Pre-operative axillary staging: should core biopsy be preferred to fine needle aspiration cytology?

Raghavan Vidya,Bernadette Bickley,Fahad Mujtaba Iqbal

doi:10.3332/ecancer.2017.724

Abstract

ObjectiveTo determine the diagnostic accuracy of ultrasound guided fine needle aspiration (FNA) cytology and core needle biopsy (CNB) of axillary lymph nodes pre-operatively in newly diagnosed operable primary breast cancer.MethodsAn observational study for all patients who underwent pre-operative FNA cytology or CNB during September 2013–August 2014 was conducted at our institution (County Hospital, Stafford, UK). The accuracy of pre-operative axillary staging was compared to the post-operative histology. For this sensitivity, specificity, positive predictive value (PPV) and negative predictive values (NPV) were calculated.ResultsA total of 81 consecutive patients were evaluated by axillary ultrasound. Patients identified with potentially abnormal axillary lymph nodes underwent definitive surgery. Seven patients had positive cytology/histology who did not undergo definitive surgery and were excluded (N = 74) from the study. CNB had a sensitivity of 100% versus 72% (p = 0.006) for FNA cytology. Both had 100% specificity and PPV. The NPV of CNB was 100% versus 72% for FNA cytology. Among 35% of patients that underwent FNA cytology required repeat procedure versus 2.6% of patients who underwent CNB. 0/38 patients that had CNB required a second operation while 7/43 patients with negative FNA cytology had positive lymph nodes identified at sentinel lymph node biopsy (SLNB) requiring surgical re-intervention with axillary node clearance.ConclusionCNB was superior to FNA cytology when interrogating the axilla. We recommend CNB to be adopted routinely in pre-operative axillary staging to reduce surgical re-intervention.

Highlights

Lymph node status is one of the most significant prognostic factors for patients with breast cancer [1]
The results are shown in Figure 1: seven patients had positive cytology/histology that did not undergo definitive surgery and were excluded from the analysis (N = 74)
True positives (TP) were cases with evidence of metastatic disease at core needle biopsy (CNB) with metastatic deposits proven at axillary lymph node clearance (Figure 1, n = 27)

Summary

Introduction

Lymph node status is one of the most significant prognostic factors for patients with breast cancer [1]. Axillary lymph node clearance negatively affects patient quality of life (QoL) with significant morbidity [3]. In order to eliminate unnecessary axillary lymph node clearance, preoperative axillary staging using ultrasound (US) is routinely performed in all newly diagnosed breast cancer patients with reported specificities of 100% [4]. Identification of metastatic spread to the lymph nodes prior to surgery using US-guided fine needle aspiration (FNA) cytology or core needle biopsy (CNB) is of great importance for accurate staging and for reducing the need for SLNB [5]. The aim of this study was to determine the diagnostic accuracy of US-guided FNA cytology and CNB of axillary lymph node pre-operatively in newly diagnosed operable primary breast cancer

Methods

Results

Discussion

Conclusion