Evaluation Of Axillary Lymph Nodes Research Articles

Pathological evaluation of the staging axillary lymph nodes: A national survey in the United Kingdom

Pathological evaluation of the staging axillary lymph nodes: A national survey in the United Kingdom

Association of Tumour Stiffness on Sonoelastography with Axillary Nodal Status in T1 Breast Carcinoma Patients

To evaluate whether tumour stiffness on sonoelastography is associated with axillary nodal metastasis in T1 breast carcinoma patients. Between May 2006 and December 2010, 200 consecutive women (mean age, 51.6; range, 27 - 81 years) who underwent B-mode ultrasound (US), sonoelastography, and curative surgery with axillary nodal evaluation for clinically node negative T1 breast carcinomas (mean invasive tumour size, 12.4; range, 3 - 20 mm at pathology) were identified. The association between the elasticity score of the tumour and histopathological axillary nodal status was evaluated using a logistic regression model after controlling for imaging and clinicopathological variables of the tumour. The overall incidence of axillary nodal metastasis was 15.5 % (31 of 200). Axillary nodal metastasis was significantly more frequent in tumours with elasticity scores ≥4 than in tumours with elasticity scores <4 (21.7 % vs. 4.2 %; P < 0.001). At multivariate analysis, an elasticity score ≥4 [odds ratio (OR), 6.95; P = 0.004], US size >10 mm (OR, 5.98; P = 0.022), and lymphovascular invasion (OR, 10.68; P < 0.001) of tumours were independently associated with axillary nodal metastasis. Tumour stiffness on sonoelastography is independently associated with axillary nodal metastasis in T1 breast carcinoma patients. • Prediction of axillary nodal status using imaging techniques is valuable. • High ultrasound elasticity scores of T1 tumours were associated with axillary metastasis • Node-positive T1 tumours frequently had elasticity scores 4 or 5. • Sonoelastography might render axillary surgery unnecessary in T1 breast carcinoma patients.

Radionuclide Methods for Breast Cancer Staging

Staging at initial presentation is one of the important prognostic factors for patients with breast cancer. Depending on the extent of disease spread, staging is divided into locoregional and distant or systemic. Locoregional staging includes axillary and internal mammary lymph node evaluation and distant or systemic staging includes evaluation of sites beyond the lymph node. Fluorodeoxyglucose-positron emission tomography (FDG-PET) is not sensitive to detect small metastasis in axillary lymph node. The current standard of axillary lymph node staging in early-stage breast cancer is therefore sentinel lymph node biopsy. Internal mammary lymph nodes are not commonly included in routine staging. In advanced-stage breast cancer, FDG-PET and PET/computed tomography (CT) are the modalities of choice to evaluate locoregional and distant metastasis. FDG-PET and PET/CT often detect occult metastasis, which is not visible on any other modalities including diagnostic CT scan. Detection of occult metastasis may potentially change in treatment options. This is particularly important in locally advanced breast cancer, which tends to develop early distant metastasis.

Lymph Node Extramedullary Hematopoiesis in Breast Cancer Patients Receiving Neoadjuvant Therapy

Extramedullary hematopoiesis (EMH) develops as a compensatory mechanism associated with hematologic processes but it may occur in association with chemotherapy. Three cases of EMH arising in axillary lymph nodes following neoadjuvant therapy for breast carcinoma are reported herein. Three women ranging in age from 41 to 47 years presented with unilateral breast masses measuring 0.6 to 4.0 cm in greatest dimension and were diagnosed with infiltrating ductal carcinoma, grade III by core needle biopsies. Two of the tumors were triple negative and one was estrogen receptor positive. All patients subsequently received neoadjuvant therapy followed by lumpectomies. No residual carcinoma was identified in postchemotherapy breast resection specimens. One patient underwent a sentinel lymph node procedure, the second patient an axillary lymph node dissection, and the third patient had a core biopsy of an enlarged axillary lymph node. The patient that underwent axillary lymph node dissection had metastatic carcinoma in one of her lymph nodes. Foci of EMH consisting of myeloid, erythroid, and megakaryocytic precursors were present within the nodal parenchyma and/or subcapsular sinuses of axillary lymph nodes of all three cases. Megakaryocytes were immunoreactive with factor VIII, erythroid elements with Glycophorin and myeloid precursors with myeloperoxidase. With increasing use of neoadjuvant therapy for breast carcinoma, EMH within lymph nodes is more likely to be encountered. Hematopoietic precursors present in lymph nodes may potentially be misdiagnosed as metastatic tumor cells, particularly as lobular carcinoma or metaplastic carcinoma. Therefore, caution should be exercised when evaluating axillary lymph nodes in the clinical setting of neoadjuvant therapy for breast carcinoma.

Impact of Multifocality and Lymph Node Metastasis on the Prognosis and Management of Microinvasive Breast Cancer

There are few data on the long-term outcome of patients with microinvasive (T1mi) breast cancer. Moreover, predictors of lymph node involvement and the impact of multifocal microinvasion are not well understood. Patients with T1mi cancer, defined as tumors ≤1mm, surgically managed at our institute and who underwent axillary lymph node evaluation were identified. Specimen slides were independently reviewed. Multivariate analysis was used to identify factors predictive of lymph node involvement. Forty-five patients with T1mi cancer were identified. Median patient age was 52years, and median size of in situ disease was 4cm. Nine tumors (20.0%) had more than one focus of microinvasion. Lymph nodes metastasis were identified in 9 patients: 1 macrometastasis (2.2%), 4 micrometastases (8.9%), and 4 isolated tumor cells (8.9%). Seven of 9 patients with lymph node involvement underwent adjuvant chemotherapy. Estrogen receptor-negative invasive disease was a significant predictor of lymph node metastasis by multivariable analysis (p<0.02). There was also a trend toward lymph node involvement in patients with multifocal microinvasion compared to unifocal disease (33.3 vs. 16.7%, respectively). At a median follow-up of 83months, 3 patients (6.3%) had disease recurrence (1 local, 1 distant, 1 local and distant). All patients with recurrence initially had tumor-free lymph nodes and only one focus of microinvasion. Microinvasive breast cancer clearly has the ability to metastasize and recur, but in this series, only 2% of patients with nodal macrometastasis. Only two patients experienced local recurrence, neither of whom had lymph node metastasis. The importance of identifying nodal micrometastasis in T1mi disease needs to be further explored.

Rare Breast Cancer: 933 Adenoid Cystic Carcinomas from the National Cancer Data Base

Adenoid cystic carcinoma (ACC) is a rare subtype of breast malignancy. Patients with ACC and infiltrating ductal carcinoma (IDC) reported to the National Cancer Data Base from 1998 to 2008 were reviewed for patient age, ethnicity, tumor size, nodal status, American Joint Committee on Cancer TNM Stage, tumor grade, initial treatment, hormone receptor status (for patients from 2004 to 2008), and survival (for patients from 1998 to 2003). A total of 933 patients with ACC and 729,938 with IDC were identified. No differences were found for incidence by race/ethnicity (p = 0.97). The group with ACC was older (median 60 vs. 58 years), had larger tumors (median 18 vs. 16 mm), had more grade 1 tumors (46 vs. 18 %), was less likely to undergo axillary lymph node evaluation (75.9 vs. 96.3 %), had fewer node-positive patients (5.1 vs. 35.5 %), had fewer estrogen receptor-positive tumors (15.4 vs. 75.6 %), had fewer progesterone receptor-positive tumors (13.3 vs. 65.2 %), and underwent breast-conserving surgery more often (69.8 vs. 59.8 %). Chemotherapy was provided less often for ACC (11.3 vs. 46.4 %), as was hormone therapy (9.1 vs. 42.3 %). All of these differences were statistically significant (p < 0.0001). With a median follow-up of 65.7 months (ACC) and 64.9 months (IDC), 5-year overall survival (OS) was 88 % for ACC vs. 84 % for IDC (p = 0.02). Grade 1 OS (ACC, 91 % vs. IDC, 92 %; p = 0.50) and stage I OS (ACC, 90 % vs. IDC, 91 %; p = 0.93) were equal. Compared with IDC, ACC has different characteristics (lower grade, hormone receptor negative, node negative), is treated differently (less axillary surgery, fewer mastectomies, less chemotherapy, less hormone therapy), and has an improved prognosis, with 88 % 5-year survival.

Axillary lymph node dissection in sentinel node positive breast cancer: is it necessary?

PURPOSE OF REVIEW: Sentinel lymph node biopsy (SLNB) has become a gold standard procedure for axillary lymph node evaluation in clinically node-negative patients. In those patients with positive SLNB, completion axillary lymph node dissection (ALND) has been routely performed. Recent clinical trials suggest that ALND is not necessary in some cases, even when the sentinel lymph node (SLN) is positive. The appropriate conditions under which ALND may be eliminated are defined in this review. RECENT FINDINGS: The American College of Surgeons Oncology Group (ACOSOG) Z0011 trial studied the impact of SLNB alone versus completion axillary node dissection (AND) on survival in clinically node-negative breast cancer patients undergoing partial mastectomy and whole breast irradiation who were found to have a positive SLN on pathological evaluation. Results of this study showed no survival advantage for complete AND in patients with one or two positive SLNs. In other words, those patients appeared to be treated safely without completion AND. SUMMARY: Despite the small sample size and limited stastical power and the relatively short median follow up for ACOSOG Z0011, many breast cancer teams no longer believe it mandatory to perform axillary dissection for patients with one or two positive SLNs. The results of other prospective randomized trials called After Mapping of the Axilla: Radiotherapy Or Surgery study and International Breast Cancer Study Group trial 23-01 study will be available soon, and may further change the confidence with which ALND is performed or eliminated.

The Comparative Study of Ultrasonography, Contrast-Enhanced MRI, and18F-FDG PET/CT for Detecting Axillary Lymph Node Metastasis in T1 Breast Cancer

PurposeA more noninvasive evaluation of axillary lymph node in breast cancer is one of the principal challenges of breast cancer treatment. To detect axillary lymph node metastasis (ALNM) in T1 breast cancer, we have compared the axillary ultrasonography (AUS), contrast-enhanced magnetic resonance imaging (cMRI), and 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) to determine the most adequate test or a combination of tests.MethodsRetrospectively, 349 T1 breast cancer patients who were preoperatively examined using AUS, cMRI, and PET/CT between 2008 and 2011 and whom underwent pathological evaluations of axillary lymph nodes were reviewed and analyzed.ResultsIn total, 26.4% (92/349) of patients exhibited ALNM. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of AUS for determining ALNM were 44.6%, 88.7%, 58.6%, 81.7%, and 77.1%, respectively. cMRI was similar to AUS. The sensitivity, specificity, PPV, NPV, and accuracy of PET/CT were 44.5%, 94.2%, 73.2%, 82.6%, and 81.1%, respectively. The combination including cMRI and PET/CT was the most accurate with sensitivity, specificity, PPV, NPV, and accuracy values of 39.1%, 98.8%, 92.3%, 81.9%, and 83.1%, respectively. The mean number (3.5±4.2) of ALNMs in the patients who were positive based on cMRI and PET/CT and also pathologically proven to exhibit ALNM was significantly larger than the number (2.16±2.26) in other patients who exhibited ALNM (p=0.035).ConclusionThere are no definitive modalities for detecting ALNM in T1 breast cancers to replace sentinel lymph node biopsy (SLNB). If ALNM is suspected based on cMRI and PET/CT, the axillary dissection without SLNB might be a better option because it is related to high possibilities of ALNM and large axillary metastatic volumes.

Abstract P1-01-24: Which combinations are helpful to predict axillary lymph node metastasis in T1 breast cancer with ultrasonography and contrast-enhanced MRI and contrast-enhanced 18F-FDG PET-CT?

Abstract Backgrounds: Axillary lymph node(ALN) status has been important factor of treatment and prognosis for patients with breast cancer. Even though the better ultrasonographic instruments have been developed, it is still difficult to predict axillary lymh node metastasis (ALNM) with only ultrasonography(US) in T1 breast cancers which most of newly diagnosed breast cancers are recently since T1 breast cancers have low rate and less tumor burden of ALNM. This study evaluated the accuracy of prediction of ALNM in T1 breast cancer with US, contrast-enhanced MRI (cMRI) and contrast-enhanced 18F-FDG PET/CT (cPET/CT) and found out adequate combinations of these modalities. Method: Retrospectively, we reviewed 351 breast cancer patients with tumors(T1) ≤2cm in size between January 2008 and December 2011 who were preoperatively examined with US, cMRI, and cPET/CT and underwent pathologic evaluation of axillary lymph nodes acquired by sentinel lymph node biopsy or axillary dissection. Results: 94(26.8%) patients of 351 had ALNM. The sensitivity, specificity, positive predictive value(PPV), negative predictive value (NPV), and accuracy of ALNM with US were 0.457, 0.887, 0.597, 0.817, 0.772, respectively. cMRI had similar results with US. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of ALNM with cPET/CT were 0.447, 0.942, 0.737, 0.823, 0.809, respectively. The sensitivity if any one or more modalities were suspicious was 0.563. The specificity if all modalities were suspicious was 0.992. The PPV if cMRI and cPET/CT were suspicious was highest than if other combinations were suspicious. Conclusion: US, cMRI, and cPET/CT are helpful in prediction of ALNM of T1 breast cancers. However, there are no definite modality and combination of modalites to predict ALNM of T1 breast cancers. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-01-24.

Comparison of the Diagnostic Value of FDG-PET/CT and Axillary Ultrasound for the Detection of Lymph Node Metastases in Breast Cancer Patients

FDG-PET/CT is increasingly being used for breast cancer staging. Its diagnostic accuracy in comparison to ultrasound as the standard non-invasive imaging modality for the evaluation of axillary lymph nodes has yet not been evaluated. To retrospectively compare the diagnostic value of full-dose, intravenously contrast-enhanced FDG-PET/CT and ultrasound for the detection of lymph node metastases in breast cancer patients. Ninety patients (one patient with a bilateral carcinoma) (89 women, one man; mean age, 55.5 +/- 16.6 years) suffering from primary breast cancer underwent whole-body FDG-PET/CT and axillary ultrasound. The ipsilateral axillary fossa (n = 91) was evaluated for metastatic spread. The sensitivity, specificity, the positive predictive value (PPV), negative predictive value (NPV), and accuracy of both methods were calculated. The sensitivity and accuracy were statistically compared using the McNemar Test (P <0.05). Analyses were made on a patient basis. The number of patients with extra-axillary locoregional lymph node metastases exclusively detected by FDG-PET/CT was evaluated. For axillary lymph node metastases histopathology served as the reference standard. The sensitivity, specificity, PPV, NPV, and accuracy of FDG-PET/CT for the detection of axillary lymph node metastases were 54%, 89%, 77%, 74%, and 75%, respectively. For ultrasound it was 38%, 78%, 54%, 65%, and 62%, respectively. FDG-PET/CT was significantly more accurate than ultrasound for the detection of axillary lymph node metastases (P = 0.019). There was no statistically significant difference between the sensitivity of both modalities (P = 0.0578). FDG-PET/CT detected extra-axillary locoregional lymph node metastases in seven patients (8%) that had not been detected by another imaging modality. Though more accurate compared to ultrasound for evaluating the axillary lymph node status FDG-PET/CT is only as sensitive as ultrasound when it comes to the detection of axillary lymph node metastases. Due to the low sensitivity FDG-PET/CT cannot act as a substitute for Sentinel lymph node biopsy. FDG-PET/CT is able to detect previously unknown locoregional extra-axillary lymph node metastases.

Intraoperative frozen section assessment in the evaluation of axillary sentinel lymph node in breast cancer

INTRODUCTION: Intraoperative frozen section analysis has become a routine procedure to evaluate the status of axillary sentinel lymph nodes in breast cancer. OBJECTIVES: To evaluate the accuracy and sensitivity of FS in the detection of metastases in axillary sentinel lymph nodes and to investigate the predictive value of variables such as patients' age, tumor staging, histology, grade, and estrogen receptor expression. MATERIAL AND METHODS: We analyzed retrospectively the results of 177 FS procedures. The patients' age and tumor characteristics were organized in a database and the association with the presence of metastases was analyzed. RESULTS: Metastases were detected in 22 cases (12%). All macrometastases and one micrometastasis were detected by FS. Additional micrometastases were detected in post-operative analysis, from which five were determined by hematoxylin and eosin staining (H) and three by immunohistochemistry (IHC). FS diagnosis data proved to have an overall accuracy of 95%, sensitivity of 64%, and specificity of 100%. None of the analyzed variables showed significant association with lymph node metastases. CONCLUSION: Our results show that intraoperative FS is a highly accurate and sensitive method to detect macrometastases. However, it is inaccurate in the detection of micrometastases. The use of IHC improves the detection of micrometastases in postoperative analyses. The patient's age and tumor characteristics such as staging, histology, grade and estrogen receptor expression have low predictive value for lymph node metastasis in breast cancer.

Role of Ultrasound and Ultrasound-Guided Fine-Needle Aspiration Cytology for Axillary Lymph Node Evaluation in Breast Cancer Patients: Correlation with Primary Tumor Size and Positive Lymph Node Number

Objectives: To evaluate the efficacy of ultrasound (US) and US-guided fine-needle aspiration (US-FNA) for axillary nodal staging in breast cancer patients. Methods: A retrospective study of breast cancer patients at our institution from January 2007 to December 2009 revealed 449 cases in which axillary US was performed. The US appearance of the axillary lymph nodes was divided into 4 categories: suspicious, borderline, benign, and not visible. The results were compared with the final pathologic outcome and correlated with the tumor size on US and the pathologic nodal stage (pN). Results: Among the 449 patients, the lymph nodes were: not visualized in 124, suspicious in 180, borderline in 39, and benign in 106 cases. The overall sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of US alone and combined US/US-FNA was 69.1%, 83.3%, 86.8%, 63%, and 74.6% and 69.1%, 100%, 100%, 67.2%, and 81.1%, respectively. The sensitivity of US increased with increasing tumor size and pN. A negative or benign US (combined n = 230) was associated with the pN0, pN1, pN2, and pN3 stage in 146, 66, 13, and 5 cases, respectively. Conclusions: Axillary staging using US criteria is about 70% sensitive and its sensitivity increases with increasing tumor size and pN stage.

Preoperative Needle Biopsy Improves the Quality of Breast Cancer Surgery

Percutaneous needle biopsy has the potential to provide a preoperative diagnosis of breast cancer, which helps to optimize surgical planning; however, its use remains an area of unexplained clinical variation. The purposes of this study were to perform a statewide assessment of diagnostic biopsy methods for women diagnosed with breast cancer and to evaluate the impact of biopsy method on the quality of breast cancer surgery. Vermont cancer registries were combined with Medicare data to identify women diagnosed with breast cancer between 1998 and 2006. Demographics, margin status, surgical evaluation of axillary nodes, and total number of operations were correlated to biopsy method. Percutaneous needle biopsy (PNB) was the initial biopsy method in 713 (62.8%) patients, and it increased significantly over the study period. Patients living in urban settings were more likely to receive PNB (70.6%) than patients living in rural areas (57.5%). Breast cancer surgery performance metrics including margin status, number of operations, and performance of axillary evaluation significantly favored PNB over open biopsy (OB). The quality of breast cancer surgery as measured by initial margin status, total number of operations, and axillary evaluation improved with preoperative PNB; however, the use of PNB varied considerably. The potential impact of PNB on the quality of patient care and health care costs is substantial. Emphasis should be placed on understanding the barriers to the use of preoperative PNB and developing strategies to expand its use in the management of breast cancer.

Post-neoadjuvant chemotherapy sentinel node biopsy and axillary sampling for node negative (N0) axilla.

1108 Background: Post neoadjuvant chemotherapy (NACT) sentinel node biopsy (SNB) is not a standard of care due to the wide variability in false negative rate (FNR), varying from 5.7% to 33%. In operable breast cancer (OBC), FNR of less than 10% is acceptable. We attempted to find out the reliability of low axillary sampling(LAS), with dissection limited below the first intercostobrachial nerve, to correctly identify the node negative axilla in the post NACT clinically node negative (N0) patients. Methods: Women with large operable (LOBC) and locally advanced breast cancer (LABC), post-NACT clinically N0, underwent concomitant blue dye-colloid guided SNB and LAS. The identification rate, FNR, and negative predictive value (NPV) of both procedures were compared. Results: Post-NACT 209 eligible women underwent combined LAS and SNB procedure. At presentation, the tumors were large (median 5.0 cm) with 70% clinically palpable nodes. All patients received 4 cycles of neo-adjuvant anthracycline-based chemotherapy and were clinically node negative after chemotherapy. SNB was defined as blue and/or hot node plus palpable node(s). A blue or hot node (median 2 nodes) was identified in 93.8%, and median of 5 sentinel nodes were removed. The false negative rate of SNB was 15.3% (95% CI 8.7%-25.3%). The LAS technique comparatively had nodal yield in 98.5% with median 8 nodes removed; and FNR 8.5% (95% CI, 4.2%-16.6%, p=0.19). Comparative NPV for LAS and SNB were 94.6% and 91.8% respectively. Conclusions: Axillary sampling results for FNR and NPV are similar if not superior to SNB and could be a reliable method of axillary nodal evaluation in advanced breast cancers following neo-adjuvant chemotherapy.

Evaluation of Ultrasound-Guided Fine Needle Aspiration of Axillary Nodes in Breast Cancer Patients With Indicated Sentinel Node Biopsy

The status of axillary lymph nodes is an important prognostic factor of breast cancer with impact on the choice of treatment and survival of patients. In the absence of distant metastasis axillary status represents one of the most important prognostic factors in assessing the patient with breast cancer. The evolution of surgical treatment of breast cancer, including in relation to axillary approach, contributed to the reduction of morbidity of treatment. The technique of sentinel lymph node biopsy (SLNB) became increasingly common practice replacing the complete axillary lymphadenectomy (AL) in evaluation of axillary lymph nodes. The preoperative diagnosis of axillary metastases may prevent the realization of the SLNB and the patient goes directly to the AL. This is a cross-sectional and prospective study aiming to analyze the use of ultrasound guided fine needle aspiration (FNA) for axillary lymph nodes and to determine the usefulness of this method in the preoperative staging of breast cancer patients candidates for SLNB. Ultrasound guided FNA were performed in 40 patients who had axillary lymph nodes with ultrasonography alterations suspected of malignancy, in a total of 41axillaes studied. Patients with malignant cytology avoided SLNB and were submitted directly to AL, patients with negative cytology held SLNB. The histological findings were compared with the results of ultrasound guided FNA. In evaluating FNA cytology, 18 (43.90%) patients presented cytology compatible with malignancy and 23 (56.10%) were benign. Comparing with the findings of the axillaries surgeries the axillary ultrasound guided FNA demonstrated a sensitivity of 81.8%, specificity of 100%, positive predictive value (PPV) of 100%, negative predictive value (NPV) of 82.6% and 90,2% of accuracy. The data demonstrate that the technique is an effective procedure in preoperative assessment in patients with breast cancer, selecting the treatment and saving costs and time.

Comparing touch imprint cytology, frozen section analysis, and cytokeratin immunostaining for intraoperative evaluation of axillary sentinel lymph nodes in breast cancer

Sentinel lymph node (SLN) biopsy has been applied to the management of breast carcinoma inorder to decrease postoperative complication and morbidity. Touch imprint cytology (TIC), frozen section (FS), scrape cytology, or combination of these methods are used as intraoperative diagnostic methods. However, the sensitivity of these intraoperative modalities for detecting metastatic disease in SLNs is not equivalent to permanent histopathologic examination as a gold standard method. The aim of this study was to review our department's results with SLN biopsy using touch imprint and frozen section for intraoperative diagnosis of breast cancer metastasis. Immunohistochemistry for cytokeratin was used on permanent sections. The sensitivities and specificities of TIC with those of FS analysis and IHC were also compared. A total of 100 consecutive SLN biopsies from 49 patients performed. The TIC and subsequently frozen were stained using hematoxylin and eosin. The cytological and frozen findings were compared and results were reported to the surgeon during operation. Final pathologic evaluation was performed on the formalin-fixed, paraffin-embedded tissue sections. Analysis of the permanent tissue included evaluation of three-step sections of the lymph node by H&E and immunohistochemical (IHC) staining. The sensitivities, specificities, positive and negative predictive values of TIC, FS and IHC for the detection of metastatic tumor in the SLNs were determined with the corresponding 95% confidence intervals (CIs). One hundred SLNs were examined from 49 patients with invasive breast carcinoma with mean age of 45.29 ° 10.6 years. Intraoperative TIC and FS failed to show metastatic involvement in 10 examined lymph nodes from three patients. No false positive results for TIC and FS was identified. The sensitivity of TIC compared with the final histopathological result, considered the gold standard, was 90% (CI, 68.49-98.81%). Similarly, the sensitivities of frozen sections and permanent were the same respectively. The specificities of TIC, FS, and permanent were 100% (CI, 94.95-100.00). The sensitivity of touch imprint cytology compared with the final histopathological result, considered the gold standard, was 90% (CI, 68.49--98.81%). Similarly, the sensitivities of frozen sections and permanent were the same respectively. The specificities of TIC, FS, and permanent were 100% (CI, 94.95-100.00). Our experience with TI and FS for the intraoperative evaluation of SLNs is similar to the findings from previously reported studies. We detected the same sensitivities for these two methods; however lower sensitivity of TI in detecting metastasis with higher false-negative rate has been addressed in the published literature. The 90% sensitivity of TI and FS with permanent histopathologic examination as the gold standard falls within the range of reported sensitivities: 33-96% for TI and 44-100% for FS. However, variations in patient selection criteria, experience of the pathologist, skill of the technician submitting specimen for intraoperative evaluation, and tumor size are important variables that influence the results.

P4-18-05: Ductal Carcinoma In Situ with Microinvasion: Clinical and Pathological Characteristics, Treatments and Outcomes.

Abstract Background: Ductal carcinoma in situ with microinvasion (DCISM) is a rising rare entity. Because of that and its controversial pathological definition, there is a lack of clear recommendations for treatment. The purpose of this study was to describe the clinical and pathological characteristics, treatments and outcomes of our single institutional experience. Patients and methods: Individual clinical and pathological data were collected from 63 women, diagnosed and treated for DCISM at the Claudius Regaud Cancer Hospital between January 2000 and April 2010. All available histological material (45 patients) was reviewed by an expert pathologist. Results: The median age was 56 years (range 34–83). Seven patients (11.5%) had a personal history of DCIS, 27 patients (42%) a familial history of breast cancer. Fourteen patients (22%) had a clinical sign at the diagnosis. Fifty one patients were mammographically detected (81%). All the patients underwent surgery, mastectomy for 17 patients (27.4%) and conservative surgery for 45 (72.6%). Secondary surgery of the breast was required for 21 patients (46.6%) after conservative surgery, enlarging surgery (N=13) or mastectomy (N=8). Surgical axillary lymph node evaluation was performed on 52 patients (82,5%), axillary dissection alone for 10 patients, sentinel node biopsy alone for 37 patients and the 2 methods for 5 patients. The median size of the DCIS was 16mm (6-80mm) with 37/60 (61.7%) grade III Van Nuys classification. The most histological subtype was comedo carcinoma (68%). Concerning the 45 reviewed biopsies, the size of the microinvasive component was ≤ 1mm for 38 lesions and between 1 and 2 mm for 7 lesions. Hormonal receptor status was positive for 29 (64.4%), 27 (64.3%) for estrogen receptors and 20 (44.4%) for progesterone receptors. HER 2 status was performed for 34 patients, among 12 (35%) of them were found overexpressed on the microinvasive component. Lymph node invasion was found among 2 of the 52 patients (3.8 %) who underwent axillary lymph node evaluation. Radiation therapy was delivered to all the patients after conservative surgery (n=37)(50 Gy with a 10 Gy boost for 22 of them) and 2 after mastectomy (chest wall irradiation (50 Gy)). Adjuvant hormonotherapy was delivered on 11 patients (18%). With a median follow-up of 36,4 months (95%CI=[27.7- 44.16]), 62 patients are alive at the last follow-up and 58/63 free of disease (2 relapses and 3 second cancers).The 3 year disease free survival rate was 91.1 (95%CI=[78.1;96.6] ). During follow-up, two local relapses occurred on patients treated by mastectomy. One of them had local invasive relapse at 43 months and she is still NED after 90 months. The second patient who had local invasive carcinoma with axillary node invasion at 32 months treated by conservative surgery, axillary dissection, radiotherapy and chemotherapy, had metastasis at 51 months and passed away after 70 months. Conclusion: Mammographic screening programmes increase the rate of small diagnosed tumours, specially DCISM. Despite a priori good prognostic outcome, 2 axillary node involvements and 2 delayed relapses were observed. So, this kind of presentation deserves better evaluation of relapse risk factors to determine adapted adjuvant therapies. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-18-05.

P3-07-32: The Role of Axillary Ultrasound in the Detection of Metastases from Primary Breast Cancers.

Abstract Background: The value of ultrasound (US) in the preoperative evaluation of axillary nodes has yet to be completely clarified. Preliminary experience with this technique in our institution was examined. Methods: Patients with a radiographic or palpable abnormality of the breast had simultaneous breast and axillary US. The exams were performed by dedicated breast radiologists using a 12 MHz linear array transducer (HDI 5000: Philips Ultrasound). Results were reviewed for all patients with invasive cancers who were cN0 and had definitive surgical procedures between June 2006 and May 2008. Criteria for abnormal lymph nodes were loss of reniform shape, focal or diffuse cortical thickening, or eccentric/replaced fatty hilum. US-guided biopsies were done using a 16g spring-loaded core biopsy device (16g MD TECH SuperCore). Patients with positive axillary node biopsies bypassed sentinel lymph node biopsy (SLNB) and had axillary dissection, whereas those with sonographically normal nodes or benign/non-diagnostic biopsy results had SLNB at the time of definitive surgery. Results: Of 128 patients diagnosed with invasive cancer, 23 (18%) had abnormal axillary US at the time of initial diagnosis. Biopsies were performed in 18 of the 23, of which 12 (67%) were malignant and 6 (33%) were benign. Ultrasounds were negative in 105 (82%) patients. SLNB was done in 110 patients: 103 with negative US; 4 patients with abnormal US but negative axillary biopsies; 2 patients with abnormal US but no core biopsies; and 1 patient with a positive US biopsy. SLNB was negative in 91 (83%) patients and positive in 19 (17%). The node-positive status was N1a in 14 patients and N1mic in 5. Axillary dissection was done in 32 (25%) of 128 patients, comprised of 11 patients with US-guided positive biopsies, 12 with positive sentinel nodes, 2 with US-guided negative biopsies, 2 with negative ultrasounds, 3 with unbiospied abnormal ultrasounds, and 2 with a false-negative SLNB. For determining axillary metastases with US, sensitivity was 16/31 (52%), specificity was 90/97 (93%), positive predictive value was 16/23 (69%), and negative predictive value was 90/105 (86%). Conclusions: US examination was a valuable method of evaluating the axilla in newly diagnosed breast cancers. Of 32 patients having an axillary dissection, abnormal US eliminated the need for SLNB in 17 (53%). Patients with US-guided positive nodes were submitted to axillary dissection without SLNB. Therefore, we were unable to determine how often US identified an abnormal non-sentinel node, thus upstaging the axilla relative to SLNB alone. This question should be the topic of further clinical study. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-32.

The Utility of Axillary Nodal Evaluation in Women with Ductal Carcinoma In Situ of the Breast with Microinvasion

The utility of axillary nodal evaluation in patients with ductal carcinoma in situ of the breast with microinvasion (DCISM) is unclear. Some studies have shown a 6-28% risk of axillary nodal involvement in these patients but others have shown no axillary involvement. In view of this uncertainty, we sought to investigate the risk of nodal involvement in a large cohort of patients treated with breast conserving therapy at a single institution.

Occult axillary lymph node metastases do not have prognostic significance in early stage breast cancer.

Axillary lymph node status is one of the most powerful prognostic indicators in patients with breast cancer and has implications for adjuvant treatment. It has been demonstrated that enhanced histologic evaluation of axillary lymph nodes, including serial sectioning of paraffin tissue blocks and immunohistochemical (IHC) staining, increases the rate of detection of occult metastases. The clinical significance of occult lymph node metastases has been the subject of debate. In the current study, the authors identified 267 patients who underwent axillary lymph node dissection (ALND) between 1987 and 1995 and were lymph node negative according to a routine pathologic evaluation, which included the complete submission of all lymph nodes and an examination of 1 hematoxylin and eosin (H&E)-stained section per paraffin block. Patients did not receive systemic chemotherapy or hormone therapy. All of the dissected lymph nodes from these patients were re-evaluated by intensified pathologic methods (serial sectioning with H&E levels plus IHC). Occult metastases were categorized by detection method and size. The clinical significance of the occult metastases was determined. Thirty-nine patients (15%) who had lymph node-negative results on routine evaluation of their ALND specimens had occult metastases identified. Eight of these patients (20%) had macrometastases >2.0 mm, 15 (40%) had micrometastases (range, >0.2 mm to ≤2 mm), and 16 (40%) had isolated tumor cells (≤0.2 mm). The presence of occult metastases and the size of metastases did not affect recurrence-free or overall survival. The presence of occult metastasis did not have clinical significance in this cohort of patients with early stage breast cancer.