for sentinel node biopsy

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

US findings versus final histology

Comments

Lancet

Eur J Cancer

Breast

Am J Surg

Am J Surg

Eur J Cancer

Eur J Cancer

Relation of number of positive axillary nodes to the prognosis of patients with primary breast cancerAn NSABP update

Cancer

Lymphatic mapping and sentinel lymphadenectomy for breast cancer

Ann Surg

The sentinel node in breast cancer—a multicenter validation study

N Engl J Med

Accuracy of ultrasound and clinical examination in the diagnosis of axillary lymph node metastases in breast cancer

Eur J Surg Oncol

Clinical surgery–international
Role of axillary ultrasound examination in the selection of breast cancer patients for sentinel node biopsy