Preoperative Axillary Ultrasound in Breast Cancer: Safely Avoiding Frozen Section of Sentinel Lymph Nodes in Breast-Conserving Surgery

Abstract

Background The ACOSOG Z0011 results provided convincing evidence that completion axillary lymph node dissection (CALND) was unnecessary in selected patients with 1–2 positive sentinel lymph nodes (SLNs). We hypothesized that preoperative axillary ultrasound (AUS) with fine needle aspiration is sufficiently sensitive to detect worrisome macrometastasis to preclude need for frozen section pathology of SLNs. Study Design A retrospective single institution study, tertiary academic referral center. 1,140 T1-2 breast cancer patients who underwent SLN biopsy ± CALND, from 1/1/07-12/31/10 were reviewed. All patients had negative preoperative AUS ± FNA. Results 144 (13%) patients were node positive at surgery. Average age, tumor size, histology, ER and PR status were similar comparing 996 SLN negative to 144 (13%) SLN positive patients. Of the SLN positive patients, 25% were premenopausal, 9% were ER negative, and 19% had additional lymph nodes at CALND. Only 19 (2%) patients had SLN metastasis ≥6 mm, 10 (1%) had metastasis >7 mm, and only 1 patient had ≥3 positive SLNs. Conclusions The addition of preoperative AUS ± FNA to patients who meet ACOSOG Z0011 eligibility criteria reduced the risk of macrometastasis measuring ≥6 mm to only 2%, very few of whom would be premenopausal, have ER negative tumors, or ≥3 positive SLNs. With the addition of AUS ± FNA, we endorse the conclusions of the ACOSOG Z0011 trial in avoiding CALND, and see marginal gain in frozen section analysis of SLNs.

Local Treatment of the Axilla in Early Breast Cancer: Concepts from the National Surgical Adjuvant Breast and Bowel Project B-04 to the Planned Intergroup Sentinel Mamma Trial

“…A second important fact of this MSKCC paper is the low SLN-positive rate of 17.6% in the analyzed BCS cohort. This finding has been confirmed by another unicentric evaluation of 1,140 patients (T1/T2) with an SLN-positive rate of 13% [13]. All of these patients at the Mayo Clinic Rochester were clinically node-negative by preoperative axillary ultrasound (AUS) with or without fine-needle aspiration (FNA) biopsy.…”

Does Conservative Surgery for Breast Carcinoma Still Require Axillary Lymph Node Evaluation? A Retrospective Analysis of 1156 Consecutive Women With Early Breast Cancer

“…3 positive SLNs. 21 The reported SLN positivity rate of < 20% in patients with early breast cancer in the era of mammograms raises questions about that same role for SLNB, and consequently the need for performing ALND when the SLNB is positive and the patient is receiving adjuvant treatment (radiotherapy or medical therapy). Radiotherapy actively contributes to the success of the conservative approach.…”

Is Axillary Sentinel Lymph Node Biopsy Required in Patients Who Undergo Primary Breast Surgery

“…A Memorial Sloan Kettering analysis revealed an SLN-positive rate of 17.6% in a breast-conserving surgery (BCS) cohort [37]. This finding is confirmed by a Mayo Clinic cohort in another unicentric evaluation of 1,140 patients (T1/T2) with an SLN-positive rate of 13% [38]. These cN0 patients were all preoperatively evaluated by axillary ultrasound (AUS) with or without fine-needle aspiration (FNA) biopsy.…”