Meta-analysis of tumour burden in pre-operative axillary ultrasound positive and negative breast cancer patients

Abstract

BackgroundManagement of the axilla in breast cancer is becoming increasingly conservative. Patients identified with a low axillary nodal burden (two or fewer involved nodes) at sentinel node biopsy (SNB) can avoid completion axillary node clearance (cANC). ‘Fast track’ to ANC in patients with involved nodes on pre-operative ultrasound may be over-treating a subgroup of these patients with low nodal burden, which would have precluded their need for ANC. This systematic review assesses the proportion of patients with involved nodes on pre-operative axillary ultrasound, which would fit low axillary burden criteria.MethodsMeta-analysis of studies comparing axillary burden of breast cancer patients identified as pre-operative ultrasound negative versus positive was performed. The primary outcome measure was the number of patients with two or fewer involved nodes (macrometastases only). Pooled odds ratio (OR), 95% confidence intervals (CIs), means and probabilities of identifying two or fewer involved nodes versus greater than two were calculated.ResultsSix studies reported the axillary burden in 4271 patients who were either directed straight to ANC or cANC after SNB. There was a significantly greater axillary burden in the ultrasound positive versus negative groups (OR 5.95, 95% CI 5.80–6.11) with mean nodal retrieval values of 2.9 [standard error (SE) 0.2] and 1.6 (SE 0.2) nodes, respectively. Cumulative probabilities identified 78.9% of ultrasound negative and 43.2% of ultrasound positive patients possessed low axillary burden.ConclusionsPre-operative ultrasound positive patients have significantly higher axillary burden. However, nearly half do fit the criteria of low axillary burden and could be considered for omission of ANC.

Deep Learning vs. Radiomics for Predicting Axillary Lymph Node Metastasis of Breast Cancer Using Ultrasound Images: Don't Forget the Peritumoral Region

“…In case of suspicious ALN, AUS alone or combined with ultrasound-guided needle biopsy is performed for axillary staging to select patients who would benefit from ALND. A recent meta-analysis has shown that the use of AUS in stratifying patients directly to fast-track ALND without SLNB leads to overtreatment in up to two-thirds of patients (32). These data indicated that AUS alone is not sufficiently accurate for axillary staging.…”

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“…Similar findings were observed by Cools et al [27], who reports that patients with ultrasound guided biopsy do not harbor more nodal metastases than who are not subjected to it. Recent meta-analysis by Muneer et al [28] concurred that 43% of patients with positive sentinel lymph node biopsy (SLNB) were subjected to unnecessary ALND.…”

Is axillary ultrasound imaging necessary for all patients with breast cancer?

“…Fast‐track ALND is based on the concept of higher axillary burden in the clinically non‐palpable (cN0) but ultrasound‐positive axilla. The latest meta‐analysis addressing the issue of axillary burden in patients undergoing ALND after a positive SNB (plus normal ultrasound examination) versus a positive ultrasound examination (and metastasis on histopathology), and which included only studies that applied the clinically relevant threshold of low axillary burden of two or fewer macrometastases, also confirmed the higher axillary nodal burden in the latter group (odds ratio 5·95, 95 per cent c.i. 5·80 to 6·11).…”

“…This has also recently been demonstrated for subtypes of breast cancer (invasive lobular), where a positive preoperative axillary ultrasound has reported a false‐positive rate of 52 per cent in discriminating between relevant thresholds of axillary burden. The meta‐analysis demonstrated that axillary ultrasonography is not sufficiently specific to identify clinically relevant high nodal burden, and its role in stratifying patients for fast‐track ALND leads to overtreatment in up to two‐thirds of patients. Overtreatment could be avoided simply by directing these patients to SNB without axillary ultrasonography, as was done in the original RCTs of SNB.…”