Reduction in the number of sentinel lymph node procedures by preoperative ultrasonography of the axilla in breast cancer

doi:10.1016/S0959-8049(02)00748-7

European Journal of Cancer

Volume 39, Issue 8, May 2003, Pages 1068-1073

https://doi.org/10.1016/S0959-8049(02)00748-7 Get rights and content

Abstract

Currently, breast cancer patients without clinically suspicious lymph nodes are candidates for sentinel lymph node procedures (SLNPs). The aims of this study were to investigate whether preoperative axillary ultrasonography and fine-needle aspiration cytology (FNA) can reduce the number of the more time-consuming SLNPs, and to identify a subset of quantitative nodal features to predict metastatic involvement. 268 axillae were ultrasonographically examined. FNA was performed on suspicious nodes (smallest diameter ⩾5 mm or atypical cortex appearance). SLNP was omitted if a tumour-positive node was found on FNA. Length, width, maximum cortex thickness and appearance of cortex and hilus were ultrasonographically established. In 93 axillae (35%), at least one node was detected with ultrasound. FNA was performed once per axilla on 66 nodes; 37 (56%) contained tumour cells. 31% of all tumour-positive axillae (macro-+micrometastases) was found by ultrasound and FNA (37/121). 41% of all axillae containing macrometastases was found by ultrasound and FNA (36/87). SLNPs were reduced by 14% (37/268). Maximum cortex thickness is the main feature to predict metastatic involvement (area under Receiver Operating Characteristic (ROC) curve (A_Z)=0.87).

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.

Section snippets

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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Reduction in the number of sentinel lymph node procedures by preoperative ultrasonography of the axilla in breast cancer

Abstract

Introduction

Section snippets

Study population

Reduction in SLNPs

Discussion

Lancet

Eur. J. Cancer

Eur. J. Surg. Oncol.

Radiol. Clin. North Am.

Relation of number of positive axillary nodes to the prognosis of patients with primary breast cancer. An NSABP update

Cancer

Assessment of morbidity from complete axillary dissection

Br. J. Cancer

Risk of lymphoedema following the treatment of breast cancer

Br. J. Surg.

Complications and local recurrence following lymphadenectomy

Br. J. Surg.

Early versus delayed shoulder motion following axillary dissectiona randomized prospective study

Ann. Surg.

Lymphatic mapping and sentinel lymphadenectomy for breast cancer

Ann. Surg.

The sentinel node in breast cancer—a multicenter validation study

N. Engl. J. Med.

Prospective observational study of sentinel lymphadenectomy without further axillary dissection in patients with sentinel node-negative breast cancer

J. Clin. Oncol.

Axillary lymph node metastases in breast cancerpreoperative detection with US

Radiology

Accuracy of ultrasound and clinical examination in the diagnosis of axillary lymph node metastases in breast cancer

Eur. J. Surg. Oncol.

[Little extra information with ultrasonic studies of the axillary glands in patients with breast carcinoma]

Ned. Tijdschr. Geneeskd.

High resolution sonographic detection of axillary lymph node metastases in breast cancer

J. Ultrasound Med.