Abstract
Axillary ultrasound (AUS) and biopsy are now part of the preoperative assessment of breast cancer based on the assumption that any nodal disease is an indication for axillary clearance (AC). The Z0011 trial erodes this assumption. We applied Z0011 eligibility criteria to patients with screen detected cancers and positive axillary assessment to determine the relevance of AUS to contemporary practice. Women screened between 1/1/2012 and 30/6/2013 and assessed for lesions with highly suspicious imaging features are included. We analysed demographic and assessment data and ascertained the final histopathology with particular reference to axillary nodal status. Among 449 lesions, AUS was recorded in 303 lesions (67.5 %). 290 (96 %) were carcinomas, 30.3 % with nodal disease. AUS was abnormal in 46 (15.9 %). AUS had a sensitivity of 39.8 %, specificity 94.6 %, positive predictive value (PPV) 79.2 % and negative predictive value (NPV) 78.1 %. Axillary FNAB was positive in 27 women, suspicious in two, benign in 16 and not performed in one. In one FNA positive case, the lesion was a nodular breast primary in the axillary tail in a multifocal breast cancer. Combining AUS and FNAB, the sensitivity was 76.5 %, specificity 90.9 %, PPV 96.3 % and NPV 55.6 %. Applying the Z0011 inclusion criteria, 24 of the 27 (88.9 %) women with abnormal AUS and positive FNA were ineligible for Z0011-based management. Of three women eligible for Z0011, one proceeded to AC after SN biopsy, leaving only two women (7.4 %) who might have been considered for SN only management had it not been for the results of the axillary assessment. Among women with negative AUS, nodal metastasis was demonstrated in 21.7 %, 86.8 % of these women having only 1–2 positive nodes. Abnormal AUS and FNA preferentially identify candidates for AC. Negative AUS predicts negative or low nodal burden. Axillary assessment streamlines care.
Similar content being viewed by others
References
Boughey JC, Moriarty JP, Degnim AC, Gregg MS, Egginton JS, Long KH (2010) Cost modeling of preoperative axillary ultrasound and fine-needle aspiration to guide surgery for invasive breast cancer. Ann Surg Oncol 17(4):953–958
BASO AoBsa (2009) Surgical guidelines for the management of breast cancer. Eur J Surg Oncol 35(Suppl 1):1–22
Giuliano AE, Hunt KK, Ballman KV et al (2011) Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA 305(6):569–575
Lyman GH, Giuliano AE, Somerfield MR et al (2005) American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol 23(30):7703–7720
Farshid G, Rush G (2004) Assessment of 142 stellate lesions with imaging features suggestive of radial scar discovered during population-based screening for breast cancer. Am J Surg Pathol 28(12):1626–1631
National Breast Cancer Centre (2002) Breast imaging: a guide for practice. National Breast Cancer Centre, Camperdown
BreastScreenAustralia (2005) BreastScreen Australia national accreditation handbook. Commonwealth of Australia, Canberra
Gooch J, King TA, Eaton A et al (2014) The extent of extracapsular extension may influence the need for axillary lymph node dissection in patients with T1–T2 breast cancer. Ann Surg Oncol 21(9):2897–2903
Straver ME, Meijnen P, van Tienhoven G et al (2010) Role of axillary clearance after a tumor-positive sentinel node in the administration of adjuvant therapy in early breast cancer. J Clin Oncol 28(5):731–737
Giuliano AE (2013) Reply to letter: are the standard tangential breast irradiation fields used in the ACOSOG Z0011 trial really covering the entire axilla? Ann Surg 257(1):e2
Gatzemeier W, Mann GB (2013) Which sentinel lymph-node (SLN) positive breast cancer patient needs an axillary lymph-node dissection (ALND)–ACOSOG Z0011 results and beyond. Breast 22(3):211–216
Robinson KA, Pockaj BA, Wasif N, Kaufman K, Gray RJ (2014) Have the American College of Surgeons Oncology Group Z0011 trial results influenced the number of lymph nodes removed during sentinel lymph node dissection? Am J Surg 208:1060–1064
Caretta-Weyer H, Greenberg CG, Wilke LG et al (2013) Impact of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial on clinical management of the axilla in older breast cancer patients: a SEER-medicare analysis. Ann Surg Oncol 20(13):4145–4152
Ainsworth RK, Kollias J, LeBlanc A, DeSilva P (2013) The clinical impact of the American College of Surgeons Oncology Group Z-0011 trial—results from the BreastSurgANZ National Breast Cancer Audit. Breast 22(5):733–735
Yamashita M, Hovanessian-Larsen L, Sener SF (2013) The role of axillary ultrasound in the detection of metastases from primary breast cancers. Am J Surg 205(3):242–244; discussion 44-5
Schipper RJ, van Roozendaal LM, de Vries B et al (2013) Axillary ultrasound for preoperative nodal staging in breast cancer patients: is it of added value? Breast 22(6):1108–1113
Nath J, Sami N, Massey J, Donnelly J, Corder AP (2013) Selection for axillary clearance in breast cancer (ultrasound negative, sentinel node positive patients have low rates of further metastases). Eur J Surg Oncol 39(5):450–454
Abe H, Schacht D, Sennett CA, Newstead GM, Schmidt RA (2013) Utility of preoperative ultrasound for predicting pN2 or higher stage axillary lymph node involvement in patients with newly diagnosed breast cancer. AJR Am J Roentgenol 200(3):696–702
Verheuvel NC, van den Hoven I, Ooms HW, Voogd AC, Roumen RM (2014) The role of ultrasound-guided lymph node biopsy in axillary staging of invasive breast cancer in the post-ACOSOG Z0011 trial era. Ann Surg Oncol 22:409–415
Choi JS, Kim MJ, Moon HJ, Kim EK, Yoon JH (2012) False negative results of preoperative axillary ultrasound in patients with invasive breast cancer: correlations with clinicopathologic findings. Ultrasound Med Biol 38(11):1881–1886
Ibrahim-Zada I, Grant CS, Glazebrook KN, Boughey JC (2013) Preoperative axillary ultrasound in breast cancer: safely avoiding frozen section of sentinel lymph nodes in breast-conserving surgery. J Am Coll Surg 217(1):7–15; discussion 15-6
Galimberti V, Cole BF, Zurrida S et al (2013) Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): a phase 3 randomised controlled trial. Lancet Oncol 14(4):297–305
Bochner MA, Farshid G, Dodd TJ, Kollias J, Gill PG (2003) Intraoperative imprint cytologic assessment of the sentinel node for early breast cancer. World J Surg 27(4):430–432
Peg V, Espinosa-Bravo M, Vieites B et al (2013) Intraoperative molecular analysis of total tumor load in sentinel lymph node: a new predictor of axillary status in early breast cancer patients. Breast Cancer Res Treat 139(1):87–93
Diepstraten SC, Sever AR, Buckens CF et al (2014) Value of preoperative ultrasound-guided axillary lymph node biopsy for preventing completion axillary lymph node dissection in breast cancer: a systematic review and meta-analysis. Ann Surg Oncol 21(1):51–59
Houssami N, Ciatto S, Turner RM, Cody HS III, Macaskill P (2011) Preoperative ultrasound-guided needle biopsy of axillary nodes in invasive breast cancer: meta-analysis of its accuracy and utility in staging the axilla. Ann Surg 254(2):243–251
Lee B, Lim AK, Krell J et al (2013) The efficacy of axillary ultrasound in the detection of nodal metastasis in breast cancer. AJR Am J Roentgenol 200(3):W314–W320
Britton PD, Goud A, Godward S et al (2009) Use of ultrasound-guided axillary node core biopsy in staging of early breast cancer. Eur Radiol 19(3):561–569
Leenders MW, Broeders M, Croese C et al (2012) Ultrasound and fine needle aspiration cytology of axillary lymph nodes in breast cancer. To do or not to do? Breast 21(4):578–583
Stachs A, Gode K, Hartmann S et al (2013) Accuracy of axillary ultrasound in preoperative nodal staging of breast cancer-size of metastases as limiting factor. Springerplus 2:350
Ganott MA, Zuley ML, Abrams GS et al (2014) Ultrasound guided core biopsy versus fine needle aspiration for evaluation of axillary lymphadenopathy in patients with breast cancer. ISRN Oncol 2014:703160
Fung AD, Collins JA, Campassi C, Ioffe OB, Staats PN (2014) Performance characteristics of ultrasound-guided fine-needle aspiration of axillary lymph nodes for metastatic breast cancer employing rapid on-site evaluation of adequacy: analysis of 136 cases and review of the literature. Cancer Cytopathol 122(4):282–291
Acknowledgments
We acknowledge the contributions of all staff, including medical officers, radiologists, pathologists and surgeons working at BreastScreen SA. We acknowledge the contributions of the anonymous reviewers whose suggestions have improved the presentation of this work.
Conflict of interest
None of the authors has declared a conflict of interest.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Farshid, G., Kollias, J. & Grantley Gill, P. The clinical utility of assessment of the axilla in women with suspicious screen detected breast lesions in the post Z0011 era. Breast Cancer Res Treat 151, 347–355 (2015). https://doi.org/10.1007/s10549-015-3388-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10549-015-3388-1