Main Article Content
Aims: Metastasis to axillary lymph nodes is an important prognostic factor in carcinoma breast patients, with implications on overall survival and progression-free survival. To evaluate the accuracy of pre-operative clinical palpation and USG axilla in patients with carcinoma breast, using histopathology as the gold standard.
Study Design: Cross-sectional observational study.
Place and Duration of Study: This was a retrospective study, carried out at Cancer Research Institute, SRHU, India, between January 2015 and December 2018.
Methodology: Data was collected from Case records and Hospital Information System for patients having undergone surgery for breast cancer. Pre-treatment clinical, ultrasound axilla, and final histopathology details were recorded. Taking histopathology as the gold standard test, diagnostic accuracy of clinical palpation and ultrasound axilla was calculated.
Results: 256 patients were enrolled in the study. Clinically, 70.7% of patients were T1/T2 stage, 53.9% were node-positive, on USG axilla 59% had abnormal nodes, pathologically 53.52% had nodal metastasis. The sensitivity, specificity for clinical palpation was 77.86% and 75%, for USG was 90.71% and 79.31%. Sensitivity and specificity of USG in c T1/2 was 88.64% and 80.21%; in c T3/4 94.23% and 65.22%; in c N negative 87% and 72.16%; in c N positive 91.74% and 75.86%.
Conclusion: The diagnostic accuracy of clinical palpation of axilla alone was low; Ultrasound axilla had high sensitivity but low specificity across all T stages of breast tumor. The ultrasound had a high negative predictive value in clinically non-palpable nodes and a high positive predictive value in clinically palpable nodes.
NCCN 2020 guidelines. Available:https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf.
Vaidya JS, Vyas JJ, Thakur MH, Khandelwal KC, Mittra I. Role of ultra-sonography to detect axillary node involvement in operable breast cancer. Eur J Surg Oncol. 1996;22(2):140–3.
KubilayErtan, Christina Linsler, Alexander di Liberto, et al. Axillary Ultrasound for breast cancer staging: An attempt to identify clinical/histopathological factors impacting diagnostic performance. Breast Cancer: Basic and Clinical Research. 2013;7:35–40. DOI: 10.4137/BCBCR.S11215
Yang WT, Ahuja A, Tang A, Suen M, King W, Metreweli C. High resolution sonographic detection of axillary lymph node metastases in breast cancer. J Ultrasound Med. 1996;15(3):241–6.
Bonnema J, van Geel AN, van Ooijen B et al. Ultrasound-guided aspira¬tion biopsy for detection of non-palpable axillary node metastases in breast cancer patients: new diagnostic method. World J Surg. 1997;21(3):270–4.
Strauss HG, Lampe D, Methfessel G, Buchmann J. Preoperative axillary sonography in breast tumor suspected of malignancy—a diagnostic advantage? Ultraschall Med. 1998;19(2):70–7.
Kebudi A, Caliskan C, Yetkin G et al. The role of pre-operative B mode ultrasound in the evaluation of the axillary lymph node metastases in the initial staging of breast carcinoma. ActaChir Belg. 2005;105: 511–4.
Mills P, Sever A, Weeks J, Fish D, Jones S, Jones P. Axillary ultrasound assessment in primary breast cancer: An audit of 653 cases. Breast J. 2010;16(5):460–446.
Jung J, Park H, Park J, Kim H. Accuracy of preoperative ultrasound and ultrasound-guided fine needle aspiration cytology for axillary staging in breast cancer. J Surg. 2010;80(4):271–5.
Garcia-Ortega MJ, Benito MA, Vahamonde EF, Torres PR, Velasco AB, Paredes MM. Pretreatment axillary ultrasonography and core biopsy in patients with suspected breast cancer: Diagnostic accuracy and impact on management. Eur J Radiol. 2011;79(1):64–72.
Natalia S. Tucker Amy E. Cyr, Foluso O. Ademuyiwa, et al. Axillary ultrasound accurately excludes clinically significant lymph node disease in patients with early stage breast cancer. Ann Surg. 2016; 264(6):1098–1102. DOI:10.1097/SLA.0000000000001549.
Laura Lidia Saltarin, Giovanna Lo Bue, Carlos A Garcia-Etienne et al. Accuracy of axillary ultrasound in the detection of nodal metastasis in breast cancer: Experience on 620 cases. Journal of Cancer Prevention & Current Research. 2016;6(4).
Rashpal Singh, Ekta Dhamija, SVS Deo et al. A prospective study to evaluate the accuracy of axillary staging using ultrasound and USG-guided fine needle aspiration cytology in early breast cancer patients in a high-volume center. Journal of Clinical Oncology 37, no. 15_suppl. DOI:10.1200/JCO.2019.37.15_suppl.e12060.
Tugba Han Yilmaz, Hasan Yerli, Baha Arslan et al. Diagnostic accuracy of axillary ultrasound in early–stage breast cancer. Indian Journal of Surgery 2019;81(5):421-425. Available:https://doi.org/10.1007/s12262-018-1828-y.
Caudle AS, Kuerer HM, Le-Petross HT, Yang W, Yi M, Bedrosian I et al. Predicting the extent of nodal dis-ease in early-stage breast cancer. Ann Surg Oncol 2014; 21:3440—7.
Schipper RJ, van Roozendaal LM, de Vries B, PijnappelRM,Beets-Tan RGH, Lobbes MBI et al. Axillary ultrasound for pre-operative nodal staging in breast cancer patients: is it of addedvalue? Breast Edinb Scotl 2013;22:1108—13.
Maxwella F, De Margerie Mellona C, Bricouta M et al. Diagnostic strategy for the assessment of axillary lymph node status in breast cancer. Diagnostic and Interventional Imaging. 2015;96,1089—1101. Available:http://dx.doi.org/10.1016/j.diii.2015.07.007.
Abe H, Schacht D, Sennett CA, Newstead GM, Schmidt RA.Utility of preoperative ultrasound for predicting pN2 orhigher stage axillary lymph node involvement in patientswith newly diagnosed breast cancer. AJR Am J Roentgenol. 2013; 200:696—702.
Belinda Lee, Adrian K. Lim, Jonathan Krell et al. The efficacy of axillary ultrasound in the detection of nodal metastasis in breast cancer. AJR. 2013;200:W314–W320. DOI:10.2214/AJR.12.9032.
Mainiero MB, Cinelli CM, Koelliker SL, et al. Axillary ultrasound and fine-needle aspiration in the preoperative evaluation of the breast cancer patient: An algorithm based on tumor size and lymph node appearance. AJR Am J Roentgenol. 2010;195:1261–7.
Oruwari JUN, Chung MA, Koelliker S, Steinhoff MM, Cady B.Axillary staging using ultrasound-guided fine-needle aspira-tion biopsy in locally advanced breast cancer. Am J Surg. 2002;184:307—9.
Rahbar H, Partridge SC, Javid SH, et al. Imaging axillary lymph nodes in patients with newly diagnosed breast cancer. Curr Probl Diagn Radiol. 2012; 41:149–58.
Pinheiro DJPC, Elias S, Nazário ACP. Axillary lymph nodes in breast cancer patients: sonographic evaluation. Radiol Bras. 2014 Jul/Ago;47(4):240–244. Available: http://dx.doi.org/10.1590/0100-3984.2013.1689.
Gentilini O, Veronesi U. Abandoning sentinel lymph node in early breast cancer? A new trial in progress at the European Institute of Oncology of Milan (SOUND: Sentinel node vs Observation after axillary UltraSouND). Breast. 2012; 21:678–81.
Vidya S Upadhyaya et al. Evaluating the preoperative breast cancer characteristics affecting the accuracy of axillary ultrasound staging, Breast J. 2020; 26(2):162-167. DOI: 10.1111/tbj.13635. Epub 2019 Sep 27.