Axillary Fine Needle Aspiration Cytology Research Articles

Preoperative axillary nodal staging of invasive lobular breast cancer with ultrasound guided fine needle aspiration in patients with suspicious ultrasound findings versus aspiration in all patients – A retrospective single institutional analysis

Introduction– At present, surgical strategies for breast cancer patients with >2 lymph nodes (LN) involved differ from those with no or lower degree of nodal involvement. Preoperative assessment of the axilla is less sensitive in patients with lobular carcinoma (ILC) than patients with other histological tumour types. Materials and methods– A retrospective analysis of axillary staging by palpation, axillary ultrasound (AXUS) and AXUS-guided fine-needle aspiration cytology (FNAC) of 153 patients with ILC diagnosed and operated on between January 2013 and December 2020 was performed. Patients had either sentinel node biopsy or axillary lymph node dissection according to current practice. In period 1, patients had FNAC only when AXUS suggested nodal involvement (n = 106), and in period 2, all ILC patients had axillary FNAC (n = 47). Results– Of the factors associated with >2LNs involvement, logistic regression suggested only AXUS/FNAC based staging as independent variable for all patients. Patients with AXUS-guided FNAC had a significantly higher proportion of true negative and lower proportion of true positive cases in the P2 period (0 vs 55% and 72% vs 11% for >2 LNs involvement, respectively; both p < 0.0001). Conclusions– AXUS-guided FNAC of all ILC patients did not result in improved preoperative identification of patients with >2 metastatic LNs but increased the false-negative rate of the assessment by producing false-negative results in patients who would not have undergone a biopsy due to negative AXUS findings.

Giant fibroadenoma of the breast: a benign breast mass mimicking malignancy

Fibroadenoma is a common benign lesion of the breast that usually occurs in young females. Giant fibroadenoma of the breast is a rare benign pathology, which is defined as fibroadenoma greater than 5 cm in size and/or weighs more than 500 g. It is usually found in adolescent women. A 37-year-old woman undergoing treatment for infertility was referred to the breast clinic with an ulcerating left breast lump that had progressively increased in size. Examination showed a fungating left breast mass that obliterated the nipple-areola complex. Ultrasound showed a large soft tissue mass in the left breast with enlarged left axillary lymph nodes. Computed tomographic (CT) scan showed a 13×17 cm left breast mass. Core biopsy of this mass reported possibility of phyllodes tumor, while axillary fine-needle aspiration cytology (FNAC) showed no evidence of malignancy. Total mastectomy with immediate reconstruction using silicone implant was performed. Final histopathology reported giant fibroadenoma. Most cases on giant fibroadenoma reported in literature are limited to adolescent or young females, however, our patient was relatively old, which makes this a rare case.

Abstract P3-01-13: FNAC: A predictor of final number of involved nodes at axillary clearance

Abstract BACKGROUND: A vital part of pre-operative breast cancer assessment is axillary staging. Fine needle aspiration cytology (FNAC) is performed on clinically or radiologically positive axillary nodes in breast cancer. Our study looks at the sensitivity of performing FNAC in these patients and whether positive FNAC of axillary nodes can predict the final number of diseased nodes on completion axillary clearance (ANC). METHODS: All primary breast cancer patients undergoing FNAC between Oct 2009 to Oct 2011 were identified from electronic computer records. Data was collected on FNAC positivity, whether sentinel lymph node biopsy (SLNB) was performed, total number of nodes harvested at ANC and also the total number of diseased nodes at ANC. Patients who underwent neoadjuvant chemotherapy after a positive FNAC were analysed separately. RESULTS: Of the 230 patients who underwent FNAC, 130 were positive (56.5%). Of those who had a negative FNAC, 32% had a positive SLNB. We compared the ANC results of those who were FNAC positive (Group 1) with those who were FNAC negative but SLNB positive (Group 2). There was no significant difference in the mean number of harvested nodes at ANC between the two groups (mean= 17, p=0.14 on t-test). There was a significant difference in the number of diseased nodes in group 1 (mean = 7 nodes) compared with group 2 (mean = 3 nodes). In group 1, 56% of patients had 4 ≥ diseased nodes compared with 8.5% of patients in group 2. Neoadjuvant chemotherapy was given to 28 patients with a positive FNA. In this cohort, the mean number of positive nodes at axillary clearance was 2 and 10 % of patients had 4≥ diseased nodes on ANC. There was no significant difference in mastectomy versus breast conserving surgery rates between FNA positive and negative patients (p= 0.28 on Chi Square). The sensitivity of performing an FNAC was 81% in this study. Outcome of Patients undergoing Axillary Fine Needle Aspiration Cytology Group 1:FNAC positiveGroup2: FNAC negative, SLNB positive Mean No Harvested Nodes at ANC1816p=0.14Mean No of diseased nodes at ANC73p&amp;lt;0.05% of Patients with 4 or more diseased nodes at ANC568.5p&amp;lt;0.05% of Patients who had Breast Conserving Surgery5453p=0.28Key: FNAC:fine needle aspiration cytology, SLNB: Sentinel lymph node biopsy, ANC: Axillary clearance CONCLUSION: This study provides a predictor of the number of diseased axillary nodes in those with positive FNAC preoperatively. Over 50% of patients with a positive FNA have four or more diseased nodes compared with less than 10% in the FNAC negative but SLNB positive group. After neoadjuvant chemotherapy, FNA positive patients have a similar disease burden in the axilla as the FNAC negative but SLNB positive patients. This information can help to guide pre-operative discussions on the likely disease burden and need for adjuvant therapies such as chemotherapy and radiotherapy. Being able to predict the need for radiotherapy in particular can guide surgical decisions regarding type and timing of reconstructions to reduce the risk of surgical complications. Citation Format: Khan A, Hussain N, Irvine T. FNAC: A predictor of final number of involved nodes at axillary clearance [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-01-13.

7. Positive pre-operative axillary ultrasound guided fine needle aspiration cytology is associated with higher axillary disease burden in breast cancer patients compared with those detected by sentinel lymph node biopsy

7. Positive pre-operative axillary ultrasound guided fine needle aspiration cytology is associated with higher axillary disease burden in breast cancer patients compared with those detected by sentinel lymph node biopsy

Axillary nodal burden in primary breast cancer patients with positive pre-operative ultrasound guided fine needle aspiration cytology: Management in the era of ACOSOG Z011

IntroductionRecent years have seen a dramatic shift to more conservative management of the axilla in patients with a positive sentinel lymph node biopsy (SLNB). Identification of nodal disease with positive pre-operative ultrasound guided axillary fine needle aspiration cytology (AUS/FNAC) may represent a higher axillary disease burden mandating an axillary clearance and thus an upfront SLNB may be avoided. The aims of this study were to quantify nodal burden in patients with positive pre-operative AUS/FNAC and identify patients who may have been able to avoid an axillary clearance (ALND) based on ACOSOG Z011 criteria. MethodsA retrospective review of a prospectively maintained database identified patients with positive pre-operative AUS/FNAC between 2007 and 2012. Core biopsies were excluded. Demographic and tumour characteristics were analysed. Eligibility for ACOSOG Z011 criteria was assessed and patients who may have avoided ALND were identified. Results432 patients were identified with positive AUS/FNAC. 85 patients were excluded leaving 347 for analysis. Median age was 56 years (22–87), median tumour size was 25 mm (1.5 mm–150 mm) and median tumour pathology was grade 3 (50%) and invasive ductal carcinoma (82%). Median number of nodes removed at ALND was 23 (1–55) with a median number of positive nodes being 4 (1–47). 134 (39%) patients had ≤2 positive nodes identified on ALND making them eligible for the ACOSOG Z011 study. When other ACOSOG Z011 exclusion factors were applied only 27 (7.8%) patients may have avoided ALND. ConclusionsNodal positivity on AUS/FNAC is associated with higher axillary disease burden. Few patients would satisfy ACOSOG/Z011 criteria and avoid ALND making an upfront SLNB unnecessary.

Axillary nodal burden in breast cancer patients with a positive pre-operative ultrasound guided fine needle aspiration cytology

Introduction: Recent years have seen dramatic shifts, based largely on the ACOSOG Z0011 study, to conservative management of the axilla in patients with a positive sentinel lymph node. However, positive pre-operative ultrasound guided axillary fine needle aspiration cytology (FNAC) may represent higher axillary disease burden. The aims of this study were to quantify nodal burden in patients with positive pre-operative axillary FNAC and identify patients who may have been spared axillary clearance (AC) based on Z11 criteria.

Abstract P2-18-05: Axillary nodal burden in patients with a positive pre-operative ultrasound guided fine needle aspiration cytology

Abstract Introduction Recent years have seen a dramatic shift to more conservative management of the axilla and the presence of a positive sentinel lymph node biopsy does not now automatically mandate an axillary clearance. This is based largely on data from the American College of Surgeons Oncology Group (ACOSOG) Z11 study, which failed to demonstrate a difference in local recurrence or overall survival when an axillary clearance was omitted in a highly selective group of patients with a positive sentinel lymph node. However, the presence of a positive pre-operative ultrasound guided axillary FNAC(Fine Needle Aspiration Cytology) may be representative of a higher burden of axillary disease. Aim Therefore, the aims of this study were firstly to quantify the actual nodal burden in breast cancer patients with a positive pre-operative ultrasound guided axillary FNAC and secondly to identify the number of patients who may have been spared an axillary clearance based on Z11 eligibility criteria. Methods A retrospective review of a prospectively maintained database within a tertiary breast cancer referral centre was performed. All patients with a positive pre-operative axillary FNAC were identified within a five year period (2007 – 2011). Demographic, tumour and biological characteristics and final nodal status were analysed. Eligibility for randomisation according to the Z11 criteria was assessed based on the final pathology and the number of patients who could have been spared an axillary clearance was identified. Results A total of 360 patients were identified with a positive axillary ultrasound guided FNAC. Sixty-three patients had no axillary surgery and three patients had recurrent disease, leaving a total of 294 for analysis. The mean age was 56 years (range 22 – 87). The mean size of the tumour was 31.3mm (range 4mm – 132mm) and the majority were an invasive grade 3 (57%) ductal carcinoma (84%). Luminal A (63%) was the commonest sub-type. The mean number of nodes removed at axillary clearance was 24 (range 7 – 58) while the mean number of positive nodes excised was 6 (range 0 – 47). Of these, the mean number of level I positive nodes was 4, level II was 1 and level III nodes was &amp;lt;1. Overall a total of 78 patients had less than three positive nodes identified in the axilla and potentially may have been eligible for the Z11 study. However, when patients who had a mastectomy, neo-adjuvant chemotherapy were excluded and the presence of extra-capsular nodal involvement was accounted for only 19 (6.4%) patients may have been spared an axillary clearance. Conclusions The presence of nodal positivity on a pre-operative FNAC is associated with a higher burden of axillary disease. Only a minority of these patients would be able to avoid an axillary clearance in the setting of the recent Z11 study. Performing an axillary ultrasound and FNAC of suspicious nodes allows patients to avoid an unnecessary sentinel lymph node biopsy and proceed directly to an axillary clearance. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-18-05.

P102. Is preoperative axillary fine needle aspiration cytology necessary?

Introduction: NICE recommends preoperative ultrasound evaluation of the axilla on all patients with breast cancer. This study evaluated our practice of preoperative axillary ultrasound (USS) and ultrasound guided fine needle aspiration cytology (USS-FNAC) at Peterborough City Hospital.

Authors' reply: Rapid on-site evaluation of axillary fine-needle aspiration cytology in breast cancer (Br J Surg 2012; 99: 807–812)

Authors' reply: Rapid on-site evaluation of axillary fine-needle aspiration cytology in breast cancer (<i>Br J Surg</i> 2012; 99: 807–812)

Rapid on-site evaluation of axillary fine-needle aspiration cytology in breast cancer (Br J Surg 2012; 99: 807–812)

Rapid on-site evaluation of axillary fine-needle aspiration cytology in breast cancer (<i>Br J Surg</i> 2012; 99: 807–812)

Rapid on-site evaluation of axillary fine-needle aspiration cytology in breast cancer

Axillary ultrasonography (AUS) and fine-needle aspiration cytology (FNAC) can establish axillary lymph node status before surgery, although this technique is hampered by poor adequacy rates. To achieve consistently high rates of FNAC adequacy, rapid on-site evaluation (ROSE) of FNAC samples was introduced. This single-centre, retrospective observational study of patients with newly diagnosed breast cancer undergoing preoperative AUS and FNAC between February 2008 and November 2010 examined the effect of the introduction of ROSE. A total of 381 patients were included. AUS revealed 152 axillae with suspicious radiological features. FNAC was positive for malignant cells in 75 (49·3 per cent) of 152 samples. Sentinel lymph node mapping was avoided in 75 patients, representing 19·7 per cent of the entire study population. Adequacy rates increased from 78 per cent to 96 per cent following the introduction of ROSE (P = 0·001). The overall sensitivity and specificity of AUS and FNAC was 80·6 and 100 per cent respectively. A lymph node diameter equal to or larger than 10 mm and extranodal extension were significantly associated with positive FNAC (P < 0·001 and P = 0·012 respectively). Maximum lymph node diameter of at least 10 mm was an independent predictor of positive FNAC (odds ratio 11·2, 95 per cent confidence interval 3·32 to 37·76; P < 0·001). AUS with FNAC provided accurate preoperative staging of the axilla for metastatic breast disease and avoided unnecessary sentinel lymph node mapping. The introduction of ROSE ensured the efficiency of AUS and FNAC.

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

IntroductionFine 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,...

The value of preoperative axillary ultrasound staging in the management of early breast cancer.

Abstract Abstract #1023 Background: The prognosis of breast cancer is strongly associated with the presence of metastatic disease in the axillary lymph nodes at the time of diagnosis. Sentinel lymph node biopsy (SLNB) is the current standard of care for staging a clinically negative axilla in early breast cancer. Approximately 25% of women with early stage breast cancer undergoing SLNB are node positive and require completion axillary lymph node dissection (ALND). Ultrasound guided fine needle aspiration cytology (FNAC) of axillary lymph nodes is a minimally invasive technique that can be used preoperatively to stage the axilla in breast cancer patients, reducing the number of operative procedures required for staging and local control of disease. Aim: To determine the sensitivity and specificity of ultrasound guided axillary FNAC to detect positive axillary lymph nodes in breast cancer patients and to determine the number of patients who avoided unnecessary SLNB. Methods: Newly diagnosed invasive breast cancer patients were prospectively followed from January 2007 to June 2008. Patients with stage IV breast cancer, clinically node positive disease and patients who did not proceed to surgery were excluded. Criteria for a suspicious sonographic axillary node included diffuse cortical thickening &amp;gt;3mm, focal nodular cortical thickening and a mass-like appearance with loss of the fatty hilum. Results: 133 patients who met the inclusion criteria were diagnosed with invasive breast cancer between January 2007 and June 2008. Median age was 60 [21-87]. 49 patients had T1 tumours, 77 patients had T2, and 7 patients had T3 tumours. 126 (95%) patients had axillary ultrasounds, 44 ( 35%) of which showed abnormal axillary lymph nodes. 38 ( 86%) of these 44 patients proceeded to ultrasound guided axillary FNAC and 27 (71%) of these were positive for malignant cells. All patients with positive axillary nodal FNAC underwent axillary clearance and all had positive nodes on final histopathology. The median number of positive nodes was 2, range was 1 to 21. 26 (20%) patients avoided unnecessary SLNB. 82 patients had a negative axillary ultrasound and 27 of these had axillary node positive disease. The median number of positive nodes was 1, the range was 1 to 8.&amp;#x2028; &amp;#x2028; Conclusion: Ultrasound guided axillary FNAC has a high specificity and positive predictive value in radiologically suspicious nodes. A positive FNAC allows definitive treatment of the axilla in radiological node positive patients and avoids the unnecessary step of SLNB. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1023.

Accuracy of fine needle aspiration cytology (FNAC) of axillary lymph nodes as a triage test in breast cancer staging

Axillary node fine needle aspiration cytology (FNAC) has the potential to triage women with operable breast cancer to initial nodal surgical procedure. Because of variability in the reported accuracy of this test its role and clinical utility in pre-operative staging remains controversial. We retrospectively evaluated the accuracy of ultrasound-guided axillary FNAC in all consecutive clinically T1-2 N0-1 breast cancers that had undergone this test (491 biopsies). We included subjects with clinically or sonographically indeterminate or suspicious nodes. Pathological node status was used as the reference standard (based on axillary dissection or sentinel node biopsy). Sensitivity of node FNAC was 72.6% (67.3-77.9) and specificity was 95.7% (92.5-98.8) for all cases, sensitivity was lower at 64.6% (59.3-70.0) if inadequate cytology was included as a negative result. FNAC sensitivity was highest in women with clinically suspicious nodes [92.5% (88.2-96.7)] and lowest in women with sonographically abnormal and clinically negative nodes [50.0% (41.3-58.7)]. Specificity was high in both groups, 81.2% (54.5-96.0) and 97.2% (94.6-99.9), respectively. The false-negative rate was 15.3% (12.1-18.5), the false-positive rate was 1.4% (0.4-2.5), and the inadequacy rate was 10.8% (8.0-13.5). The likelihood of node FNAC being positive was significantly associated with tumour grade and stage, and the number of nodes involved with metastases. Our data show that axillary FNAC has moderate sensitivity (which varies according to selection criteria for the test) and consistently high specificity, is associated with low inadequacy and very few false positives. We estimate that its use would have improved triage to initial nodal procedure in about one quarter of our cases. If one accepts the premise that initial surgical staging of the axilla should be based on all information available through pre-operative diagnosis, then axillary FNAC should be adopted routinely into clinical practice.