Axillary ultrasound in staging breast cancer: diagnostic accuracy and effect on subsequent axillary surgery - the Plymouth experience

Abstract

Introduction Digital breast tomosynthesis (DBT) may improve the accuracy of mammography by enabling visual separation of overlapping tissues (Andersson et al. 2008, Poplack et al. 2007). Methods Following local research ethics approval, all women attending the assessment clinic for evaluation of a mammographic abnormality found on routine screening (film-screen) were invited to take part in the study subject to informed consent. Participants underwent bilateral two-view two-dimensional (2D) digital mammography and bilateral twoview DBT. Mammography scores using the RCR Breast Group classification were sequentially obtained for the screening mammogram, 2D digital and DBT, and these were each compared with the final assessment outcome. Results Ninety-one percent of eligible women participated. Results from the first 300 participants are presented in Table 1 below. Kappa coefficients for agreement of each imaging method with final assessment outcome were calculated. Screening mammograms had the lowest agreement with the final outcome (Kappa = 0.02; P = 0.22), 2D digital mammography was better (Kappa = 0.26; P = 0.0000) and DBT had the highest score (Kappa = 0.37; P = 0.0000). Conclusion The preliminary results of this ongoing study show that DBT increases the diagnostic confidence of the radiologist. This supports the need for a larger multicentre study. Markers of screen reading performance (overall and first reader cancer detection rates, recall rates, positive predictive value of recall and missed cancers) were compared with volume of films read. Readers were categorised into four groups, according to film reading volume over the 3-year period: <15,000 (that is, on average less than the recommended 5,000/year); 15,000 to <20,000; 20,000 to <25,000; and ≥25,000. Statistical analysis was undertaken using SPSS for Windows version 13. Results The recall rate in low volume readers (<5,000/year) was 6.9% and was significantly higher than in the other groups combined (4.8%; P ≤ 0.001). These readers also had a lower positive predictive value than higher volume readers (11.7% versus 15.7%, P ≤ 0.001).The cancer detection rate at first read was significantly lower in the higher volume readers (≥25,000) in comparison to the other groups combined (6.6 per 1,000 versus 8.2 per 1000, P ≤ 0.001). Conclusion These data support the recommendation that readers should read a minimum of 5,000 mammograms/year. They also suggest that there is an upper limit above which reader performance deteriorates (in terms of cancer detection). With the imminent programme expansion this has implications for service quality. Consideration should be given to the introduction of an upper limit of mammographic reads. O2 Breast Cancer Research

Management of early breast cancer in older women: from screening to treatment

“…ALND may also be a cause of morbidity in older women (lymphedema, parethesias, adhesive capsulitis, etc) or may worsen a preexisting disability. 26 In order to reduce the number of patients undergoing unnecessary ALND, axillary ultrasound and fine-needle aspiration of suspicious lymph nodes are usually performed preoperatively. When negative, sentinel lymph node technique seems to be a promising option to rule out any metastases.…”

Choices in Surgery for Older Women with Breast Cancer

“…Demographically, the application of SLNB in patients with breast cancer has progressively increased from 26.5% in 1998 to 65.5% in 2005 according to 1 study [48]. SLNB has thus now become the new standard of care for nodal staging in early-stage breast disease [43,47]. It is reported to predict the status of the remaining axillary lymph nodes in early breast cancer with an accuracy of 95-97% and false-negative rates of 0-13% [49].…”

“…Lymphoedema is regarded as the most feared and problematic longterm complication [42]. To minimize the number of patients undergoing unnecessary axillary dissection, current practice relies on the use of preoperative ultrasonography of the axillary area and fine needle aspiration cytology of any suspicious node; if negative, patients are usually offered a sentinel lymph node biopsy (SLNB) to ascertain the presence of metastatic deposits [43]. The real advantages of axillary dissection are much debated; there are reports of survival gains in patients who undergo this procedure [44], while others report on the lack of advantages [45].…”