Can We Identify or Exclude Extensive Axillary Nodal Involvement in Breast Cancer Patients Preoperatively?

Abstract

Background Breast cancer treatment has rapidly changed in the last few years. Particularly, treatment of patients with axillary nodal involvement has evolved after publication of several randomized clinical trials. Omitting axillary lymph node dissection in selected early breast cancer patients with one or two positive sentinel nodes did not compromise overall survival nor regional disease control in these trials. Hence, either excluding or identifying extensive axillary nodal involvement becomes increasingly important. Purpose To evaluate whether the current diagnostic modalities can accurately identify or exclude extensive axillary nodal involvement. Evaluated modalities were axillary ultrasound, ultrasound-guided needle biopsy, MRI, and PET/CT. Methods A literature search was performed in the Cochrane Library, EMBASE, and PubMed databases up to June 2019. The search strategy included terms for breast cancer, lymph nodes, and the different imaging modalities. Only articles that reported pathological N-stage or the total number of positive axillary lymph nodes were considered for inclusion. Studies with patients undergoing neoadjuvant systemic therapy were excluded. Conclusion There is no evidence that any of the current preoperative axillary imaging modalities can accurately exclude or identify breast cancer patients with extensive nodal involvement. Both negative PET/CT and negative MRI scans (with gadolinium-based contrast agents) are promising in excluding extensive nodal involvement. Larger studies should be performed to strengthen this conclusion. False-negative rates of axillary ultrasound and ultrasound-guided needle biopsy are too high to rely on negative results of these modalities in excluding extensive nodal involvement.

PET/CT and MRI for Identifying Axillary Lymph Node Metastases in Breast Cancer Patients: Systematic Review and Meta‐Analysis

“…[43][44][45] Furthermore, some studies have raised doubts regarding whether PET/CT could accurately identify the axillary status. 11,12 Combined with the results of our current analysis, further prospective studies are needed to reach a definitive conclusion using unified inclusion and exclusion criteria.…”

“…Upon meta‐regression analysis, the included studies using SUV max as a separate index, the pooled sensitivity increased slightly and specificity decreased significantly ( P = 0.90 and P < 0.05, respectively), which was a little different from the result of Chung et al 45 Many other factors have been reported to affect the accuracy of PET/CT, such as estrogen receptor positivity, lymph node size, and the histopathological procedure used (eg, whether micrometastasis was taken as a positive or negative result) 43–45 . Furthermore, some studies have raised doubts regarding whether PET/CT could accurately identify the axillary status 11,12 . Combined with the results of our current analysis, further prospective studies are needed to reach a definitive conclusion using unified inclusion and exclusion criteria.…”

“…The sensitivity and specificity of PET/CT for detecting metastatic ALN have been reported to range from 50-80% and 90-100%, [7][8][9][10] respectively, but some studies have raised issues regarding whether PET/CT could able to identify the axillary status accurately and, further, underestimated the number of metastatic ALN. [11][12][13] Magnetic resonance imaging (MRI) is increasingly used for the assessment of tumors and the status of ALNs. The MRI criteria for ALNM include morphological features such as a short axis exceeding 10 mm, long axis to short axis ratio less than 1.5, irregular shape, loss of fatty hilum, enhancement features such as an initial enhancement rate above 100% or signal deficiency on T 2 *-weighted imaging when using ultrasmall super paramagnetic iron oxide (USPIO) as an enhancement contrast, and an apparent diffusion coefficient (ADC) lower than that of nonmetastatic ALN.…”

“…The criteria for the use of PET/CT to detect ALNM include higher uptake of the lymph node than surrounding tissue as well as the maximum standardized uptake value (SUV max ). The sensitivity and specificity of PET/CT for detecting metastatic ALN have been reported to range from 50–80% and 90–100%, 7–10 respectively, but some studies have raised issues regarding whether PET/CT could able to identify the axillary status accurately and, further, underestimated the number of metastatic ALN 11–13 …”

18F-Alfatide II for the evaluation of axillary lymph nodes in breast cancer patients: comparison with 18F-FDG

“…Many 18 F-FDG PET or PET/CT studies have also shown promising results for ALN evaluation. It has been reported that the speci city of 18 F-FDG for detecting metastatic ALN is up to 90-100%, but the sensitivity is relatively low to 50-80% (7)(8)(9). Accordingly, 18 F-FDG PET or PET/CT may underestimate the number of metastatic ALN.…”