Elsevier

Surgery

Volume 154, Issue 4, October 2013, Pages 831-840
Surgery

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

https://doi.org/10.1016/j.surg.2013.07.017Get rights and content

Background

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.

Methods

We studied 988 consecutive patients with invasive breast cancers who underwent operation including axillary surgery in 2010–2011.

Results

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.

Conclusion

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.

Section snippets

Patients and methods

With approval from the institutional research board, we identified 1,206 consecutive patients with invasive breast cancer who underwent operation including axillary surgery at our institution in 2010 and 2011 from our prospective breast surgery database. After we excluded patients treated with neoadjuvant systemic therapy, our study population consisted of 988 cases. We reviewed demographic, pathology, treatment, and imaging data for analysis.

AUS was performed by a group of dedicated breast

Results

Patient, treatment, and tumor features of the 988 breast cancer cases are summarized in Table I. The majority of patients (71.2%) had T1 tumors. Of the entire patient cohort, 297 patients (30.1%) were node-positive, and 82 patients (8.3%) had 3 or more metastatic LNs on final pathology. Preoperative AUS was performed in 906 patients (91.7%) and breast MRI with axillary imaging in 505 (51.1%). The AUS was normal in 643 (71.0%) and abnormal in 263 (29.0%), whereas the axillary MRI was normal in

Discussion

In our contemporary series, preoperative AUS with USNB for suspicious axillary LNs proved valuable for operative treatment planning by permitting ALND without SLNB in 28.6% of node-positive patients and in 8.6% of our newly diagnosed patients with invasive breast cancer treated with primary surgical therapy overall. USNB-positive patients had a greater number of metastatic nodes, larger metastases, and more extranodal extension of disease at ALND. The benefits of omitting SLNB for node-positive

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