Axillary ultrasound accuracy in the symptomatic breast service

Accuracy of ultrasound of the axilla and ultrasound guided FNAC/biopsy in the assessment of metastatic axillary lymphadenopathy in breast malignancy at presentation through the symptomatic service.

Following the introduction of both axillary node ultrasound as part of the routine pre-operative assessment of breast cancer at presentation and sentinel lymph node biopsy (SNLB), patients with operable breast malignancy with proven pre-operative axillary lymph node metastasis proceed directly to axillary node clearance (ANC) at the time of initial surgery. Patients without a pre-operative diagnosis of axillary node metastases undergo SLNB and if positive, undergo second stage surgery to clear the axilla. Ultrasound evaluation and guided FNA/biopsy plays a pivotal role in this decision making. Accurate pre-operative diagnosis of axillary nodal metastases saves the patient a second operative procedure. There is no agreed standard for accuracy but several groups have published their results [1-8]. The reported sensitivity for detection of metastatic axillary lymph nodes ranges from 54.1% to 69.4% and the sensitivity of ultrasound guided FNAC/biopsy ranges from 28.5 % to 55.6%.

The standard: 

1. Ultrasound should identify nodes with metastatic involvement

2. Ultrasound should be performed in all cases of primary tumours >10mm in maximal size

3. Ultrasound guided FNAC/biopsy should be accurate in the identification of metastatic disease in nodes which appear abnormal on ultrasound

Target: 

1. 50% sensitivity

2. 100% [9]

3. Sensitivity should be equal to prevalence of axillary nodal metastatic disease in first time presenters to the local symptomatic breast service [6]

Indicators: 

1. Sensitivity of ultrasound diagnosis

   a. Numerator– Number of patients with suspicious axillary lymph nodes in ultrasound, proven to be malignant in SLNB or ANC

   b. Denominator – Number of patients with malignant axillary lymph nodes in SLNB or ANC

2. Cases of BI-RADS score 4 or 5 measuring >10mm have a documentation of ipsilateral axillary US examination

3. Sensitivity of USG guided FNAC/biopsy

   a. Numerator– Number of patients with malignant cytology in USG guided FNAC/biopsy proven to be malignant in SLNB or ANC

   b. Denominator - same as above

Data items to be collected: 

1. List of patients with breast malignancy who had surgery and SLNB/ANC

2. List of patients with axillary lymph node metastasis in SLNB or ANC

3. Details of ultrasound evaluation of axilla and cytology results if FNAC/biopsy performed

4. If individual operator details are also collected then individuals can use the results for revalidation purposes

The above data should be available from pathology and radiology database.

Suggested number: 

12 months of data.

1. Review local definition of abnormal lymph node

2. Review local policy regarding repeat cytology and/or consider core biopsy

3. Review individual operator results to determine whether there is a need for further training

1. Secretarial assistance in data or case note extraction

2. 4-6 hours of Radiologist’s time

1. Baruah, B.P., Goyal, A., Young, P., Douglas-Jones, A.G. & Mansel, R.E. 2010, "Axillary node staging by ultrasonography and fine-needle aspiration cytology in patients with breast cancer.", The British journal of surgery, vol. 97, no. 5, pp. 680-3.

2. Damera, A., Evans, A.J., Cornford, E.J., Wilson, A.R.M., Burrell, H.C., James, J.J., Pinder, S.E., Ellis, I.O., Lee, A.H.S. & Macmillan, R.D. 2003, "Diagnosis of axillary nodal metastases by ultrasound-guided core biopsy in primary operable breast cancer.", British journal of cancer, vol. 89, no. 7, pp. 1310-3.

3. Jung, J., Park, H., Park, J. & Kim, H. 2010, "Accuracy of preoperative ultrasound and ultrasound-guided fine needle aspiration cytology for axillary staging in breast cancer", ANZ Journal of Surgery, vol. 80, no. 4, pp. 271-275.

4. Sapino, A., Cassoni, P., Zanon, E., Fraire, F., Croce, S., Coluccia, C., Donadio, M. & Bussolati, G. 2003, "Ultrasonographically-guided fine-needle aspiration of axillary lymph nodes: role in breast cancer management.", British journal of cancer, vol. 88, no. 5, pp.702-6.

5. Susini, T., Nori, J., Olivieri, S., Molino, C., Marini, G. & Bianchi, S. 2009, "Predicting the status of axillary lymph nodes in breast cancer: A multiparameter approach including axillary ultrasound scanning", Breast (Edinburgh, Scotland), vol. 18, no. 2, pp. 103-8.

6. Houssami et al, "Preoperative Ultrasound-Guided Needle Biopsy of Axillary Nodes in Invasive Breast Cancer. Meta-Analysis of Its accuracy and Utility in Staging the Axilla", Annals of Surgery, 254(2):243-51, 2011 Aug.

7. Lee B et al, “The Efficacy of Axillary US in the Detection of Nodal Metastasis in Breast Cancer”. 2013; 200(3); W314-W320.

8. Zhang YN, Wang CJ, Xu Y, Zhu QL, Zhou YD, Zhang J, Mao F, Jiang YX, Sun Q 2015. Sensitivity, Specificity and Accuracy of Ultrasound in Diagnosis of Breast Cancer Metastasis to the Axillary Lymph Nodes in Chinese Patients. Ultrasound Med Biol. 41(7):1835-41.

9. Pereira da CostaPinehiro DJ, Elias , Pinto Nazario AC 2014. Axillary lymph nodes in breast cancer patients: sonographic evaluation. Radiol Bras 47(4): 240-244.

Dr. Senthil Kumar Arcot Ragupathy. Updated by D Howlett