The evolving role of axillary lymph node fine‐needle aspiration in the management of carcinoma of the breast

Cancer Cytopathology (Impact Factor: 4.43). 10/2011; 119(5):328 - 334. DOI: 10.1002/cncy.20152

ABSTRACT BACKGROUND:Image-guided fine-needle aspiration (FNA) studies of axillary lymph nodes (LN) to evaluate breast carcinoma have shown high specificity but variable sensitivity. The purposes of this study were to evaluate the performance of axillary LN FNA depending on clinicoradiologic findings and to document how treatment varied according to FNA results.METHODS:The study cohort consisted of consecutive axillary LN FNA cases over a 4-year period, in which subsequent treatment was known. Clinicoradiologic assessment was classified as “low suspicion” or “high suspicion” and cytopathologic findings as “positive,” “negative,” or “indeterminate”. The test performance for each, using surgical pathology outcome as the “gold standard,” was calculated. The impact of axillary LN FNA on subsequent management decisions was analyzed.RESULTS:Of the 163 cases, axillary FNA was positive in 94 of 163 (58%), negative in 55 of 163 (34%), and atypical/nondiagnostic in 14 of 163 (8%). A clinicoradiologic assessment of “high suspicion” had a positive predictive value (PPV) of 88%, whereas a “low suspicion” assessment had a negative predictive value (NPV) of only 68%. In contrast, the PPV and NPV of axillary LN FNA were 98.7% and 81.8%, respectively. Whereas all of the FNA-nonpositive cases were managed surgically, surgery was deferred in 26 of 94 of the FNA-positive cases, including 11 cases of neoadjuvant treatment. Most of the remaining (65 of 68) FNA-positive patients were spared sentinel lymph node biopsy.CONCLUSIONS:Image-guided LN FNA is highly sensitive and specific for lymph node involvement by breast carcinoma and plays a role both in sparing sentinel lymph node biopsy and in triaging cases for systemic therapy. Cancer (Cancer Cytopathol) 2011. © 2011 American Cancer Society.

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    ABSTRACT: Image-guided axillary lymph node fine-needle aspirates (FNAs) correlate well with pathologic lymph node staging in cases of invasive breast carcinoma. The objective of this study was to determine the prognostic significance of a positive lymph node. Consecutive cases of nonmetastatic (M0) invasive breast carcinoma evaluated by image-guided FNA were identified (4-year period, median follow-up of 51 months). "Positive" and "nonpositive" groups were compared using Kaplan-Meier survival analysis. Multivariate Cox regression was used to correct for clinicopathologic and treatment factors. A total of 142 cases was included, 70 with positive axillary FNA and 72 with a nonpositive result. FNA-positive and nonpositive cases did not differ in patient age, tumor subtype, or hormone receptor status. Positive FNA was significantly associated with advanced T and N pathologic stage, and with HER2 (human epidermal growth factor receptor 2) positivity. FNA-positive patients were more likely to undergo mastectomy and to receive chemotherapy. Kaplan-Meier analysis showed that positive FNA is associated with poor prognosis, both with respect to disease-free survival (89% nonpositive versus 73% positive at 5 years, P < .001) and overall survival (94% versus 81%, respectively, at 5 years, P = .01). Multivariate analysis showed that when correcting for other variables, FNA positivity was not independently significant. Positive axillary lymph node FNA is associated with poor prognosis on univariate analysis. By contrast, overall nodal staging is independently significant on multivariate analysis. The prognostic significance of axillary FNA likely results from its ability to predict for nodal status. Axillary FNA has utility as a preoperative staging procedure. Cancer (Cancer Cytopathol) 2013. © 2013 American Cancer Society.
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    ABSTRACT: It has been demonstrated that axillary ultrasound-guided fine-needle aspiration (US-FNA) has excellent positive predictive value for the axillary lymph node status of patients with breast cancer before surgery or neoadjuvant therapy and, thus, can obviate the need for sentinel lymph node biopsy in FNA-positive patients. However, US-FNA has only moderate sensitivity, in part because of the collection of nondiagnostic or equivocal specimens. Rapid on-site evaluation for adequacy (ROSE) can improve definitive diagnosis rates but has not been well characterized in this setting. One hundred thirty-three patients with breast carcinoma were identified who underwent 136 US-FNAs of axillary lymph nodes, all with ROSE, and the results were correlated with the diagnosis on a subsequent surgical procedure. The adequacy rate was 95.6% (130 of 136 FNAs), and a definitive diagnosis was made in 91.2% (124 of 136 FNAs). Among definite diagnoses, sensitivity was 75%, specificity was 100%, the positive predictive value was 100%, and the negative predictive value was 79%. Sources of false-negative and potential false-positive diagnoses were evaluated among these cases and in the literature. Small metastasis size is the most common cause of false-negative results, whereas interpretation errors by pathologists are quite rare. ROSE appears to improve adequacy and definitive diagnosis rates and, thus, can more accurately triage patients to appropriate care. Cancer (Cancer Cytopathol) 2013. © 2013 American Cancer Society.
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    ABSTRACT: Axillary lymph node status is an important staging and prognostic factor in breast cancer. This study aimed to evaluate the efficacy of axilla fine needle aspiration cytology (FNAC) in primary breast cancer without a palpable node and even without image characteristics of a metastatic node. From June 2008 to January 2012, 77 patients met the inclusion criteria of having received a FNAC procedure during the diagnostic protocol of primary breast cancer with the characteristic of impalpable axilla nodes, and of having received axillary surgery after that, according to the guidelines. The patients' characteristics, clinical-pathological features, pre-operative axillary lymph node FNAC findings, surgical lymph node report, and definite pathologic staging were reviewed. The FNAC procedures had a reported sensitivity of 58.82%, specificity of 100%, positive predictive value of 100%, negative predictive value of 72.55%, and accuracy of 80.28%. There were no false positives on FNAC; therefore, the positive likelihood ratio approached infinity. The negative likelihood ratio was 41.18%. Axillary lymph node FNAC is feasible in newly diagnosed breast cancer patients to evaluate metastatic lymph nodes even in those without clinical or ultrasonic evidence of lymphadenopathy. FNAC can be a routine evaluation for most primary breast cancer patients with benefits in expediting treatment. For those patients with positive findings of the axilla, sentinel node biopsy can be avoided.
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