Advertisement

Annals of Surgical Oncology

, Volume 21, Issue 9, pp 2904–2910 | Cite as

Axillary Ultrasonography in Breast Cancer Patients Helps in Identifying Patients Preoperatively with Limited Disease of the Axilla

  • A. M. MoormanEmail author
  • R. L. J. H. Bourez
  • H. J. Heijmans
  • E. A. Kouwenhoven
Breast Oncology

Abstract

Background

The sentinel lymph node biopsy (SLNB) procedure is the method of choice for the identification and monitoring of regional lymph node metastases in patients with breast cancer. In the case of a positive sentinel lymph node (SLN), additional lymph node dissection is still warranted for regional control, although 40–65 % have no additional axillary disease. Recent studies show that after breast-conserving surgery, SLNB, and adjuvant systemic therapy, there is no significant difference between recurrence-free period and overall survival if there are ≤2 positive axillary nodes. The purpose of this study was preoperative identification of patients with limited axillary disease (≤2 macrometastases) by using ultrasonography.

Methods

Data from 1,103 consecutive primary breast cancer patients with tumors smaller than 50 mm, no palpable adenopathy, and a maximum of 2 SLNs with macrometastases were collected. The variable of interest was US of the axilla.

Results

Of the 1,103 patients included, 1,060 remained after exclusion criteria. Of these, 102 (9.6 %) had more than 2 positive axillary nodes on ALND. Selected by unsuspected US, the chance of having >2 positive lymph nodes (LNs) is substantially lower (4.2 %). This is significant on univariate and multivariate analysis. After excluding the patients with extracapsular extension of the SLN, the chance of having >2 positive LNs is only 2.6 %. For pT1–2, this is 2.2 %.

Conclusions

The risk of more than 2 positive axillary nodes is relatively small in patients with cT1–2 breast cancer. US of the axilla helps in further identifying patients with a minimal risk of additional axillary disease, putting ALND up for discussion.

Keywords

Sentinel Lymph Node Sentinel Lymph Node Biopsy Positive Lymph Node Axillary Lymph Node Dissection Positive Sentinel Lymph Node 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Bergkvist L, de Boniface J, Jonsson PE, et al. Axillary recurrence rate after negative sentinel node biopsy in breast cancer: three-year follow-up of the Swedish Multicenter Cohort Study. Ann Surg. 2008;247:150–6.PubMedCrossRefGoogle Scholar
  2. 2.
    Giuliano AE, Haigh PI, Brennan MB, et al. Prospective observational study of sentinel lymphadenectomy without further axillary dissection in patients with sentinel node-negative breast cancer. J Clin Oncol. 2000;18:2553–9.PubMedGoogle Scholar
  3. 3.
    Veronesi U, Paganelli G, Viale G, et al. A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. N Engl J Med. 2003;349:546–53.PubMedCrossRefGoogle Scholar
  4. 4.
    Lucci A, McCall LM, Beitsch PD, et al. Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011. J Clin Oncol. 2007;25:3657–63.PubMedCrossRefGoogle Scholar
  5. 5.
    Celebioglu F, Perbeck L, Frisell J, Grondal E, Svensson L, Danielsson R. Lymph drainage studied by lymphoscintigraphy in the arms after sentinel node biopsy compared with axillary lymph node dissection following conservative breast cancer surgery. Acta Radiol. 2007;48:488–95.PubMedCrossRefGoogle Scholar
  6. 6.
    Cancer clinical practice Guidelines, the Netherlands. Version 13-02-2012. Breast cancer. http://www.oncoline.nl. Accessed Feb 2012.
  7. 7.
    Chu KU, Turner RR, Hansen NM, Brennan MB, Bilchik A, Giuliano AE. Do all patients with sentinel node metastasis from breast carcinoma need complete axillary node dissection? Ann Surg. 1999;229:536–41.PubMedCentralPubMedCrossRefGoogle Scholar
  8. 8.
    Fant JS, Grant MD, Knox SM, et al. Preliminary outcome analysis in patients with breast cancer and a positive sentinel lymph node who declined axillary dissection. Ann Surg Oncol. 2003;10:126–30.PubMedCrossRefGoogle Scholar
  9. 9.
    Fisher B, Jeong JH, Anderson S, Bryant J, Fisher ER, Wolmark N. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med. 2002;347:567–75.PubMedCrossRefGoogle Scholar
  10. 10.
    Grube BJ, Giuliano AE. Observation of the breast cancer patient with a tumor-positive sentinel node: implications of the ACOSOG Z0011 trial. Semin Surg Oncol. 2001;20:230–7.PubMedCrossRefGoogle Scholar
  11. 11.
    Guenther JM, Hansen NM, DiFronzo LA, et al. Axillary dissection is not required for all patients with breast cancer and positive sentinel nodes. Arch Surg. 2003;138:52–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Hwang RF, Gonzalez-Angulo AM, Yi M, et al. Low locoregional failure rates in selected breast cancer patients with tumor-positive sentinel lymph nodes who do not undergo completion axillary dissection. Cancer. 2007;110:723–30.PubMedCrossRefGoogle Scholar
  13. 13.
    Jeruss JS, Winchester DJ, Sener SF, et al. Axillary recurrence after sentinel node biopsy. Ann Surg Oncol. 2005;12:34–40.PubMedCrossRefGoogle Scholar
  14. 14.
    Katz A, Gage I, Evans S, et al. Sentinel lymph node positivity of patients with ductal carcinoma in situ or microinvasive breast cancer. Am J Surg. 2006;191:761–6.PubMedCrossRefGoogle Scholar
  15. 15.
    Kim T, Giuliano AE, Lyman GH. Lymphatic mapping and sentinel lymph node biopsy in early-stage breast carcinoma: a metaanalysis. Cancer. 2006;106:4–16.PubMedCrossRefGoogle Scholar
  16. 16.
    Naik AM, Fey J, Gemignani M, et al. The risk of axillary relapse after sentinel lymph node biopsy for breast cancer is comparable with that of axillary lymph node dissection: a follow-up study of 4008 procedures. Ann Surg. 2004;240:462–8; discussion 468–71.Google Scholar
  17. 17.
    Van Zee KJ, Manasseh DM, Bevilacqua JL, et al. A nomogram for predicting the likelihood of additional nodal metastases in breast cancer patients with a positive sentinel node biopsy. Ann Surg Oncol. 2003;10:1140–51.PubMedCrossRefGoogle Scholar
  18. 18.
    Carter CL, Allen C, Henson DE. Relation of tumor size, lymph node status, and survival in 24,740 breast cancer cases. Cancer. 1989;63:181–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Hoe AL, Iven D, Royle GT, Taylor I. Incidence of arm swelling following axillary clearance for breast cancer. Br J Surg. 1992;79:261–2.PubMedCrossRefGoogle Scholar
  20. 20.
    Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg. 1994;220:391–8; discussion 398–401.Google Scholar
  21. 21.
    Krag DN, Weaver DL, Alex JC, Fairbank JT. Surgical resection and radiolocalization of the sentinel lymph node in breast cancer using a gamma probe. Surg Oncol. 1993;2:335–9; discussion 340.Google Scholar
  22. 22.
    Chu KU, Turner RR, Hansen NM, Brennan MB, Giuliano AE. Sentinel node metastasis in patients with breast carcinoma accurately predicts immunohistochemically detectable nonsentinel node metastasis. Ann Surg Oncol. 1999;6:756–61.PubMedCrossRefGoogle Scholar
  23. 23.
    Kamath VJ, Giuliano R, Dauway EL, et al. Characteristics of the sentinel lymph node in breast cancer predict further involvement of higher-echelon nodes in the axilla: a study to evaluate the need for complete axillary lymph node dissection. Arch Surg. 2001;136:688–92.PubMedCrossRefGoogle Scholar
  24. 24.
    Straver ME, Meijnen P, van Tienhoven G, et al. Role of axillary clearance after a tumor-positive sentinel node in the administration of adjuvant therapy in early breast cancer. J Clin Oncol. 2010;28:731–7.PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Swedish Organised Service Screening Evaluation Group. Effect of mammographic service screening on stage at presentation of breast cancers in Sweden. Cancer. 2007;109:2205–12.CrossRefGoogle Scholar
  26. 26.
    Yi M, Giordano SH, Meric-Bernstam F, et al. Trends in and outcomes from sentinel lymph node biopsy (SLNB) alone vs. SLNB with axillary lymph node dissection for node-positive breast cancer patients: experience from the SEER database. Ann Surg Oncol. 2010;17(Suppl 3):343–51.PubMedCrossRefGoogle Scholar
  27. 27.
    D’Eredita’ G, Troilo VL, Fischetti F, Rubini G, Berardi T. Comparison of two models for predicting non-sentinel lymph node metastases in sentinel lymph node-positive breast cancer patients. Updates Surg. 2011;63:163–70.PubMedCrossRefGoogle Scholar
  28. 28.
    Smidt ML, Kuster DM, van der Wilt GJ, Thunnissen FB, Van Zee KJ, Strobbe LJ. Can the Memorial Sloan-Kettering Cancer Center nomogram predict the likelihood of nonsentinel lymph node metastases in breast cancer patients in the Netherlands? Ann Surg Oncol. 2005;12:1066–72.PubMedCrossRefGoogle Scholar
  29. 29.
    Ponzone R, Maggiorotto F, Mariani L, et al. Comparison of two models for the prediction of nonsentinel node metastases in breast cancer. Am J Surg. 2007;193:686–92.PubMedCrossRefGoogle Scholar
  30. 30.
    Degnim AC, Reynolds C, Pantvaidya G, et al. Nonsentinel node metastasis in breast cancer patients: assessment of an existing and a new predictive nomogram. Am J Surg. 2005;190:543–50.PubMedCrossRefGoogle Scholar
  31. 31.
    Dauphine CE, Haukoos JS, Vargas MP, Isaac NM, Khalkhali I, Vargas HI. Evaluation of three scoring systems predicting non sentinel node metastasis in breast cancer patients with a positive sentinel node biopsy. Ann Surg Oncol. 2007;14:1014–9.PubMedCrossRefGoogle Scholar
  32. 32.
    Cserni G, Bianchi S, Vezzosi V, et al. Validation of clinical prediction rules for a low probability of nonsentinel and extensive lymph node involvement in breast cancer patients. Am J Surg. 2007;194:288–93.PubMedCrossRefGoogle Scholar
  33. 33.
    Alran S, De Rycke Y, Fourchotte V, et al. Validation and limitations of use of a breast cancer nomogram predicting the likelihood of non-sentinel node involvement after positive sentinel node biopsy. Ann Surg Oncol. 2007;14:2195–201.PubMedCrossRefGoogle Scholar
  34. 34.
    Coutant C, Olivier C, Lambaudie E, et al. Comparison of models to predict nonsentinel lymph node status in breast cancer patients with metastatic sentinel lymph nodes: a prospective multicenter study. J Clin Oncol. 2009;27:2800–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305:569–75.PubMedCrossRefGoogle Scholar
  36. 36.
    Bilimoria KY, Bentrem DJ, Hansen NM, et al. Comparison of sentinel lymph node biopsy alone and completion axillary lymph node dissection for node-positive breast cancer. J Clin Oncol. 2009;27:2946–53.PubMedCrossRefGoogle Scholar
  37. 37.
    Giuliano AE, McCall L, Beitsch P, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: the American College of Surgeons Oncology Group Z0011 randomized trial. Ann Surg. 2010;252:426–32; discussion 432–3.Google Scholar
  38. 38.
    Cho N, Moon WK, Han W, Park IA, Cho J, Noh DY. Preoperative sonographic classification of axillary lymph nodes in patients with breast cancer: node-to-node correlation with surgical histology and sentinel node biopsy results. AJR Am J Roentgenol. 2009;193:1731–7.PubMedCrossRefGoogle Scholar
  39. 39.
    Alvarez S, Anorbe E, Alcorta P, Lopez F, Alonso I, Cortes J. Role of sonography in the diagnosis of axillary lymph node metastases in breast cancer: a systematic review. AJR Am J Roentgenol. 2006;186:1342–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Rattay T, Muttalib M, Khalifa E, Duncan A, Parker SJ. Clinical utility of routine pre-operative axillary ultrasound and fine needle aspiration cytology in patient selection for sentinel lymph node biopsy. Breast. 2012;21:210–4.PubMedCrossRefGoogle Scholar
  41. 41.
    Purushotham AD, Upponi S, Klevesath MB, et al. Morbidity after sentinel lymph node biopsy in primary breast cancer: results from a randomized controlled trial. J Clin Oncol. 2005;23:4312–21.PubMedCrossRefGoogle Scholar
  42. 42.
    Peintinger F, Reitsamer R, Stranzl H, Ralph G. Comparison of quality of life and arm complaints after axillary lymph node dissection vs sentinel lymph node biopsy in breast cancer patients. Br J Cancer. 2003;89:648–52.PubMedCentralPubMedCrossRefGoogle Scholar
  43. 43.
    Rutgers EJ. Sentinel node biopsy: interpretation and management of patients with immunohistochemistry-positive sentinel nodes and those with micrometastases. J Clin Oncol. 2008;26:698–702.PubMedCrossRefGoogle Scholar
  44. 44.
    Fisher B, Montague E, Redmond C, et al. Comparison of radical mastectomy with alternative treatments for primary breast cancer: a first report of results from a prospective randomized clinical trial. Cancer. 1977;39(6 Suppl):2827–39.PubMedCrossRefGoogle Scholar
  45. 45.
    Louis-Sylvestre C, Clough K, Asselain B, et al. Axillary treatment in conservative management of operable breast cancer: dissection or radiotherapy? Results of a randomized study with 15 years of follow-up. J Clin Oncol. 2004;22:97–101.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2014

Authors and Affiliations

  • A. M. Moorman
    • 1
    Email author
  • R. L. J. H. Bourez
    • 2
  • H. J. Heijmans
    • 1
  • E. A. Kouwenhoven
    • 1
  1. 1.Departments of SurgeryHospital Group TwenteAlmeloThe Netherlands
  2. 2.Departments of RadiologyHospital Group TwenteAlmeloThe Netherlands

Personalised recommendations