Sentinel lymph node biopsy often is done before or during breast cancer surgery to help figure out if the cancer has spread to lymph nodes in the nearby underarm (axillary) area. If cancer cells are found in the sentinel node, both the sentinel node and other axillary lymph nodes are usually removed, either during the breast cancer surgery or later with another surgery, depending on when the sentinel node biopsy results are available.
The small study reviewed here found that doing an ultrasound of the underarm lymph nodes before breast cancer surgery accurately identified the cancer's spread to the lymph nodes in nearly 30% of women diagnosed with breast cancer that had spread to those nodes. Knowing that the cancer had spread to the underarm lymph nodes before breast cancer surgery meant that the women had axillary lymph node dissection instead of sentinel node biopsy, avoiding a second surgery after sentinel node biopsy. The results were presented at the 2009 ASCO Breast Cancer Symposium.
The 274 women in the study were diagnosed with early-stage breast cancer and were having a lumpectomy. Several days before surgery, all of the women had an ultrasound of their underarm lymph nodes on the same side as the breast cancer to see if the cancer had spread to those lymph nodes. If the ultrasound showed a suspicious area, the women had a fine needle biopsy of the lymph nodes. If the fine needle biopsy showed cancer in the lymph nodes, the women had axillary biopsy during breast cancer surgery. If the fine needle biopsy showed no cancer or the ultrasound had no suspicious areas, the women had sentinel node biopsy during breast cancer surgery.
Overall, 57 (20.8%) of the 274 women had cancer in the axillary lymph nodes.
It's important to note that ultrasound didn't suggest that cancer had spread to the lymph nodes when it actually had not. In other words, underarm ultrasound didn't result in any false positives.
In this study, cancer in the axillary lymph nodes was mainly diagnosed by sentinel node biopsy, NOT underarm ultrasound. While ultrasound helped some women, sentinel node biopsy was a critical diagnostic step for most of the women. If you've been diagnosed with early-stage breast cancer and working on a treatment plan with your doctor, you might want to ask your doctor about the results of this study. The results suggest an underarm ultrasound done before sentinel node biopsy and breast cancer surgery might accurately identify the cancer's spread to the axillary lymph nodes, allowing you to have axillary node biopsy as part of your breast cancer surgery without having sentinel node biopsy. If the ultrasound shows no spread, it's likely that you'll have sentinel node biopsy.
You can learn more about lymph node surgery in the Breastcancer.org Lymph Node Removal pages.
SAN FRANCISCO (MedPage Today) -- Ultrasound of axillary lymph nodes before breast cancer surgery, with fine-needle aspiration for confirmation of metastases, could spare many early-stage patients from sentinel node biopsy and reoperation, researchers here said.
This strategy picked up 29.8% of macrometastases in women scheduled for lumpectomy, with an overall accuracy of 84.4%, Bedanta Baruah, MD, of Cardiff University in Cardiff, U.K., and colleagues reported at the ASCO Breast Cancer Symposium.
Those metastases were removed at the time of surgery, preventing a second procedure that would otherwise have been necessary after the postsurgical results of sentinel node biopsy.
In England, those results are typically not available until days after the initial surgery, Baruah noted.
"Even in the U.S. and other centers where the results of the sentinel node biopsy are usually available at the time of initial surgery," he said, "using this technique would still prevent a very high number of unnecessary sentinel node biopsies."
Axillary ultrasound had been tried before as a stand-alone diagnostic technique -- without any kind of confirmatory biopsy -- but false positives were a problem.
So Baruah's group added fine-needle aspiration in a study that included all 274 patients scheduled to undergo breast conservation surgery at a single center over a one-year period.
Each patient had ultrasound of the axillary lymph nodes roughly three days before surgery. Those with suspicious nodes on ultrasound proceeded to fine-needle aspiration cytology.
If the findings were positive, patients had all axillary nodes removed at the time of lumpectomy. If they were negative or if ultrasound had picked up no unusual deposits, patients had sentinel lymph node biopsy during surgery.
Final histology showed nodal macrometastases in 20.8% of patients. Of these 57 women, ultrasound and fine-needle aspiration had caught 29.8%.
Thus the technique had a sensitivity of 29.8%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 84.4%.
Because ultrasound was paired with fine-needle aspiration, there were no false positives. Nor were there any serious complications or delays in surgery for the imaging and cytology results.
"The only drawback was that this technique was unable to detect micrometastases, or very small deposits of cancer cells in the nodes," Baruah said. All seven cases appeared normal on preoperative ultrasound.
However, micrometastases are relatively uncommon and of unclear biological or clinical significance, he said, though some recent evidence has linked these isolated tumor cells to poorer outcomes.
"To be on the safe side, at least in our unit, we do offer patients who are detected to have micrometastases a procedure of axillary clearance," he said.
Baruah's group recommended ultrasound with fine-needle aspiration confirmation of suspicious nodes for all patients before breast-conserving surgery. "This means a significant reduction in the trauma, costs, and anxiety for these patients," he said.
However, a more cautious approach was suggested by Lori Pierce, MD, of the University of Michigan in Ann Arbor, who moderated a press briefing highlighting these results and served as co-chair of the conference program committee.
"The take-home message is that for patients with early-stage breast cancer," she said, "they should discuss with their doctors the best method for determining whether cancer cells have gone to their lymph nodes under the arm."
The researchers reported no conflicts of interest.
Pierce reported having received research funding from the National Institutes of Health and the Breast Cancer Research Foundation.
Primary source: ASCO Breast Cancer Symposium Source reference: Baruah BP, et al "Should axillary ultrasound and fine-needle aspiration cytology be performed routinely in early breast cancer patients eligible for breast conservation?" ASCO Breast 2009.
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