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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    • "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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