Keywords:
Breast, Lymph nodes, Oncology, Ultrasound, Biopsy, Cancer
Authors:
N. Alberdi1, N. Baraibar Argota1, I. Baraibar1, P. Lopez Sala1, M. Mellado1, S. Cervantes1, P. L. Alejandre García1, I. Sanmartin2, N. Alonso Ordás1; 1Pamplona/ES, 2Tudela/ES
DOI:
10.26044/ecr2019/C-1503
Aims and objectives
Breast cancer is the most common malignant tumor in women after non-melanocytic skin cancer and the leading cause of cancer death among them[1].
Locally advanced breast cancer constitutes a heterogeneous entity that includes advanced-stage primary tumors,
cancers with extensive locoregional nodal involvement (axillary,
supraclavicular or internal mammary nodes),
cancers that involve the skin or the underlying muscles of the chest and inflammatory breast carcinomas[2].
Axillary nodal status is the most important prognostic factor for patients with breast cancer,
so axillary lymph node evaluation is essential [3].
Ultrasound is the imaging modality of choice for staging the axilla in the initial locoregional staging,
though the reported sensitivity and specificity vary widely[4].
Bedi’s classification is used for ultrasonography axillary lymph nodes assessment,
according to their sonographic appearance on the basis of cortical morphologic features [5] (Table 1 ):
- Type 1: Hyperechoic,
no visible cortex.
- Type 2: Thin (< 3 mm) hypoechoic cortex.
- Type 3: Hypoechoic cortex thicker than 3 mm.
- Type 4: Generalized lobulated hypoechoic cortex.
- Type 5: Focal hypoechoic cortical lobulation.
- Type 6: Totally hypoechoic node with no hilum.
Types 1-4 are considered benign,
whereas types 5 and 6 are considered suspicious.
Nowadays,
sentinel lymph node biopsy (SLNB) is the gold standard to evaluate the axillary staging of breast cancer and to select the patients for whom axillary lymphadenectomy does not provide benefit[6].
The one-step nucleic acid amplification (OSNA) method is an increasingly used procedure for intraoperative analysis of sentinel lymph node (SLN) status in breast cancer patients.
It measures cytokeratin 19 (CK19) mRNA copy numbers in homogenized samples of SLN.
CK19 has been chosen to identify node metastasis because most breast cancers express this molecule.
However,
to avoid false-negative OSNA results,
testing the preoperative needle core biopsy of breast carcinomas for CK19 by immunohistochemistry has been recommended.
Lymph nodes status can be classified according to the OSNA results [7]:
- Isolated tumor cells: Less than 0.2 mm in size (CK19 mRNA 100-250 copies/μl)
- Micrometastases: Size 0.2-2 mm (CK19 mRNA 250–5000 copies/ μl).
- Macrometastases: Greater than 2 mm in size (CK19 mRNA ⩾5000 copies/μl).
Presurgical neoadjuvant chemotherapy is becoming the standard of care in the treatment of locally advanced breast cancer and is a treatment option for patients with early-stage[8,9].
The use of neoadjunvancy allows downstage the primary tumor and affected lymph nodes to improve the surgical approach and provides prognostic information based on the treatment response [10].
Persistence of lymph nodes disease after neoadjuvant treatment and right before surgery can be assessed by ultrasonography.
Therefore,
the study has a double aim:
- To assess the diagnostic precision of axillary ultrasound (AU) in patients with locally advanced ductal breast cancer (LADBC) candidates for neoadjuvant chemotherapy.
- To evaluate the role of AU assessing the persistence of lymph nodes disease after completing neoadjuvancy.