Reduction in the number of sentinel lymph node procedures by preoperative ultrasonography of the axilla in breast cancer
Introduction
The prognosis of breast cancer patients is for a large part based on the presence of axillary lymph node metastases [1]. For many years, the lymph node status of a breast cancer patient was determined by performing an axillary lymph node dissection (ALND). However, the disadvantage of this method is the significant morbidity that is associated with it, e.g. lymph oedema of the arm with a decreased ability for movement 2, 3, 4, 5. Several studies have shown that a sentinel lymph node procedure (SLNP) can safely replace ALND for axillary staging 6, 7, 8, 9, 10. The selection of patients for SLNP is based on physical examination of the axilla. SLNP is performed only in patients without clinically suspicious nodes. However, the sensitivity of physical examination of the axilla is only 33–68% 11, 12, 13, 14.
The sentinel node contains tumour cells in approximately 40% of all breast cancer patients [15]. 50% of these malignant nodes are palpably enlarged during surgery, but are not detected by physical examination preoperatively. By detecting these nodes before surgery, these patients could immediately be scheduled for ALND, which is less labour-intensive than the SLNP plus subsequent ALND if a tumour-positive sentinel node is found. Alternatively, patients may be candidates for neo-adjuvant chemotherapy.
Predictive lymph node characteristics on ultrasound images may provide quantitative guidelines in deciding whether or not a node should be aspirated, thereby increasing specificity without compromising sensitivity. This would result in a reduction of the number of fine-needle aspirations (FNAs) on normal nodes. Several authors have studied predictive lymph node characteristics, e.g. length, shape and cortex appearance 16, 17, 18, 19, 20, 21, 22. However, the discriminating power of these features is limited and large variations have been reported. This may be due to subjectivity in the rating of the features.
The first aim of this study was to investigate whether the use of combined preoperative axillary ultrasonography and FNA in breast cancer patients without palpable lymph nodes reduces the number of SLNPs. The second aim was to identify an optimal subset of quantitative features to predict metastatic involvement of a node.
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Study population
Between August 1999 and January 2001, all 265 breast cancer patients who were eligible for a SLNP in our hospital were included in this study. 3 patients had bilateral breast cancer; so 268 axillae were examined. Most patients (82%) had a palpable breast lesion. All patients had a clinically negative axilla. Mean age was 56 years (range 27–91 years). The mean diameter of the primary tumour as measured by the pathologist was 19 mm (range 2–80 mm). The tumour types were invasive ductal carcinomas
Reduction in SLNPs
Table 1 shows the result of ultrasound and FNA in relation to the axillary lymph node status.
In 93 axillae (35%), at least one lymph node was detected by ultrasonography. The mean number of ultrasonographic visible nodes was 1.6 (range 1–6). Mean length of the lymph nodes was 11.3 mm (range 2.5–33.7 mm); mean width was 6.2 mm (range 1.9–18.2 mm). Twenty-seven lymph nodes (29%) were not aspirated (due to technical problems or unsuspicious nodes with a smallest diameter of <5 mm). FNA was
Discussion
Initial results indicate that a reduction in the number of sentinel lymph node procedures can be obtained by preoperative ultrasonography of the axilla. Because ultrasonographic examination of the axilla is far less time-consuming (5–10 min) than a SLNP, which involves multiple procedures in several departments, we believe that ultrasound is a useful tool for preoperative screening of the axilla in patients scheduled to undergo a SLNP.
To our knowledge, there are only two studies that can be
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