Suspicious Axillary Lymph Nodes Identified on Clinical Breast MRI in Patients Newly Diagnosed with Breast Cancer: Can Quantitative Features Improve Discrimination of Malignant from Benign?

doi:10.1016/j.acra.2014.10.010

Academic Radiology

Volume 22, Issue 4, April 2015, Pages 430-438

https://doi.org/10.1016/j.acra.2014.10.010 Get rights and content

Rationale and Objectives

To determine whether quantitative dynamic contrast-enhanced (DCE) and diffusion-weighted (DW) magnetic resonance imaging (MRI) features can discriminate malignant from benign axillary lymph nodes (ALNs) identified as suspicious on clinical breast MRI in patients newly diagnosed with breast cancer.

Materials and Methods

After approval from institutional review board, all clinical breast MR examinations performed from March 2006 through January 2010 describing at least one morphologically suspicious ipsilateral ALN in patients with newly diagnosed breast cancer were identified. Each suspicious ALN underwent ultrasound-guided core needle biopsy, and nodes with benign results were subsequently sampled surgically. Quantitative DCE and DW MRI parameters (diameters, volume, enhancement kinetics, and apparent diffusion coefficients [ADC]) were measured for each suspicious ALN and a representative contralateral normal node, and each feature was compared between the ALN groups (normal, benign, and malignant).

Results

Thirty-four suspicious ALNs (18 malignant and 16 benign) and 34 contralateral normal-appearing ALNs were included. Suspicious malignant and benign nodes exhibited larger size, greater volume, and lower ADCs than normal ALNs (P < .05). Among suspicious ALNs, the only quantitative measure that discriminated between malignant from benign outcome was percent of ALN demonstrating washout kinetics (P = .02).

Conclusions

In ALNs deemed morphologically suspicious on breast MRI, quantitative MRI features show little value in identifying those with malignant etiology.

Section snippets

Materials and methods

This study was approved by our institutional review board (IRB) and was performed in compliance with the Health Insurance Portability and Accountability Act. Data were obtained retrospectively from the Consortium Oncology Data Integration (CODI) project, which is an IRB-approved solid tumor clinical database developed and maintained by the Fred Hutchinson Cancer Research Center in collaboration with the University of Washington. CODI encompasses data from a variety of sources, including the

Results

The median age of the patients included in the study was 50 years (range, 30–90 years). Of the 34 women with ALNs identified as suspicious on prospective MRI interpretation, sixteen (47%) patients had benign, whereas 18 (53%) patients had malignant nodes on CNB. One of the 16 patients with malignant ALN had isolated tumor cells (confirmed on SLNB), whereas the remainder of patients had metastatic deposits greater than 2 mm. Similar distributions of index tumor features were observed between the

Discussion

To our knowledge, this study examining ALNs that were described as suspicious on clinical breast MRIs in patients newly diagnosed with breast cancer is the first to achieve one-to-one correlation of quantitative features to final pathology outcomes. In our cohort, the PPV of a positive MRI assessment was 53%, which is within the range of previous publications (38%–83%) 17, 18, 19. By directly correlating imaging features with specific ALN pathologic outcomes, our study confirmed that lymph

Conclusions

We found that in patients newly diagnosed with breast cancer and a positive axillary assessment on clinical breast MRI, the addition of quantitative imaging features provides little potential to improve the PPV of these assessments. Although MRI may still have some value for improving the management of the axilla in the preoperative setting, our study suggests that it cannot reliably discriminate malignant from benign reactive ALNs to aid in standard surgical management at this time.

Acknowledgments

The authors acknowledge their source of funding for this study (National Institutes of Health/National Cancer Institute R01CA151326).

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Breast cancer is a heterogeneous disease that can be grouped into four main molecular subtypes: luminal A, luminal B, HER2-enriched, and triple negative. These subtypes have different patient outcomes and treatments. Diffusion-weighted imaging biomarkers are associated with these cancer subtypes and response to treatment. They have also been associated with other markers of tumor aggressiveness, tumor invasiveness, and tumor extent. The associations between imaging biomarkers and cancer prognosis and outcomes are areas of robust research, with some conflicting results. This chapter summarizes the literature, including areas of disagreement and where future research is needed.
Intravoxel incoherent motion diffusion-weighted magnetic resonance imaging in characterization of axillary lymph nodes: Preliminary animal experience
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Citation Excerpt :
DWI is a noninvasive MRI technique that can reveal microscopic details about the architecture of both normal and anomalous tissues by their water diffusion properties. So far, the feasibility of DWI in differentiating metastatic from non-metastatic axillary LNs has been investigated in several studies [5–19] with comparison of ADC. However, the results varied and were even contradictive.
To investigate the diagnostic value of intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI) for discriminating axillary metastatic from non-metastatic lymph nodes (LNs) in rabbit models.
The institutional animal care and use committee approved this study. Forty New Zealand white rabbits were randomly divided into two groups. The axillary LN models were created by inoculating VX2 cell suspension and complete Freund's adjuvant in the mammary glands of 20 female rabbits of each group, respectively. Conventional MRI and IVIM DWI were performed after animal models successfully established. Images of axillary LNs were analyzed with regard to long-axis diameter (L), short-axis diameter (S), apparent diffusion coefficient (ADC) and IVIM parameters (D, D*, f). Receiver operating characteristic analyses were conducted to determine the diagnostic performance of aforementioned criteria.
A total of 42 metastatic and 30 non-metastatic LNs were successfully isolated. ADC and D of metastatic LNs were significantly lower than those of non-metastatic ones (all P < 0.001), whereas D* was statistically higher (P = 0.033). L, S, and f showed no significant difference between the two groups (P = 0.089, 0.058, 0.054, respectively). Optimal cutoff values, area under the curve, sensitivity, and specificity for differentiation were as follows: ADC = 1.101 × 10⁻³ mm²/s, 0.886, 78.6%, 90.0%; D = 0.938 × 10⁻³ mm²/s, 0.927, 83.3%, 93.3%; and D* = 12.635 × 10⁻³ mm²/s, 0.657, 52.4%, 80.0%.
IVIM DWI is useful to distinguish metastatic from non-metastatic LNs in axilla. D was the most discriminative variable for predicting metastatic LNs.
Developments in Breast Imaging: Update on New and Evolving MR Imaging and Molecular Imaging Techniques
2018, Magnetic Resonance Imaging Clinics of North America
Use of Breast Magnetic Resonance Imaging and Ultrasonography for Identifying Nonpalpable Axillae Metastases in Newly Diagnosed Breast Cancer Patients
2018, Clinical Breast Cancer
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The assessment of enlarged ALNs in BC patients using MRI has been previously reported,10 and the findings appear promising. For the detection of malignant and benign nodes, unenhanced MRI yielded greater value than quantitative dynamic contrast-enhanced MRI.11,12 However, the feasibility of identifying nonpalpable ALN metastasis in newly diagnosed BC patients using MRI remains unclear.
The metastasis of axillary lymph node (ALNs) is a critical step in the initial cancer staging of newly diagnosed breast cancer (BC) patients. Various imaging modalities can enhance the sensitivity of clinical examination in assessing the ALN status.
We enrolled 135 patients with BC, confirmed via histopathology, including 4 bilateral BC cases. A total of 139 ipsilateral ALNs adjacent to the breast lesion were examined via physical examination, ultrasonography (US), and magnetic resonance imaging (MRI); of these, 100 were nonpalpable ALNs, as determined by experienced breast surgeons and physicians. The relative size parameters on MRI and US images were recorded. Receiver operating characteristic (ROC) analyses were conducted, and the area under the ROC curve (AUC) was compared.
Of 139 ALNs, 67 (48%) were malignant and 72 (52%) were benign on pathological examination. In all of the ALNs, the US short diameter appeared to be the most discriminative quantitative measurement for detecting positive findings (AUC, 0.854). In nonpalpable ALNs as well, the US short diameter exhibited the greatest discriminability (AUC, 0.746). However, the 2-dimensional and 3-dimensional parameters on MRI did not exhibit any significant differences between the enrolled and nonpalpable ALNs (P > .05).
The shortest diameter on US exhibited better discriminative ability than MRI for predicting positive ALNs in nonpalpable axillae. Moreover, the 2-dimensional and 3-dimensional parameters on MRI did not differ in terms of discriminability.
MRI and Prediction of Pathologic Complete Response in the Breast and Axilla after Neoadjuvant Chemotherapy for Breast Cancer
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In the setting where determining extent of residual disease is key for surgical planning after neoadjuvant chemotherapy (NAC), we evaluate the reliability of MRI in predicting pathologic complete response (pCR) of the breast primary and axillary nodes after NAC.
Patients who had MRI before and after NAC between June 2014 and August 2015 were identified in a prospective database after IRB approval. Post-NAC MRI of the breast and axillary nodes was correlated with residual disease on final pathology. Pathologic complete response was defined as absence of invasive and in situ disease.
We analyzed 129 breast cancers. Median patient age was 50.8 years (range 27.2 to 80.6 years). Tumors were human epidermal growth factor receptor 2 amplified in 52 of 129 (40%), estrogen receptor-positive/human epidermal growth factor receptor 2-negative in 45 of 129 (35%), and triple negative in 32 of 129 (25%), with respective pCR rates of 50%, 9%, and 31%. Median tumor size pre- and post-NAC MRI were 4.1 cm and 1.45 cm, respectively. Magnetic resonance imaging had a positive predictive value of 63.4% (26 of 41) and negative predictive value of 84.1% (74 of 88) for in-breast pCR. Axillary nodes were abnormal on pre-NAC MRI in 97 patients; 65 had biopsy-confirmed metastases. The nodes normalized on post-NAC MRI in 33 of 65 (51%); axillary pCR was present in 22 of 33 (67%). In 32 patients with proven nodal metastases and abnormal nodes on post-NAC MRI, 11 achieved axillary pCR. In 32 patients with normal nodes on pre- and post-NAC MRI, 6 (19%) had metastasis on final pathology.
Radiologic complete response by MRI does not predict pCR with adequate accuracy to replace pathologic evaluation of the breast tumor and axillary nodes.

View all citing articles on Scopus

: Funding Sources: The study was funded by National Institutes of Health (R01CA151326).

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Original InvestigationSuspicious Axillary Lymph Nodes Identified on Clinical Breast MRI in Patients Newly Diagnosed with Breast Cancer: Can Quantitative Features Improve Discrimination of Malignant from Benign?

Rationale and Objectives

Materials and Methods

Results

Conclusions

Section snippets

Materials and methods

Results

Discussion

Conclusions

Acknowledgments

Eur J Radiol

Clin Imaging

Acad Radiol

Curr Probl Diagn Radiol

Clin Imaging

Hematol Oncol Clin North Am

Magn Reson Imaging Clin N Am

Clinicopathologic factors associated with false-negative sentinel lymph-node biopsy in breast cancer

Ann Surg

A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer

N Engl J Med

Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial

JAMA

Discrimination of axillary metastatic from nonmetastatic lymph nodes with PROPELLER diffusion-weighted MR imaging in a metastatic breast cancer model and its correlation with cellularity

J Magn Reson Imaging

Original Investigation
Suspicious Axillary Lymph Nodes Identified on Clinical Breast MRI in Patients Newly Diagnosed with Breast Cancer: Can Quantitative Features Improve Discrimination of Malignant from Benign?