Axillary lymph node dissection in breast cancer patients after sentinel node biopsy<sup/>

The role of diffusion-weighted MR imaging in discrimination between benign and malignant axillary lymph nodes in breast cancer patients

Background

Noninvasive preoperative evaluation of axillary lymph nodes proved to have a significant role not only on the protocol of treatment of breast cancer but also impact the whole life of the patient. Complications of lymph node biopsy or axillary clearance increase the need for noninvasive reliable diagnostic tool. We aimed in the current study to evaluate the role of diffusion-weighted magnetic resonance imaging (DW-MRI) and apparent diffusion coefficient (ADC) in discrimination between benign and malignant axillary lymph nodes. We included 44 suspicious lymph nodes from 29 patients. Qualitative DW-MRI was analyzed into restricted or not; ADC maps and cut-off value were calculated, and they were correlated with histopathological results, which were the gold standard tool of the current study.

Results

The cut-off value of ADC-differentiated between malignant and benign lymph nodes was 0.89 × 10−3 mm2/s. The statistical indices including the sensitivity, specificity, PPV, NPV and accuracy were 89.66%, 86.67%, 93.9, 81.2% and 87.8%, respectively, with P value < 0.001, while DW-MRI results were classified into restricted or not restricted with qualitative statistical indices of 96.6%, 80%, 90.3%, 92.3% and 90.9% for sensitivity, specificity, PPV, NPV and accuracy, respectively, with P value < 0.001.

Conclusion

DW-MRI and ADC both have significant role in discrimination between benign and malignant axillary lymph nodes increasing the accuracy of MRI examination in breast cancer patients.

18F-Alfatide II for the evaluation of axillary lymph nodes in breast cancer patients: comparison with 18F-FDG

PURPOSE

¹⁸F-Alfatide II has been translated into clinical use and been proven to have good performance in identifying breast cancer. In this study, we investigated ¹⁸F-Alfatide II for evaluation of axillary lymph nodes (ALN) in breast cancer patients and compared the performance with ¹⁸F-FDG.

METHODS

A total of 44 female patients with clinically suspected breast cancer were enrolled and underwent ¹⁸F-Alfatide II and ¹⁸F-FDG PET/CT within a week. Tracer uptakes in ALN were evaluated by visual analysis, semi-quantitative analysis with maximum standardized uptake value (SUV_max), mean standardized uptake value (SUV_mean), and SUV_max ratio of target/non-target (T/NT).

RESULTS

Among 44 patients, 37 patients were pathologically diagnosed with breast cancer with metastatic (17 cases) or non-metastatic (20 cases) ALN. The sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of visual analysis were 70.6%, 90%, 81.1%, 85.7%, and 78.3% for ¹⁸F-Alfatide II, 64.7%, 90%, 78.4%, 84.6%, and 75% for ¹⁸F-FDG, respectively. By combining ¹⁸F-Alfatide II and ¹⁸F-FDG, the sensitivity significantly increased to 82.4%, the specificity was 85%, the accuracy increased to 83.8%, the PPV was 82.4%, and the NPV significantly increased to 85.0%. Three cases of luminal B subtype were false negative for both ¹⁸F-Alfatide II and ¹⁸F-FDG. The other 2 false negative cases of ¹⁸F-Alfatide II were triple-negative subtype and 3 false negative cases of ¹⁸F-FDG were luminal B subtype too. The AUCs of three semi-quantitative parameters (SUV_max, SUV_mean, T/NT) for ¹⁸F-Alfatide II were between 0.8 and 0.9, whereas those for ¹⁸F-FDG were more than 0.9. ¹⁸F-Alfatide II T/NT had the highest Youden index (76.5%), specificity (100%), accuracy (89.2%), and PPV (100%) among these semi-quantitative parameters. ¹⁸F-Alfatide II uptake as well as ¹⁸F-FDG uptake in metastatic axillary lymph nodes (MALN) was significantly higher than that in benign axillary lymph nodes (BALN). Both ¹⁸F-Alfatide II and ¹⁸F-FDG did not show difference in primary tumor uptake irrespective of ALN status.

CONCLUSION

¹⁸F-Alfatide II can be used in breast cancer patients to detect metastatic ALN, however, like ¹⁸F-FDG, with high specificity but relatively low sensitivity. The combination of ¹⁸F-Alfatide II and ¹⁸F-FDG can significantly improve sensitivity and NPV. ¹⁸F-Alfatide II T/NT may serve as the most important semi-quantitative parameter to evaluate ALN.

Omission of sentinel node biopsy for breast cancer: Historical context and future perspectives on a modern controversy

For older patients with clinically lymph node-negative breast cancer who have estrogen receptor-positive tumors and are treated with tamoxifen, randomized trials comparing axillary lymph node dissection (ALND) versus no ALND show that the omission of ALND improves patient quality of life and has no adverse effects on mortality. These results have served to justify sentinel node biopsy (SNB) omission in selected older patients with breast cancer. More recently, clinical trials were launched to assess SNB omission in younger patients, with recurrence and survival as the primary outcomes of interest. Three important considerations serve as the basis for these ongoing trials. First, it is assumed that SNB omission will improve patient quality of life, although, to date, there is no level I evidence to support this assumption. Second, axillary surgery has never been shown to reduce breast cancer mortality, but it does reduce the risk of axillary recurrences, although adjuvant systemic therapy and radiotherapy also reduce these recurrence risks. Finally, nodal status is losing importance as a guide for adjuvant systemic therapy decision making because these decisions are now increasingly predicated on tumor biomarkers and gene profiling, but it is gaining importance for adjuvant radiotherapy decision making. Because quality-of-life considerations are the primary motivation for abandoning SNB, there is a need for randomized trials comparing SNB versus no SNB/no axillary surgery, with quality of life as the primary end point (level I evidence). Moreover, suitable alternatives to guide adjuvant radiotherapy decision making will require validation before SNB omission can be justified for patients of all ages who have clinically node-negative breast cancer. LAY SUMMARY: In this review article, the authors provide a brief historical overview of the role of axillary surgery in breast cancer management and discuss additional studies and ramifications that should be considered before abandoning the sentinel node biopsy (SNB) procedure. Specifically, there is a need for level I evidence demonstrating that omission of the SNB procedure will improve patient quality of life and a need to validate suitable alternatives to SNB as a guide for adjuvant radiotherapy decision making.

Is Axillary Sentinel Lymph Node Biopsy Required in Patients Who Undergo Primary Breast Surgery?

Local treatment of the axilla in clinically node-negative (cN0) early breast cancer patients with routine sentinel lymph node biopsy (SLNB) is debated for various reasons: i) pN staging information may not be necessary for the postoperative treatment decision regarding adjuvant systemic therapy in the great majority of patients; ii) the SLNB-positive rate is declining below 20% in specialized breast centers; iii) albeit being a minimally invasive procedure, SLNB causes a significant reduction in quality of life in 23% of patients; and iv) previous randomized trials from the pre-SLNB era did not show a disadvantage for patients without axillary surgery with regard to overall survival. These data support the hypothesis that avoiding axillary treatment in patients with clinically and sonographically unsuspicious lymph nodes seems to be a safe option, although omitting axillary surgery may increase the risk of locoregional recurrence. Currently, the information regarding node-positive status is essential to guide postoperative treatment such as systemic or radiation therapies in a non-negligible minority of patients. Three ongoing prospective European trials (SOUND, INSEMA, BOOG 2013-08) with axillary observation alone versus SLNB in cN0 patients and primary breast-conserving surgery have the objective to evaluate oncologic safety when omitting SLNB.

What Is the Best Management of cN0pN1(sn) Breast Cancer Patients?

Although the majority of breast cancer patients are clinically node-negative (cN0) at diagnosis, 15-20% will have a metastatic sentinel lymph node (SLN, pN1(sn)). While a less radical approach regarding axillary surgery in cN0 patients with a positive SLN biopsy is advocated, the limitations of 5 published trials on axillary management in pN1(sn) are discussed intensely in the literature and support the performance of ongoing validation and extension trials, especially considering the lack of data in the setting of mastectomy. As locoregional radiotherapy has a significant effect on both recurrence and survival, a standardization of locoregional radiotherapy in the situation of SLN biopsy alone in pN1(sn) patients has to be defined in the future, and de-escalation trials should embrace a truly multidisciplinary approach. This is also of utmost importance considering the fact that high-volume nodal disease requires an intensified adjuvant chemotherapy strategy to which patients omitting axillary dissection cannot be stratified. Finally, there is mounting evidence that the therapeutic role of extensive axillary surgery in low-volume nodal disease is negligible, and multidisciplinary and translational efforts must be undertaken to individualize treatment in order to gain a reasonable balance between necessary staging information and unnecessary treatment-related morbidity.

Axillary lymph node metastasis detection by magnetic resonance imaging in patients with breast cancer: A meta-analysis

BACKGROUND

The study was conducted to evaluate the diagnostic performance of magnetic resonance imaging (MRI) for the detection of axillary lymph node metastasis in patients with breast cancer.

METHODS

PubMed, Medline, Web of Science, Cochrane Embase, Chinese Biomedical Literature, and China National Knowledge Infrastructure databases were searched for open published studies relevant to the use of MRI for the detection of axillary lymph node metastasis in breast cancer patients. The pooled diagnostic sensitivity, specificity, and the symmetric receiver operating characteristic (SROC) curve was calculated by combining the individual data extracted from 26 included studies.

RESULTS

The pooled diagnostic sensitivity and specificity of MRI to detect axillary lymph node metastasis in patients with breast cancer were 0.77 (95% confidence interval [CI] 0.75-0.80) and 0.90 (95% CI 0.89-0.91), respectively. The pooled positive and negative likelihood ratios were 7.67 (95% CI 5.09-11.53) and 0.23 (95% CI 0.17-0.32), respectively, by random effect method. The area under the SROC curve was 0.93 for MRI to detect axillary lymph node metastasis in breast cancer patients.

CONCLUSION

With high sensitivity, specificity, and area under the curve, MRI is an effective method to differentiate metastatic axillary lymph node in breast cancer patients, which can provide useful information for surgical procedure selection.