Preoperative Axillary Ultrasound Research Articles

Abstract P1-01-08: Diagnostic accuracy of pre-operative ultrasonographic evaluation of axillary lymph nodes in breast cancer patients: Is there a place for axillary ultrasonography in future nomograms?

Abstract Background During the years there has been a significant interest in the development of clinical prediction tools to estimate the risk of having positive lymph nodes in the axilla, and thereby making it possible to plan specific therapies. A non-invasive and widely available method is axillary ultrasonography. Aim The purpose of this study was to evaluate the diagnostic accuracy of axillary ultrasonography. Patients and methods Between January 2007 and July 2011, pre-operative axillary ultrasonography was performed in 1124 consecutive primary breast cancer patients who underwent surgery with sentinel node biopsy (SNB) and/or complete axillary lymph node dissection (ALND). Suspected lymph nodes (cortex thickness > 2.3 mm) were further analysed by cytology or histology. In case of a negative axillary ultrasonography, standard SNB was performed during operation. In case of suspected lymph nodes with axillary ultrasonography, confirmed by biopsy, routine complete ALND was performed. Results Of the 1124 patients, 922 (82%) had unsuspected lymph nodes and 202 (18%) had suspicious lymph nodes during axillary ultrasonography. The sensitivity and specificity of axillary ultrasonography was 46.6% and 93.0% respectively in case of a macrometastases. In all cases of suspected malignancy, axillary core biopsy was performed. The sensitivity and specificity of axillary ultrasonography in combination with core biopsy was 40.5% and 97.2% respectively. With increasing number of axillary nodes the sensitivity increases: 53.9% in case of 2 macrometastases and 83.3% in case of 3 macrometastases. Conclusion Ultrasonography and core biopsy are effective in predicting the presence of axillary metastases in breast cancer patients. Especially the high specificity might be of additional value for future nomograms in the surgical treatment of breast cancer patients. In addition, the sensitivity is of greater value in case of gross nodal disease. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-08.

Audit on clinical coding of breast surgery clinic outcomes

Audit on clinical coding of breast surgery clinic outcomes

Risk Stratification of Patients With Early Breast Cancer

BackgroundSentinel lymph node biopsy (SLNB) is the standard procedure performed to stage the axillae, and axillary node clearance (ANC) or radiotherapy is the treatment for nodal involvement. The aims of this study were to assess (1) the role of preoperative axillary ultrasonography (US), (2) the number of positive lymph nodes on ANC after either positive SLNB results or preoperative ultrasonographically guided nodal biopsy, and (3) the role of ANC in patients with node-positive breast cancer. Patients and MethodsAll patients with invasive breast cancer and axillary node involvement (but clinically negative nodes on presentation) who underwent ANC between January 2008 and December 2009 were identified, and information regarding clinicopathologic parameters and the nodal yield was collected. ANC was performed for 3 groups: patients with micrometastasis seen in SLNB specimens, macrometastasis seen in SLNB specimens, and positive axillary nodes detected on US biopsy. ResultsANC was performed 141 times over the 2-year period. Forty-two percent of axillary node involvement was diagnosed by biopsy or preoperative US, and 40% of these patients received neoadjuvant chemotherapy. The remainder of cases were diagnosed by SLNB: 30% had micrometastases and 70% had macrometastases. Fifty percent of cancers with an ultrasonographic diagnosis of lymph node involvement were high grade and 56% had 4 or more positive nodes on ANC; this was significantly higher than in patients with positive SLNB results (P = .0001). Only 20% of patients with macrometastases on SLNB had 4 or more positive nodes in comparison with 56% with positive axillary lymph nodes by US (P < .0001). ConclusionThe routine use of preoperative axillary US and biopsy of abnormal nodes helps in identifying high-risk patients and thus aids in planning treatment.

Preoperative axillary imaging with percutaneous lymph node biopsy is valuable in the contemporary management of patients with breast cancer

ACOSOG Z11 and other studies showing little benefit to axillary dissection (ALND) for early-stage breast cancers with limited nodal disease have led to questioning the value of preoperative axillary imaging ± ultrasound-guided needle biopsy (USNB). Data are lacking on the value of this approach in identifying cases that fall outside Z11 guidelines. We studied 988 consecutive patients with invasive breast cancers who underwent operation including axillary surgery in 2010-2011. Preoperative axillary ultrasonography (AUS) was performed in 92% and breast/axillary magnetic resonance imaging (MRI) in 51%; 82 (33.5%) of 245 patients with suspicious lymph nodes (LN) were USNB-positive. Regarding nodal status, AUS, MRI, and USNB had negative and positive predictive values of 78%, 76%, 70% and 54%, 58%, 100%, respectively. AUS/MRI visualization of one versus multiple abnormal LNs visualized predicted >2LN+ on final pathology (13.5%/15.1% % vs 30.8%/32.6%, P < .009). Among USNB-LN+ T1/T2 patients, 51.6% had 1-2 LN+ while 60% with multiple and 31% with one AUS-abnormal LN(s) had > 2LN+, P = .001. In our contemporary series, preoperative AUS±USNB streamlined surgical care for 29% of node-positive patients. Two-thirds of T1/T2 USNB-LN+ patients with multiple AUS-suspicious LNs had >2LN+, suggesting they should undergo ALND without SLNB. AUS±USNB helps identify node-positive breast cancer patients who fall outside Z11 guidelines.

Preoperative Axillary Ultrasound in Breast Cancer: Safely Avoiding Frozen Section of Sentinel Lymph Nodes in Breast-Conserving Surgery

The American College of Surgeons Oncology Group Z0011 trial results provided convincing evidence that completion axillary lymph node dissection (CALND) was unnecessary in selected patients with 1 to 2 positive sentinel lymph nodes (SLNs). We hypothesized that preoperative axillary ultrasound (AUS) with fine-needle aspiration is sufficiently sensitive to detect worrisome macrometastasis to preclude the need for frozen-section pathology of SLNs. We conducted a retrospective single-institution study at a tertiary academic referral center. Atotal of 1,140 T1 to 2 breast cancer patients who underwent SLN biopsy with or without CALND from January 1, 2007 to December 31, 2010 were reviewed. All patients had negative preoperative AUS with or without fine-needle aspiration. One hundred forty-four (13%) patients were node positive at surgery. Mean age, tumor size, histology, and estrogen receptor and progesterone receptor status were similar comparing 996 SLN-negative with 144 (13%) SLN-positive patients. Of the SLN-positive patients, 25% were premenopausal, 9% were estrogen receptor-negative, and 19% had additional lymph nodes at CALND. Only 19 (2%) patients had SLN metastasis ≥6 mm, 10 (1%) had metastasis >7 mm, and only 1 patient had ≥3 positive SLNs. The addition of preoperative AUS with or without fine-needle aspiration to management of patients who meet American College of Surgeons Oncology Group Z0011 trial eligibility criteria reduced the risk of macrometastasis measuring ≥6 mm to only 2%; very few of these patients would be premenopausal, have estrogen receptor-negative tumors, or ≥3 positive SLNs. With the addition of AUS with or without fine-needle aspiration, we endorse the conclusions of the American College of Surgeons Oncology Group Z0011 trial to avoid CALND, and see marginal gain in frozen-section analysis of SLNs.

MRI for the pre-operative workup of invasive lobular breast cancer: Change in diagnosis

MRI for the pre-operative workup of invasive lobular breast cancer: Change in diagnosis

Abstract P1-01-22: The utility of axillary ultrasound and sentinel lymph node biopsy in the management of metaplastic breast carcinoma

Abstract Background: Metaplastic breast carcinoma (MBC) accounts for &amp;lt;5% of all breast malignancies. This entity represents a heterogenous group of tumors in which the adenocarcinomatous element is admixed with one or more neoplastic mesenchymal (spindle, squamous, chondroid, or osseous) elements. Patients typically present with large triple negative tumors and have a poor prognosis. The likelihood of lymph node (LN) involvement has been reported to be low in MBC patients. Due to the paucity of data, we undertook this study to explore the role of axillary ultrasound (US) and sentinel LN biopsy (SLNB) in the management of MBC. Methods: With IRB approval, we retrospectively identified patients diagnosed with MBC from 2001–2011 from the surgical pathology database. Histopathology and imaging were reviewed. Demographic, treatment and outcome data were obtained by clinical chart review. Data were analyzed using JMP 9.0 software. Results: We identified 41 women with MBC. Median age was 60 years (range 33–90). Histologic subtypes were spindle cell (46%), mixed adenocarcinoma and mesenchymal elements (20%), squamous cell (17%) chondroid/osseous (10%) and adenosquamous (7%). Tumor stage was T1 (24%), T2 (44%), T3 (12%) and T4 (20%). 26 patients (63%) were treated by mastectomy and 15 (37%) by wide excision. Of the 38 patients who underwent LN surgery (6 low-grade MBC, 32 intermediate/high-grade MBC), 10 (26%) were LN positive. All low-grade MBC patients were LN negative while 10 of 32 intermediate/high-grade MBC patients (31%) had LN metastasis. 22 patients had a preoperative axillary US. 14 patients had a negative axillary US and none had LN metastasis. 4 of 8 patients with suspicious axillary US findings had a preoperative axillary LN fine needle aspiration biopsy (FNAB) and 3 were positive for cancer. These patients proceeded directly to axillary LN dissection (ALND). 24 patients had a SLNB of whom one was SLN positive and underwent completion ALND. LN metastasis was associated with larger tumor size (p = 0.003), higher tumor grade (p = 0.04), angioinvasion (p = 0.07) and abnormal axillary US (p = 0.003). Surviving patients were followed for a mean (median) of 41 (30) months during which 13 (32%) recurred at a median of 6 months (IQR 3–17 months) and 11 (27%) subsequently died of disease. One SLN negative patient developed an axillary recurrence at 8 months, was successfully treated by ALND and is disease-free at 38 months. There were no axillary LN relapses after ALND. Conclusions: For clinically node-negative MBC patients, our contemporary data series suggests the incidence of occult LN metastasis is sufficiently high to warrant LN staging especially for patients with intermediate and high-grade tumors. This can be accomplished in a minimally invasive fashion with reasonable accuracy (∼97%) with axillary US, FNAB of sonographically suspicious LNs, and SLNB for patients with negative axillary US or FNAB. Axillary LND should be performed for patients with clinically and/or FNAB-positive LN for enhanced disease control. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-01-22.

Influence of Tumor Histology on Preoperative Staging Accuracy of Breast Metastases to the Axilla

Histologic confirmation of axillary nodal metastases preoperatively avoids a sentinel node biopsy and enables a one step surgical procedure. The aim of this study was to establish the local positive predictive value of axillary ultrasound (AUS) and guided needle core biopsy (NCB) in axillary staging of breast cancer, and to identify factors influencing yield. A prospective audit of 142 consecutive patients (screening and symptomatic) presenting from 1st December 2008-31st May 2009 with breast lesions categorized R4-R5, who underwent a preoperative AUS, and proceeded to surgery was undertaken. Ultrasound-guided NCB was performed on nodes radiologically classified R3-R5. Lymph node size, number, and morphological features were documented. Yield was correlated with tumor size, grade, and histologic type. AUS/NCB was correlated with post surgical pathologic findings to determine sensitivity, specificity, positive and negative predictive value of AUS and NCB. A total of 142 patients underwent surgery, of whom 52 (37%) had lymph node metastases on histology. All had a preoperative AUS, 51 (36%) had abnormal ultrasound findings. 46 (90%) underwent axillary node NCB of which 24 (52%) were positive. The smallest tumor size associated with positive nodes at surgery was 11.5 mm. The sensitivity of AUS was 65%. Specificity was 81%, with a positive predictive value (PPV) of 67% and negative predictive (NPV) value of 80%. Sensitivity of U/S-guided NCB was 75%, with a specificity of 100%, PPV 100% and NPV 64%. Sensitivity of AUS for lobular carcinoma was 36% versus 76% for all other histologies. Sensitivity of NCB for lobular cancer was 33% versus 79% for all other histologies. The most significant factor producing discordance between preoperative AUS and definitive histologic evidence of lymph node metastasis was tumor type. Accurate preoperative lymph node staging was prejudiced by lobular histology (p < 0.0019).

False Negative Results of Preoperative Axillary Ultrasound in Patients with Invasive Breast Cancer: Correlations with Clinicopathologic Findings

The purpose of this study was to investigate false-negative results of preoperative axillary ultrasound (US) and to evaluate clinicopathologic factors related to false-negative results in patients with invasive breast cancer. Four-hundred eighty-two patients with 483 invasive breast cancers who had no suspicious findings on preoperative axillary US were included in this study. All patients underwent sentinel lymph node biopsy (SLNB) or axillary lymph node dissection. False-negative and true-negative results were compared in terms of age, body mass index (BMI), T-stage, pathologic N-stage and final diagnosis of breast cancer. Statistical analyses were performed using the chi-square or Fisher's exact tests. Of the 483 axillae with negative results on axillary US, 93 axillae of 93 patients showed false-negative results and the negative predictive value of axillary US was 80.8% (390/483). Seventy-five axillae (15.5%, 75/483) had N1 and 18 axillae (3.7%, 18/483) had N2 or N3 disease. Eighteen false-negative results with N2/N3 disease showed a significantly higher T stage (T2/T3) than those with N1 disease. As the T-stage increased, false-negative results were found more often on preoperative axillary US (p < 0.05). Age, BMI and final diagnosis of primary breast cancer were not associated with false-negative results on preoperative axillary US. Preoperative axillary US alone is insufficiently specific to obviate the need for SLNB because of the substantial number of false-negative results in patients with invasive breast cancer, although preoperative axillary US alone may exclude most cases of N2 and N3 disease.

Should axillary ultrasound be used in patients with a preoperative diagnosis of ductal carcinoma in situ?

BackgroundWe evaluated the usefulness of axillary ultrasound (US) in patients with core biopsy–proven ductal carcinoma in situ (DCIS). MethodsPreoperative axillary US, fine-needle aspiration (FNA), and sentinel lymph node (SLN) data from women with DCIS were reviewed. ResultsEighty-two women with DCIS underwent axillary US. In 16 women (19.5%) US was abnormal; however, FNA was negative in all cases. Sixty-one women (74%) underwent SLN surgery; 2 were positive for macrometastasis (3%) and 1 had isolated tumor cells. None of them had an abnormal US. Axillary US did not change the management in any of the cases. ConclusionsAxillary US and FNA did not change the management in any of the 82 cases. In women with a core biopsy diagnosis of DCIS, positive nodes are uncommon and unlikely to be detected by axillary US. Routine preoperative axillary US is not recommended for pure DCIS on core biopsy.

Improving the service for patients with benign breast biopsy Results: lessons learnt from a busy District General Hospital

Improving the service for patients with benign breast biopsy Results: lessons learnt from a busy District General Hospital

Clinical utility of routine pre-operative axillary ultrasound and fine needle aspiration cytology in patient selection for sentinel lymph node biopsy

In patients with operable breast cancer, pre-operative evaluation of the axilla may be of use in the selection of appropriate axillary surgery. Pre-operative axillary ultrasound (US) and fine needle aspiration cytology (FNAC) assessments have become routine practice in many breast units, although the evidence base is still gathering. This study assessed the clinical utility of US+/−FNAC in patient selection for either axillary node clearance (ANC) or sentinel lymph node biopsy (SLNB) in patients undergoing surgery for operable breast cancer.Over a two-year period, 348 patients with a clinically negative axilla underwent axillary US. 67 patients with suspicious nodes on US also underwent FNAC. The sensitivity and specificity of axillary investigations to determine nodal involvement were 56% (confidence interval: 47–64%) and 90% (84–93%) for US alone, and 76% (61–87%) and 100% (65–100%) for FNAC combined with US, respectively. With a positive US, the post-test probability was 78%. A negative US carried a post-test probability of 25%. When FNAC was positive, the post-test probability was greater than unity. A negative FNAC yielded a post-test probability of 52%.All patients with positive FNAC and most patients with suspicious US were listed for axillary node clearance (ANC) after consideration at the multi-disciplinary team (MDT) meeting. With pre-operative axillary US+/−FNAC, 20% of patients were saved a potential second axillary procedure, facilitating a reduction in the overall re-operation rate to 12%.In this study, a positive pre-operative US+/−FNAC directs patients towards ANC. When the result is negative, other clinico-pathological factors need to be taken into account in the selection of the appropriate axillary procedure.

Axillary ultrasonography and fine needle aspiration as a method of routine preoperative staging for patients with invasive breast cancer in the Edinburgh Breast Unit

Introduction: Sentinel node biopsy (SNB) has become routine for axillary staging in patients with invasive breast cancer. Despite reducing the number of patients who undergo axillary node clearance (ANC), a number of patients still undergo both SNB and delayed ANC. Preoperative axillary ultrasonography (AUS) and fine needle aspiration (FNA) of suspicious nodes can be used to identify patients with axillary metastases who can proceed directly to ANC. The aim of this study was to assess the use of AUS FNA as a means of routine preoperative staging of the axilla in patients with invasive breast cancer in our unit.

Consequences of Axillary Ultrasound in Patients with T2 or Greater Invasive Breast Cancers

Background. Axillary ultrasound (AUS) with needle biopsy is used to detect metastasis in patients with invasive breast cancers. Our hypothesis is that preoperative AUS significantly reduces sentinel node biopsy (SLNB) use in patients with invasive breast tumors >2 cm upon clinical examination. Methods. A single-institution database of patients with breast cancer and AUS was reviewed. Patients with incomplete records, clinical tumor <2 cm, or postoperative AUS were excluded. A control cohort of non-AUS patients with clinical T2 (cT2) or greater disease was identified. Clinicopathologic data were collected. Simple Kappa coefficient and chi-square statistical analyses were performed. Results. AUS was performed in 153 patients vs. 370 controls. Of AUS patients, 112 (73.2%) had cT2 disease vs. 272 (73.5%) controls. Median AUS patient age was 53.7 (range, 22.8–85.8) years vs. 53.8 (range, 26.7–91.6) years; median pathologic tumor was 3.8 (range, 1.0–20.0) cm in AUS patients vs. 2.5 (range, 0.1–11.0) cm. Among AUS patients, 78% had needle biopsy; 85 of 120 (70.8%) were positive. Sixty-eight patients had SLNB: 33 after negative AUS and 35 after negative needle biopsy. Twenty-three SLNB (37.3%) were positive; 15 of 33 after negative AUS and 8 of 35 after a negative needle biopsy. Axillary dissection was performed in 102 of 153 vs. 225 of 370 controls. Sensitivity and specificity of AUS was 86.2% and 40.5%. Sensitivity of AUS plus needle biopsy was 89.3% with 100% specificity. Neoadjuvant chemotherapy was given to 49.7% of AUS patients. AUS reduced costs by more than $4,000 per patient. Conclusions. AUS reduces SLNB use and affects treatment in patients with cT2 or greater breast cancer. Routine AUS should be considered in this population.

Re: Selective Application of Routine Preoperative Axillary Ultrasonography Reduces Costs for Invasive Breast Cancers

The approach of selective use of axillary ultrasound concentrating on breast cancer patients most likely to benefit from knowing preoperatively that an ultrasound-guided fine-needle aspiration is cytologically positive is examined.

Selective Application of Routine Preoperative Axillary Ultrasonography Reduces Costs for Invasive Breast Cancers

Preoperative axillary sonography with fine needle aspiration (FNA) in patients with invasive breast cancer identifies patients with nodal metastasis who can be spared further surgery. Indiscriminate use of the diagnostic modality can increase costs and yield inaccurate results. We evaluate the costs associated with the use of highly sensitive axillary ultrasonography in patients with stage ≥T2 tumors. We constructed a decision analysis tree using TreeAge Pro 2009 software comparing direct hospital charges between patients with and without routine use of axillary ultrasound. Base case estimates were derived from our institutional data and compared with those derived from the literature. One- and two-way sensitivity analyses were performed to check the validity of our inferences. We found that, for the base case estimate with 35% lymph node positivity in stage ≥T2 tumors and sensitivity of the axillary ultrasound set at 86% with a specificity of 40%, the strategy to perform preoperative axillary ultrasound yielded rollback costs of $15,215, compared with $15,940 for surgery plus sentinel lymph node biopsy (cost difference, $725 per patient favoring axillary ultrasound). On two-way sensitivity analysis, the cost benefit for axillary ultrasound was not seen in patients with a low risk for nodal metastasis. The adoption of routine preoperative axillary sonography with FNA is a lower-cost strategy than conventional strategies in patients with stage ≥T2 invasive breast cancer.

Pre-operative Axillary Ultrasound and FNA in Invasive Breast Cancer

Introduction: We intend to describe departmental experience of routine pre-operative axillary ultrasound scans (AUS) in breast cancer patients, and to assess whether our data supports experience described in the literature.

Abstract P1-01-19: Comparison of Ultrasound-Guided Fine Needles Aspiration Cytology and Ultrasound Guided Core Biopsy in Pre-Operative Axillary Staging for Early Breast Cancer

Abstract Introduction: Pre-operative axillary staging is now widely accepted as a prerequisite in surgical management of the axilla for patients newly diagnosed with early breast cancer. For those patients having breast tumour excision who are found to have nodal involvement, axillary clearance can be performed at the same time without prior sentinel node biopsy. Ultrasound (US) alone has low sensitivity, but can be used to direct needle biopsy. We assessed and compared the sensitivity and specificity of US-guided core biopsies (USCB) and US-guided fine needle cytology (USFNAC) used in our unit. Patients and methods: A retrospective and prospective data collection was performed between November 2007 and May 2010 on all newly diagnosed breast cancer patients in our unit since the introduction of routine pre-operative axillary US. Patients whose nodes looked benign or normal on US were offered sentinel node biopsy (SNB). Patients found to have suspicious nodes were offered USFNAC or USCB, according to the individual preference of the radiologists. Patients with positive cytology or histology underwent axillary node clearances (ANC), those with benign cytology or histology were offered SNB. The final histology results were reviewed and correlated to their pre-operative histology or cytology. Results: Of 559 Axillary ultrasound scans performed in our department between November 2007 and May 2010, 229 patients had pre-operative US scans of the axilla for newly diagnosed, clinically node-negative breast cancer. Of these 46 had USFNAC, 44 had USCB and 139 had normal/benign US. The USFNAC and USCB groups had similar proportions of positive results on postoperative histology, namely 70% and 79% respectively, allowing direct comparisons to be made. Of the 46 USFNAC patients, 17 (37%) had positive cytology (all confirmed by axillary clearance final histology). The 29 USFNAC patients with negative cytology had 15 (52%) with positive histology on sentinel node biopsy. The sensitivity of USFNAC was 53% and the specificity 100%. Of the 44 USCB patients, 26 (59%) were positive (all confirmed by axillary clearance final histology). Of the 18 USCB-negative patients, 7 (39%) were found to be positive on axillary clearance. The sensitivity of USCB was 79% and the specificity 100%. Of the 139 patients with normal US, 42 (30%) were found to be positive on sentinel node biopsies. For US alone, sensitivity was 61% and specificity was 80%. Conclusion: US staging of the axilla is superior to clinical staging. However, there is still a high incidence of false negative results, making US a crude way of assessing the axilla and confirming the necessity for sentinel node biopsy in US-negative axillae. For patients with axillae that are indeterminate on US, our data supports routine use of ultrasound core biopsy (USCB) over Ultrasound fine needle aspiration cytology (USFNAC) for preoperative staging of the axilla, where technically feasible. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-19.

Sensitivity and Specificity of Preoperative Ultrasonography for Diagnosing Nodal Metastases in Patients with Breast Cancer

Rational therapy planning should aim to minimize the rate of axillary lymph node dissection (ALND) in patients without metastatic disease. By the same token, the frequency of sentinel lymph node biopsies (SLNB) should not be unnecessarily high in patients with axillary node disease. Preoperative axillary ultrasonography is a generally available noninvasive technique for assessing nodal status. Based on retrospective data, we analyzed the sensitivity, specificity, positive and negative predictive value, and efficiency of preoperative ultrasonography US. A total of 429 axillary ultrasonographic examinations were included, and the management decisions were based on the ultrasonographic findings. Patients with suspicious US results were scheduled for ALND, while patients with unremarkable findings underwent SLNB. Axillary metastases were found in 146 of 429 (34 %) cases. In 75 of 429 (17 %) axillary examinations, ultrasonography revealed suspicious findings. In these cases, we proceeded with ALND, thereby reducing the number of SLNB by 17 %. 219 of 429 cases were classified correctly as not having metastasis, thus lowering the rate of ALND, which is associated with higher postoperative morbidity, by 51 %. Preoperative ultrasonography had a sensitivity of 53.6 %, specificity of 75.5 %, and a positive predictive value of 77.3 %. The negative predictive value was 51.3 % and the efficiency was 68.5 %. Ultrasonography is a moderately sensitive, but quite specific, preoperative method for assessing the axillary lymph nodes.

Impact of Preoperative Ultrasonography and Fine-Needle Aspiration of Axillary Lymph Nodes on Surgical Management of Primary Breast Cancer

To evaluate the accuracy of preoperative ultrasonography (US) and US-guided fine-needle aspiration (US-FNA) for detecting axillary lymph node (ALN) metastasis. We retrospectively reviewed 382 breast cancer patients with clinically negative ALN who underwent US and/or US-FNA for ALN. US-FNA of ALN was performed in 121 patients with suspicious findings on US. The diagnostic performance of US alone or with the addition of US-FNA for detecting ALN metastasis was calculated on the basis of final pathologic reports of ALN surgery. Among a total of 382 patients, 129 had metastatic ALNs while 253 exhibited no signs of axillary metastasis on final pathology. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of axillary US alone were 56.6% (73/129), 81.0% (205/253), 60.3% (73/121), and 78.5% (205/261), respectively. Addition of US-FNA resulted in sensitivity, specificity, PPV, and NPV of 39.5% (51/129), 95.7% (242/253), 82.3% (51/62), and 75.6% (242/320), respectively. Excluding complete responders to neoadjuvant chemotherapy, specificity and PPV after adding US-FNA were increased to 99.6% (242/243) and 98.1% (51/52), respectively. The sensitivity and specificity of ALN metastasis were similar between the palpable and nonpalpable breast cancer groups; however, after adding US-FNA, NPV was increased in the nonpalpable breast cancer group compared with the palpable breast cancer group (p=0.0398). By including preoperative axillary US and US-FNA, 16.2% (62/382) of all breast cancer patients were able to avoid unnecessary sentinel lymph node biopsy (SLNB). The combination of axillary US and US-FNA is useful in preoperative work-up of breast cancer patients and provides valuable information for planning proper breast cancer management.