evaluating the axilla and other nodal areas with non ... · evaluating the axilla and other nodal...
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Evaluating the Axilla and Other Nodal Areas with Non-Invasive
TechniquesNagi Khouri M.D.
Associate Professor of Radiology and OncologyThe Johns Hopkins University
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PREOPERATIVE STAGING OF BREAST CANCER
• Local extent of the cancer• Multifocality• Multicentricity• Contralateral breast• Regional lymph node extension• Systemic Extension
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ULTRASOUND EVALUATION OF REGIONAL NODES IN BREAST CANCER
• Axillary nodes• Internal mammary nodes• Supra and infraclavicular and low cervical
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Variability of breast imager’s approach to the axilla in breast cancer
• Will not look• Ultrasound evaluation• Information from MRI• +/- Needle biopsy
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Pathologic distribution of cancer cells in metastatic lymph nodes
• Isolated tumor cells• Islands of metastatic cancer• Focal mass• Total replacement
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Sonographic Criteria of Indeterminate/Suspicious/Metastatic Nodes
• Size• Thickening of cortex (diffuse or eccentric)• Lobulation of cortex• Rounded or vertically oriented lymph node• Complete disappearance of the hilum
Don’t forget that you can compare to the other side!
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BENIGN CAUSESAXILLARY ADENOPATHY
• Normal• Hyperplasia• Recent Biopsy (>3 weeks)• HIV• Collagen Vascular Diseases• Dermatopathic• Silicone adenopathy• Toxoplasmosis
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Metastatic / Reactive Nodes
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Accuracy of Sonography of Axillary Lymph Nodes in Breast Cancer
SENSITIVITYPalpable and Non-palpable
Size 66-77%Morphology 55-92% Non-palpable Only
Size 49-87%Morphology 26-76%
Ultrasound Guided Biopsy 43-95%
SPECIFICITYPalpable and Non-palpable
Size 44-98%Morphology 80-97%Non-palpable Only
Size 55-97%Morphology 88-98%
Ultrasound Guided Biopsy97-100%
AJR 2006, 186:1342-1348
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FNA in High Risk Pts.Clinically Neg. Nodes
37 / 114 pts.
22 Abn. US 15 Neg. US
FNA+ FNA- SN+ SN-15 (68%) 7 4 11
SN+3
In total 22/37 had metastatic disease on final histology64% had grade 3 mean size 5cm with lymphatic invasion in 50% , positive FNA 68%
In total 15/37 had no lymph node metastases87% had grade 2 mean size 3.2cm with lymphatic invasion in 8%
Annals of Surg. Onc .2006, 13(12):1545-1552
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FNA Axillary NodesThe Johns Hopkins Experience
23 T1 41 N0
69 Axillae32 T2 22 N1
FNA + FNA -41 ( 59%) 28
Neoadj. Chemo. 56% SN +7 (25%)
• Sensitivity 82% PPV 100%• Specificity 100% NPV 70%
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Technical aspects of FNA of lymph nodes
• Needle 23-20g• Ventral, caudal, cephalad and dorsal sampling• Avoid the hilum• Three passes of same node or one pass of three
separate nodes• 30 to 40 excursions-stop when blood in hub
of needleLearn to smear slides- Avoid dryness
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Challenges to successful FNA of lymph nodes in breast cancer
• Skills of axillary ultrasound performance and interpretation
• Skills of performance of FNA• Skills of cytopathologic interpretation
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Impact of Axillary US and FNA
• Reasonable sensitivity, high specificity
• If FNA is positive for cancer cells:
Patient candidate for surgery and LN dissectionor
Preoperative Chemotherapy followed by surgery
• If FNA is negative for cancer cells:
Patient needs sentinel node biopsy