DOI: http://dx.doi.org/10.18203/2349-2902.isj20213991

Evaluation of the combined role of axillary ultrasound with fine-needle aspiration cytology and sentinel lymph node biopsy in detecting axillary metastasis in clinically N0 axilla at tertiary care center Kerala

Nitinkumar D. Chaudhary, Dhaval Chaudhari

Abstract


Background: Sentinel lymph node biopsy (SLNB) is the gold standard for histopathological staging of early breast cancer. Combination of axillary ultrasound with fine-needle aspiration cytology (Ax US with FNAC) of suspicious lymph nodes, specificity for diagnosis of metastatic lymph nodes can be increased.

Methods: This prospective study was done among 205 cases with clinically N0 axilla visited at surgical oncology department at Amrita institute of medical sciences from January 2014 to February 2017. Exclusion criteria was patients with locally advanced breast cancer, previous axillary surgery, prior breast irradiation, proven distant metastasis, inflammatory breast cancer and neo-adjuvant chemotherapy. All patients were subjected to ultrasound of breast and axilla during preoperative evaluation. Suspicious looking nodes were subjected to image guided FNAC. Benign appearing nodes or a negative FNAC, a SLNB procedure with intra-operative frozen section sentinel node (FS SN) was performed at the time of surgery.

Results: Present study found sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of Ax US was 62.9%, 84.4%, 67.7%, 81.4% and 77.1% respectively. Sensitivity, specificity, PPV, NPV and accuracy of Ax US with FNAC was 90.0%, 100.0%, 100.0%, 83.3% and 93.3% respectively. Sensitivity, specificity, PPV, NPV and accuracy of SLNB with FS SN was 64.5%, 97.5%, 87.0%, 91.5% and 90.8% respectively.

Conclusions: US guided fine-needle aspiration biopsy (FNAB) has highest specificity and sensitivity. Combining Ax US±FNAC and intra-operative FS SN in the detecting axillary metastasis very much decrease the chance of false results. The results of sonography would allow patients with sonographically positive axillae to be directed to axillary lymph node dissection (ALND). The remaining patients would be candidates for SN biopsy.

 


Keywords


Ax US, Axillary lymph node, FNAC, Metastasis, SLNB

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References


Cianfrocca M, Goldstein LJ. Prognostic and predictive factors in early-stage breast cancer. Oncologist. 2004;9(6):606-16.

Fisher ER, Anderson S, Redmond C, Fisher B. Pathologic findings from the National Surgical Adjuvant Breast Project protocol B-06.10-year pathologic and clinical prognostic discriminants. Cancer. 1993;71(8):2507-14.

Swinson C, Ravichandran D, Nayagam M, Allen S. Ultrasound and fie needle aspiration cytology of the axilla in the pre operative identification of axillary nodal involvement in breast cancer. Eur J Surg Oncol. 2009;35:1152-7.

Giuliano AE, Hunt KK, Ballman KV, Beitsch PD, Whitworth PW, Blumencranz PW et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: A randomized clinical trial. JAMA. 2011;305:569 75.

Boland MR, Prichard RS, Daskalova I, Lowery AJ, Evoy D, Geraghty J et al. Axillary nodal burden in primary breast cancer patients with positive pre operative ultrasound guided fie needle aspiration cytology: Management in the era of ACOSOG Z011. Eur J Surg Oncol. 2015;41:559 65.

Moorman AM, Bourez RL, De Leeuw DM, Kouwenhoven EA. Pre-operative ultrasonographic evaluation of axillary lymph nodes in breast cancer patients: For which group still of additional value and in which group cause for special attention? Ultrasound Med Biol. 2015;41:2842-8.

Bedi DG, Krishnamurthy R, Krishnamurthy S, Edeiken BS, LePetross H, Fornage BD et al. Cortical morphologic features of axillary lymph nodes as a predictor of metastasis in breast cancer: in vitro sonographic study. Am J Roentgenol. 2008;191(3):646-52.

Alvarez S, Anorbe E, Alcorta P, Lopez F, Alonso I, Cortes J. Role of sonography in the diagnosis of axillary lymph node metastases in breast cancer: a systematic review. Am J Roentgenol. 2006;186(5):1342-8.

Abe H, Schmidt RA, Kulkarni K, Sennett CA, Mueller JS, Newstead GM. Axillary lymph nodes suspicious for breast cancer metastasis: sampling with US-guided 14-gauge core-needle biopsy-clinical experience in 100 patients. Radiology. 2009;250(1):41-9.

Rattay T, Muttalib M, Khalifa E, Duncan A, Parker SJ. Clinical utility of routine pre-operative axillary ultrasound and fine needle aspiration cytology in patient selection for sentinel lymph node biopsy. Breast. 2012;21(2):210-14.

Lee MC, Eatrides J, Chau A, Han G, Kiuk JV, Khakpour N et al. Consequences of axillary ultrasound in patients with T2 or greater invasive breast cancers. Ann Surg Oncol. 2011;18(1):72-7.

Fernandez AG, Fraile M, Gimenez N, Rene A, Torras M, Canales L et al. Use of axillary ultrasound, ultrasound-fine needle aspiration biopsy and magnetic resonance imaging in the preoperative triage of breast cancer patients considered for sentinel node biopsy. Ultrasound Med Biol. 2011;37(1):16-22.

Park SH, Kim MJ, Park BW, Moon HJ, Kwak JY, Kim EK. Impact of preoperative ultrasonography and fine-needle aspiration of axillary lymph nodes on surgical management of primary breast cancer. Ann Surg Oncol. 2011;18(3):738-44.

Lee B, Lim AK, Krell J, Lewis JS, Stebbing J. The Efficacy of Axillary Ultrasound in the Detection of Nodal Metastasis in Breast Cancer. Am J Roentgenol. 2013;200:W314-20.

Hu X, Zhou X, Yang H, Wei W, Jiang Y, Liu J. Axillary ultrasound and fie needle aspiration biopsy in the preoperative diagnosis of axillary metastases in early stage breast cancer. Oncol letters. 2016;15:8477-83.

Goel G, Janaki PD, Smitha NV, Anupama R, Sundaram PS, Nataraj YS et al. Role of Axillary Ultrasound, Fine Needle Aspiration Cytology and Sentinel Lymph Node Biopsy in clinically N0 Breast Cancer. Indian J Surg Oncol. 2016;7(4):407-12.

Mainiero MB, Cinell CM. Axillary Ultrasound and Fine-Needle Aspiration in the Preoperative Evaluation of the Breast Cancer Patient: An Algorithm Based on Tumor Siz and Lymph Node Appearance. Am J Roentgenol. 2010;195:1261-7.

Kuenen Boumeester V, Menke Pluymers M, De Kanter AY, Obdeijn IM, Urich D, Van Der Kwast TH. Ultrasound guided fine needle aspiration cytology of axillary lymph nodes in breast cancer patients. A preoperative staging procedure. Eur J Cancer. 2003;39:170-4.

Krishnamurthy S, Sneige N, Bedi DG, Edieken BS, Fornage BD, Kuerer HM et al. Role of ultrasound guided fie needle aspiration of indeterminate and suspicious axillary lymph nodes in the initial staging of breast carcinoma. Cancer. 2002;95:982 8.

Davis JT, Brill YM, Simmons S, Sachleben BC, Cibull ML, McGrath P et al. Ultrasound-guided fine-needle aspiration of clinically negative lymph nodes vs. sentinel node mapping in patients at high risk for axillary metastasis. Ann Surg Oncol. 2006;13:1545-52.

Leenders MWH, Broeders M, Croese C. Langenhorst BL, Meijer S, Schreurs WH et al. Ultrasound and fine needle aspiration cytology of axillary lymph nodes in breast cancer. To do or not to do? Breast. 2012;21(4):578-3.