Axillary Lymph Nodes In Patients Research Articles

Internal Mammary Sentinel Lymph Node Biopsy after Neoadjuvant Chemotherapy in Breast Cancer.

PurposeThe definition of nodal pathologic complete response (pCR) after a neoadjuvant chemotherapy (NAC) just included the evaluation of axillary lymph node (ALN) without internal mammary lymph node. This study aimed to evaluate the feasibility of internal mammary-sentinel lymph node biopsy (IM-SLNB) in patients with breast cancer who underwent NAC.MethodsFrom November 2011 to 2017, 179 patients with primary breast cancer who underwent operation after NAC were included in this study. All patients received radiotracer injection with modified injection technology. IM-SLNB would be performed on patients with internal mammary sentinel lymph node (IMSLN) visualization.ResultsAmong the 158 patients with cN+ disease, the rate of nodal pCR was 36.1% (57/158). Among the 179 patients, the visualization rate of IMSLN was 31.8% (57/179) and was 12.3% (7/57) and 87.7% (50/57) among those with cN0 and cN+ disease, respectively. Furthermore, the detection rate of IMSLN was 31.3% (56/179). The success rate of IM-SLNB was 98.2% (56/57). The IMSLN metastasis rate was 7.1% (4/56), and all of them were accompanied by ALN metastasis. The number of positive ALNs in patients with IMSLN metastasis was 3, 6, 8, and 9. The pathology nodal stage had been changed from pN1/pN2 to pN3b. The pathology stage had been changed from IIA/IIIA to IIIC.ConclusionPatients with visualization of IMSLN should perform IM-SLNB after NAC, especially for patients with cN+ disease, in order to complete lymph nodal staging. IM-SLNB could further improve the definition of nodal pCR and guide the internal mammary node irradiation.

The Correlation between Fasting Blood Glucose Level with Infiltrated Axillary Limph Node Rate in Infiltrating Ductal Carcinoma of the Breast

Cancer cell have been shown to extensively use glucose for proliferation, even at hypoxia environment. The consumption of glucose in a hypoxia environment induced HIF and VEGF, which play a role in cancer cell infiltration process . The objective of study is to determine the relationship between fasting blood glucose levels with the amount of infiltrated axillary lymph node in patients with infiltrating ductal carcinoma. This is an analytic observational study with cross sectional design. The data obtained were tested with chi-square test (α < 0.05). This study was conducted on 24 infiltrating ductal carcinoma patients. The results showed p value of 0.004, indicating there is a significant correlation between fasting blood glucose levels with the amount of infiltrated axillary lymph nodes. The correlation coefficient ( r) value was 0.505; indicating medium level correlation. As conclusion, there is a significant correlation between fasting blood glucose levels with the amount of infiltrated axillary lymph node in patients with infiltrating ductal carcinoma.Keywords: axillary lymph nodes, breast cancer, fasting blood glucose level, infiltrating ductal carcinoma

Microbubble detection and ultrasound-guided vacuum-assisted biopsy of axillary lymph nodes in patients with breast cancer

To assess the feasibility of undertaking microbubble-guided vacuum-assisted biopsy (VAB) of the sentinel lymph node (SLN) and determine its sensitivity in detecting metastases. Patient experience and the impact of VAB on subsequent axillary surgery were also evaluated. Patients with a normal axillary ultrasound or benign core biopsy planned for surgical SLN biopsy were recruited. Part 1 of the study was used to establish the technique of ultrasound microbubble contrast to detect the SLN. In Part 2 microbubble detection of the SLN was followed by 13 G VAB. All patients subsequently had surgical histological correlation. One hundred and thirty-nine patients were recruited: 36 to Part 1 and 103 to Part 2. Of the 100 patients in Part 2 included for analysis, 82 (82%) underwent successful biopsy. Sensitivity for detecting metastases was 58.8% (95% confidence interval: 32.9%, 81.6%). The procedure was generally well tolerated; however, VAB interfered adversely with subsequent surgical SLN biopsy with surgeons reporting moderate or severe interference in 48% of patients and an additional 8.3% with complete failure of SLNB. It is possible to perform VAB of microbubble-detected SLNs. Although the sensitivity for detecting metastases was reasonable, the adverse effect on subsequent surgery was significant.

Accuracy of axillary ultrasound after different neoadjuvant chemotherapy cycles in breast cancer patients.

BackgroundThis study determined whether axillary ultrasound (AUS) accurately predicted the status of axillary lymph nodes of patients who received different number of cycles of neoadjuvant chemotherapy (NAC).Materials and MethodsFrom 2008 to 2015, 656 cases of patients with breast cancers who received NAC and had subsequent axillary lymph node dissection were included in this study. The findings of preoperative AUS were tested by pathological examination. We evaluated the sensitivity, specificity and accuracy of AUS for patients who received two-, four-, and six-cycle NAC.ResultsIn the two-cycle subgroup, the sensitivity (Sn), specificity (Sp) and diagnostic odds ratio (DOR) were 80.2% (95% CI: 74.3%-86.2%), 61.4% (95% CI: 48.8%-74.0%) and 6.64 (95% CI: 3.36-12.4) respectively. In the four-cycle subgroup, the Sn, Sp and DOR were 69.7% (95% CI: 62.2%-77.1%), 66.1% (95% CI: 53.7%-78.5%) and 4.47 (95% CI: 2.32-8.62), respectively. In the six-cycle subgroup, the Sn, Sp and DOR were 56.7% (95% CI: 49.5%-64.0%), 74.5% (95% CI: 62.8%-87.2%) and 3.83 (95% CI: 1.863-7.86), respectively. Furthermore, the patients with normal AUS findings after six cycles of NAC have few positive nodes than patients with suspicious findings (p < 0.001).ConclusionPreoperative AUS is a potentially useful imaging modality to predict the pathologic status of the axillary within four cycles of NAC. Although the accuracy is lower for patients who completed six cycles of NAC than that who received four- and two- cycles, the number of positive lymph nodes for patients with normal findings on AUS is low.

B-mode ultrasound, sono-elastography and diffusion-weighted MRI in differentiation of enlarged axillary lymph nodes in patients with malignant breast disease

AimTo evaluate role of B-mode ultrasound, ultrasound elastography and DWI in differentiating benign and malignant axillary lymph nodes. Patients and methodsFrom July 2014 to July 2015, 30 patients with enlarged axillary nodes in patients with malignant breast disease were examined by B mode ultrasound, US elastography and DWI. Finally, findings of B-mode US, elastography and DWI were compared with pathological results (reference standard). ROC analysis was constructed to obtain best cutoff values for B-mode criteria: elasticity score, strain ratio and ADC value. ResultsMean SR of malignant nodes (8.26) was significantly higher than that of benign nodes (2.08) with P value <0.0001. Mean ADC value of malignant nodes (0.7) was significantly lower than mean ADC value of benign nodes (1.4) with P value <0.0001. Comparing results of three imaging modalities showed that DWI had higher sensitivity and accuracy (100%, 96.4%, respectively) than ultrasound elastography (88.89%, 93.33%, respectively) with both modalities which had same specificity (91.67%). Also, DWI and US elastography had higher sensitivity, specificity, accuracy than B-mode ultrasound (77.78%, 66.7%, 73.3% respectively). ConclusionDWI and US elastography significantly aid in improving characterization of metastatic axillary nodes than B-mode US, besides reducing unnecessary invasive biopsy.

The Diagnosis of Metastatic Axillary Lymph Nodes of Breast Cancer By Diffusion Weighted Imaging: a meta-analysis and systematic review.

BackgroundThe purpose of this meta-analysis was to evaluate the clinical significance of diffusion-weighted imaging in assessing the status of axillary lymph nodes in patients with breast cancer.MethodsWe searched the PubMed, Cochrane, and EMBASE databases, selected studies by inclusion and exclusion criteria, and assessed the quality of selected studies. We explored the source of heterogeneity; calculated sensitivity, specificity, positive and negative likelihood ratios, and pretest probability. A summary receiver operating characteristic curve was performed. Student’s t test was used to compare the different mean apparent diffusion coefficient values of different status lymph nodes.ResultsIn selected 10 studies, a total of 801 patients and 2305 lymph nodes were included following inclusion criteria. All scores of the quality assessment of the included studies were greater than or equal to 10 points. The sensitivity was 0.89 (95 % CI 0.79–0.95), the specificity was 0.83 (95 % CI 0.71–0.91), the positive and negative likelihood ratios were 3.86 (95 % CI 2.75–5.41) and 0.17 (95 % CI 0.09–0.32), the pretest probabilities were 53 and 54 %, the area under the curve were 0.93 (95 % CI 0.90–0.95), respectively. The mean apparent diffusion coefficient value of metastatic lymph nodes was significantly lower than that of nonmetastatic axillary lymph nodes.ConclusionsDiffusion-weighted imaging is a promising tool to discriminate between metastatic and nonmetastatic axillary lymph nodes. Combined with the mean apparent diffusion coefficient value, it can quantitatively diagnose lymph node metastases. Conducting large-scale, high-quality researches can improve the clinical significance of diffusion-weighted imaging to distinguish metastatic and nonmetastatic axillary lymph nodes in patients with breast cancer and provide the evidence to assess the status of axillary lymph nodes.

The role of ultrasound and lymphoscintigraphy in the assessment of axillary lymph nodes in patients with breast cancer.

Breast cancer is the most common malignancy and the leading cause of death due to cancer in European women. Mammography screening programs aimed to increase the detection of early cancer stages were implemented in numerous European countries. Recent data show a decrease in mortality due to breast cancer in many countries, particularly among young women. At the same time, the number of sentinel node biopsy procedures and breast-conserving surgeries has increased. Intraoperative sentinel lymph node biopsy preceded by lymphoscintigraphy is used in breast cancer patients with no clinical signs of lymph node metastasis. Due to the limited sensitivity and specificity of physical examination in detecting metastatic lesions, developing an appropriate diagnostic algorithm for the preoperative assessment of axillary lymph nodes seems to be a challenge. The importance of ultrasound in patient qualification for sentinel lymph-node biopsy has been discussed in a number of works. Furthermore, different lymphoscintigraphy protocols have been compared in the literature. The usefulness of novel radiopharmaceuticals as well as the methods of image acquisition in sentinel lymph node diagnostics have also been assessed. The aim of this article is to present, basing on current guidelines, literature data as well as our own experience, the diagnostic possibilities of axillary lymph node ultrasound in patient qualification for an appropriate treatment as well as the role of lymphoscintigraphy in sentinel lymph node biopsy.

Three-Dimensional Sonography of Axillary Lymph Nodes in Patients With Breast Cancer.

Sonography is useful in the evaluation of axillary lymph nodes in patients with breast cancer. In this pictorial essay, we review the range of grayscale and Doppler appearances of abnormal axillary lymph nodes on 2-dimensional and 3-dimensional imaging.

Abstract P3-01-17: A technique for preoperative axillary lymph node tattooing in patients with breast cancer

Abstract Purpose: To describe the ultrasound technique for tattooing axillary lymph nodes (ALNs) after lymph node (LN) biopsy in patients with breast cancer. Background: Preoperative evaluation of metastatic disease within ALNs in patients with newly diagnosed breast cancer has significant prognostic value and is quickly becoming routine, particularly in the neoadjuvant setting. A recent study showed tattooed LNs are visible intraoperatively and on histological evaluation months following the tattooing procedure. These results suggest that LN tattooing can obviate the need for additional localization procedures during axillary staging, such as wire localization. Given the increasing use of preoperative ALN biopsy, a robust technique to insure proper LN tattoo marking is proposed. Methods and Technique: Tattooing was performed under real-time US guidance using a 5-cm long 21-gauge hypodermic needle attached to a 1 mL tuberculin syringe containing 1 mL carbon suspension tattoo ink (SPOT™, GI-supply Inc). Imaging was performed with the patient in a supine oblique position with the patient's arm over their head. The anatomically anterior and lateral aspects of the node and perinodal fat were marked with ink. The only regions of the LN not targeted for ink tattooing were the hilum and the posterior cortex and perinodal fat. At least 0.5 mL of ink was used. Results: Optimal technique for intraoperative visualization was determined to be tattooing the anatomically anterior and lateral aspects of the LN cortex and the adjacent perinodal fat using at least 0.5mL of ink. Tattooed LNs which had undergone biopsy and tattooing months prior to surgery were visible intraoperatively and on histological evaluation. Factors contributing to less optimal visualization of the tattooed lymph node included: using less than 0.5mL of ink, tattooing only the superficial cortex and not the perinodal fat, and tattooing a portion of the LN that was not visible with the patient in the operative position. Discussion: The most easily accessed portion of the LN during the US procedure may not be the portion of the LN most easily seen intraoperatively. Locating and tattooing the anatomically anterior and lateral aspects of the LN, regardless of the patient position and orientation of the ultrasound probe, is the primary challenge. Doing so will maximize the likelihood that the tattoo ink will be visible by the surgeon when the patient is in a supine position with the arm abducted 90 degrees using an axillary incision. Tattooing using less than 0.5 mL resulted in suboptimal visualization. Using a larger volume of ink may be judged necessary for larger LNs, very fatty axillae, and for deeply seated nodes. Other reports in the medical literature suggest cutaneous tattooing can result in ink within ALNs. In patients with ipsilateral cutaneous tattoos, an alternative method of marking any biopsied LNs should be considered to avoid false positives associated with prior migration of the cutaneous tattoo ink to the LN. Tattooing of ALNs under ultrasound guidance is a straightforward technique which can be performed at the time of initial biopsy and obviates the need for future preoperative wire localization of the LN. Citation Format: Wapnir IL, Downey JR, Lipson JA, Ikeda DM. A technique for preoperative axillary lymph node tattooing in patients with breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-01-17.

Diagnostic Accuracy and Impact on Management of Ultrasonography-Guided Fine-Needle Aspiration to Detect Axillary Metastasis in Breast Cancer Patients: A Prospective Study

Background: The axillary nodal status is essential to determine the stage of disease at diagnosis. Our aim was to prospectively assess the diagnostic accuracy of ultrasonography-guided fine-needle aspiration (US-FNA) for the detection of metastasis in axillary lymph nodes in patients with breast cancer (BC) and its impact on the therapeutic decision. Materials and Methods: Ultrasonography (US) was performed in 407 axillae of 396 patients who subsequently underwent surgery. US-FNA was conducted when lymph nodes were detected by US. Axillary dissection (AD) was performed when US-FNA was positive for metastasis. Patients with negative US-FNA and breast tumors of 30 mm in size were candidates for selective sentinel lymph node biopsy (SLNB). The anatomopathological results of AD or SLNB were used as reference tests. Results: Lymph nodes were detected by US in 207 (50.8%) axillae. Of these, US-FNA was performed on 180 (86.9%). 94 axillae (52.2%) were positive for carcinoma and 79 women received AD. US-FNA had 77.5% sensitivity, 100% specificity, 100% positive predictive value, 69.3% negative predictive value, and 85.1% diagnostic accuracy. US-FNA avoided SLNB in 18.1% of patients who underwent AD. Conclusions: Axillary US-FNA is an accurate technique in the staging of patients with BC. It allows reducing the number of SLNB and, when positive, offers a fast and useful tool.

Axillary ultrasound and fine-needle aspiration in preoperative staging of axillary lymph nodes in patients with invasive breast cancer.

ObjectiveTo propose an algorithm to determine the necessity for ultrasonography-guided fine-needle aspiration (US-FNA) in preoperative axillary lymph node staging of patients with invasive breast cancer.Materials and MethodsProspective study developed at National Cancer Institute. The study sample included 100 female patients with breast cancer referred for axillary staging by US-FNA.ResultsThe overall US-FNA sensitivity was set at 79.4%. The positive predictive value was calculated to be 100%, and the negative predictive value, 69.5%. The US-FNA sensitivity for lymph nodes with normal sonographic features was 0%, while for indeterminate lymph nodes it was 80% and, for suspicious lymph nodes, 90.5%. In the assessment of invasive breast tumors stages T1, T2 and T3, the sensitivity was respectively 69.6%, 83.7% and 100%. US-FNA could avoid sentinel node biopsy in 54% of cases.ConclusionAxillary ultrasonography should be included in the preoperative staging of all patients with invasive breast cancer. The addition of US-FNA in cases of lymph nodes suspicious for malignancy may prevent more than 50% of sentinel lymphadenectomies, significantly shortening the time interval to definitive therapy.

Retrospective preoperative assessment of the axillary lymph nodes in patients with breast cancer and literature review

To evaluate the accuracy of axillary ultrasound, compared with published literature, identify women at low risk for lymph node (LN) involvement, and to determine which clinical, pathological, and imaging findings best predict LN involvement. From June 2010 to April 2012, 288 women with breast lesions that were suspicious of malignancy (category 4) or malignant (category 5) underwent axillary ultrasound examination. A 3mm LN cortical thickness was used as the threshold to prompt fine-needle aspiration biopsy (FNAB) of the LN. Data were gathered regarding size, site, and grade of the index breast lesion and cortical thickness of the LN. Using a cut-off point of <3mm versus ≥3mm, abnormal cortical thickness had a sensitivity and specificity of 56.3% and 86.7%, respectively. Breast cancer size was significantly associated with the odds of LN metastasis (p<0.001). There were 69 patients with breast cancers of ≤10mm and 18% had positive axillary LNs. A much higher rate of malignancy was observed in breast cancers located in multiple sites and in a central location. The likelihood of axillary LN metastasis increases with cortical thickness ≥3mm and this concurs with the literature. A low-risk group of women was identified with screen-detected, low-grade small cancers with LNs with a cortical thickness of <3mm. Additional features other than cortical thickness >3mm (such as shape [rounding], echogenicity [markedly hypo-echoic cortex], and morphology [hilar compressional displacement, loss of echogenic outer capsule and angular margins]) should be used to indicate FNAB in patients with a palpable lump, multiple or central cancers, and cancers >20mm.

The efficacy and efficiency of half frozen section assessment of breast cancer sentinel lymph nodes: A retrospective analysis of 1116 cases.

1055 Background: Sentinel lymph node (SLN) biopsy became the standard of care for the staging of clinically negative axillary lymph node in patients with invasive breast cancer. Surgeons often requ...

Abstract P2-01-25: Not all sentinel lymph nodes are equal – A predictive model for axillary burden in early breast cancer

Abstract Introduction The Z11 trial demonstrates that an axillary lymph node dissection (ALND) can be avoided in patients with low axillary burden who undergo breast conserving surgery (BCS), combined with whole-breast radiotherapy and systemic therapy. Our group propose a standardisation of sentinel lymph node biopsy (SLNB), incorporating 2 novel sentinel nodal stations (SNS) which represent sequential echelons of SLN draining the breast – the intercostalbrachial nerve (ICB) and the medial pectoral neurovascular bundle (MP). By increasing the specificity and positive predictive value of SLNB, we aim to identify a subgroup of patients who undergo mastectomy who can be spared from ALND and its associated complications. Materials and Methods 313 female patients who underwent sentinel lymph node biopsy for breast cancer from 2 February 2012 to 19 December 2013 were prospectively studied. 12 patients had bilateral breast cancers, and each laterality was counted as distinct cases, giving a total of 325 cases. 7 had breast surgery performed prior to the SLNB, and the rest had their oncological surgery performed at the same setting of the SLNB. The surgeries were performed by three surgeons in the National Cancer Centre Singapore, using a specific surgical technique to identify SLN at the 2 SNS. Relevant patient demographics, status of SNS and the rates of metastatic non-sentinel lymph nodes were collected and analysed. Results A total of 325 SLNBs using the ICB and MP SNS were identified from 169 simple mastectomies, 35 skin sparing mastectomies, and 129 breast conserving surgeries. The median age was 56 (range 27-89). The ICB SLN and MP SLN were identified in 313 (96.3%) and 258 (79.4%) cases respectively. In 249 (76.6%) cases were both ICB and MP nodes identified, of which 55 (16.9%) had metastatic involvement of the SLN. An axillary clearance was performed if at least one ICB or MP node was positive, and only 27 (49.1%) had further axillary involvement. More than 2 positive SLNs had 100% positive predictive value for further axillary LN metastases. There was a low sensitivity (29.6%) and high false negative rate (70.4%) for positive axillary nodes in patients with ≤2 positive SLNs. MP nodal status, however, was 85.7% specific (p&amp;lt;0.001) and 48.1% sensitive (p=0.649) and a positive predictive value of 76.5% for axillary nodal involvement. Logistic regression also shows that MP node status is significant for predicting axillary nodal status (OR 5.57, p=0.006). Conclusion Our study shows that MP node status is specific, and has a positive predictive value for further axillary LN metastases. Therefore, we propose that in all patients who undergo SLNB with their BCS or mastectomy, an axillary clearance should be performed if the MP node is positive, regardless of the number of positive SLNs. Citation Format: Yirong Sim, Sue Zann Lim, Shaun S Tan, Alvona Z Loh, Cindy Lim, Preetha Madhukumar, Gay H Ho, Veronique KM Tan, Kong Wee Ong. Not all sentinel lymph nodes are equal – A predictive model for axillary burden in early breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-01-25.

Diagnostic accuracy of 1.5 Tesla breast magnetic resonance imaging in the pre-operative assessment of axillary lymph nodes.

The purpose of this study was to test the accuracy of 1.5 Tesla magnetic resonance imaging (1.5T MRI) in the preoperative evaluation of axillary lymph nodes in patients with invasive breast cancer. The authors retrospectively analyzed 26 patients with invasive breast cancer who had undergone sentinel lymph node biopsy (SLNB) and/or axillary lymph node dissection (ALND). All patients had been submitted to preoperative contrast enhanced breast 1.5T MRI. On the basis of lymph nodes morphological and dynamic characteristics, lymph nodes were classified as "negative" (short axis < 5 mm), "borderline" (short axis > 5 mm, absence of a hilum) or "positive" (short axis > 5 mm, absence of a hilum and also other suspicious features). The authors compared 1.5T MRI results with the outcome of histological analysis performed according to the TNM criteria; sensitivity (SE), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV) of 1.5T MRI were evaluated. Considering only the lymph nodes "positive", 1.5 T MRI showed: SE 37.8%, SP 99.3%, FP 0.7%, PPV 92.5%, and NPV 88.1%. However, considering also "borderline", 1.5T MRI achieved: SE 75.7%, SP 99.3%, FP 0.7%, PPV 96.1%, and NPV was 95%. Contrast enhanced breast 1.5T MRI is not yet a valid alternative to histological analysis but it is a valid tool for a preoperative study of the topography of axillary lymph nodes and has the potential to become a routine method for evaluating the metastatic lymph nodes before submission to ALND.

Prediction of macrometastasis in axillary lymph nodes of patients with invasive breast cancer and the utility of the SUV lymph node/tumor ratio using FDG-PET/CT.

BackgroundAxillary lymph node dissection (ALND) is important for improving the prognosis of patients with node-positive breast cancer. However, ALND can be avoided in select micrometastatic cases, preventing complications such as lymphedema or paresthesia of the upper limb. To appropriately omit ALND from treatment, evaluation of the axillary tumor burden is critical. The present study evaluated a method for preoperative quantification of axillary lymph node metastasis using positron emission tomography/computed tomography (PET/CT).MethodsThe records of breast cancer patients who received radical surgery at the Gifu University Hospital (Gifu, Japan) between 2009 and 2014 were reviewed. The axillary lymph nodes were preoperatively evaluated by PET/CT. Lymph nodes were dissected by sentinel lymph node biopsy (SLNB) or ALND and were histologically diagnosed by experienced pathologists. The maximum standardized uptake value (SUVmax) was measured in both the axillary lymph node (SUV-LN) and primary tumor (SUV-T). The SUV-LN/T ratio (NT ratio) was calculated by dividing the SUV-LN by the SUV-T, and the efficacies of the NT ratio and SUV-LN were compared using receiver operating characteristic (ROC) curve analysis. The diagnostic performance was also compared between the techniques with the McNemar test.ResultsA total of 171 operable invasive breast cancer patients were enrolled, comprising 69 node-positive patients (macrometastasis (Mac): n = 55; micrometastasis (Mic): n = 14) and 102 node-negative patients (Neg). The NT ratio for node-positive patients was significantly higher than in node-negative patients (0.5 vs. 0.316, respectively, P = 0.041). The NT ratio for Mac patients (0.571) was significantly higher than in Mic (0.227) and Neg (0.316) patients (P <0.01 and P = 0.021, respectively). The areas under the curves (AUCs) by ROC analysis for the NT ratio and SUV-LN were 0.647 and 0.811, respectively (P <0.01). In patients with an SUV-T ≥2.5, the modified AUCs for the NT ratio and SUV-LV were 0.757 and 0.797 (not significant).ConclusionThe NT ratio and SUV-LN are significantly higher in patients with axillary macrometastasis than in those with micrometastasis or no metastasis. The NT ratio and SUV-LN can help quantify axillary lymph node metastasis and may assist in macrometastasis identification, particularly in patients with an SUV-T ≥2.5.Electronic supplementary materialThe online version of this article (doi:10.1186/s12957-014-0424-2) contains supplementary material, which is available to authorized users.

Diffusion weighted images of metastatic as compared with nonmetastatic axillary lymph nodes in patients with newly diagnosed breast cancer

To investigate the ability of diffusion weighted images (DWI) to differentiate between metastatic and nonmetastatic axillary lymph nodes (LNs) in patients with newly diagnosed breast cancer. From January 2010 to February 2012, DWI was performed at b values of 0 and 800 for 16 metastatic LNs from 16 patients with breast cancer, and 20 nonmetastatic LNs from 20 women without breast cancer. The metastatic LNs were proven by ultrasound (US) guided core biopsy and the same LNs were identified on MRI by comparing the US images with MR images. Nonmetastatic LNs were verified by the stability in size and shape for at least 2 years on MRI. The apparent diffusion coefficient (ADC) value of the metastatic and nonmetastatic axillary LNs was compared. Receiver-operating-characteristics (ROC) analysis was performed to evaluate the diagnostic performance of the ADC value in differentiating between metastatic and nonmetastatic axillary LNs. The mean ADC value was 0.746 × 10(-3) for metastatic LNs and 1.033 × 10(-3) for nonmetastatic LNs (P < 0.001). The area under the ROC curve was 0.884. The sensitivity and specificity for differentiating metastatic from nonmetastatic axillary LNs using a cutoff ADC value of 0.852 were 85% and 81%, respectively. There is a statistically significant difference between the ADC values of pathologically proven metastatic LNs and nonmetastatic LNs. DWI and ADC values are a useful tool for differentiating metastatic from nonmetastatic axillary LNs.

Suspicious Axillary Lymph Nodes Identified on Clinical Breast MRI in Patients Newly Diagnosed with Breast Cancer: Can Quantitative Features Improve Discrimination of Malignant from Benign?

To determine whether quantitative dynamic contrast-enhanced (DCE) and diffusion-weighted (DW) magnetic resonance imaging (MRI) features can discriminate malignant from benign axillary lymph nodes (ALNs) identified as suspicious on clinical breast MRI in patients newly diagnosed with breast cancer. After approval from institutional review board, all clinical breast MR examinations performed from March 2006 through January 2010 describing at least one morphologically suspicious ipsilateral ALN in patients with newly diagnosed breast cancer were identified. Each suspicious ALN underwent ultrasound-guided core needle biopsy, and nodes with benign results were subsequently sampled surgically. Quantitative DCE and DW MRI parameters (diameters, volume, enhancement kinetics, and apparent diffusion coefficients [ADC]) were measured for each suspicious ALN and a representative contralateral normal node, and each feature was compared between the ALN groups (normal, benign, and malignant). Thirty-four suspicious ALNs (18 malignant and 16 benign) and 34 contralateral normal-appearing ALNs were included. Suspicious malignant and benign nodes exhibited larger size, greater volume, and lower ADCs than normal ALNs (P < .05). Among suspicious ALNs, the only quantitative measure that discriminated between malignant from benign outcome was percent of ALN demonstrating washout kinetics (P = .02). In ALNs deemed morphologically suspicious on breast MRI, quantitative MRI features show little value in identifying those with malignant etiology.

Radiation doses to axillary lymph nodes in patients with early breast cancer receiving field-in-field forward-planned intensity-modulated radiotherapy for whole breast irradiation after breast-conserving surgery

Objective To evaluate the radiation doses to the axillary lymph nodes in patients with early breast cancer receiving field-in-field forward-planned intensity-modulated radiotherapy (FIF-FP-IMRT) for whole breast irradiation after breast-conserving surgery,and to analyze the factors influencing the doses to the axillary lymph nodes.Methods Thirty-seven patients with breast cancer treated by breast-conserving surgery were evaluated.All patients received FIF-FP-IMRT for whole breast irradiation (not involving regional lymph nodes).Delineation of axillary levels Ⅰ-Ⅲ,interpectoral lymph nodes,and axillary vein was made on CT images,and a dosimetric analysis was made using 3D treatment planning software.The influential factors for the dose distribution in axillary lymph nodes were analyzed by paired t-test.Results The mean percent volumes receiving at least 95％ of the prescribed dose (50 Gy/25 fractions for whole breast PTV)(V95) for axillary levels Ⅰ,Ⅱ,and Ⅲ and interpectoral lymph nodes were 34.7％,6.1％,0.4％,and 39.6％,respectively,and the mean doses to axillary levels Ⅰ,Ⅱ,Ⅲ and interpectoral lymph nodes were 30.8 Gy,15.7 Gy,5.0 Gy,and 28.8 Gy,respectively.The mean V95 values for the lymph node areas below and above the axillary vein were 45.6％ and 0.7％,respectively,and the mean doses were 38.2 Gy and 6.7 Gy,respectively.The distance between the upper border of the radiation field and the humeral head was the only significant factor influencing the mean dose to the lymph node area below the axillary vein (P =0.037).Conclusions In FIF-FP-IMRT for whole breast irradiation,the actual dose delivered to the axillary lymph nodes below the axillary vein cannot be neglected and should be taken into consideration when analyzing the local control of the axillary lymph nodes after breast-conserving surgery. Key words: Breast neoplasms/three-dimensional conformal radiotherapy; Axillary lymph nodes; Dosimetry

Efficiency of a preoperative axillary ultrasound and fine-needle aspiration cytology to detect patients with extensive axillary lymph node involvement.

BackgroundRecent studies have demonstrated that axillary lymph node dissection (ALND) does not affect patient survival, even in those with one or two positive sentinel lymph nodes (SLNs). On the other hand, patients with 3 or more metastatic lymph nodes are eligible for chemotherapy. Therefore, it is crucial to identify a priori patients at risk of having a high number of metastatic axillary lymph nodes for their surgical and/or clinical management. Ultrasound (US) guided Fine-Needle Aspiration (FNA) has been proven to be a useful and highly specific method for detecting metastatic axillary lymph nodes. However, only one recent study has evaluated the efficiency of this method in identifying patients with high metastatic nodal involvement. Our aim was to validate US-guided FNA as a reliable method to discriminate a priori patients with >3 metastatic lymph nodes.MethodsA retrospective series of 1287 breast cancer patients who underwent a simultaneous preoperative breast and axillary US to stage their axilla was collected. A total of 365 patients, with either positive SLNs (278) or positive axillary lymph nodes detected via US-guided FNA (87), underwent ALND. In these two subgroups, we compared the number of metastatic lymph nodes in the axilla.ResultsThe number of metastatic axillary lymph nodes in patients who underwent US-guided FNA was significantly higher (63% had >3 metastatic lymph nodes) than that in patients with SLNs positive for micro- or macrometastases (3% and 27%, respectively) (P<0.001, χ 2 = 117.897).ConclusionsPreoperative axillary US-guided FNA could act as a reliable tool in identifying breast cancer patients with extensive nodal involvement.