Fiona Langlands

The use of ultrasound in pre-operative assessment of the axilla in breast cancer.

Abstract #1019 Introduction Sentinel lymph node biopsy is now standard practice in axillary staging in breast cancer. It is associated with less morbidity than an axillary node clearance. A drawback of sentinel node biopsy is the need for a second surgical procedure if the sentinel node shows metastases. Clinical examination of the axilla has been the standard pre-operative assessment but this has been shown to be unreliable. More recently ultrasound has been used to identify axillary metastases pre-operatively. The aim of our study is to assess the role of pre-operative ultrasound and fine needle aspirate cytology in refining the selection of patients for whom sentinel node biopsy is appropriate.
 Methods Three hundred patients with primary operable invasive breast cancer had axillary ultrasound preoperatively. If the ultrasound was normal the patient was offered a sentinel node procedure. If it identified equivocal nodes a fine needle cytology was performed. If the cytology was benign a sentinel node biopsy was performed. If the cytology was malignant then an axillary node clearance was performed. In cases where pathological nodes were identified on imaging, cytology was performed to confirm malignancy. An axillary node clearance was then performed.
 Results. Eighty three percent of our patients (n=249) had a normal axillary ultrasound pre-operatively. Of these 74.5% had a benign sentinel node biopsy. Sixty two percent of patients with equivocal nodes on pre-operative imaging had metastases on final histology (n=19). Of these 63% (n=12) were correctly identified pre-operatively with fine needle aspirate cytology of the equivocal node and had an axillary node clearance performed form the outset. Ultrasound identified pathological nodes in 7% of our patients (n=20). Malignancy was confirmed on cytology and an axillary node clearance was performed.
 Using ultrasound and fine needle aspirate cytology to assess the axilla pre-operatively sentinel node biopsy was performed in 265 patients (88%). Of these, 74.8% had a benign final histology. Thirty two patients had a pre-operative diagnosis of nodal metastases and had an axillary node clearance. All 32 had lymph node metastases on final histology. Factors that predicted for a malignant sentinel node were lymphovascular invasion (p Conclusion Eighty eight percent of our patients had a sentinel lymph node biopsy to stage the axilla. Pre-operative ultrasound combined with cytology correctly determined the status of the node in 78% of cases. Our rate of second axillary operations was reduced by 32%. Importantly all patients diagnosed with node metastases pre-operatively and advised to have an axillary node clearance did have metastases on final histology. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1019.

Abstract P2-01-08: Imaging overview of metaplastic carcinomas of the breast; a study of 46 cases

Background: Metaplastic breast cancer (MBC) is a rare form of breast cancer affecting <1% of breast cancer patients. Previous studies report that the size of MBC is greater than conventional invasive ductal carcinoma at presentation. This may reflect the rapid growth rate of MBC or the difficulty in diagnosis. Imaging characteristics of MBC are not well described but the few published reports suggest that MBC often mimics benign lesions on imaging. The aim of this study therefore is to review the clinical presentation, baseline imaging features, surgical management and final surgical pathology of MBC in a large UK breast cancer unit. Methods: All female patients diagnosed with MBC during the time period Jan 2005-2012 were identified from the pathology database at Leeds University Teaching Hospitals Trust. Pathology reports were reviewed and data on MBC type (following the WHO classification), size, grade, nodal and molecular marker status was extracted. Mammography, Ultrasound (USS), CT and MRI features were recorded. Follow-up was complete until May 2013. Results : 46 patients were identified with a median age of 61yrs and a 5yr survival of 32.6% (median 50 months). Of the 46 cases, 33 presented symptomatically (71.7%), 37 (80.4%) showed a mass on mammography of which 28 (75.7%) was ill defined, 4 (10.8%) well defined and 5 (13.5%) spiculated. All 46 cases had a mass on USS. The imaging score was Bi-rads (Breast Imaging-Reporting and Data System) 5 in 23 cases, Birads 4c in 17 cases and 4a,b in 6 cases. Thirteen patients had MRI. This was performed either to determine disease extent or for neoadjuvant chemotherapy monitoring. All but one of the tumours was seen as a solid mass with some central necrosis the other was seen as an area of nodular enhancement. Nine cases had a staging CT scan for metastatic disease which was negative in all cases.The average size was 28mm (range 11-75mm), 8 (17.3%) were histological grade 3, 5 (10.9%) cases had involved lymph nodes and 28 (60.8%) cases were triple receptor negative. Only 2 cases were HER2 positive. Conclusion : In this series metaplastic cancers were symptomatic in >70%, tended to be large at the time of presentation and only 11% of cases had nodal involvement which is consistent with previous reports. Review of our radiology revealed that all modalities used (mammogram, USS and MRI) reliably showed characteristics suggestive of malignancy. Features suggestive of malignancy include spiculated or irregular ill defined masses on mammography or ultrasound and on MRI large irregular masses with central necrosis and rim enhancement following contrast. These are characteristic or suggestive of malignancy which is contrary to many previous studies of MBC that suggest MBC is difficult to pick up on imaging and commonly exhibits benign features. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-01-08.

P1-08-10: Invasive Lobular Breast Cancer – No Increased Risk of Contralateral Disease.

Background: Invasive lobular carcinoma (ILC) is the second most common type of breast cancer accounting for up to 14% of invasive breast cancers. Worldwide the incidence of breast cancer is increasing each year. Large population based studies using the Surveillance, Epidemiology, and End results (SEER) data have shown that the incidence of ILC has increased from 1977 to 1995. ILC has historically been thought to be associated with an increased risk of developing contralateral breast cancer and this belief may, in part, be responsible for the increasing trend towards contralateral prophylactic mastectomy. Methods: All female patients diagnosed with breast cancer during the time period 1998–2003 were identified from two large cancer registries, Northern and Yorkshire Cancer Registry and Information Service (NYCRIS) and West Midlands Cancer Intelligence Unit (WMCIU). All patients diagnosed with either Infiltrating duct(adeno) carcinoma, microinvasive ductal carcinoma, infiltrating ductular carcinoma (all classified as ‘ductal9) or lobular (adeno)carcinoma were included. Patients with a mixed type of breast cancer were excluded from the analysis. Follow-up was complete until October 2010. Data were compiled for diagnosed contralateral breast cancer of any histological type. Results: Of the 32,735 patients with invasive ductal cancer 898 (2.74%) developed a contralateral breast cancer. In comparison 166 (3.1%) of 5397 patients with lobular cancer developed a contralateral breast cancer. The median time to first contralateral event was equivalent for both morphologies (ductal 40 months and lobular 39 months). Conclusion: This study suggests that there is no increased risk for developing a contralateral breast cancer in patients diagnosed with an invasive lobular breast cancer. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-08-10.

Pathological and Patient Factors Affecting the Accuracy of Ultrasound Combined with Fine Needle Aspiration Cytology in Pre-Operative Staging of the Axilla in Breast Cancer.

Introduction:Ultrasound combined with fine needle aspiration cytology is effective in pre-operative staging of the axilla in breast cancer. Accurate pre-operative diagnosis of lymph node metastases allows for a one stage axillary operation and may also influence decisions regarding neo-adjuvant chemotherapy and breast reconstruction. The aim of this study is to identify pathological and patient factors that influence the accuracy of ultrasound and FNAC in determining the status of the axilla pre-operatively.Methods:Three hundred patients with primary operable invasive breast cancer had an axillary ultrasound pre-operatively. If the ultrasound was normal the patient was offered a sentinel node biopsy. If it identified equivocal or pathological nodes a fine needle aspirate cytology was performed. If the cytology was malignant then an axillary node clearance was performed.Results:Ultrasound combined with FNAC correctly determined the status of the axilla pre-operatively in 78% of cases. Sensitivity for the detection of metastases was 32% with 100% specificity. Factors affecting the accuracy of ultrasound and FNAC were the pathological size of tumour (p Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5020.

Predicting Axillary Lymph Node Status Using Preoperative Ultrasound-Guided Fine Needle Aspiration Cytology of Radiologically Equivocal and Abnormal Nodes.:

Introduction:The superiority of ultrasound (US) over clinical examination in the assessment of axillary nodes in patients with breast carcinoma is well recognised. Fine needle aspiration cytology (FNAC) is a quick and minimally invasive procedure to determine the status of axillary lymph nodes pre-operatively. Sentinel lymph node biopsy (SLNB) is now widely accepted as the primary axillary staging procedure in the management of early breast cancer. A negative SLNB obviates the need for more extensive axillary surgery, thereby reducing the morbidity associated with axillary node clearance (ANC) in patients with node negative breast cancer. Patients with a SLNB positive for metastasis usually require further axillary treatment, which may include completion ANC and/or radiotherapy. Improving the accuracy of pre-operative staging is desirable in reducing the number of completion ANC procedures necessitated following positive SLNB. The aim of this study is to assess the accuracy of pre-operative US-guided FNAC of radiologically equivocal or abnormal axillary lymph nodes.Method:Patients with a diagnosis of invasive breast carcinoma underwent axillary US. Those with radiologically equivocal or abnormal nodes had US-guided FNAC. Patients with a metastatic FNAC had ANC, whereas those with insufficient (i.e. no lymphocytes seen on cytology), benign or equivocal FNAC had SLNB.Results:The positive predictive value of suspicious or malignant cytology from a radiologically equivocal or abnormal node is 97%. The negative predictive value is 70%. US-guided FNAC used in the context has 83% sensitivity and 94% specificity.Of the five patients with radiologically equivocal or abnormal nodes and an inadequate cytology (no lymphocytes seen), four had a metastatic sentinel node biopsy.One patient had a malignant FNAC prior to neoadjuvant chemotherapy (NACT) and had benign histology on subsequent ANC. If this patient is excluded from analysis, the positive predictive value rises to 100%.Conclusion:US-guided FNAC of radiologically equivocal or abnormal axillary lymph nodes accurately predicts node positivity and can be used to avoid an unnecessary SLNB procedure.Inadequate FNAC from an equivocal or abnormal node is not sufficient evidence to recommend SLNB rather than ANC as the initial surgical axillary procedure. Patients with such findings should have a repeat US-guided FNAC before choosing to proceed with SLNB. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1031.