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Researchers said that Ultrasound of axillary lymph nodes before breast cancer surgery, with fine-needle aspiration for confirmation of metastases, could spare many early-stage patients from sentinel node biopsy and reoperation.

This strategy picked up 29.8% of macrometastases in women scheduled for lumpectomy, with an overall accuracy of 84.4%, Bedanta Baruah, MD, of Cardiff University in Cardiff, U.K., and colleagues reported at the ASCO Breast Cancer Symposium.

Those metastases were removed at the time of surgery, preventing a second procedure that would otherwise have been necessary after the postsurgical results of sentinel node biopsy.

In England, those results are typically not available until days after the initial surgery, Baruah noted.

"Even in the U.S. and other centers where the results of the sentinel node biopsy are usually available at the time of initial surgery," he said, "using this technique would still prevent a very high number of unnecessary sentinel node biopsies."

Axillary ultrasound had been tried before as a stand-alone diagnostic technique -- without any kind of confirmatory biopsy -- but false positives were a problem.

So Baruah's group added fine-needle aspiration in a study that included all 274 patients scheduled to undergo breast conservation surgery at a single center over a one-year period.

Each patient had ultrasound of the axillary lymph nodes roughly three days before surgery. Those with suspicious nodes on ultrasound proceeded to fine-needle aspiration cytology.

If the findings were positive, patients had all axillary nodes removed at the time of lumpectomy. If they were negative or if ultrasound had picked up no unusual deposits, patients had sentinel lymph node biopsy during surgery.

Final histology showed nodal macrometastases in 20.8% of patients. Of these 57 women, ultrasound and fine-needle aspiration had caught 29.8%.

Thus the technique had a sensitivity of 29.8%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 84.4%.

Because ultrasound was paired with fine-needle aspiration, there were no false positives. Nor were there any serious complications or delays in surgery for the imaging and cytology results.

"The only drawback was that this technique was unable to detect micrometastases, or very small deposits of cancer cells in the nodes," Baruah said. All seven cases appeared normal on preoperative ultrasound.

However, micrometastases are relatively uncommon and of unclear biological or clinical significance, he said, though some recent evidence has linked these isolated tumor cells to poorer outcomes.

"To be on the safe side, at least in our unit, we do offer patients who are detected to have micrometastases a procedure of axillary clearance," he said.

Baruah's group recommended ultrasound with fine-needle aspiration confirmation of suspicious nodes for all patients before breast-conserving surgery. "This means a significant reduction in the trauma, costs, and anxiety for these patients," he said.

However, a more cautious approach was suggested by Lori Pierce, MD, of the University of Michigan in Ann Arbor, who moderated a press briefing highlighting these results and served as co-chair of the conference program committee.

"The take-home message is that for patients with early-stage breast cancer," she said, "they should discuss with their doctors the best method for determining whether cancer cells have gone to their lymph nodes under the arm."

Source: ASCO Breast Cancer Symposium

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