Preoperative ultrasound-guided fine-needle aspiration cytology for axillary staging in breast carcinoma

The accuracy of ultrasound-guided fine-needle aspiration and core needle biopsy in diagnosing axillary lymph nodes in women with breast cancer: a systematic review and meta-analysis

Background

This study evaluates the diagnostic accuracy of ultrasound-guided fine needle aspiration (US-FNA) and core needle biopsy (US-CNB) for detecting axillary lymph nodes in women with breast cancer.

Methods

Eligible studies and pertinent literature resources were identified in Cochrane, PubMed, Embase, CNKI, VIP, and Wanfang databases using subject-specific keywords. Study outcomes were tested for heterogeneity, and meta-analyses were performed to estimate sensitivity, specificity, and diagnostic odds ratios (DORs). The summary receiver operating characteristic (SROC) curve analysis was also performed.

Results

A total of 22 studies involving 3,548 patients were included to evaluate the diagnostic accuracy of US-FNA and 11 studies involving 758 patients were included to evaluate the diagnostic accuracy of US-CNB in identifying axillary lymph nodes in women with breast cancer. The accuracy of US-FNA in identifying suspicious axillary lymph nodes was as follows: overall sensitivity, 79% (95% CI: 73%-84%); global specificity, 96% (95% CI: 92%-98%); overall positive likelihood ratio, 18.55 (95% CI: 10.53-32.69); overall negative likelihood ratio, 0.22 (95% CI: 0.17-0.28); DOR, 71.68 (95% CI: 37.19-138.12); and the area under the SROC curve, 0.94 (95% CI: 0.92-0.96). The accuracy of US-CNB in identifying suspicious axillary lymph nodes was as follows: overall sensitivity, 85% (95% CI: 81%-89%); global specificity, 93% (95% CI: 87%-96%); overall positive likelihood ratio, 11.88 (95% CI: 6.56-21.50); overall negative likelihood ratio, 0.16 (95% CI: 0.12-0.21); overall DOR, 66.83 (95% CI: 33.28-134.21), and the area under SROC curve 0.96 (95% CI: 0.94-0.97).

Conclusions

The results indicate that both US-FNA and US-CNB have high accuracy for suspicious axillary lymph nodes.

Node Positivity Among Sonographically Suspicious but FNA-Negative Axillary Nodes

BACKGROUND

Fine needle aspiration (FNA) of sonographically suspicious axillary lymph nodes is helpful to clinically stage patients and guide consideration of neoadjuvant therapy in breast cancer. However, data are limited for suspicious nodes that are FNA negative. Our goal is to compare the frequency of node positivity between patients with negative axillary ultrasound (AUSneg) versus suspicious AUS with negative FNA (FNAneg).

METHODS

With IRB approval, we identified all clinically node-negative (cN0) patients with invasive breast cancer treated with upfront surgery at our tertiary care center between 2016 and 2021. AUS is routinely performed with FNA of suspicious lymph node(s). We compared clinicopathologic characteristics and nodal positivity rates between AUSneg and FNAneg groups.

RESULTS

A total of 1580 cN0 patients with invasive breast cancer were analyzed, including 1240 AUSneg and 340 FNAneg patients. The FNAneg group was younger (median age 59.7 years versus 63.5 years, p < 0.001) and had higher clinical T (cT) category (29.1% versus 21.7% with cT2-cT4 disease, p = 0.005). Final axillary pathologic node positivity did not differ significantly between the AUSneg and FNAneg groups (16.5% versus 19.1%, p = 0.25). Among FNAneg patients, 58/340 (17.1%) had a clip placed, with retrieval confirmed in 28/58 (48.3%). Of the 28 retrieved clipped nodes, 27 were sentinel nodes. Final pathologic nodal status (pN+%) did not differ between patients in whom retrieval of the clipped node was confirmed versus not confirmed (28.6% versus 16.7%, p = 0.28).

CONCLUSIONS

Both patients with sonographically suspicious node(s) and negative FNA and patients with negative AUS have a similarly low chance of positive nodes. Additionally, routine targeted excision of FNA-negative clipped nodes is not warranted.

Is ultrasound-guided fine needle aspiration biopsy of axillary lymph nodes a viable alternative to sentinel lymph node biopsy?

BACKGROUND

Axillary lymph node (ALN) ultrasound-guided fine needle aspiration biopsy (US-FNAB), a minimally invasive procedure, may be used for the preoperative evaluation of ALN status of breast cancer patients. Despite the relative ease of use and low cost, paucity of comparative studies and variation in the reported sensitivity of FNAB preclude its clinical utility in evaluation of ALNs. This study aims to determine the accuracy of US-FNAB in detecting metastasis in ALN pre-operatively and to assess US-FNAB as a viable alternative to sentinel lymph node (SLN) excision.

METHODS

The 228 consecutive ALN US-FNABs with subsequent histologic follow up performed from 2005 to 2020 in patients with breast carcinoma were retrospectively evaluated. FNAB results were correlated with histologic diagnosis. Sensitivity, specificity, accuracy, and risk of malignancy of FNAB were calculated.

RESULTS

157/228 (69%) FNABs were concordant with histology, 37/228 (16%) discordant. Positive FNAB findings correlated with primary tumor size, grade, number of metastatic lymph nodes and size of metastases. FNAB with negative diagnosis carried a 22% risk of malignancy, atypical 43%, suspicious 80%, and positive a 100% risk of malignancy (100% positive predictive value [PPV]). The sensitivity and specificity were 78% and 95% respectively; accuracy was 77%. SLN biopsy was avoided in all 82 (36%) cases with positive FNAB results.

CONCLUSION

Negative FNAB result does not exclude metastatic carcinoma. With 100% PPV, full ALN dissection and/or neoadjuvant chemotherapy can be safely planned after a positive FNAB result, avoiding SLN biopsy, reducing management costs and shortening time interval to definitive therapy.

Pretherapeutic Imaging for Axillary Staging in Breast Cancer: A Systematic Review and Meta-Analysis of Ultrasound, MRI and FDG PET

BACKGROUND

This systematic review aimed at comparing performances of ultrasonography (US), magnetic resonance imaging (MRI), and fluorodeoxyglucose positron emission tomography (PET) for axillary staging, with a focus on micro- or micrometastases.

METHODS

A search for relevant studies published between January 2002 and March 2018 was conducted in MEDLINE database. Study quality was assessed using the QUality Assessment of Diagnostic Accuracy Studies checklist. Sensitivity and specificity were meta-analyzed using a bivariate random effects approach; Results: Across 62 studies (n = 10,374 patients), sensitivity and specificity to detect metastatic ALN were, respectively, 51% (95% CI: 43-59%) and 100% (95% CI: 99-100%) for US, 83% (95% CI: 72-91%) and 85% (95% CI: 72-92%) for MRI, and 49% (95% CI: 39-59%) and 94% (95% CI: 91-96%) for PET. Interestingly, US detects a significant proportion of macrometastases (false negative rate was 0.28 (0.22, 0.34) for more than 2 metastatic ALN and 0.96 (0.86, 0.99) for micrometastases). In contrast, PET tends to detect a significant proportion of micrometastases (true positive rate = 0.41 (0.29, 0.54)). Data are not available for MRI.

CONCLUSIONS

In comparison with MRI and PET Fluorodeoxyglucose (FDG), US is an effective technique for axillary triage, especially to detect high metastatic burden without upstaging majority of micrometastases.

Diagnostic Accuracy of Fine-Needle Aspiration Cytology and Core-Needle Biopsy in the Assessment of the Axillary Lymph Nodes in Breast Cancer-A Meta-Analysis

BACKGROUND

The present study aims to evaluate the diagnostic accuracy between ultrasonography-guided fine-needle aspiration cytology (US-FNAC) and core needle biopsy (CNB) of axillary lymph nodes (ALNs) in patients with breast cancer through a meta-analysis and a diagnostic test accuracy (DTA) review.

METHODS

The present meta-analysis and DTA review included 67 eligible studies. The diagnostic accuracy of various preoperative assessments, including US-FNAC and CNB, was evaluated for ALNs assessments in patients with breast cancer. In addition, a subgroup analysis based on methods of cytologic preparation was performed. In the DTA review, the sensitivity, specificity, diagnostic odds ratio (OR) and area under the curve (AUC) on the summary receiver operating characteristic (SROC) curve were calculated.

RESULTS

The diagnostic accuracy of the preoperative assessments of ALNs was 0.850 (95% confidence interval (CI) 0.833-0.866) for patients with breast cancer. The diagnostic accuracy of CNB was significantly higher than that of US-FNAC (0.896, 95% CI 0.844-0.932 vs. 0.844, 95% CI 0.825-0.862; p = 0.044 in a meta-regression test). In the subgroup analysis based on cytologic preparation, the diagnosis accuracies were 0.860, 0.861 and 0.859 for the methods of conventional smear, liquid-based preparation and cell block, respectively. In the DTA review, CNB showed higher sensitivity than US-FNAC (0.849 vs. 0.760). However, there was no difference in specificity between US-FNAC and CNB (0.997 vs. 1.000). US-FNAC with liquid-based preparation and CNB showed the highest diagnostic OR and AUC on the SROC, respectively.

CONCLUSION

Both US-FNAC and CNB are useful in preoperative assessments of ALNs in patients with breast cancer. Although the most sensitive test was found to be CNB in this study, there was no difference in specificity between various preoperative evaluations and the application of US-FNAC or CNB may be impacted by various factors.

Correlation of Ultrasound Findings and Fine-Needle Aspiration Cytology for the Diagnosis of Axillary Lymph Node Metastasis in Patients with Breast Carcinoma

OBJECTIVE

Ultrasound-guided fine-needle aspiration cytology (USG-FNAC) is used for the detection of axillary lymph node (ALN) metastasis in patients with breast carcinoma (BC). US findings have a good diagnostic accuracy with high sensitivity and specificity. The aim of this study is to correlate the detection of ALN metastases on US with FNAC in BC patients.

STUDY DESIGN

In 75 BC patients, over a period of 9 months (January to September 2017), the size, cortical thickness (CT), presence or absence of hilar fat, and length/width ratio of ALN on US were reviewed and correlated with FNAC findings.

RESULTS

The age range was 29-78 (mean 52) years. There were 38 patients with a single ALN and 37 with multiple ALNs. ALNs with a maximum length of > 2.5 cm were malignant in 100% of cases while those ≥1.5 cm were malignant in 80.4%. ALNs with a CT of > 3 mm had metastasis in 78.1% cases. ALNs with absent hilar fat showed tumour in 87.5% cases. A length/width ratio of < 2 showed a metastatic tumour in 66.7% of aspirates.

CONCLUSION

An association was seen between metastatic carcinoma on FNAC and axillary US features of a maximum length of ≥1.5 cm, the absence of hilar fat, and a CT of > 3 mm (p < 0.05).

Synergy of cytological methods in the pathological staging of breast cancer: Axillary fine-needle aspiration and intraoperative scrape cytology of the sentinel lymph node

BACKGROUND

Sentinel lymph node biopsy (SLNB) has become the standard in breast cancer staging, but it is costly and time-consuming. Fine-needle aspiration cytology (FNAC) under ultrasonographic guidance identifies patients who need axillary lymph-node dissection (ALND), thus reducing costs. As an alternative to frozen sections (FS), intraoperative scrape cytology (ISC) for SLNB is an inexpensive, rapid, accurate and safe technique. We evaluated the synergy of FNAC and SLNB in determining the axillary burden and the performance of the ISC method.

METHODS

Over a nine-year period, 894 breast cancer patients were analyzed. Of these, 439 patients with echographic suspicious nodes underwent preoperative FNAC; negative axillary ultrasounds or FNACs resulted in 606 intraoperative SLNB, performed using the ISC technique. The results were compared with histological diagnosis, and sensitivity, specificity, predictive values and accuracy were calculated.

RESULTS

Of the 439 FNACs, 121 were positive and underwent immediate ALND, and 242 negative patients underwent intraoperative SLNB (69% sensitivity, 99% specificity). Positive cases often had multiple nodal involvement (55% pN2-3). Of the 606 SLNB-ISC smears, 510 were true negative; 65 true positives allowed for one-step ALND (71% sensitivity, 99% specificity).

CONCLUSION

Preoperative positive axillary FNAC predicts a higher disease burden and determines the avoidance of SLNB for patients eligible for immediate ALND. ISC instead of FS is a safe and sensitive technique to identify metastases, indicating completion of ALND.

PARTIALLY PRESENTED AT

Joint International Oncology (sentinel node & cancer metastasis) Congress, May 27-29, 2013, San Francisco, California, USA 18 ° International Congress of Cytology (ICC 2013-1161), May 26-30, 2013, Paris, France Convegno Nazionale GISMa - Finalborgo (Savona), Italy,19-20 maggio 2016.

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

The efficacy of axillary lymph node dissection (ALND) following sentinel lymph node biopsy (SLNB) has been questioned. The present study was performed to determine the sensitivity, specificity and accuracy of axillary ultrasound (US) and fine needle aspiration biopsy (FNAB) in the diagnosis of axillary metastases in patients with early breast cancer. A total of 214 patients with stage I and II breast cancer between June 2015 and January 2017 were included. All of the patients received axillary US as a primary investigation for lymph node status. US-guided FNAB was performed on suspicious lymph nodes. Those with non-suspicious and FNAB-negative axillary nodes proceeded to SLNB at the time of primary breast surgery. ALND was performed when the result of the US-guided FNAB was positive. The results of US and cytology were compared to histopathological results to determine their sensitivity, specificity, positive and negative predictive value and accuracy. A total of 76 out of 214 patients (35.5%) had axillary lymph node metastases at final histology. The sensitivity and specificity of axillary US alone were 59.2% (45/76) and 78.3% (108/138), respectively. Axillary US with FNAB identified 32 patients with positive lymph node metastases, and increased the sensitivity and specificity to 71.1% (32/45) and 100.0% (30/30). Combined with FNAB, the positive and negative predictive values were 100.0% (32/32) and 69.8% (30/43), respectively. Axillary US-alone or combined US/FNAB had a high accuracy rate and a satisfactory result as they cost less and it is easy to assess the status of axillary lymph nodes. Thus, axillary US with FNAB may avoid unnecessary SLNB in a significant number of patients.

Comparative study between ultrasound-guided fine needle aspiration cytology of axillary lymph nodes and sentinel lymph node histopathology in early-stage breast cancer

The replacement of sentinel lymph node biopsy (SNB) by ultrasound-guided fine-needle aspiration (US-guided FNA) cytology of axillary lymph nodes is controversial, despite the simplicity and reduced cost of the latter. In the present study, US-guided FNA was performed in 27 patients with early-stage breast cancer for comparison with SNB. Data were analyzed by calculation of sample proportions. Tumor subtypes included invasive ductal carcinoma (85%), invasive lobular carcinoma (7%), and tubular and metaplastic carcinoma (4%). FNA had a sensitivity of 45%, specificity of 100%, positive predictive value of 100% and a negative predictive value of 73%. Axillary lymph node cytology obtained by US guided-FNA in patients with breast cancer had a specificity similar to that of sentinel lymph node histopathology in the presence of axillary node metastases. However, when lymph node cytology is negative, it does not exclude the existence of metastatic implants, due to its low sensitivity in comparison to sentinel lymph node histopathology.

Preoperative Evaluation of Axillary Lymph Nodes in Malignant Breast Lesions with Ultrasonography and Histopathologic Correlation

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.

Predictive value of fine needle aspiration biopsy of axillary lymph nodes in preoperative breast cancer staging

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.

Do All Women With Abnormal Sonographic Axillary Lymph Nodes Need a Biopsy?

PURPOSE

With the increased use of breast ultrasound for different indications, sonographically abnormal axillary lymph nodes are not a rare finding. We examined clinical and imaging characteristics in correlation with pathological reports of the sonographic guided biopsies to assess the yield of needle biopsy of these nodes.

METHODS

Clinical, imaging and pathology data were collected for 171 consecutive patients who underwent sonographic guided needle biopsy of an abnormal lymph node between 2008 and 2013. Malignancy rates were examined for different clinical settings: palpable axillary mass, previous history of breast cancer, findings suggestive of a systemic disease, and those with a breast finding of low suspicion or an incidental abnormal axillary lymph node. Patients with newly diagnosed breast cancer were excluded.

RESULTS

Twelve patients (7%) were found to have a malignancy on their axillary lymph node biopsy. Malignancy rates increased with age, and varied with clinical presentation: Axillary mass (8, 26%); history of breast cancer (2, 11%); systemic disease (0%) and breast finding of low suspicion or incidental abnormal lymph node on screening (1, 1%). Low rates of malignancy were found when the cortex was <6 mm (1, 0.8%). The most important imaging finding associated with malignancy was lack of a preserved hilum, in which case almost a third (10, 29%) of the biopsies were malignant. Only 1 of 89 women with a breast finding of low suspicion or an incidental abnormal axillary lymph node was found to have malignancy. In this case the lymph node had no hilum.

CONCLUSIONS

In women without breast cancer, a highly suspicious breast mass or an axillary mass, more stringent criteria should be used when evaluating an abnormal axillary lymph node on sonography, as the malignancy rates are very low (1%).

Determinants of False-Negative Fine-Needle Aspirates of Axillary Lymph Nodes in Women with Breast Cancer: Lymph Node Size, Cortical Thickness and Hilar Fat Retention

OBJECTIVE

Ultrasound-guided fine-needle aspiration (UG-FNA) is utilized to sample axillary lymph nodes in breast cancer patients. Diagnostic sensitivity is good but few data exist regarding the causes of false-negative results.

STUDY DESIGN

Fifty-four UG-FNAs of sentinel lymph nodes with histologic follow-up were identified. Gross and radiographic lymph node size, the percentage replaced by carcinoma and the cortical thickness were correlated with false-negative rates.

RESULTS

Thirty-seven aspirates were negative, 5 of these being false-negative (9%). True-positive lymph nodes averaged 1.3 cm in dimension while false-negatives averaged 0.92 cm. Percentage involvement by carcinoma for true-positive FNAs averaged 69% while false-negatives averaged 25%. Cortical thickness averaged 5.6 mm in true-positive FNAs but 2.9 mm in false-negatives.

CONCLUSION

A relationship exists between lymph node size and the likelihood of a false-negative FNA. Lymph nodes <1.2 cm have a higher incidence of false-negative results. Lymph nodes with <30% involvement demonstrated a higher percentage of false-negatives than those with >30% replacement. Sentinel lymph nodes <1 cm appear to be relatively poor candidates for UG-FNA. Lymph nodes with a cortical thickness <3.5 mm are more often associated with a false-negative result than nodes with a thicker cortex.

Staging the axilla in women with breast cancer: the utility of preoperative ultrasound-guided needle biopsy

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.

A new clinical cut-off of cytokeratin 19 mRNA copy number in sentinel lymph node better identifies patients eligible for axillary lymph node dissection in breast cancer

AIMS

Cytokeratin 19 (CK19) mRNA copy number predicts the probability of tumour load in axillary lymph nodes (ALN) and can help in decision-making regarding the axillary dissection. The purpose of this study was to define a new cut-off of CK19 mRNA copy number using the one-step nucleic acid amplification (OSNA) assay on metastatic sentinel lymph nodes (SLN) in order to identify cases at risk of having one or more positive ALN.

METHODS

1296 SLN from 1080 patients were analysed with the OSNA assay. 194 patients with positive SLN underwent ALN dissection and the mean value of CK19 copy number (320 000) of their SLN was set as initial cut-off. Receiver operative characteristics curve identify a best cut-off of 7700 (sensitivity 78%, specificity 57%). A comparison between our and the traditional cut-off (5000) was performed.

RESULTS

The cut-off of 7700 successfully identifies patients with positive ALN (p=0.001, false- negative cases: 17%). In the range between 5000 and 7700, one patient with positive ALN would not undergo axillary dissection, whereas eight patients with negative ALN would be correctly identified.

CONCLUSIONS

We suggest that the level of CK19 mRNA copy number could be the only parameter to consider in the intraoperative management of the axilla.

Accuracy of individual descriptors and grading of nodal involvement by axillary ultrasound in patients of breast cancer

Background. Four-node sampling is a useful substitute for sentinel node biopsy in low resource settings. USG is being increasingly used as a preoperative tool to evaluate axilla. We conducted this study to assess the accuracy of different descriptors of axillary ultrasound and to formulate a model on grading of axillary involvement. Material and Methods. Thirty-four patients with clinically negative axilla underwent preoperative axillary ultrasound. The suspicious nodes were marked and details of various descriptors were noted. These nodes were sampled during axillary dissection and correlation of ultrasonographic findings with histopathological report was done to calculate accuracy of different descriptors. Based on this, a grading system of axillary lymph nodes involvement was formulated. Results. Based on the presence of various descriptors, five grades of nodal involvement could be defined. The most accurate descriptors to indicate nodal involvement were loss of hilar fat and hypoechoic internal echoes with specificity of 83% and positive predictive value of 92% each. The combination of descriptors of round shape with loss of hilar fat and hypoechoic internal echos had 100% specificity and positive predictive value. Conclusions. Grading of nodal involvement on axillary USG can be useful for selecting the most suspicious nodes for sampling during axillary dissection.

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.

Efficiency of ultrasound and ultrasound-guided fine needle aspiration cytology in preoperative assessment of axillary lymph node metastases in breast cancer

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.

Preoperative staging of the axilla in women with invasive breast cancer

SUMMARY Axillary node status is an important prognostic factor in invasive breast cancer. Axillary lymph node dissection (ALND) was previously the primary management approach; however, sentinel node biopsy (SNB) has largely replaced ALND, which is currently predominantly used to manage SNB-positive patients. Preoperative imaging-based staging of the axilla (with ultrasound, PET or MRI) for the detection of suspicious nodes has been applied to inform and potentially streamline axillary surgical management. Ultrasound with ultrasound-guided needle biopsy is the most accurate imaging-based strategy and has been shown to have clinical utility for preoperative axillary staging. A meta-analysis has reported a median sensitivity of 79.4% and a specificity of 100% for ultrasound-based staging, and estimated that ultrasound-guided needle biopsy triages 55.2% of women with metastatic axillary nodes (or a median of 17.7% of patients) directly to ALND, thereby avoiding unnecessary SNB. Although ultrasound-based staging has had a role in preoperative axillary assessment, it appears likely that this role will be shaped in the future by the ongoing evolution in surgical management of the axilla, particularly in light of recent evidence that challenges the need for ALND in some SNB-positive patients.

Preoperative ultrasound-guided needle biopsy of axillary nodes in invasive breast cancer: meta-analysis of its accuracy and utility in staging the axilla

OBJECTIVE

Systematic evidence synthesis of ultrasound-guided needle biopsy (UNB) of axillary nodes in breast cancer.

SUMMARY BACKGROUND DATA

Women affected by invasive breast cancer undergo initial staging with sentinel node biopsy, generally progressing to axillary node dissection (AND) if metastases are found. Preoperative UNB can potentially identify and triage women with node metastases directly to AND.

METHODS

Review and meta-analysis of studies reporting UNB accuracy: we estimated sensitivity, specificity, and PPV, using bivariate random-effects models and examined the effect of covariates; we calculated UNB utility (effect on axillary surgery).

RESULTS

Thirty-one studies provided 2874 UNB data from 6166 subjects (median proportion with metastatic nodes 47.2%; IQR 39.5%, 61.2%). Modeled estimates for UNB were: sensitivity 79.6% (95% confidence intervals [CI] 74.1-84.2), specificity 98.3% (95%CI 97.2-99.0), PPV 97.1% (95%CI 95.2-98.3); median UNB insufficiency was 4.1% (IQR0%-10.9%). UNB sensitivity increased with increasing ultrasound sensitivity, and was higher in studies performing UNB for "suspicious" than for "visible" nodes. Specificity was higher in studies of consecutive (vs. selected) subjects, in studies reporting ultrasound data, and in more recent studies. Median proportion of women triaged directly to AND (attributed to UNB) was 19.8% (IQR11.6%-28.1%) or 17.7% (IQR11.6%-27.1%) if restricted to clinically node-negative series. Median proportion of women with metastatic axillary nodes potentially triaged to AND was 55.2% (IQR41.8%-68.2%) and was higher (65.6%; IQR48.9%-69.7%) in the subgroup of studies with median tumor size ≥21 mm.

CONCLUSIONS

Preoperative UNB of the axilla is accurate for initial staging of women with invasive breast cancer. Meta-analysis indicates that UNB provides better utility in women with average or higher underlying risk of node metastases.

Axillary fine needle aspiration cytology for pre-operative staging of patients with screen-detected invasive breast carcinoma

Introduction

Fine needle aspiration cytology (FNAC) of radiologically abnormal axillary lymph nodes in patients with breast cancer can identify patients suitable for primary axillary clearance (AC) rather than sentinel node biopsy, enabling surgical axillary staging by a single operation. This study assessed the accuracy of FNAC in predicting positive axillary lymph nodes.

Methods

161 patients with screen-detected invasive carcinoma and who had pre-operative FNAC of a radiologically abnormal axillary lymph node were identified from two screening units, The axillary FNAC reports were correlated with sentinel node biopsy and AC reports, and sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were calculated.

Results

FNAC had a moderate sensitivity (66.3%) and NPV (71.8%), and a high specificity (98.7%) and PPV (98.3%). Most patients (86%) had a single axillary operation. The sensitivity was highest in grade 3 (81.8%) and ductal type (77.8%) tumours. The sensitivity was lower in tumours of special type (34.8%), grade 1 tumours (50%) and those without lymphovascular invasion (LVI) (55.9%). The NPV was highest in pT1 (86.7%) and in grade 1 (84.5%) tumours, and lowest (44%) in tumours with LVI. The PPV was 100% in grade 1 and 3 tumours, stage pT2 and pT3 tumours and those without LVI, and was high (>96%) in all other groups. In lymph-node-positive patients, the mean number of lymph nodes involved was higher in the case of a positive (6.4) than negative FNAC (4.4).

Conclusions

FNAC of ultrasonically abnormal axillary lymph nodes achieved surgical staging by a single operation in most patients with screen-detected invasive breast carcinoma, with moderate sensitivity and high specificity.

[Surgery for invasive breast cancer]

As most solid tumors, surgery is often the first step of the multidisciplinary management for breast cancers. Although mastectomy and axillar lymphadenectomy still have indications, conservative treatment and sentinel node detection are commonly used. Thanks to induction chemotherapy and oncoplastic techniques, surgery is conservative in most cases, even for important tumors without overall survival prejudice. There is no consensus about resection margins status but a limit of 2 to 3 mm seems to be reasonable while oncoplastic surgery allows large resection and good cosmetic outcomes. In this overview, we present the state of the art for breast cancer surgery including conservative and radical treatments, axillar lymphadenectomy and sentinel lymph node detection, margins status, oncoplastic techniques.

Accuracy of lymph nodes cell block preparation according to ultrasound features in preoperative staging of breast cancer

To analyse the correlation between axillary ultrasonography (US), cell block (CBs) preparation, and histological diagnosis of lymph nodes from patients with primary breast cancer with the intention to assess the accuracy of cell block (CB) technique in preoperative staging. We tested a series of 26 patients who underwent axillary cell blocks from ultrasound guided fine-needle aspiration with histologic follow-up (axillary lymph nodes dissection). The specificity of axillary cell block was 100% vs. 14% for axillary ultrasound and the sensitivity was 73% for axillary cell block and 87% for axillary ultrasound. The positive and negative predictive values of cell block were respectively, 100 and 78%. Based on these results, we concluded that CB preparation was a feasible and specific technique to evaluate axillary lymph nodes status of patients with primary invasive breast cancer.

Current applications and future prospects of fine-needle aspiration biopsy of locoregional lymph nodes in the management of breast cancer

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.

Comparison of accuracy of diagnostic modalities for evaluation of breast cancer with review of literature

This study was conducted to confirm which of these modalities [mammography (MG), fine-needle aspiration cytology (FNAC), core-needle biopsy (CNB), or intraoperative touch imprint cytology (IOTIC)] is useful to detect breast cancer and to compare the accuracy of these modalities for the diagnostic setting. One hundred seventy-five, 85, 78, and 25 patients were selected who underwent FNAC, MG, IOTIC, and CNB, respectively. Histopathology was used as a gold standard for comparison of the results of all diagnostic modalities. Twenty-five patients with combinations of three preoperative tests (MG, FNAC, CNB) showed 100% accurate results when compared with histopathology, while the overall accuracy for MG, FNAC, and CNB was 91.7%, 91.5%, and 96%, respectively. Both touch and scrape imprints' sensitivity, specificity, positive predictive value, negative predictive value (NPV), and accuracy were 100% for class V and class II smears, while sensitivity, accuracy, and NPV were 87, 95, and 83% for IOTIC and 94%, 96%, and 89% for IOSC for class III and IV smears. On comparison of the results of all these procedures, the difference was nonspecific (P = 0.2, 0.3, 0.5, 0.55, and 0.6 for MG, FNAC, IOTI, IOSC, and CNB, respectively). Combinations of preoperative tests (MG, FNAC, CNB) were more accurate, reliable, and acceptable when compared with individual diagnostic procedure, but these have their own technical limitations. The accuracy of CNB was much higher than that of MG and FNAC. IOTP and IOSC are simple and cost effective diagnostic tests with better accuracy that can be used as an alternate to frozen section in diagnostic settings and margin assessments.

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

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.

Preoperative Identification of the Sentinel Lymph Node in Breast Cancer

BACKGROUND

Preoperative diagnosis of sentinel lymph node (SLN) metastasis would justify a single axillary operation. We hypothesized that ultrasound-guided core needle biopsy (USGCNB) of a morphologically normal or abnormal lymph node in the anatomic position of the SLN would accomplish this goal.

METHODS

A total of 179 clinically N0 breast cancer patients underwent high-resolution lower axillary ultrasound (US) evaluation with core needle biopsy and microclip placement of a node when feasible. SLN biopsy was performed in 131 patients and the node X-rayed when appropriate. The node was removed surgically, and the one identified and analyzed preoperatively was compared with it clinically, radiologically and/or pathologically.

RESULTS

A node was seen on US in 145 (81%) of 179 patients, and a core needle biopsy was performed in 121 patients. A total of 3.5 +/- 1.38 (mean +/- SD) core samples were obtained per node. Of those node biopsy samples, 55 (45.5%) had metastases. Metastasis size was 14.9 +/- 10.1 mm. Metastases were found in 9 (13.6%) of 66 patients in whom the needle core was negative; in these falsely negative biopsy samples, the node metastases were 8.73 +/- 6.24 mm (P = .120). Eight (33.3%) of 24 nodes that did not undergo biopsy had metastases. Seven (20.6%) of 34 of those not seen on US had SLN metastases. In 47 (78.3%) of 60 patients, the node that underwent core needle biopsy was the SLN found by the surgeon during surgery (P < .001).

CONCLUSIONS

Preoperative identification, core needle biopsy, and documentation of metastasis in the first SLN in breast cancer was achieved by focused lower ipsilateral axillary US. Knowledge of the lymph node status might change the patient's planned surgery.