The Evolving Role of Axillary Lymph Node Fine-Needle Aspiration in the Management of Carcinoma of the Breast

Cancer Cytopathology (Impact Factor: 3.35). 10/2011; 119(5):328 - 334. DOI: 10.1002/cncy.20152


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.
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.
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.
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.

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    • "across all studies9,11-17,21-23,25-28,30,31,33-50. Axillary treatment consisted of triage directly to ALND for the vast majority (and avoidance of SNB) but in some studies UNB was used to affect neoadjuvant therapy prior to ALND9,31,41,47. The median prevalence of node metastases (proportion of patients found to have node metastases on surgical histology) across the 35 studies was 43.2% (IQR 38.7%-51.2%)9,11-17,21-23,25-28,30,31,33-50. In Figure 1, the bubble plot (bubble size reflects study size) displays study-specific proportion of utility (proportion of subjects triaged to axillary surgery based on UNB result) in relation to study-specific underlying prevalence of node metastases. "
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    ABSTRACT: Preoperative staging of the axilla in women with invasive breast cancer using ultrasound-guided needle biopsy (UNB) identifies approximately 50% of patients with axillary nodal metastases prior to surgical intervention. Although moderately sensitive, it is a highly specific staging strategy that is rarely falsely-positive, hence a positive UNB allows patients to be triaged to axillary lymph-node dissection (ALND) avoiding potentially unnecessary sentinel node biopsy (SNB). In this review, we extend our previous work through an updated literature search, focusing on studies that report data on UNB utility. Based on data for 10,934 breast cancer patients, sourced from 35 studies, a positive UNB allowed triage of 1,745 cases (simple proportion 16%) to axillary surgical treatment: the utility of UNB was a median 19.8% [interquartile range (IQR) 11.6%-26.7%] across these studies. We also modelled data from a subgroup of studies, and estimated that amongst patients with metastases to axillary nodes, the odds ratio (OR) for high nodal disease burden for a positive UNB versus a negative UNB was 4.38 [95% confidence interval (95% CI): 3.13, 6.13], P<0.001. From this model, the estimated proportion with high nodal disease burden was 58.9% (95% CI: 50.2%, 67.0%) for a positive UNB, whereas the estimated proportion with high nodal disease burden was 24.6% (95% CI: 17.7%, 33.2%) if UNB was negative. Overall, axillary UNB has good clinical utility and a positive UNB can effectively triage to ALND. However, the evolving landscape of axillary surgical treatment means that UNB will have relatively less utility where surgeons have modified their practice to omission of ALND for minimal nodal metastatic disease.
    Cancer Biology and Medicine 06/2014; 11(2):69-77. DOI:10.7497/j.issn.2095-3941.2014.02.001
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    • "A number of prospective studies looking at the role of ultrasound-guided sampling of axillary lymph nodes in breast cancer have been published [8,16-18]. Reported sensitivities and specificities in the literature were 40% to 87%, and 56% to 100%, respectively [16]. In the previous study by Marti et al. [17], the axillary FNAC was 86% sensitive, 100% specific, and 91% accurate; PPV was 100% and NPV was 78%. "
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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.
    World Journal of Surgical Oncology 11/2013; 11(1):296. DOI:10.1186/1477-7819-11-296 · 1.41 Impact Factor
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    • "The clinical staging and preoperative lymph node status are important for the evaluation of eligible patient to neoadjuvant therapy. In the axillary lymph node FNAC, Chang et al. [33] "
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    ABSTRACT: Despite the fact that CNB has been progressively replaced by FNAC in the investigation of nonpalpable lesions or microcalcifications without a clinical or radiological mass lesion, FNAC has yet a role in palpable lesions provided it is associated with the triple diagnosis and experienced cytologist. In these conditions, FNAC is a safe, effective, economical, and accurate technique for breast cancer evaluation. Numerous literature reviews and meta-analyses illustrated the advantages and disadvantages of both methods CNB and FNAC. The difference does not seem significant when noninformative and unsatisfactory FNAC was excluded. Recently, cytological methods using liquid-based cytology (LBC) technology improve immunocytological and molecular tests with the same efficiency as classical immunohistochemistry. The indications of FNAC were, for palpable lesions, relative contraindication of CNB (elderly or frailty), staging of multiple nodules in conjunction or not with CNB, staging of lymph node status, newly appearing lesion in patient under neoadjuvant treatment, decreasing of anxiety with a rapid diagnosis, evaluation of biomarkers and new biomarkers, and chronological evaluation of biomarker following the neoadjuvant therapy response.
    07/2013; 2013:935796. DOI:10.1155/2013/935796
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