Unnecessary Sentinel Lymph Node Biopsy Research Articles

Prospect and guideline update of sentinel lymph node biopsy for patients with early-stage breast carcinoma

Axillary lymph nodes are the most common and initial site of metastasis of breast carcinoma. Precise axillary staging of breast carcinoma before initial treatment is crucial as it allows efficient identification for local and systemic treatment options, and provides prognostic information. Sentinel lymph node biopsy (SLNB) is an accurate minimally invasive technology for axillary staging. Although top evidence of high-quality clinical trials showed that SLNB could safely and effectively replace axillary lymph node dissection (ALND) for axillary negative patients with decrease in complications and improvement in quality of life, there are specific indications and contraindications for SLNB. Clinicians should balance the compliance of guideline and native clinical practice, especially for the circumstance of multifocal/multicentric lesion, breast biopsy history, and neoadjuvant chemotherapy. With the accumulation of clinical practice and new results of clinical trials, axillary therapy has changed from unique surgery to patient-tailored multi-disciplinary intervention, although ALND should be recommended traditionally if SLNB is positive. Intensive and accurate preoperative axillary staging is gradually valued by clinicians. Development of imaging modality especially ultrasonography and ultrasound-guided biopsy can identify some extra lymph node positive patients directly to ALND with avoidance of unnecessary SLNB. Thus, the positive rate of SLNB will decline significantly. It seems possible that axillary management will step into a noninvasive era abandoning SLNB in some patients with small breast cancer. In this article we review the prospect and guideline update of SLNB for patients with early-stage breast cancer.

Staging the axilla in women with breast cancer: the utility of preoperative ultrasound-guided needle biopsy.

Preoperative staging of the axilla in women with invasive breast cancer using ultrasound-guided needle biopsy (UNB) identifies approximately 50% of patients with axillary nodal metastases prior to surgical intervention. Although moderately sensitive, it is a highly specific staging strategy that is rarely falsely-positive, hence a positive UNB allows patients to be triaged to axillary lymph-node dissection (ALND) avoiding potentially unnecessary sentinel node biopsy (SNB). In this review, we extend our previous work through an updated literature search, focusing on studies that report data on UNB utility. Based on data for 10,934 breast cancer patients, sourced from 35 studies, a positive UNB allowed triage of 1,745 cases (simple proportion 16%) to axillary surgical treatment: the utility of UNB was a median 19.8% [interquartile range (IQR) 11.6%-26.7%] across these studies. We also modelled data from a subgroup of studies, and estimated that amongst patients with metastases to axillary nodes, the odds ratio (OR) for high nodal disease burden for a positive UNB versus a negative UNB was 4.38 [95% confidence interval (95% CI): 3.13, 6.13], P<0.001. From this model, the estimated proportion with high nodal disease burden was 58.9% (95% CI: 50.2%, 67.0%) for a positive UNB, whereas the estimated proportion with high nodal disease burden was 24.6% (95% CI: 17.7%, 33.2%) if UNB was negative. Overall, axillary UNB has good clinical utility and a positive UNB can effectively triage to ALND. However, the evolving landscape of axillary surgical treatment means that UNB will have relatively less utility where surgeons have modified their practice to omission of ALND for minimal nodal metastatic disease.

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

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

Axillary Staging of Breast Cancer: What the Radiologist Should Know

Identifying the presence of axillary node and internal mammary node metastases in patients with invasive breast cancer is critical for determining prognosis and for deciding on appropriate treatment. Sentinel lymph node biopsy (SLNB) is the definitive method to exclude axillary metastases. Patients with positive SLNB results generally undergo axillary lymph node dissection (ALND). The benefit of preoperative identification of axillary metastases is that it allows the surgeon to proceed directly to ALND and to avoid an unnecessary SLNB and the need for a second surgical procedure involving the axillary nodes. Knowledge of the important anatomic landmarks of the axilla is important in finding and accurately reporting suspicious lymph nodes. The pathologic features of nodal metastases illuminate the imaging appearances of these nodes, as depicted with all modalities. Ultrasonography (US) is the primary imaging modality for evaluating axillary nodes. Morphologic criteria, such as cortical thickening, hilar effacement, and nonhilar cortical blood flow, are more important than size criteria in the identification of metastases. US-guided lymph node sampling, especially with core biopsy, is invaluable in confirming the presence of a metastasis in a suspicious node. Core biopsy has been shown to be equal in safety to fine needle aspiration and has a significantly lower false-negative rate. Magnetic resonance imaging is also useful, with the added benefit of providing a global view of both axillae. Computed tomography and radionuclide imaging play a lesser role in imaging the axilla. Preoperative image-based identification and sampling of abnormal lymph nodes that have a high positive predictive value for metastases is an extremely important component in the management of patients with invasive breast cancer.

Diagnostic value and health economic evaluation of ultrasound-combined fine-needle aspiration cytology in primary breast cancer

To explore the diagnostic value and health economic evaluation of ultrasound-combined fine-needle aspiration cytology for axillary lymph node status in breast cancer. We reviewed retrospectively collected the data from 2503 cases of biopsy-proved breast cancer (T0-2) at our breast center between May 2005 and June 2010. The diagnostic fees of ultrasound-combined fine-needle aspiration cytology and clinical examination were calculated and assessed with cost-minimization analysis. Ultrasound-combined fine-needle aspiration cytology prevented 10.9 percent of the patients with positive clinical findings from unnecessary sentinel lymph node biopsy and achieved a saving of 155.55 RMB per patient. However, only 29.4 percent of the cases were diagnosed with ultrasonographic abnormal axillary nodes. Ultrasound-combined fine-needle aspiration cytology has great application values. The ultrasonic diagnostic criteria of abnormal axillary nodes should be loosened.

Prediction of underestimated invasiveness in patients with ductal carcinoma in situ of the breast on percutaneous biopsy as rationale for recommending concurrent sentinel lymph node biopsy

AimTo develop a model to predict invasion and improve the indication of concurrent sentinel lymph node biopsy (SLNB) for patients with ductal carcinoma in situ (DCIS) on minimally invasive biopsy. MethodsWe evaluated the data of 205 patients with DCIS in minimally invasive biopsy specimens. Clinical, radiological and histological variables were assessed in order to identify predictors of invasive carcinoma in final pathology using logistic regression analyses. We developed and retrospectively tested an algorithm to indicate concurrent SLNB. ResultsInvasiveness was underestimated in 18.0% (37 of 205). Univariate analysis revealed the following significant risk factors: lesion palpability, a mass lesion on ultrasound, the presence of a mammographically detectable mass, architectural distortion or density, a BI-RADS score of 5, a lesion diameter ≥50 mm, and ≥50% of histologically affected ducts. With a palpable mass, which remained the only independent predictor of invasion after multivariate adjustment, and the presence of at least three of the remaining five risk factors, the probability of invasion was 56.0%. If the prediction model had been used to indicate SLNB 9.8% (20 of 205) of patients could have been benefited (i.e. spared unnecessary or correctly recommended concurrent SLNB) compared to the factual performed SLNB procedures. Those patients with pure DCIS treated with breast conserving surgery (BCS) benefited most with a relative risk reduction of nearly 50% for unnecessary SLNB. ConclusionThe prediction model could rationally guide an informed discussion about risks and benefits of concurrent SLNB in patients with DCIS on minimally invasive biopsy.

Preoperative Axillary Ultrasound and Fine-needle Aspiration Biopsy in the Diagnosis of Axillary Metastases in Patients with Breast Cancer: Predictors of Accuracy and Future Implications

The utility of axillary lymph node dissection after sentinel lymph node biopsy has been called into question. We sought to determine the sensitivity, specificity, and accuracy of axillary ultrasound and fine-needle aspiration biopsy (FNAB) in the identification of axillary nodal metastasis in early breast cancer patients. Data of patients with stage I and II breast cancer who underwent surgery and staging were reviewed. Axillary ultrasound findings were assessed and lymph node status recorded after axillary dissection. The data were cross-tabulated, and test characteristics were calculated. Of 235 patients, none demonstrated more than 2 positive sentinel lymph nodes. Ductal carcinoma was present in 68%, estrogen and progesterone receptors were positive in 81 and 64%, respectively, Her-2/neu was positive in 10%, and 36% were axillary node positive. The sensitivity and specificity of ultrasound alone were 55 and 88%, respectively. Predictors of abnormal ultrasound included size of metastasis, estrogen receptor and Her-2 status, tumor grade, and presence of lymphovascular invasion. Addition of FNAB increased the sensitivity and specificity to 69 and 100%. In conjunction with FNAB, the positive and negative predictive values were 100 and 54%, respectively. Ten percent of patients with nodal metastases demonstrated a positive FNAB. Patients with a positive FNAB did not harbor more nodal metastases or a greater proportion of gross extranodal disease compared to patients not subjected to FNAB. Axillary ultrasound with FNAB has an accuracy of >70% in this series. It is easily performed and may avoid unnecessary sentinel lymph node biopsy in a significant number of patients.

Ultrasound and fine needle aspiration cytology of axillary lymph nodes in breast cancer. To do or not to do?

AimThe purpose of our study was to evaluate the accuracy of axillary ultrasound and ultrasound-guided fine needle aspiration cytology (FNAC) in the preoperative diagnosis of axillary metastases. MethodsBetween 2004 and 2009, 1132 female patients were evaluated and treated in our clinic for histologically proven breast carcinoma. Preoperative axillary ultrasound with subsequent FNAC in case of suspicious lymph nodes was performed in 1150 axillae (18 bilateral breast carcinomas). We analyzed the results of axillary ultrasound and FNAC retrospectively. Pathological node status was used as the reference standard (based on axillary dissection or sentinel node biopsy). ResultsAxillary ultrasound showed suspicious lymph nodes in 327 axillae (28.4%). FNAC showed axillary metastases in 107 of these 327 axillae. Final histological analysis confirmed 106 metastases (one false positive). Histological analysis showed metastatic disease in 429 of 1150 axillae (37.3%). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of axillary ultrasound alone were 43.8% (188/429), 80.7% (582/721), 57.5% (188/327) and 70.7% (582/823), respectively. When combining axillary ultrasound with FNAC of suspicious lymph nodes, sensitivity was 24.7% (106/429), specificity was 99.9% (720/721), PPV was 99.1% (106/107) and NPV was 69.0% (720/1043). Conclusions106/429 (24.7%) Node-positive axillae were identified by ultrasound-guided FNAC and spared unnecessary sentinel node biopsy. Unfortunately, the percentage of false negative results of ultrasound-guided FNAC (28.1%, 323/1150) was very high.

Preoperative staging of the axilla in women with invasive breast cancer

SUMMARY Axillary node status is an important prognostic factor in invasive breast cancer. Axillary lymph node dissection (ALND) was previously the primary management approach; however, sentinel node biopsy (SNB) has largely replaced ALND, which is currently predominantly used to manage SNB-positive patients. Preoperative imaging-based staging of the axilla (with ultrasound, PET or MRI) for the detection of suspicious nodes has been applied to inform and potentially streamline axillary surgical management. Ultrasound with ultrasound-guided needle biopsy is the most accurate imaging-based strategy and has been shown to have clinical utility for preoperative axillary staging. A meta-analysis has reported a median sensitivity of 79.4% and a specificity of 100% for ultrasound-based staging, and estimated that ultrasound-guided needle biopsy triages 55.2% of women with metastatic axillary nodes (or a median of 17.7% of patients) directly to ALND, thereby avoiding unnecessary SNB. Although ultrasound-based staging has had a role in preoperative axillary assessment, it appears likely that this role will be shaped in the future by the ongoing evolution in surgical management of the axilla, particularly in light of recent evidence that challenges the need for ALND in some SNB-positive patients.

551 Impact of Preoperative Axillary Imaging and Fine-Needle Aspiration to Avoid Unnecessary Sentinel Node Biopsy in Breast Cancer Patients

551 Impact of Preoperative Axillary Imaging and Fine-Needle Aspiration to Avoid Unnecessary Sentinel Node Biopsy in Breast Cancer Patients

Audit of accuracy of ultrasound-guided axillary core biopsy

Sentinel lymph node biopsy (SLNB) is the preferred method of axillary staging in breast cancer. If metastases are detected, axillary node clearance (ANC) is necessary. Preoperative detection of nodal metastases using ultrasound-guided core biopsy (USCB) allows the surgeon to proceed directly to ANC. Negative CBs do not exclude metastases. All patients still need SLNB. However, by minimising false negatives, unnecessary SLNBs can be minimised. We compared our USCB results with the results of subsequent SLNB + axillary node sampling (ANS) or ANC to assess our accuracy.

The use of needle washing in axillary node fine needle aspiration cytology increases accuracy and sensitivity with a resultant reduction in unnecessary sentinel node biopsy

Introduction: Both NICE and ABS at BASO recommend the use of pre-operative axillary ultrasound scan (A-USS) and biopsy, as appropriate, in the treatment of patients with invasive breast cancer. The use of needle washings to enhance cellularity of lymph node biopsy samples is routinely used across many areas of medicine. We assessed the efficacy of fine-needle aspiration cytology (FNAC) and the introduction of additional needle washings in pre-operative identification of the metastatic axilla.

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.

Deep margin involvement after shave biopsy for melanoma and requirement for sentinel lymph node biopsy (SLNB).

e19029 Background: One indication for SLNB in thin melanomas is an involved deep margin. While shave biopsy is discouraged as a method of diagnosing pigmented lesions, it is frequently used by dermatologists, particularly in the community. This approach can lead to a positive deep margin, which would result in unnecessary SLNBs. Patients undergoing SLNB for melanoma were analyzed to determine how frequently shave biopsy with positive margins alone led to a recommendation for SLNB. Methods: Patients who underwent SLNB for primary cutaneous melanoma with Breslow thickness less than 1 mm between 2000 and 2006 were identified from the Emory Prospective Melanoma Database. Charts were reviewed for patient, diagnostic and therapeutic data to determine how frequently a shave biopsy with a positive deep margin was the only indication for SLNB. Results: Of 250 melanomas with Breslow thickness less than 1 mm that underwent SLNB, 156 (62%) were shave biopsies of which 85 (34%) were transected with positive deep margins. Sixty-one (72%) of these were Clark's Level IV and 1 (1.1%) was ulcerated. Thus 27% (n = 23) of patients with positive deep margins from shave biopsy underwent SLNB with no other indication. Of the 85 transected shave biopsies, 3 (3.5%) had a positive SLNB compared with 2 (2.8%) of the remaining 71 nontransected shave biopsies. Conclusions: For patients at high risk for general anesthesia the increased rate of SLNBs due to shave biopsy warrants careful consideration of the use of this biopsy technique. However, shave biopsy may be a reasonable diagnostic method for patients at low risk for general anesthesia. Shave biopsy does not appear to impact incidence of positive SLNBs. No significant financial relationships to disclose.

Pre-Operative Axillary Nodal Staging by Ultrasonography and Fine-Needle Cytology Reduces the Number of Unnecessary Sentinel Node Biopsies in Breast Cancer Patients.

Abstract Aims: The role of pre-operative axillary ultrasound for nodal staging in early breast cancer patients is evolving. In this study, we evaluated the role of axillary ultrasound (AUS) and fine-needle aspiration cytology (FNAC) to stage the axilla pre-operatively in a large series of operable breast cancer patients including its role in the detection of nodal micrometastases. A second objective was to ascertain whether a significant learning curve is associated with this technique.Methods: Between October 2006 and March 2009, all patients diagnosed with invasive breast cancer in our unit had an AUS pre-operatively. Patients with suspicious nodes on ultrasound underwent FNAC. Cytology positive patients proceeded directly to axillary clearance, while others underwent sentinel lymph node biopsy. Data from this retrospective study was analyzed using appropriate statistical techniques to evaluate the efficacy of this technique to detect nodal metastases pre-operatively.Results: 495 patients scheduled to undergo surgery for invasive breast cancer were included in this study. 7 patients had bilateral malignancies and, therefore, a total of 502 axillae were examined using ultrasound. The median age of patients in our study was 61 years (range 32-91). 137 patients (27.3%) had proven nodal metastases on final histology. 39 of 137 (28.5%) node positive patients were accurately identified by pre-operative AUS and FNAC and, therefore, spared an unnecessary sentinel node biopsy. The combined technique of AUS and FNAC had an overall accuracy of 80.5% (95% CI: 76.8-83.7), sensitivity of 28.5% (95% CI: 21.6-36.5), specificity of 100% (95% CI: 99-100), positive predictive value of 100% (95% CI: 91-100), and negative predictive value of 78.8% (95% CI: 74.9-82.3). Pre-operative AUS and FNAC was normal in all patients with nodal micrometastases (n=15) and isolated tumour cells (n=11) on histopathology. No significant learning curve was demonstrated for this technique in our study. Overall, 28.5% of node positive patients and 7.9% of all breast cancer patients avoided an unnecessary sentinel node biopsy due to this procedure.Conclusions: Pre-operative AUS and FNAC is an inexpensive, minimally-invasive outpatient procedure with an accuracy of more than 80% that can avoid unnecessary sentinel lymph node biopsy in 28.7% of node positive patients. It has no role in the detection of nodal micrometastases and there is no demonstrable learning curve seen with this technique. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1018.

Predicting Axillary Lymph Node Status Using Preoperative Ultrasound-Guided Fine Needle Aspiration Cytology of Radiologically Equivocal and Abnormal Nodes.

Abstract Introduction:The superiority of ultrasound (US) over clinical examination in the assessment of axillary nodes in patients with breast carcinoma is well recognised. Fine needle aspiration cytology (FNAC) is a quick and minimally invasive procedure to determine the status of axillary lymph nodes pre-operatively. Sentinel lymph node biopsy (SLNB) is now widely accepted as the primary axillary staging procedure in the management of early breast cancer. A negative SLNB obviates the need for more extensive axillary surgery, thereby reducing the morbidity associated with axillary node clearance (ANC) in patients with node negative breast cancer. Patients with a SLNB positive for metastasis usually require further axillary treatment, which may include completion ANC and/or radiotherapy. Improving the accuracy of pre-operative staging is desirable in reducing the number of completion ANC procedures necessitated following positive SLNB. The aim of this study is to assess the accuracy of pre-operative US-guided FNAC of radiologically equivocal or abnormal axillary lymph nodes.Method:Patients with a diagnosis of invasive breast carcinoma underwent axillary US. Those with radiologically equivocal or abnormal nodes had US-guided FNAC. Patients with a metastatic FNAC had ANC, whereas those with insufficient (i.e. no lymphocytes seen on cytology), benign or equivocal FNAC had SLNB.Results:Correlation of FNAC result and final histologyFNAC ResultN=59Node positivity N=42Inadequate54Benign173Equivocal10Suspicious11Malignant3534 The positive predictive value of suspicious or malignant cytology from a radiologically equivocal or abnormal node is 97%. The negative predictive value is 70%. US-guided FNAC used in the context has 83% sensitivity and 94% specificity.Of the five patients with radiologically equivocal or abnormal nodes and an inadequate cytology (no lymphocytes seen), four had a metastatic sentinel node biopsy.One patient had a malignant FNAC prior to neoadjuvant chemotherapy (NACT) and had benign histology on subsequent ANC. If this patient is excluded from analysis, the positive predictive value rises to 100%.Conclusion:US-guided FNAC of radiologically equivocal or abnormal axillary lymph nodes accurately predicts node positivity and can be used to avoid an unnecessary SLNB procedure.Inadequate FNAC from an equivocal or abnormal node is not sufficient evidence to recommend SLNB rather than ANC as the initial surgical axillary procedure. Patients with such findings should have a repeat US-guided FNAC before choosing to proceed with SLNB. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1031.

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

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

Value of axillary ultrasound and cytology in assessing nodal status preoperatively.

Abstract Abstract #1007 Preoperative identification of axillary node involvement in early breast cancer allows correct surgical procedures to be performed and avoids second axillary operations. We compared preoperative axillary assessment using ultrasound ± cytology with the eventual histopathological results to identify the accuracy of preoperative axillary node assessment.&amp;#x2028; Methods: Preoperative axillary ultrasound was used to identify the presence of suspicious or malignant nodes which were then confirmed with cytological assessment to allow management decisions regarding axillary clearance (or sentinel node biopsy (SNB) if nodes appeared negative).&amp;#x2028; Results: Overall 79/365 (21%) early breast cancer patients had suspicious or malignant nodes on ultrasound, of which 78 were confirmed on cytology, thus avoiding an unnecessary SNB operation in these patients. Ultrasound and cytology accurately identified patients with ER negative (P=≤0.001), high grade (P=≤0.001) and large size tumours ≤20mm (P=≤0.001), with involved nodes. Only 11% ER negative compared to 46% ER positive tumours were incorrectly classified (P=0.002). In contrast ER positive, low grade, small tumours were most likely to have a false negative axillary assessment. Specificity of cytological assessment of nodes was 99% and sensitivity 54%.&amp;#x2028; Conclusions: Axillary ultrasound combined with cytological assessment of suspicious nodes accurately identifies majority of women who require axillary clearance.&amp;#x2028; &amp;#x2028; Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1007.

Ultrasonography and Fine-Needle Aspiration Cytology Can Spare Breast Cancer Patients Unnecessary Sentinel Lymph Node Biopsy

Some 30% to 40% of the breast cancer patients scheduled for sentinel node biopsy have axillary metastasis. Pilot studies suggest that ultrasonography is useful in the preoperative detection of such nodes. The aims of this study were to evaluate the sensitivity of preoperative ultrasonography and fine-needle aspiration cytology for detecting axillary metastases and to assess how often sentinel node biopsy could be avoided. Between October 1999 and December 2003, 726 patients with clinically negative lymph nodes were eligible for sentinel node biopsy. A total of 732 axillae were examined. Preoperative ultrasonography with subsequent fine-needle aspiration cytology in case of suspicious lymph nodes was performed in all patients. The sentinel node procedure was omitted in patients with tumor-positive axillary lymph nodes in lieu of axillary lymph node dissection. Ultrasound and fine-needle aspiration cytology established axillary metastases in 58 (8%) of the 726 patients. These 58 were 21% of the total of 271 patients who were proven to have axillary metastasis in the end. Of the patients with ultrasonographically suspicious lymph nodes and negative cytology, 31% had tumor-positive sentinel nodes. Patients with preoperatively established metastases by ultrasonography and fine-needle aspiration cytology had more tumor-positive lymph nodes (P < .001) than patients with metastases established later on. The sensitivity of ultrasonography and fine-needle aspiration cytology is 21%, and unnecessary sentinel node biopsy is avoided in 8% of the patients. This approach improves the selection of patients eligible for sentinel node biopsy.