title: The Relevance of Ultrasound Imaging of Suspicious Axillary Lymph Nodes and Fine-needle Aspiration Biopsy in the Post-ACOSOG Z11 Era in Early Breast Cancer.
abstract: Evaluation of nodal involvement in early-stage breast cancers (T1 or T2) changed following the Z11 trial; however, not all patients meet the Z11 inclusion criteria. Hence, the relevance of ultrasound imaging of the axilla and fine-needle aspiration biopsy (FNA) in early-stage breast cancers was investigated.
  
  
  
  In this single-center, retrospective study, 758 subjects had pathology-verified breast cancer diagnosis over a 3-year period, of which 128 subjects with T1 or T2 breast tumors had abnormal axillary lymph nodes on ultrasound, had FNA, and proceeded to axillary surgery. Ultrasound images were reviewed and analyzed using multivariable logistic regression to identify the features predictive of positive FNA. Accuracy of FNA was quantified as the area under the receiver operating characteristic curve with axillary surgery as reference standard.
  
  
  
  Of 128 subjects, 61 were positive on FNA and 65 were positive on axillary surgery. Sensitivity, specificity, positive predictive value, and negative predictive value of FNA were 52 of 65 (80%), 54 of 63 (85.7%), 52 of 61(85.2%), and 54 of 67 (80.5%), respectively. After adjusting for neoadjuvant chemotherapy between FNA and surgery, a positive FNA was associated with higher likelihood for positive axillary surgery (odds ratio: 22.7; 95% confidence interval [CI]: 7.2-71.3, P < .0001), and the accuracy of FNA was 0.801 (95% CI: 0.727-0.876). Among ultrasound imaging features, cortical thickness and abnormal hilum were predictive (P < .017) of positive FNA with accuracy of 0.817 (95% CI: 0.741-0.893).
  
  
  
  Ultrasound imaging and FNA can play an important role in the management of early breast cancers even in the post-Z11 era. Higher weightage can be accorded to cortical thickness and hilum during ultrasound evaluation.
authors.affiliation: University of Massachusetts Medical School, 55 Lake Ave N, Worcester, MA 01655. Electronic address: Gopal.Vijayaraghavan@umassmemorial.org.
authors.forename: Gopal R
authors.initials: GR
authors.lastname: Vijayaraghavan
authors.affiliation: University of Massachusetts Medical School, 55 Lake Ave N, Worcester, MA 01655.
authors.forename: Srinivasan
authors.initials: S
authors.lastname: Vedantham
authors.affiliation: University of Massachusetts Medical School, 55 Lake Ave N, Worcester, MA 01655.
authors.forename: Milliam
authors.initials: M
authors.lastname: Kataoka
authors.affiliation: University of Massachusetts Medical School, 55 Lake Ave N, Worcester, MA 01655.
authors.forename: Carolynn
authors.initials: C
authors.lastname: DeBenedectis
authors.affiliation: University of Massachusetts Medical School, 55 Lake Ave N, Worcester, MA 01655.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Quinlan
mesh_terms: D000328:Adult; D000368:Aged; D001365:Axilla / Q000473:pathology; D044963:Biopsy, Fine-Needle; D001943:Breast Neoplasms / Q000473:pathology*; D055088:Early Detection of Cancer; D005260:Female; D006801:Humans; D008198:Lymph Nodes / Q000000981:diagnostic imaging* / Q000473:pathology*; D008207:Lymphatic Metastasis; D008875:Middle Aged; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D021701:Sentinel Lymph Node Biopsy / Q000379:methods; D014463:Ultrasonography / Q000379:methods*
keywords: Breast cancer; axilla; axillary lymph node dissection; fine-needle aspiration; lymph node; sentinel node biopsy; ultrasound