Document Type : Original Article

Authors

1 Breast Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

2 Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran

3 Department of Surgical Oncology Shiraz University of Medical Sciences, Shiraz, Iran

4 General Medical Council, London, UK

5 School of Medicine, Islamic Azad University of Tehran, Faculty of Medicine, Tehran, Iran

6 Department of Pathology, Shiraz University of Medical Sciences, Shiraz, Iran

Abstract

Background: In the present paper, the main diagnostic tool for re-evaluation of axillary lymph node involvement and planning of surgery after neoadjuvant chemotherapy (NAC) is ultrasound whose accuracy we aimed to determine herein. The high precision of ultrasound in diagnosis of metastatic axillary lymph nodes in untreated patients is well known; however, its worth in patients who received NAC is highly controversial.
Method: We enrolled 165 breast cancer patients receiving NAC in this retrospective cohort study. They all had undergone post-NAC ultrasound done before surgery. The ultrasound reports were reassessed and validated by a breast radiologist. Finally, the histopathology reports were compared to those of the ultrasound.
Results: Among 165 surveyed post-NAC ultrasounds, 53 women had positive results and 112 had negative results. Pathology and ultrasound reports were accordant in 93 women and adverse in 112 others. The false negative rate of post-NAC axillary ultrasound was calculated as 60.6%. The sensitivity and specificity of post-NAC AxUS were 39.4% and 79%, respectively. After NAC, there were certain changes in ultrasound reports from positive to negative in 50% and pathologic complete clearance was observed in just 28% of the women who were initially clinically lymph node positive.
Conclusion: Ultrasound was not found to be an accurate and appropriate tool for evaluation of axillary lymph node involvement in breast cancer patients who receive NAC. By changing the primarily established surgical plan from ALND to SLNB, based on the ultrasound findings, patients may remain undertreated. Furthermore, the axillary nodes pathologic clearance after NAC was observed in less than one third of the women who were initially clinically node positive; accordingly, surgeons should be cautious about the optimum response of axillary metastatic lymph nodes to NAC.

Keywords

How to cite this article:

Akrami M, Sefidbakht S, Golchini A, Ghoddusi Johari M, Shariat M, Tahmasebi S, et al. Ultrasound accuracy in detection of metastatic axillary lymph nodes in breast cancer after neoadjuvant chemotherapy. Middle East J Cancer. 2023;14(1):153-61. doi: 10. 30476/mejc.2022.90917.1596.

  1. Carter CL, Allen C, Henson DE. Relation of tumor size, lymph node status, and survival in 24,740 breast cancer cases. Cancer. 1989;63(1):181-7. doi: 10.1002/1097-0142(19890101)63:1<181::aid-cncr2820630129>3.0.co;2-h.
  2. Liu SV, Melstrom L, Yao K, Russell CA, Sener SF. Neoadjuvant therapy for breast cancer. J Surg Oncol. 2010;101(4):283-91. doi: 10.1002/jso.21446.
  3. Specht J, Gralow JR. Neoadjuvant chemotherapy for locally advanced breast cancer. Semin Radiat Oncol. 2009;19(4):222-8. doi: 10.1016/j.semradonc. 2009.05.001.
  4. Mathew J, Asgeirsson KS, Cheung KL, Chan S, Dahda A, Robertson JF. Neoadjuvant chemotherapy for locally advanced breast cancer: a review of the literature and future directions. Eur J Surg Oncol. 2009;35(2):113- 22. doi: 10.1016/j.ejso.2008.03.015.
  5. Wang M, Hou L, Chen M, Zhou Y, Liang Y, Wang S, et al. Neoadjuvant chemotherapy creates surgery opportunities for inoperable locally advanced breast cancer. Sci Rep. 2017;7:44673. doi: 10.1038/srep44673.
  6. Killelea BK, Yang VQ, Mougalian S, Horowitz NR, Pusztai L, Chagpar AB, et al. Neoadjuvant chemotherapy for breast cancer increases the rate of breast conservation: results from the National Cancer Database. J Am Coll Surg. 2015;220(6):1063-9. doi: 10.1016/j.jamcollsurg.2015.02.011.
  7. Liedtke C, Mazouni C, Hess KR, André F, Tordai A, Mejia JA, et al. Response to neoadjuvant therapy and long-term survival in patients with triple-negative breast cancer. J Clin Oncol. 2008;26(8):1275-81. doi: 10.1200/JCO.2007.14.4147.
  8. Boughey JC, Suman VJ, Mittendorf EA, Ahrendt GM, Wilke LG, Taback B, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with nodepositive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 2013;310(14):1455-61.
  9. Chen JH, Feig BA, Hsiang DJ, Butler JA, Mehta RS, Bahri S, et al. Impact of MRI-evaluated neoadjuvant chemotherapy response on change of surgical recommendation in breast cancer. Ann Surg. 2009;249(3):448-54. doi: 10.1097/SLA.0b013e 31819a6e01.
  10. Fowler AM, Mankoff DA, Joe BN. Imaging neoadjuvant therapy response in breast cancer. Radiology. 2017;285(2):358-75.
  11. Pinheiro DJ, Elias S, Nazário AC. Axillary lymph nodes in breast cancer patients: sonographic evaluation. Radiol Bras. 2014;47(4):240-4. doi: 10.1590/0100- 3984.2013.1689.
  12. Talei A, Tahmasebi S, Akrami M, Zangouri V, Rezaianzadeh A, Arasteh P, et al. The Shiraz Breast Cancer Registry (SBCR): study design and primary reports. Per Med. 2018;15(6):471-9. doi: 10.2217/pme- 2018-0047.
  13. Jackson RS, Mylander C, Rosman M, Andrade R, Sawyer K, Sanders T, et al. Normal axillary ultrasound excludes heavy nodal disease burden in patients with breast cancer. Ann Surg Oncol. 2015;22(10):3289-95. doi: 10.1245/s10434-015-4717-7.
  14. Sencha AN, Evseeva EV, Mogutov MS, Patrunov YN. Breast ultrasound: Springer Science & Business Media. 1st edition: Springer-Verlag: Berlin Heidelberg; 2014.p. 202-222.
  15. Morency D, Dumitra S, Parvez E, Martel K, Basik M, Robidoux A, et al. Axillary lymph node ultrasound following neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: Results from the SN FNAC study. Ann Surg Oncol. 2019;26(13):4337-45. doi: 10.1245/s10434-019-07809-7.
  16. Laws A, Hughes ME, Hu J, Barry WT, Dominici L, Nakhlis F, et al. Impact of residual nodal disease burden on technical outcomes of sentinel lymph node biopsy for node-positive (cN1) breast cancer patients treated with neoadjuvant chemotherapy. Ann Surg Oncol. 2019;26(12):3846-55. doi: 10.1245/s10434- 019-07515-4.
  17. Osorio-Silla I, Gómez Valdazo A, Sánchez Méndez JI, York E, Díaz-Almirón M, Gómez Ramírez J, et al. Is it always necessary to perform an axillary lymph node dissection after neoadjuvant chemotherapy for breast cancer? Ann R Coll Surg Engl. 2019;101(3):186- 92. doi: 10.1308/rcsann.2018.0196.
  18. Schwentner L, Helms G, Nekljudova V, Ataseven B, Bauerfeind I, Ditsch N, et al. Using ultrasound and palpation for predicting axillary lymph node status following neoadjuvant chemotherapy - Results from the multi-center SENTINA trial. Breast. 2017;31:202- 7. doi: 10.1016/j.breast.2016.11.012.
  19. Boughey JC. Identifying residual nodal disease in sentinel lymph node surgery after neoadjuvant chemotherapy for breast cancer. Ann Surg Oncol. 2019;26(12):3794-7. doi: 10.1245/s10434-019-07733-w.