Background. Four-node sampling is a useful substitute for sentinel node biopsy in low resource settings. USG is being increasingly used as a preoperative tool to evaluate axilla. We conducted this study to assess the accuracy of different descriptors of axillary ultrasound and to formulate a model on grading of axillary involvement. Material and Methods. Thirty-four patients with clinically negative axilla underwent preoperative axillary ultrasound. The suspicious nodes were marked and details of various descriptors were noted. These nodes were sampled during axillary dissection and correlation of ultrasonographic findings with histopathological report was done to calculate accuracy of different descriptors. Based on this, a grading system of axillary lymph nodes involvement was formulated. Results. Based on the presence of various descriptors, five grades of nodal involvement could be defined. The most accurate descriptors to indicate nodal involvement were loss of hilar fat and hypoechoic internal echoes with specificity of 83% and positive predictive value of 92% each. The combination of descriptors of round shape with loss of hilar fat and hypoechoic internal echos had 100% specificity and positive predictive value. Conclusions. Grading of nodal involvement on axillary USG can be useful for selecting the most suspicious nodes for sampling during axillary dissection. 1. Introduction Metastatic involvement of axillary lymph node is the single most important prognostic factor in breast cancer. The presence of axillary involvement in breast cancer determines the patient’s survival and staging of the disease and plays an important part in local control. Until recently, axillary lymph node (ALND) dissection was considered as the reference method for detecting lymph node involvement. However the rate of axillary lymph node metastasis is very low in patients diagnosed at an early stage [1, 2]. Hence studies in the last decade discourage the use of ALND because of significant associated morbidities such as lymphedema, paresthesias, infection, and decreased range of movement of shoulder. To avoid these unnecessary morbidities the concept of sentinel node biopsy (SLNB) has gained increasing acceptance. Studies have proved that the drainage of breast lymphatics is in an orderly manner through initial node(s)—the sentinel lymph node (SLN) and almost 100% of breast cancer drain to axilla irrespective of the primary tumor’s location [3]. Studies have proved that SLND alone is sufficient for management of axilla in early cancers if SLN is negative [4, 5]. However
References
[1]
C. Lanng, J. Hoffmann, H. Galatius, and U. Engel, “Assessment of clinical palpation of the axilla as a criterion for performing the sentinel node procedure in breast cancer,” European Journal of Surgical Oncology, vol. 33, no. 3, pp. 281–284, 2007.
[2]
B. A. Mincey, T. Bammer, E. J. Atkinson, and E. A. Perez, “Role of axillary node dissection in patients with T1a and T1b breast cancer: mayo clinic experience,” Archives of Surgery, vol. 136, no. 7, pp. 779–782, 2001.
[3]
S. Shivers, C. Cox, G. Leight et al., “Final results of the department of defense multicenter breast lymphatic mapping trial,” Annals of Surgical Oncology, vol. 9, no. 3, pp. 248–255, 2002.
[4]
L. Bergkvist and J. Frisell, “Multicentre validation study of sentinel node biopsy for staging in breast cancer,” The British Journal of Surgery, vol. 92, no. 10, pp. 1221–1224, 2005.
[5]
U. Veronesi, G. Paganelli, G. Viale et al., “Sentinel-lymph-node biopsy as a staging procedure in breast cancer: update of a randomised controlled study,” The Lancet Oncology, vol. 7, no. 12, pp. 983–990, 2006.
[6]
R. de Freitas Jr., M. V. Costa, S. V. Schneider, M. A. Nicolau, and E. Marussi, “Accuracy of ultrasound and clinical examination in the diagnosis of axillary lymph node metastases in breast cancer,” European Journal of Surgical Oncology, vol. 17, no. 3, pp. 240–244, 1991.
[7]
M. B. Popli, M. Sahoo, N. Mehrotra et al., “Preoperative ultrasound-guided fine-needle aspiration cytology for axillary staging in breast carcinoma,” Australasian Radiology, vol. 50, no. 2, pp. 122–126, 2006.
[8]
M. C. van Rijk, E. E. Deurloo, O. E. Nieweg et al., “Ultrasonography and fine-needle aspiration cytology can spare breast cancer patients unnecessary sentinel lymph node biopsy,” Annals of Surgical Oncology, vol. 13, no. 1, pp. 31–35, 2006.
[9]
J. T. Davis, Y. M. Brill, S. Simmons et al., “Ultrasound-guided fine-needle aspiration of clinically negative lymph nodes versus sentinel node mapping in patients at high risk for axillary metastasis,” Annals of Surgical Oncology, vol. 13, no. 12, pp. 1545–1552, 2006.
[10]
S. Ciatto, B. Brancato, G. Risso et al., “Accuracy of fine needle aspiration cytology (FNAC) of axillary lymph nodes as a triage test in breast cancer staging,” Breast Cancer Research and Treatment, vol. 103, no. 1, pp. 85–91, 2007.
[11]
A. Sapino, P. Cassoni, E. Zanon et al., “Ultrasonographically-guided fine-needle aspiration of axillary lymph nodes: role in breast cancer management,” The British Journal of Cancer, vol. 88, no. 5, pp. 702–706, 2003.
[12]
Y. S. Rajesh, S. Ellenbogen, and B. Banerjee, “Preoperative axillary ultrasound scan: its accuracy in assessing the axillary nodal status in carcinoma breast,” Breast, vol. 11, no. 1, pp. 49–52, 2002.
[13]
P. Mustonen, P. Farin, and O. Kosunen, “Ultrasonographic detection of metastatic axillary lymph nodes in breast cancer,” Annales Chirurgiae et Gynaecologiae, vol. 79, no. 1, pp. 15–18, 1990.
[14]
W. T. Yang, A. Ahuja, A. Tang, M. Suen, W. King, and C. Metreweli, “High resolution sonographic detection of axillary lymph node metastases in breast cancer,” Journal of Ultrasound in Medicine, vol. 15, no. 3, pp. 241–246, 1996.
[15]
M. Y. T. Sousa, M. E. B. Illescas, M. L. R. Rodríguez et al., “Preoperative staging of axillary lymph nodes in breast cancer: ultrasonographic parameters and ultrasound-guided core needle biopsy,” Radiologia, vol. 53, no. 6, pp. 544–551, 2011.
[16]
J. Verbanck, I. Vandewiele, H. de Winter, J. Tytgat, F. van Aelst, and W. Tanghe, “Value of axillary ultrasonography and sonographically guided puncture of axillary nodes: a prospective study in 144 consecutive patients,” Journal of Clinical Ultrasound, vol. 25, pp. 53–56, 1997.
[17]
A. Oz, F. B. Demirkazik, M. G. Akpinar et al., “Efficiency of Ultrasound and Ultrasound-guided fine needle aspiration cytology in preoperative assessment of axillary lymph node metastasis in breast cancer,” Journal of Breast Cancer, vol. 15, no. 2, pp. 211–217, 2012.
[18]
H. Altinyollar, G. Dingil, and U. Berberoglu, “Detection of infraclavicular lymph node metastases using ultrasonography in breast cancer,” Journal of Surgical Oncology, vol. 92, no. 4, pp. 299–303, 2005.
[19]
H. Madjar and E. B. Mendelson, “Lymph nodes,” in The Practice of Breast Ultrasound, H. Madjar and E. B. Mendelson, Eds., p. 191, Thieme, New York, NY, USA, 2008.
[20]
R. D. Macmillan, D. Barbera, D. J. Hadjiminas et al., “Sentinel node biopsy for breast cancer may have little to offer four-node-samplers. results of a prospective comparison study,” European Journal of Cancer, vol. 37, no. 9, pp. 1076–1080, 2001.
[21]
U. Chetty, P. K. Y. Chin, P. H. S. Soon, W. Jack, and J. S. J. Thomas, “Combination blue dye sentinel lymph node biopsy and axillary node sampling: the Edinburgh experience,” European Journal of Surgical Oncology, vol. 34, no. 1, pp. 13–16, 2008.
[22]
K. Narui, T. Ishikawa, A. Kito et al., “Observational study of blue dye-assisted four-node sampling for axillary staging in early breast cancer,” European Journal of Surgical Oncology, vol. 36, no. 8, pp. 731–736, 2010.
