title: Cross-sectional imaging to evaluate the extent of regional nodal disease in breast cancer patients undergoing neoadjuvant systemic therapy.
abstract: OBJECTIVE
  Cross-sectional imaging often is performed in breast cancer patients undergoing neoadjuvant systemic therapy (NST) and may identify level III axillary and extra-axillary nodal disease. Our aim was to investigate associations of radiologic nodal staging with pathological N (pN) stage at operation and to explore how this might aid surgical and radiotherapy treatment planning.
  
  
  METHODS
  With IRB approval, we reviewed pre-treatment breast MRI, PET/CT, and CT imaging and clinicopathologic data on 348 breast cancer patients with imaging available for review undergoing NST followed by operation at our institution 1/2008-9/2013. We defined abnormal lymph node findings on MRI, CT, and PET/CT to include cortical thickening, FDG-avidity and loss of fatty hilum. Patients were assigned a radiologic nodal (rN) stage based on imaging findings. Statistical analysis was performed using JMP 10.1 software RESULTS: Pre-NST imaging included axillary ultrasound in 338 patients (97%), breast MRI in 305 (88%) and PET/CT or CT in 215 (62%). 213 patients (61%) were biopsy-proven axillary lymph node-positive (LN+) pre-treatment. cT stage was T1 in 9%, T2 in 49%, T3 in 29%, T4 in 12%; median tumor size was 4cm. Pre-treatment rN stage across all the patients was rN0 in 86 (25%), rN1 in 173 (50%), and rN3 in 89 (26%). rN3 disease included level III axillary, supraclavicular and suspicious internal mammary lymph nodes in 47 (53%), 32 (37%) and 45 (52%), respectively. Of patients LN+ at diagnosis, 78 (37%) were rN3. After NST, 162 patients (47%) were node-positive at operation with a median (mean) of 3 (5.9±0.4) positive lymph nodes including 128 of 213 (60%) LN+ at diagnosis. Pre-NST rN stage correlated with the likelihood and extent of axillary disease at operation, p=0.002. Fifty four of 89 rN3 patients (61%) were node-positive at operation with a median (mean) of 5 (8±1) positive nodes. rN3 patients had larger nodal metastases (median 9 vs 6mm) and more frequent extranodal extension (61% vs 43%) than rN0/rN1 patients, both p<0.03.
  
  
  CONCLUSIONS
  Information on rN stage from pre-NST cross-sectional imaging informs the likelihood and extent of axillary nodal disease at operation. This information may be used for surgical and radiotherapy treatment planning and to inform patient expectations.
authors.affiliation: Mayo Clinic, Department of Radiology, 200 First Street SW, Rochester, MN, 55905, USA. Electronic address: anderson.tara@mayo.edu.
authors.forename: Tara L
authors.initials: TL
authors.lastname: Anderson
authors.affiliation: Mayo Clinic, Department of Radiology, 200 First Street SW, Rochester, MN, 55905, USA. Electronic address: glazebrook.katrina@mayo.edu.
authors.forename: Katrina N
authors.initials: KN
authors.lastname: Glazebrook
authors.affiliation: Mayo Clinic, Department of Surgery, 200 First Street SW, Rochester, MN, 55905, USA. Electronic address: murphy.brittany@mayo.edu.
authors.forename: Brittany L
authors.initials: BL
authors.lastname: Murphy
authors.affiliation: Mayo Clinic, Department of Radiology, 200 First Street SW, Rochester, MN, 55905, USA. Electronic address: viers.lyndsay@mayo.edu.
authors.forename: Lyndsay D
authors.initials: LD
authors.lastname: Viers
authors.affiliation: Mayo Clinic, Department of Surgery, 200 First Street SW, Rochester, MN, 55905, USA. Electronic address: hieken.tina@mayo.edu.
authors.forename: Tina J
authors.initials: TJ
authors.lastname: Hieken
mesh_terms: D000328:Adult; D001365:Axilla / Q000473:pathology; D001706:Biopsy; D001940:Breast / Q000473:pathology; D001943:Breast Neoplasms / Q000473:pathology / Q000628:therapy*; D005260:Female; D006801:Humans; D008198:Lymph Nodes / Q000473:pathology; D008207:Lymphatic Metastasis; D008279:Magnetic Resonance Imaging; D008875:Middle Aged; D064847:Multimodal Imaging; D020360:Neoadjuvant Therapy; D000072078:Positron Emission Tomography Computed Tomography; D014057:Tomography, X-Ray Computed
keywords: Axillary lymph nodes; Breast cancer; Cross-sectional imaging; Neoadjuvant systemic therapy; Nodal staging