Annals of Surgical Oncology

, Volume 21, Issue 11, pp 3440–3447 | Cite as

Predicting the Extent of Nodal Disease in Early-Stage Breast Cancer

  • Abigail S. CaudleEmail author
  • Henry M. Kuerer
  • Huong T. Le-Petross
  • Wei Yang
  • Min Yi
  • Isabelle Bedrosian
  • Savitri Krishnamurthy
  • Bruno D. Fornage
  • Kelly K. Hunt
  • Elizabeth A. Mittendorf
Breast Oncology



The role of regional nodal ultrasound (US) has been questioned since publication of the American College of Surgeons Oncology Group (ACOSOG) Z0011 data. The goal of this study was to determine if imaging and clinicopathologic features could predict the extent of axillary nodal involvement in breast cancer.

Study Design

Patients with T1–T2 tumors who underwent regional nodal US and axillary lymph node dissection from 2002 to 2012 were identified from a prospective database excluding those who received neoadjuvant chemotherapy. Patients whose metastases were identified by US confirmed by needle biopsy were compared with those identified by sentinel lymph node dissection (SLND) after a negative US.


Metastases were identified by US in 190 patients, and by SLND in 518 patients. SLND patients had fewer positive nodes (2.2 vs. 4.1; p < 0.0001), smaller metastases (5.3 vs. 13.8 mm; p < 0.0001), and a lower incidence of extranodal extension (24 vs. 53 %; p < 0.0001) than the US group. Even when US identified ≤2 abnormal nodes, patients were still more likely to have ≥3 positive nodes (45 %) than SLND patients (19 %; p < 0.001). After adjusting for tumor size, receptor status, and histology, multivariate analysis revealed that metastases identified by US [odds ratio (OR) 4.01; 95 % confidence interval (CI) 2.75–5.84] and lobular histology (OR 1.77; 95 % CI 1.06–2.95) predicted having ≥3 positive nodes.


Imaging and clinicopathologic features can be used to predict the extent of nodal involvement. Patients with US-detected metastases, even if small volume, have a higher burden of nodal involvement than patients with SLND-detected metastases and may not be comparable with patients in the ACOSOG Z0011 trial.


Hormone Receptor Positive Lymph Node Axillary Lymph Node Dissection Sentinel Lymph Node Dissection Suspicious 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.



The University of Texas MD Anderson Cancer Center is supported in part by a Cancer Center Support Grant (CA016672) from the National Institutes of Health.


  1. 1.
    National Comprehensive Cancer Network (NCCN). Clinical practice guidelines in oncology: breast. Version 2012. NCCN; 2012.Google Scholar
  2. 2.
    Giuliano, A, Hunt K, Ballman K, et al. Axillary dissection vs. no axillary dissection in women with invasive breast cancer and sentinel node metastasis. JAMA. 2011;305(6):569–575.PubMedCrossRefGoogle Scholar
  3. 3.
    Giuliano A, 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(3):426–32.PubMedGoogle Scholar
  4. 4.
    Galimberti V, Cole B, Zurrida S, et al. Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): a phase 3 randomised controlled trial. Lancet Oncol. 2013;14(4):297–305.PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Caudle A, Hunt K, Tucker S, et al. American College of Surgeons Oncology Group (ACOSOG) Z0011: impact on surgeon practice patterns. Ann Surg Oncol. 2012;19(10):3144–51.PubMedCrossRefGoogle Scholar
  6. 6.
    Gainer S, Hunt K, Beitsch P, Caudle A, Mittendorf E, Lucci A. Changing behavior in clinical practice in response to the ACOSOG Z0011 trial: a survey of the American Society of Breast Surgeons. Ann Surg Oncol. 2012;19(10):3152–8.PubMedCrossRefGoogle Scholar
  7. 7.
    van Rijk M, Deurloo E, Nieweg O, et al. Ultrasonography and fine-needle aspiration cytology can spare breast cancer patients unnecessary sentinel lymph node biopsy. Ann Surg Oncol. 2006;13(1):31–5.PubMedCrossRefGoogle Scholar
  8. 8.
    Boughey J, Moriarty J, Degnim A, Gregg M, Egginton J, Long K. Cost modeling of preoperative axillary ultrasound and fine-needle aspiration to guide surgery for invasive breast cancer. Ann Surg Oncol. 2010;17(4):953–8.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Krishnamurthy S, Sneige N, Bedi D, et al. Role of ultrasound-guided fine-needle aspiration of indeterminate and suspicious axillary lymph nodes in the initial staging of breast carcinoma. Cancer. 2002;95(5):982–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Rao R, Lilley L, Andrews V, Radford L, Ulissay M. Axillary staging by percutaneous biopsy: sensitivity of fine-needle aspiration versus core needle biopsy. Ann Surg Oncol. 2009;16(5):1170–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Kwak H, Chae B, Bae J, et al. Feasibility of sentinel lymph node biopsy in breast cancer patients clinically suspected of axillary lymph node metastasis on preoperative imaging. World J Surg Oncol. 2013;21(11):104.CrossRefGoogle Scholar
  12. 12.
    Leenders M, Broeders M, Croese C, et al. Ultrasound and fine needle aspiration cytology of axillary lymph nodes in breast cancer. To do or not to do? Breast. 2012;21(4):578–83.PubMedCrossRefGoogle Scholar
  13. 13.
    Cserni G, Bianchi S, Vezzosi V, et al. The value of cytokeratin immunohistochemistry in the evaluation of axillary sentinel lymph nodes in patients with lobular breast carcinoma. J Clin Pathol. 2006;59(5):518–22.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Mittendorf E, Sahin A, Tucker S, et al. Lymphovascular invasion and lobular histology are associated with increased incidence of isolated tumor cells in sentinel lymph nodes from early-stage breast cancer patients. Ann Surg Oncol. 2008;15(12):3369–77.PubMedCrossRefGoogle Scholar
  15. 15.
    Park S, Kim M, Park B, Moon H, Kwak J, Kim E. Impact of preoperative ultrasonography and fine-needle aspiration of axillary lymph nodes on surgical management of primary breast cancer. Ann Surg Oncol. 2011;18(3):738–44.PubMedCrossRefGoogle Scholar
  16. 16.
    Baruah B, Goyal A, Young P, Douglas-Jones A, Mansel R. Axillary node staging by ultrasonography and fine-needle aspiration cytology in patients with breast cancer. Br J Surg. 2010;97(5):680–3.PubMedCrossRefGoogle Scholar
  17. 17.
    Mittendorf E, Boughey J, Bassett R, et al. Incorporation of sentinel lymph node metastasis size into a nomogram predicting nonSLN involvement in breast cancer patients with a positive sentinel lymph node. Ann Surg. 2012;255(1):109–115.PubMedCrossRefGoogle Scholar
  18. 18.
    Van Zee K. Manasseh D, Bevilacqua J, 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(10):1140–51.PubMedCrossRefGoogle Scholar
  19. 19.
    Hieken T, Trull B, Boughey J, Jones K, Reynolds C, Shah S, et al. Preoperative axillary imaging with percutaneous lymph node biopsy is valuable in the contemporary management of patients with breast cancer. Surgery. 2013;154(4):831–40.PubMedCrossRefGoogle Scholar
  20. 20.
    Huang E, Tucker S, Strom E, et al. Postmastectomy radiation improves local-regional control and survival for selected patients with locally advanced breast cancer treated with neoadjuvant chemotherapy and mastectomy. J Clin Oncol. 2004;22(23):4691–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Truong P, Olivotto I, Kader H, Panades M, Speers C, Berthelet E. Selecting breast cancer patients with T1–T2 tumors and one to three positive axillary nodes at high postmastectomy locoregional recurrence risk for adjuvant radiotherapy. Int J Radiat Oncol Biol Phys. 2005;51(5):1337–47.CrossRefGoogle Scholar
  22. 22.
    Whelan T, Olivotto I, Ackerman I, et al. NCIC-CTG MA.20: an intergroup trial of regional nodal irradiation in early breast cancer (abstract LBA1003). J Clin Oncol. 2011;29(18 Suppl).Google Scholar
  23. 23.
    Dominici L, Mittendorf E, Wang X, et al. Implications of constructed biologic subtype and its relationship to locoregional recurrence following mastectomy. Breast Cancer Res. 2012;14(3):R82.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Caudle A, Hunt K, Kuerer H, et al. Multidisciplinary considerations in the implementation of the findings from the American College of Surgeons Oncology Group (ACOSOG) Z0011 study: a practice-changing trial. Ann Surg Oncol. 2011;19(8):2407–12.CrossRefGoogle Scholar
  25. 25.
    Nguyen P, Taghian A, Katz M, et al. Breast cancer subtype approximated by estrogen receptor, progesterone receptor, and HER-2 is associated with local and distant recurrence after breast-conserving therapy. J Clin Oncol. 2008;26(14):2373–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Voduc K, Cheang M, Tyldesley S, Gelmon K, Nielson T, Kennecke H. Breast cancer subtypes and the risk of local and regional relapse. J Clin Oncol. 2010;28(10):1684–91.PubMedCrossRefGoogle Scholar
  27. 27.
    Dowsett M, Dunbier A. Emerging biomarkers and new understanding of traditional markers in personalized therapy for breast cancer. Clin Cancer Res. 2008;14(24):8019–26.PubMedCrossRefGoogle Scholar
  28. 28.
    Kim M, Ro J, Ahn S, Kim H, Gong G. Clinicopathologic significance of the basal-like subtype of breast cancer: a comparison with hormone receptor and Her2/neu-overexpressing phenotypes. Hum Pathol. 2006;37(9):1217–26.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2014

Authors and Affiliations

  • Abigail S. Caudle
    • 1
    Email author
  • Henry M. Kuerer
    • 1
  • Huong T. Le-Petross
    • 1
  • Wei Yang
    • 1
  • Min Yi
    • 1
  • Isabelle Bedrosian
    • 1
  • Savitri Krishnamurthy
    • 1
  • Bruno D. Fornage
    • 1
  • Kelly K. Hunt
    • 1
  • Elizabeth A. Mittendorf
    • 1
  1. 1.The University of Texas MD Anderson Cancer CenterHoustonUSA

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