Vaccine-associated axillary lymphadenopathy with a focus on COVID-19 vaccines

Axillary lymphadenopathy (LA) after COVID-19 vaccination is now known to be a common side effect. In these cases, malignancy cannot always be excluded on the basis of morphological imaging criteria.Narrative review for decision-making regarding control and follow-up intervals for axillary LA according to currently published research. This article provides a practical overview of the management of vaccine-associated LA using image examples and a flowchart and provides recommendations for follow-up intervals. A particular focus is on patients presenting for diagnostic breast imaging. The diagnostic criteria for pathological lymph nodes (LN) are explained.Axillary LA is a common adverse effect after COVID-19 vaccination (0.3-53%). The average duration of LA is more than 100 days. LA is also known to occur after other vaccinations, such as the seasonal influenza vaccine. Systematic studies on this topic are missing. Other causes of LA after vaccination (infections, autoimmune diseases, malignancies) should be considered for the differential diagnosis. If the LA persists for more than 3 months after COVID-19 vaccination, a primarily sonographic follow-up examination is recommended after another 3 months. A minimally invasive biopsy of the LA is recommended if a clinically suspicious LN persists or progresses. In the case of histologically confirmed breast cancer, a core biopsy without a follow-up interval is recommended regardless of the vaccination, as treatment appropriate to the stage should not be influenced by follow-up intervals. For follow-up after breast cancer, the procedure depends on the duration of the LA and the woman's individual risk of recurrence.Vaccination history should be well documented and taken into account when evaluating suspicious LN. Biopsy of abnormal, persistent, or progressive LNs is recommended. Preoperative staging of breast cancer should not be delayed by follow-up. The risk of false-positive findings is accepted, and the suspicious LNs are histologically examined in a minimally invasive procedure. · The vaccination history must be documented (vaccine, date, place of application).. · If axillary LA persists for more than 3 months after vaccination, a sonographic follow-up examination is recommended after 3 months.. · Enlarged LNs that are persistent, progressive in size, or are suspicious on control sonography should be biopsied.. · Suspicious LNs should be clarified before starting oncological therapy, irrespective of the vaccination status, according to the guidelines and without delaying therapy.. · Wilpert C, Wenkel E, Baltzer PA et al. Vaccine-associated axillary lymphadenopathy with a focus on COVID-19 vaccines. Fortschr Röntgenstr 2024; DOI 10.1055/a-2328-7536.

Distinguishing Axillary Lymphadenopathy after COVID-19 Vaccination from Malignant Lymphadenopathy

Objectives: To study the differences between malignant hypermetabolic axillary lymphadenopathy (MHL) and COVID-19 vaccine-associated axillary hypermetabolic lymphadenopathy (VAHL) using clinical imaging. Methods: A total of 1096 patients underwent Positron Emission Tomography-Computed Tomography (PET-CT) between 1 June 2021 and 30 April 2022 at Ehime University Hospital. In total, 188 patients with axillary lymphadenopathy after the COVID-19 vaccination were evaluated. The patients were classified into three groups such as VAHL (n = 27), MHL (n = 21), and equivocal hypermetabolic axillary lymphadenopathy (EqHL; n = 140). Differences in lymph node (LN) swellings were statistically analyzed using clinical imaging (echography, CT, and 18F-FDG PET). Results: MHL included a higher female population (90.5%) owing to a higher frequency of breast cancer (80.9%). Axillary LNs of MHL did not show any LN fatty hilums (0%); however, those of VAHL and EqHL did (15.8 and 36%, respectively). After the logistic regression analysis of the patients who had axillary lymphadenopathy without any LN fatty hilums, the minor axis length and ellipticity (minor axis/major axis) in the largest axillary LN, SUVmax, and Tissue-to-Background Ratio (TBR) were useful in distinguishing malignant lymphadenopathies. A receiver-operating characteristic (ROC) analysis indicated that a cut-off value of ≥7.3 mm for the axillary LN minor axis (sensitivity: 0.714, specificity: 0.684) and of ≥0.671 for ellipticity (0.667 and 0.773, respectively) in the largest LN with the highest SUVmax and TBR were predictive of MHL. Conclusions: Axillary lymphadenopathy of the minor axis and ellipticity in LN without fatty hilums may be useful to be suspicious for malignancy, even in patients who have received COVID-19 vaccination. Further examinations, such as 18F-FDG PET, are recommended for such patients.

Deep Learning-Based Segmentation of Locally Advanced Breast Cancer on MRI in Relation to Residual Cancer Burden: A Multi-Institutional Cohort Study

BACKGROUND

While several methods have been proposed for automated assessment of breast-cancer response to neoadjuvant chemotherapy on breast MRI, limited information is available about their performance across multiple institutions.

PURPOSE

To assess the value and robustness of deep learning-derived volumes of locally advanced breast cancer (LABC) on MRI to infer the presence of residual disease after neoadjuvant chemotherapy.

STUDY TYPE

Retrospective.

SUBJECTS

Training cohort: 102 consecutive female patients with LABC scheduled for neoadjuvant chemotherapy (NAC) from a single institution (age: 25-73 years). Independent testing cohort: 55 consecutive female patients with LABC from four institutions (age: 25-72 years).

FIELD STRENGTH/SEQUENCE

Training cohort: single vendor 1.5 T or 3.0 T. Testing cohort: multivendor 3.0 T. Gradient echo dynamic contrast-enhanced sequences.

ASSESSMENT

A convolutional neural network (nnU-Net) was trained to segment LABC. Based on resulting tumor volumes, an extremely randomized tree model was trained to assess residual cancer burden (RCB)-0/I vs. RCB-II/III. An independent model was developed using functional tumor volume (FTV). Models were tested on an independent testing cohort and response assessment performance and robustness across multiple institutions were assessed.

STATISTICAL TESTS

The receiver operating characteristic (ROC) was used to calculate the area under the ROC curve (AUC). DeLong's method was used to compare AUCs. Correlations were calculated using Pearson's method. P values <0.05 were considered significant.

RESULTS

Automated segmentation resulted in a median (interquartile range [IQR]) Dice score of 0.87 (0.62-0.93), with similar volumetric measurements (R = 0.95, P < 0.05). Automated volumetric measurements were significantly correlated with FTV (R = 0.80). Tumor volume-derived from deep learning of DCE-MRI was associated with RCB, yielding an AUC of 0.76 to discriminate between RCB-0/I and RCB-II/III, performing similar to the FTV-based model (AUC = 0.77, P = 0.66). Performance was comparable across institutions (IQR AUC: 0.71-0.84).

DATA CONCLUSION

Deep learning-based segmentation estimates changes in tumor load on DCE-MRI that are associated with RCB after NAC and is robust against variations between institutions.

EVIDENCE LEVEL

2.

TECHNICAL EFFICACY

Stage 4.

Nomogram based on multiparametric analysis of early-stage breast cancer: Prediction of high burden metastatic axillary lymph nodes

BACKGROUND

The Z0011 and AMAROS trials found that axillary lymph node dissection (ALND) was no longer mandatory for early-stage breast cancer patients who had one or two metastatic axillary lymph nodes (mALNs). The aim of our study was to establish a nomogram which could be used to quantitatively predict the individual likelihood of high burden mALN (≥3 mALN).

METHODS

We retrospectively analyzed 564 women with early breast cancer who had all undergone both ultrasound (US) and magnetic resonance imaging (MRI) to examine axillary lymph nodes before radical surgery. All the patients were divided into training (n = 452) and validation (n = 112) cohorts by computer-generated random numbers. Their clinicopathological features and preoperative imaging associated with high burden mALNs were evaluated by logistic regression analysis to develop a nomogram for predicting the probability of high burden mALNs.

RESULTS

Multivariate analysis showed that high burden mALNs were significantly associated with replaced hilum and the shortest diameter >10 mm on MRI, with cortex thickness >3 mm on US (p < 0.05 each). These imaging criteria plus higher grade (grades II and III) and quadrant of breast tumor were used to develop a nomogram calculating the probability of high burden mALNs. The AUC of the nomogram was 0.853 (95% CI: 0.790-0.908) for the training set and 0.783 (95% CI: 0.638-0.929) for the validation set. Both internal and external validation evaluated the accuracy of nomogram to be good.

CONCLUSION

A well-discriminated nomogram was developed to predict the high burden mALN in early-stage breast patients, which may assist the breast surgeon in choosing the appropriate surgical approach.

Evaluating the Performance of Algorithms in Axillary Microwave Imaging towards Improved Breast Cancer Staging

Breast cancer is the most common and the fifth deadliest cancer worldwide. In more advanced stages of cancer, cancer cells metastasize through lymphatic and blood vessels. Currently there is no satisfactory neoadjuvant (i.e., preoperative) diagnosis to assess whether cancer has spread to neighboring Axillary Lymph Nodes (ALN). This paper addresses the use of radar Microwave Imaging (MWI) to detect and determine whether ALNs have been metastasized, presenting an analysis of the performance of different artifact removal and beamformer algorithms in distinct anatomical scenarios. We assess distinct axillary region models and the effect of varying the shape of the skin, muscle and subcutaneous adipose tissue layers on single ALN detection. We also study multiple ALN detection and contrast between healthy and metastasized ALNs. We propose a new beamformer algorithm denominated Channel-Ranked Delay-Multiply-And-Sum (CR-DMAS), which allows the successful detection of ALNs in order to achieve better Signal-to-Clutter Ratio, e.g., with the muscle layer up to 3.07 dB, a Signal-to-Mean Ratio of up to 20.78 dB and a Location Error of 1.58 mm. In multiple target detection, CR-DMAS outperformed other well established beamformers used in the context of breast MWI. Overall, this work provides new insights into the performance of algorithms in axillary MWI.

Evaluation of treatment responses among subgroups of breast cancer patients receiving neoadjuvant chemotherapy

BACKGROUND

Breast MRIs are helpful for determining treatment plans, responses, and prospective survival analyses. In this retrospective cross-sectional study, we compared the preoperative MRI treatment response to neoadjuvant chemotherapy (NAC) administration with the postoperative pathological response in breast cancer patients.

MATERIALS AND METHODS

We analyzed data from 108 hospitalized patients receiving NAC between 2020 and 2022. We used MRI to evaluate the treatment response to NAC in patients with locally advanced breast cancers who had not received any prior treatment. We recorded the longest diameter of the primary tumor and the numbers of secondary tumors and axillary lymph nodes. In addition, we examined the correlation between the MRI response rate and pathological specimen results.

RESULTS

In our subgroup analyses, we found the best pathological response in patients with luminal B (Ki-67 index >14%) breast cancer and positivity for both hormone receptor and HER-2 markers. After comparing the pathological and radiological treatment responses in tumors and lymph nodes, the sensitivities were 90.3% for the pathological assessment and 42.8% for the radiological assessment, while the accuracies were 84.2% for the pathological assessment and 61.1% for the radiological assessment.

CONCLUSION

Using MRI techniques and sequence intervals and examining the histopathological characteristics of tumors may help increase the accuracy of the pathological complete response.

Modelling level I Axillary Lymph Nodes depth for Microwave Imaging

PURPOSE

Patient-specific information on the depth of Axillary Lymph Nodes (ALNs) is important for the development of new diagnostic imaging technologies, e.g. Microwave Imaging (MWI), aiming to assess the diagnosis of ALNs during breast cancer staging. Studies about ALNs depth have been presented for treatment planning, but they lack information on sample size and usability of the data to infer the depth of ALNs. The aim of this study was to create a mathematical model that can be used to predict a depth interval where level I ALNs are likely to be located.

METHODS

We extracted biometric features of 98 patients who underwent breast Magnetic Resonance Imaging (MRI) to train two types of regression models. We then tested different combination of features to predict ALNs depth and found the best predictor. The final prediction models were then implemented in an algorithm used for MWI and tested with anthropomorphic phantoms of the axillary region.

RESULTS

Body Mass Index (BMI) was the feature with best performance to predict ALNs depth with coefficient of determination (R²) ranging from 0.49 to 0.55 and Root Mean Squared Error (RMSE) ranging from 0.68 to 0.91 cm. The proposed model showed satisfactory results in microwave images of patients with different BMIs.

CONCLUSIONS

The presented results contribute to the development of reconstruction algorithms for new imaging technologies and to the assessment of ALNs in other medical applications.

Role of shear wave elastography as an adjunct to axillary ultrasonography in predicting nodal metastasis in breast cancer patients with suspicious nodes

OBJECTIVE

To evaluate the role of shear wave elastography (SWE) of suspicious axillary lymph nodes and its combination with B-mode USG in predicting nodal metastasis in breast cancer patients.

METHODS

Prospective observational study was performed from June 2018 to August 2020 on breast cancer patients with suspicious axillary nodes on USG. B-mode features (cortical thickness, effacement of fatty hilum, non-hilar blood flow and round shape) and SWE parameters (Emax, Emin, Emean and ESD) of the node with the thickest cortex were evaluated. Diagnostic performances of USG, SWE and their combination were estimated using pathological status of the node on biopsy as the gold standard.

RESULTS

Of the 54 patients evaluated, optimal elasticity maps were obtained in 49 nodes of 49 patients (mean age, 46.3 ± 12.1 years; 48/49 (98%) females). On biopsy, 38 nodes (77.6%) had metastasis, while 11 (22.4%) had reactive hyperplasia. Emax, Emin, Emean and ESD of both cortex and hilum were significantly higher in metastatic than reactive nodes. Emax (cortex) ≥14.9 kPa had the best diagnostic performance (sensitivity, 73.7%; specificity, 81.8%). Cortical thickness ≥6.7 mm had the best diagnostic performance among B-mode features (sensitivity, 89.5%; specificity, 72.7%). Combining cortical thickness with effacement of fatty hilum and/or non-hilar blood flow yielded sensitivity of 89.5% and specificity of 90.9%. Addition of Emax (cortex) to cortical thickness and combination of ≥2 B-mode features increased their specificities to 90.9 and 100%, respectively.

CONCLUSIONS

Metastatic axillary nodes are stiffer than reactive nodes on SWE in breast cancer patients. Emax (cortex) has the best diagnostic performance in differentiating between reactive hyperplasia and nodal metastasis. Combination of Emax (cortex) and cortical thickness increases the specificity for diagnosing metastasis, especially in nodes showing only cortical thickening.

ADVANCES IN KNOWLEDGE

Combination of SWE and B-mode USG is highly specific for differentiating metastasis from reactive hyperplasia in suspicious nodes of breast carcinoma patients, especially in nodes with only cortical thickening.

MRI Findings Suggestive of Metastatic Axillary Lymph Nodes in Patients with Invasive Breast Cancer

Purpose

This study aimed to investigate the diagnostic performance of features suggestive of nodal metastasis on preoperative MRI in patients with invasive breast cancer.

Materials and Methods

We retrospectively reviewed the preoperative breast MRI of 192 consecutive patients with surgically proven invasive breast cancer. We analyzed MRI findings of axillary lymph nodes with regard to the size, long/short ratio, cortical thickness, shape and margin of the cortex, loss of hilum, asymmetry, signal intensity (SI) on T2-weighted images (T2WI), degree of enhancement in the early phase, and enhancement kinetics. Receiver operating characteristic (ROC) analysis, chi-square test, t test, and McNemar’s test were used for statistical analysis.

Results

Increased shorter diameter, uneven cortical shape, increased cortical thickness, loss of hilum, asymmetry, irregular cortical margin, and low SI on T2WI were significantly suggestive of metastasis. ROC analysis revealed the cutoff value for the shorter diameter and cortical thickness as 8.05 mm and 2.75 mm, respectively. Increased cortical thickness (> 2.75 mm) and uneven cortical shape showed significantly higher sensitivity than other findings in McNemar’s test. Irregular cortical margins showed the highest specificity (100%).

Conclusion

Cortical thickness > 2.75 mm and uneven cortical shape are more sensitive parameters than other findings, and an irregular cortical margin is the most specific parameter for predicting axillary metastasis in patients with invasive breast cancer.

Axillary ultrasonography combined with pre-operative wire localisation of clipped node in nodal restaging after neoadjuvant chemotherapy in node positive breast cancer patients: a pilot study

OBJECTIVE

To evaluate the role of axillary ultrasonography (axUS) and ultrasound-guided pre-operative wire localisation of pre-treatment positive clipped node (CN) for prediction of nodal response to neoadjuvant chemotherapy (NACT) in node positive breast carcinoma patients.

METHODS AND MATERIALS

A prospective study was conducted between June 2018 and August 2020 after Ethics Committee approval. Breast carcinoma patients (cT1-cT4b) with palpable axillary nodes (cN1-cN3) and suitable for NACT were recruited after written informed consent. Single, most suspicious node was biopsied and clipped. Nodal response to NACT was assessed on axUS. Wire localisation of CN was performed prior to axillary lymph node dissection (ALND). Diagnostic performances of axUS and CN excision were assessed.

RESULTS

Of the 69 patients evaluated, 32 patients (mean age, 43.5 ± 11.8 years; females, 31/32 [97%]; pre-menopausal, 18/32 [56.3%]) with metastatic nodes who received NACT were included. Nodal pathological complete response rate was 34.4% (11/32) overall and 70% (7/10) in patients with ≤2 suspicious nodes on pre-NACT axUS. False-negative rates (FNRs) of axUS and CN excision were 4.8% and 28.6% respectively. Combination of post-NACT axUS and CN excision had an FNR of 4.8% overall and 0% in patients with ≤2 suspicious nodes on pre-NACT axUS.

CONCLUSION

Combination of AxUS and ultrasound-guided wire localisation of pre-treatment positive CN has high diagnostic accuracy for nodal restaging after NACT in node positive breast cancer patients.

ADVANCES IN KNOWLEDGE

Addition of axUS assessment to wire localisation of CN reduces its FNR for detecting residual metastasis after NACT.

Determining the axillary nodal status with four current imaging modalities including 18F-FDG PET/MRI in newly diagnosed breast cancer: A comparative study using histopathology as reference standard

Purpose: To compare breast magnetic resonance imaging (MRI), thoracal MRI, thoracal 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET)/MRI and axillary sonography for the detection of axillary lymph node metastases in women with newly diagnosed breast cancer. Materials and Methods: This prospective double-center study included patients with newly diagnosed breast cancer between March 2018 and December 2019. Patients underwent thoracal (18F-FDG PET/)MRI, axillary sonography, and dedicated prone breast MRI. Datasets were evaluated separately regarding nodal status (nodal+ vs. nodal-). Histopathology served as reference standard in all patients. The diagnostic performance of breast MRI, thoracal MRI, thoracal PET/MRI and axillary sonography in detecting nodal positive patients was tested by creating receiver-operating-characteristic curves (ROC) with a calculated area under the curve (AUC). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for all four modalities. A McNemar test was used to assess differences. Results: 112 female patients (mean age 53.04 ± 12.6 years) were evaluated. Thoracal PET/MRI showed the highest ROC-AUC with a value of 0.892. The AUC for breast MRI, thoracal MRI and sonography were 0.782, 0.814 and 0.834, respectively. Differences between thoracal PET/MRI and axillary sonography, thoracal MRI and breast MRI were statistically significant (PET/MRI vs. axillary sonography, P = 0.01; PET/MRI vs. thoracal MRI, P = 0.02; PET/MRI vs. breast MRI, P = 0.03). PET/MRI showed the highest sensitivity (81.8%, 36/44) (95%-CI: 67.29-91.81%) while axillary sonography had the highest specificity (98.5%, 65/66), 95%-CI: 91.84-99.96%). Conclusion: 18F-FDG PET/MRI outperforms axillary sonography, breast MRI and thoracal MRI in determining the axillary lymph node status. In a clinical setting, the combination of 18F-FDG PET/MRI and axillary sonography might be considered to provide even more accuracy in diagnosis.

Diagnostic accuracy of axillary staging by ultrasound in early breast cancer patients

BACKGROUND

Axillary ultrasound (AUS) is a standard procedure in the preoperative clinical identification of axillary metastatic lymph node (LN) involvement. It guides decisions about local and systemic therapy for patients with early breast cancer (EBC). But there is only weak evidence on the diagnostic criteria and standard interpretation. The aim of this study was to assess the performance of AUS in the detection and exclusion of LN metastases.

METHODS

In a retrospective single-center study, 611 consecutive EBC patients with 622 axillae underwent AUS +/- core needle biopsy (CNB) plus axillary surgery, i.e. sentinel lymph node biopsy and/or axillary lymph node dissection. For all patients, AUS image documentation of at least the most suspicious LN was saved during the initial diagnostic work-up. The diagnostic outcome measures were sensitivity, specificity, accuracy, Youden-index (YI), and diagnostic odds ratio (DOR) on the basis of the daily routine interpretation and on the basis of previously recommended diagnostic criteria by two blinded examiners.

RESULTS

On the basis of the daily routine interpretation, AUS had a sensitivity (95 % CI) of 53.3 % (46.4-60.1), a specificity (95 % CI) of 93.6 % (90.8-95.8), an accuracy (95 % CI) of 79.7 % (76.4-82.8), a YI (95 % CI) of 0.47 (0.40 - 0.54), and a DOR (95 % CI) of 16.75 (10.37-27.05). Systematic application of previously recommended diagnostic criteria did not improve the diagnostic accuracy of routinely interpreted AUS.

CONCLUSION

AUS performance alone is not sufficient to accurately identify or exclude axillary metastatic disease in unselected patients with EBC.

Development of an Anthropomorphic Phantom of the Axillary Region for Microwave Imaging Assessment

We produced an anatomically and dielectrically realistic phantom of the axillary region to enable the experimental assessment of Axillary Lymph Node (ALN) imaging using microwave imaging technology. We segmented a thoracic Computed Tomography (CT) scan and created a computer-aided designed file containing the anatomical configuration of the axillary region. The phantom comprises five 3D-printed parts representing the main tissues of interest of the axillary region for the purpose of microwave imaging: fat, muscle, bone, ALNs, and lung. The phantom allows the experimental assessment of multiple anatomical configurations, by including ALNs of different size, shape, and number in several locations. Except for the bone mimicking organ, which is made of solid conductive polymer, we 3D-printed cavities to represent the fat, muscle, ALN, and lung and filled them with appropriate tissue-mimicking liquids. Existing studies about complex permittivity of ALNs have reported limitations. To address these, we measured the complex permittivity of both human and animal lymph nodes using the standard open-ended coaxial-probe technique, over the 0.5 GHz–8.5 GHz frequency band, thus extending current knowledge on dielectric properties of ALNs. Lastly, we numerically evaluated the effect of the polymer which constitutes the cavities of the phantom and compared it to the realistic axillary region. The results showed a maximum difference of 7 dB at 4 GHz in the electric field magnitude coupled to the tissues and a maximum of 10 dB difference in the ALN response. Our results showed that the phantom is a good representation of the axillary region and a viable tool for pre-clinical assessment of microwave imaging technology.

Variations of the musculofascial axillary arch with the adjacent lymph nodes

PURPOSE

This unique case gives the extent of knowledge in the axilla area with axillary arch (AA) and a discussion of its clinical importance.

MATERIALS AND METHOD

The anatomical anomaly was found during the dissection class for the brachial plexus. It was identified through the precise dissection of the structures bilaterally.

RESULTS

The cadaver had fascial and muscular AA bilaterally. The fascial AA was separated into the superficial and deep arch group. The superficial arch group connected to the clavipectoral fascia and the axillary fascia. The deep arch group attached to the subscapular fascia. The muscular AA had superficial and deep variations. The superficial muscular AA attached between accessory slip of latissimus dorsi muscle (LDa) and pectoralis quartus muscle (PQ). The deep muscular AA attached to the crest of lesser tubercle of the humerus from LDa. The adipose tissue with the level one central lymph node was located lateral to the pectoralis minor muscle expand from pectoral lymph node through between LDa and PQ.

CONCLUSION

This case showed the fascial and muscular AA together. The muscular AA had both complete and incomplete attachment types. It could give functional and neurological problems in the axilla, such as thoracic outlet syndrome. Additionally, the structures presented with the axillary lymph node. It helps to understand the patient's condition with the AA in the axilla and could provide.

Association between negative preoperative axillary node staging and surgical sentinel node biopsy in patients with newly diagnosed breast cancer: A retrospective analysis

AIM

The aim of this retrospective study was to analyse the preoperative ultrasound findings in patients with minimal or almost no morphological changes of axillary lymph nodes (LN) and to correlate these findings with the results of sentinel node (SN) biopsy.

MATERIALS AND METHODS

Between January 2014 and September 2018, 289 female patients with newly diagnosed breast cancer and negative preoperative axillary staging were examined with preoperative ultrasound evaluation of axillary LNs. Patients with no evidence of LN metastases underwent primary surgical treatment with SN biopsy. Negative predictive value (NPV) of preoperative ultrasound was evaluated and the histopathological findings in positive SN biopsies were correlated with tumour type and preoperative ultrasound LN imaging.

RESULTS

Of 289 patients with negative preoperative axillary staging who had primary surgical treatment, 268 patients had negative SN biopsy while SN metastases were detected in 21 patients. Of patients with positive SN biopsies, 2 patients had negative core biopsy of axillary LN before surgery. The preoperative ultrasound examination was negative in the remaining 19 patients with SN metastases.

CONCLUSIONS

Preoperative ultrasonography is very accurate in the detecting of axillary LN metastases. Patients with primary tumour size ≥ 1 cm, with grade ≥ 2 no special type carcinomas (NST - no special type, also known as invasive ductal carcinoma) or multicentric lobular invasive cancer should undergo a more thorough ultrasound evaluation.

Association between Expression of Tissue Inhibitors of Metalloproteinases-1, Matrix Metalloproteinase-2, and Matrix Metalloproteinase-9 Genes and Axillary Lymph Nodes Metastasis in Patients with Breast Cancer

Background

Certain enzymatic biomarkers such as matrix metalloproteinase (MMPs) are instrumental in the breast cancer. Hence, they are viewed as predictive biomarkers in the primary prognosis of this type of cancer. Furthermore, they enjoy a predictive value in the evaluation of the disease, recurrence of tumor, invasion of tumor cells to other areas as well as therapeutic outcomes. The present study aimed to determine the association between the expression of the three tissue inhibitors of metalloproteinases-1 (TIMP1), MMP2, and MMP9 genes and axillary lymph nodes involvement in patients with breast cancer.

Methods

Patients in this study were categorized into two groups, first with axillary lymph nodes involvement (as the case group) and second group without the involvement of axillary lymph nodes (as the control group) referred to Cancer Institute at Imam Khomeini Hospital in Tehran in 2016. The gene expression was assessed using the reverse transcription polymerase-chain reaction technique.

Results

There was no significant difference in the mRNA level of MMP2 and MMP9 genes between the cancer tissues with and without axillary lymph node metastasis in comparison with normal samples. However, the mRNA level of TIMP1 gene was considerably higher in the cancer tissue with axillary lymph node metastasis as compared to the samples without metastasis. In other words, the presence of axillary lymph node metastasis induced a 77.8-fold increase in mRNA expression when compared to condition without metastasis.

Conclusions

The expression of TIMP1 gene is strongly associated with axillary lymph node metastasis in breast cancer patients.

Preoperative Axillary Lymph Node Evaluation in Breast Cancer: Current Issues and Literature Review

Axillary lymph node (ALN) status is an important prognostic factor for overall breast cancer survival. In current clinical practice, ALN status is evaluated before surgery via multimodal imaging and physical examination. Mammography is typically suboptimal for complete ALN evaluation. Currently, ultrasonography is widely used to evaluate ALN status; nonetheless, results may vary according to operator. Ultrasonography is the primary imaging modality for evaluating ALN status. Other imaging modalities including contrast-enhanced magnetic resonance imaging, computed tomography, and positron emission tomography/computed tomography can play additional roles in axillary nodal staging.The purpose of this article is (1) to review the strengths and weaknesses of current imaging modalities for nodal staging in breast cancer patients and (2) to discuss updated guidelines for ALN management with regard to preoperative ALN imaging.

Supine MRI for regional breast radiotherapy: imaging axillary lymph nodes before and after sentinel-node biopsy

Regional radiotherapy (RT) is increasingly used in breast cancer treatment. Conventionally, computed tomography (CT) is performed for RT planning. Lymph node (LN) target levels are delineated according to anatomical boundaries. Magnetic resonance imaging (MRI) could enable individual LN delineation. The purpose was to evaluate the applicability of MRI for LN detection in supine treatment position, before and after sentinel-node biopsy (SNB). Twenty-three female breast cancer patients (cTis-3N0M0) underwent 1.5 T MRI, before and after SNB, in addition to CT. Endurance for MRI was monitored. Axillary levels were delineated. LNs were identified and delineated on MRI from before and after SNB, and on CT, and compared by Wilcoxon signed-rank tests. LN locations and LN-based volumes were related to axillary delineations and associated volumes. Although postoperative effects were visible, LN numbers on postoperative MRI (median 26 LNs) were highly reproducible compared to preoperative MRI when adding excised sentinel nodes, and higher than on CT (median 11, p  <  0.001). LN-based volumes were considerably smaller than respective axillary levels. Supine MRI of LNs is feasible and reproducible before and after SNB. This may lead to more accurate RT target definition compared to CT, with potentially lower toxicity. With the MRI techniques described here, initiation of novel MRI-guided RT strategies aiming at individual LNs could be possible.

A comparison of the diagnostic accuracy of magnetic resonance imaging to axillary ultrasound in the detection of axillary nodal metastases in newly diagnosed breast cancer

Patients with a diagnosis of invasive breast cancer are increasingly undergoing breast magnetic resonance imaging (MRI) for preoperative staging including evaluation of axillary lymph node metastases (ALNM). This retrospective study aims to evaluate the utility of adding axillary ultrasound (AUS) in the preoperative setting when an MRI is planned or has already been performed. This IRB approved, HIPAA compliant study reviewed a total of 271 patients with a new diagnosis of invasive breast cancer at a single institution, between June 1, 2010 and June 30, 2013. The study included patients who received both AUS and MRI for preoperative staging. Data were divided into two cohorts, patients who underwent MRI prior to AUS and those who underwent AUS prior to MRI. AUS and MRI reports were categorized according to BI-RADS criteria as "suspicious" or "not suspicious" for ALNM. In the setting of a negative MRI and subsequent positive AUS, only one out of 25 cases (4%) were positive for metastases after correlating with histologic pathology. MRI detected metastatic disease in four out of 27 (15%) patients who had false-negative AUS performed prior to MRI. Our results indicate the addition of AUS after preoperative MRI does not contribute significantly to increased detection of missed disease. MRI could serve as the initial staging imaging method of the axilla in the setting that AUS is not initially performed and may be valuable in identification of lymph nodes not identified on AUS.

Simple bioconjugate chemistry serves great clinical advances: albumin as a versatile platform for diagnosis and precision therapy

Albumin is the most abundant circulating protein in plasma and has recently emerged as a versatile protein carrier for drug targeting and for improving the pharmacokinetic profile of peptide or protein based drugs. Three drug delivery technologies related to albumin have been developed, which include the coupling of low-molecular weight drugs to exogenous or endogenous albumin, conjugating bioactive proteins by albumin fusion technology (AFT), and encapsulation of drugs into albumin nanoparticles. This review article starts with a brief introduction of human serum albumin (HSA), and then summarizes the mainstream chemical strategies of developing HSA binding molecules for coupling with drug molecules. Moreover, we also concisely condense the recent progress of the most important clinical applications of HSA-binding platforms, and specify the current challenges that need to be met for a bright future of HSA-binding.

Heterogeneity in intratumoral regions with rapid gadolinium washout correlates with estrogen receptor status and nodal metastasis

PURPOSE

To evaluate heterogeneity within tumor subregions or "habitats" via textural kinetic analysis on breast dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for the classification of two clinical prognostic features; 1) estrogen receptor (ER)-positive from ER-negative tumors, and 2) tumors with four or more viable lymph node metastases after neoadjuvant chemotherapy from tumors without nodal metastases.

MATERIALS AND METHODS

Two separate volumetric DCE-MRI datasets were obtained at 1.5T, comprised of bilateral axial dynamic 3D T1 -weighted fat suppressed gradient recalled echo-pulse sequences obtained before and after gadolinium-based contrast administration. Representative image slices of breast tumors from 38 and 34 patients were used for ER status and lymph node classification, respectively. Four tumor habitats were defined based on their kinetic contrast enhancement characteristics. The heterogeneity within each habitat was quantified using textural kinetic features, which were evaluated using two feature selectors and three classifiers.

RESULTS

Textural kinetic features from the habitat with rapid delayed washout yielded classification accuracies of 84.44% (area under the curve [AUC] 0.83) for ER and 88.89% (AUC 0.88) for lymph node status. The texture feature, information measure of correlation, most often chosen in cross-validations, measures heterogeneity and provides accuracy approximately the same as with the best feature set.

CONCLUSION

Heterogeneity within habitats with rapid washout is highly predictive of molecular tumor characteristics and clinical behavior.

Suspicious axillary lymph nodes identified on clinical breast MRI in patients newly diagnosed with breast cancer: can quantitative features improve discrimination of malignant from benign?

RATIONALE AND OBJECTIVES

To determine whether quantitative dynamic contrast-enhanced (DCE) and diffusion-weighted (DW) magnetic resonance imaging (MRI) features can discriminate malignant from benign axillary lymph nodes (ALNs) identified as suspicious on clinical breast MRI in patients newly diagnosed with breast cancer.

MATERIALS AND METHODS

After approval from institutional review board, all clinical breast MR examinations performed from March 2006 through January 2010 describing at least one morphologically suspicious ipsilateral ALN in patients with newly diagnosed breast cancer were identified. Each suspicious ALN underwent ultrasound-guided core needle biopsy, and nodes with benign results were subsequently sampled surgically. Quantitative DCE and DW MRI parameters (diameters, volume, enhancement kinetics, and apparent diffusion coefficients [ADC]) were measured for each suspicious ALN and a representative contralateral normal node, and each feature was compared between the ALN groups (normal, benign, and malignant).

RESULTS

Thirty-four suspicious ALNs (18 malignant and 16 benign) and 34 contralateral normal-appearing ALNs were included. Suspicious malignant and benign nodes exhibited larger size, greater volume, and lower ADCs than normal ALNs (P < .05). Among suspicious ALNs, the only quantitative measure that discriminated between malignant from benign outcome was percent of ALN demonstrating washout kinetics (P = .02).

CONCLUSIONS

In ALNs deemed morphologically suspicious on breast MRI, quantitative MRI features show little value in identifying those with malignant etiology.

Assessment of axillary lymph nodes in patients with breast cancer with diffusion-weighted MR imaging in combination with routine and dynamic contrast MR imaging

PURPOSE

To assess axillary lymph nodes in patients with breast cancer with diffusion-weighted MR imaging in combination with routine and dynamic contrast MR imaging.

MATERIALS AND METHODS

Prospective study was conducted on 65 enlarged axillary lymph nodes in 34 consecutive female patients (28-64 years: mean 51 years) with breast cancer. They underwent T2-weighted, dynamic contrast-enhanced and diffusion-weighted MR imaging of the breast and axilla using a single-shot echo-planar imaging with a b factor of 0500 and 1000 s/mm². Morphologic and quantitative parameters included ADC value of the axillary lymph node which was calculated and correlated with surgical findings.

RESULTS

The mean ADC value of metastatic axillary lymph nodes was 1.08 ± 0.21 × 10⁻³ mm²/s and of benign lymph nodes was 1.58 ± 0.14 × 10⁻³ mm²s. There was statistically difference in mean ADC values between metastatic and of benign axillary lymph nodes (P = 0.001). Metastatic nodes were associated with low ADC ≤ 1.3 (OR = 8.0), short axis/long axis (TS/LS) > 0.6 (OR = 7.0) and absent hilum (OR = 6.21). When ADC of 1.3 × 10⁻³ mm²/s was used as a threshold value for differentiating metastatic from benign axillary lymph nodes, the best result was obtained with an accuracy of 95.6%, sensitivity of 93%, specificity of 100%, positive predictive value of 100 %, negative predictive value of 87.5 % and area under the curve of 0.974. Multivariate model involving combined ADC value and TS/LS improved the diagnostic performance of MR imaging with AUC of 1.00.

CONCLUSION

We concluded that combination of diffusion-weighted MR imaging with morphological and dynamic MR imaging findings helps for differentiation of metastatic from benign axillary lymph nodes.

Axillary lymph nodes in breast cancer patients: sonographic evaluation

Axillary staging of patients with early-stage breast cancer is essential in the treatment planning. Currently such staging is intraoperatively performed, but there is a tendency to seek a preoperative and less invasive technique to detect lymph node metastasis. Ultrasonography is widely utilized for this purpose, many times in association with fine-needle aspiration biopsy or core needle biopsy. However, the sonographic criteria for determining malignancy in axillary lymph nodes do not present significant predictive values, producing discrepant results in studies evaluating the sensitivity and specificity of this method. The present study was aimed at reviewing the literature approaching the utilization of ultrasonography in the axillary staging as well as the main morphological features of metastatic lymph nodes.

The role of general nuclear medicine in breast cancer

The rising incidence of breast cancer worldwide has prompted many improvements to current care. Routine nuclear medicine is a major contributor to a full gamut of clinical studies such as early lesion detection and stratification; guiding, monitoring, and predicting response to therapy; and monitoring progression, recurrence or metastases. Developments in instrumentation such as the high-resolution dedicated breast device coupled with the diagnostic versatility of conventional cameras have reinserted nuclear medicine as a valuable tool in the broader clinical setting. This review outlines the role of general nuclear medicine, concluding that targeted radiopharmaceuticals and versatile instrumentation position nuclear medicine as a powerful modality for patients with breast cancer.

Possible Synchronous Lung Metastasis of Breast Mass Detected Using Breast Ultrasonography: A Report of Two Cases

Ultrasonography (US), which is used for the diagnosis of breast cancer and the evaluation of its local metastasis, has proven its worth as a diagnostic method. In breast ultrasonographic examination peripherally localized metastatic lesions at the posterior of the screened breast tissue can also be detected. In this case report, two female patients whose breast ultrasonography showed lumps. Their peripheral lung metastases were screened ultrasonographically, and the patients were diagnosed in a timely manner. Ultrasonographic examination at a patient's first appointment - and especially during routine check-ups after the primary treatment - can allow an early diagnosis of peripherally localized lung metastasis at the posterior of the screened breast tissue and make a vital contribution to the patient's prognosis.

Diagnostic value of breast MRI for predicting metastatic axillary lymph nodes in breast cancer patients: diffusion-weighted MRI and conventional MRI

PURPOSES

To evaluate the diagnostic value of diffusion-weighted MRI (DWI) and combination of conventional MRI and DWI to predict metastatic axillary lymph nodes in breast cancer.

MATERIALS AND METHODS

Two hundred fifty-two breast cancer patients with 253 axillae were included. The morphological parameters on axial T2-weighted images without fat saturation and apparent diffusion coefficient (ADC) values were retrospectively analyzed. An independent t-test/chi-square test and receiver operating characteristics (ROC) curve analysis were used.

RESULTS

On conventional MRI, short and long axis length, maximal cortical thickness, relative T2 value, loss of fatty hilum (p<0.001 for each), and eccentric cortical thickening (p<0.003) were statistically significantly different between the metastatic and nonmetastatic groups. The short axis to long axis ratio was not a statistically significant parameter. The ADC value was significantly different between the 2 groups, with an AUC that was higher than that of conventional MR parameters (AUC, 0.815; threshold, ≤0.986×10-3 mm(2)/sec; sensitivity, 75.8%; specificity, 83.9%). Using the adopted thresholds for each parameter, a total number of findings suggesting malignancy of 4 or higher was determined as the threshold, with high specificity (90.1%).

CONCLUSION

Using conventional MRI and DWI, we can evaluate the axilla in breast cancer with high specificity.

Real-time ultrasound and freehand-SPECT. Experiences with sentinel lymph node mapping

Aim of this work is to report first experiences of the feasibility and applicability of a hybrid freehandSPECT/ultrasound (fh-SPECT/US) imaging concept, with regard to SLN imaging, in patients with breast cancer and malignant melanoma.

PATIENTS, METHODS

18 patients with breast cancer or malignant melanoma received standard SLN scintigraphy. Following this, fh-SPECT using declipse®SPECT (SurgicEye, Munich, Germany) was performed, a handheld-gamma camera-based method to visualize activity distribution within a region of interest as a cross-sectional data set. These data were transferred to an ultrasound device and sensor-navigated ultrasound was performed combining fh-SPECT data with ultrasound images, displaying superimposed images. Quality of fh-SPECT and co-registration accuracy was assigned to one of four categories and occurrence of artefacts was assessed.

RESULTS

In 4/18 examinations, there was a no deviation regarding co-registration of both data sets. For 9/18 patients, there was a deviation of <1 cm (mean 0.7±0.3 cm, range 0.3-1.0 cm). For 3/18 patients, a deviation >1 cm was present (mean 1.7±0.3 cm, range 1.5-2.0 cm). In 2/18 examinations no lymph node was found in the region of highest activity. Fh-SPECT reconstruction artifacts occurred in 6/18 examinations.

CONCLUSION

The fusion imaging concept combining SLN information with ultrasound images presented here proves to be feasible and technically successful. However, significant technical limitations were shown in fh-SPECT quality and fusion precision. Subject to technical optimisation of SPECT quality and co-registration, a meaningful contribution to the preoperative planning of lymph node therapy is imaginable. Thus, fundamentally a preoperative histological examination by fh-SPECT/US-guided biopsy is possible.

Evaluation of the potential for lymph node metastasis using CRP 1846C>T genetic polymorphism in invasive breast cancer

Lymph node status is a key indicator of the best approach to treatment of invasive breast cancer. However, the accuracy with which lymph node metastasis is diagnosed is not currently satisfactory. New and more reliable methods that enable one to know who has a greater potential for lymph node metastasis would be highly desirable. We previously reported that lymph node involvement in esophageal and lung cancer may have a genetic component: C-reactive protein (CRP) 1846C>T genetic polymorphism. Here we examined the diagnostic value of CRP 1846C>T polymorphism for assessing the risk of lymph node metastasis in cases of invasive breast cancer. The study participants were 185 women with invasive breast cancer who underwent curative surgery with lymph node dissection. Using DNA from blood samples and polymerase chain reaction-restriction fragment length polymorphism, the utility of CRP genetic 1846C>T polymorphism (rs1205) for assessing the risk of lymph node metastasis was evaluated. Fifty-two (28 %) patients had lymph node metastasis. After the patients were divided into two groups based on their CRP 1846 genotypes (C/C+C/T and T/T), the clinical characteristics did not differ between the groups, but there was a significantly greater incidence of lymph node metastasis among patients in the T/T group. Moreover, the odds ratio for lymph node involvement in patients carrying the 1846 T/T genotype was more than 2.2 in multivariate logistic regression models. CRP genetic polymorphism may be a novel predictor of the risk of lymph node metastasis in invasive breast cancer.

Breast magnetic resonance imaging technique at 1.5 T and 3 T: requirements for quality imaging and American College of Radiology accreditation

Although there are multiple variations in acquisition protocols for breast magnetic resonance (MR) imaging, there is agreement that components of high-quality technique include a bilateral acquisition obtained with a dedicated breast coil. Further, key pulse sequences should be included and spatial and temporal resolution should be sufficiently high to assess lesion morphology and kinetics. Artifacts must be recognized and avoided. The American College of Radiology Breast MRI Accreditation Program requirements provide minimum standards to guide facilities in technique. MR imaging at 3 T is increasingly available and offers signal-to-noise ratio advantages over 1.5 T but also some technical challenges.

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

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.

Preoperative axillary imaging with percutaneous lymph node biopsy is valuable in the contemporary management of patients with breast cancer

BACKGROUND

ACOSOG Z11 and other studies showing little benefit to axillary dissection (ALND) for early-stage breast cancers with limited nodal disease have led to questioning the value of preoperative axillary imaging ± ultrasound-guided needle biopsy (USNB). Data are lacking on the value of this approach in identifying cases that fall outside Z11 guidelines.

METHODS

We studied 988 consecutive patients with invasive breast cancers who underwent operation including axillary surgery in 2010-2011.

RESULTS

Preoperative axillary ultrasonography (AUS) was performed in 92% and breast/axillary magnetic resonance imaging (MRI) in 51%; 82 (33.5%) of 245 patients with suspicious lymph nodes (LN) were USNB-positive. Regarding nodal status, AUS, MRI, and USNB had negative and positive predictive values of 78%, 76%, 70% and 54%, 58%, 100%, respectively. AUS/MRI visualization of one versus multiple abnormal LNs visualized predicted >2LN+ on final pathology (13.5%/15.1% % vs 30.8%/32.6%, P < .009). Among USNB-LN+ T1/T2 patients, 51.6% had 1-2 LN+ while 60% with multiple and 31% with one AUS-abnormal LN(s) had > 2LN+, P = .001.

CONCLUSION

In our contemporary series, preoperative AUS±USNB streamlined surgical care for 29% of node-positive patients. Two-thirds of T1/T2 USNB-LN+ patients with multiple AUS-suspicious LNs had >2LN+, suggesting they should undergo ALND without SLNB. AUS±USNB helps identify node-positive breast cancer patients who fall outside Z11 guidelines.