Meta-analysis of ultrasound-guided biopsy of suspicious axillary lymph nodes in the selection of patients with extensive axillary tumour burden in breast cancer

Wely, Bob J. van; Wilt, Johannes H. W. de; Francissen, C.; Teerenstra, Steven; Strobbe, Luc J. A.

doi:10.1002/bjs.9663

Cited by 68 publications

(47 citation statements)

References 42 publications

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“…Furthermore, while survival was expectedly worse in the needle biopsy cohort reported by Verheuvel el al that presented with more advanced-stage disease, there was no difference in regional recurrence, with only one isolated regional relapse in each group.. A meta-analysis including 6 additional studies also reported a higher percentage of pN2 disease in women with a positive needle biopsy compared to those with negative axillary imaging with a positive sentinel lymph node (46% versus 30%). 16 These studies concluded that SLNB may not be appropriate for women diagnosed with nodal disease by US and needle biopsy because this represents a higher-risk population; however, these studies do not represent women meeting Z0011 criteria, and yet 30%–52% of patients had low volume nodal disease and, in the appropriate context, could be spared ALND.…”

Section: Discussionmentioning

confidence: 99%

Does a Positive Axillary Lymph Node Needle Biopsy Result Predict the Need for an Axillary Lymph Node Dissection in Clinically Node-Negative Breast Cancer Patients in the ACOSOG Z0011 Era?

et al. 2015

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Background ACOSOG Z0011 defined clinical node negativity by physical exam alone. Although axillary US with biopsy has a positive predictive value for lymph node (LN) metastases approaching 100%, it may not appropriately identify clinically node-negative women with ≥3 positive LNs (+LNs) who require ALND. We sought to identify the total number of +LNs in women presenting with cT1-2N0 breast carcinoma with a positive preoperative LN biopsy to evaluate the potential for overtreatment when ALND is performed on the basis of a positive needle biopsy in patients who otherwise meet ACOSOG Z0011 eligibility criteria. Methods Patients with cT1-2N0 breast cancer by physical exam with a positive preoperative LN biopsy were identified from a prospective institutional database. Clinicopathologic characteristics and axillary imaging results were compared between women with 1-2 total +LNs and ≥3 total +LNs. Results Between 5/2006-12/2013, 141 women with cT1-2N0 breast cancer had abnormal axillary imaging and a preoperative +LN biopsy (median patient age: 51yrs, median tumor size:2.4cm,86% ductal histology,79% ER+). 66 (47%) women had 1-2 total +LNs, 75 (53%) had ≥3 total +LNs. Women with ≥3 total +LNs had larger tumors (2.4 vs 2.2cm, p=0.03), fewer tumors with ductal histology (79% vs 94%, p=0.01), more lymphovascular invasion (80% vs 61%,p=0.01) and higher median BMI (29.2 vs 27.1,p=0.04). Having >1 abnormal LN on axillary imaging was significantly associated with having ≥3 total +LNs on final pathology (68% vs 43% p=0.003). Conclusions Axillary imaging with preoperative LN biopsy does not accurately discriminate low-versus high-volume nodal disease in clinically node-negative patients.

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Section: Discussionmentioning

confidence: 99%

Does a Positive Axillary Lymph Node Needle Biopsy Result Predict the Need for an Axillary Lymph Node Dissection in Clinically Node-Negative Breast Cancer Patients in the ACOSOG Z0011 Era?

et al. 2015

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“…The sensitivity of axillary ultrasound (in combination with tissue sampling where deemed necessary) is approximately 80% [15]. Furthermore, a negative axillary ultrasound excludes the presence of four or more lymph node metastases, with a negative predictive value of 93–96% in the general breast cancer population [16–18]. Therefore, axillary ultrasound improves preoperative selection of node negative patients, as it selects patients with a more favourable tumour load and confidently excludes advanced nodal disease.…”

Section: Introductionmentioning

confidence: 99%

Clinically node negative breast cancer patients undergoing breast conserving therapy, sentinel lymph node procedure versus follow-up: a Dutch randomized controlled multicentre trial (BOOG 2013-08)

et al. 2017

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BackgroundStudies showed that axillary lymph node dissection can be safely omitted in presence of positive sentinel lymph node(s) in breast cancer patients treated with breast conserving therapy. Since the outcome of the sentinel lymph node biopsy has no clinical consequence, the value of the procedure itself is being questioned. The aim of the BOOG 2013–08 trial is to investigate whether the sentinel lymph node biopsy can be safely omitted in clinically node negative breast cancer patients treated with breast conserving therapy.MethodsThe BOOG 2013–08 is a Dutch prospective non-inferiority randomized multicentre trial. Women with pathologically confirmed clinically node negative T1–2 invasive breast cancer undergoing breast conserving therapy will be randomized for sentinel lymph node biopsy versus no sentinel lymph node biopsy. Endpoints include regional recurrence after 5 (primary endpoint) and 10 years of follow-up, distant-disease free and overall survival, quality of life, morbidity and cost-effectiveness. Previous data indicate a 5-year regional recurrence free survival rate of 99% for the control arm and 96% for the study arm. In combination with a non-inferiority limit of 5% and probability of 0.8, this result in a sample size of 1.644 patients including a lost to follow-up rate of 10%. Primary and secondary endpoints will be reported after 5 and 10 years of follow-up.DiscussionIf the sentinel lymph node biopsy can be safely omitted in clinically node negative breast cancer patients undergoing breast conserving therapy, this study will cost-effectively lead to a decreased axillary morbidity rate and thereby improved quality of life with non-inferior regional control, distant-disease free survival and overall survival.Trial registrationThe BOOG 2013–08 study is registered in ClinicalTrials.gov since October 20, 2014, Identifier: NCT02271828. https://clinicaltrials.gov/ct2/show/NCT02271828

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“…While the ACOSOG Z0011 trial identified clinically node-negative patients by physical exam alone, some have suggested that axillary imaging with or without needle biopsy may be beneficial to allocate high-risk node-positive patients directly to ALND 9-13 , omitting SLNB and the possible need for two-step axillary surgery. However, when managing patients according to ACOSOG Z0011, preoperative axillary imaging is only beneficial if it accurately discriminates between patients with metastases in 1 or 2 axillary nodes and those with involvement of 3 or more nodes or gross extracapsular extension (matted nodes) who require ALND.…”

Section: Introductionmentioning

confidence: 99%

Is Preoperative Axillary Imaging Beneficial in Identifying Clinically Node-Negative Patients Requiring Axillary Lymph Node Dissection?

Pilewskie

Jochelson

Gooch

et al. 2016

Journal of the American College of Surgeons

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Background ACOSOG Z0011 results support the omission of axillary lymph node dissection (ALND) in women with <3 positive sentinel lymph nodes (SLNs) undergoing breast-conserving surgery (BCS) and radiation therapy. We sought to determine if abnormal axillary imaging is predictive of the need for ALND in this population. Study Design Patients with cT1-2N0 breast cancer by physical examination undergoing BCS were managed according to Z0011 criteria independent of axillary imaging. Patient characteristics and rates of ALND were compared among those with and without abnormal LNs detected by mammogram, ultrasound (US), or MRI. All available axillary imaging was reviewed by one breast radiologist. Results Between 8/2010–12/2013, 3253 breast cancer patients were treated with BCS and SLN biopsy; 425 patients met Z0011 criteria (cT1-2N0) and had nodal metastasis on SLN biopsy. Clinicopathologic features were: median patient age 58 years; median tumor size 1.8cm; 85% ductal histology; 89% estrogen receptor positive. All women had a mammogram, 242 had axillary US, 172 had MRI. Abnormal LNs were seen on 7%, 25%, and 30% of mammograms, US, and MRIs, respectively. While abnormal LNs on mammogram or US were associated with a significant increase in ALND and a non-significant trend was seen with MRI, 68–73% of women with abnormal axillary imaging did not require ALND. Conclusions Among clinically node negative patients with abnormal axillary imaging, 71% did not meet criteria for ALND and were spared further surgical morbidity. Abnormal nodes on US, MRI, or mammogram in clinically node-negative patients are not reliable indicators of the need for ALND.

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Meta-analysis of ultrasound-guided biopsy of suspicious axillary lymph nodes in the selection of patients with extensive axillary tumour burden in breast cancer

Abstract: Patients with breast cancer in whom axillary metastases are detected by ultrasound-guided biopsy have significantly more involved nodes than SLNB-positive patients. This finding enables further preoperative tailoring of axillary treatment in breast cancer.

Cited by 68 publications

References 42 publications

Does a Positive Axillary Lymph Node Needle Biopsy Result Predict the Need for an Axillary Lymph Node Dissection in Clinically Node-Negative Breast Cancer Patients in the ACOSOG Z0011 Era?

Does a Positive Axillary Lymph Node Needle Biopsy Result Predict the Need for an Axillary Lymph Node Dissection in Clinically Node-Negative Breast Cancer Patients in the ACOSOG Z0011 Era?

Clinically node negative breast cancer patients undergoing breast conserving therapy, sentinel lymph node procedure versus follow-up: a Dutch randomized controlled multicentre trial (BOOG 2013-08)

Is Preoperative Axillary Imaging Beneficial in Identifying Clinically Node-Negative Patients Requiring Axillary Lymph Node Dissection?

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