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Another Role for Ultrasonography in the Management of Breast Cancer

Division of Surgical Oncology, University of Vermont College of Medicine, 89 Beaumont Avenue, E309C Given Building, Burlington, Vermont 05401

Correspondence: Address correspondence and reprint requests to: Seth P. Harlow, MD; E-mail: seth.harlow{at}uvm.edu

In this issue of Annals of Surgical Oncology, van Rijk et al.¹ describe their institution’s experience with ultrasound imaging and ultrasound-guided fine-needle aspiration (FNA) biopsy of axillary lymph nodes in clinically node-negative breast cancer patients. Ultrasound imaging has been an important tool in the evaluation of breast lesions and breast cancer for many years; its utility for evaluating the regional lymph nodes, however, has been a more recent development. This article represents the largest series on ultrasound evaluation of the axillary nodes in patients with invasive breast cancer in the literature and makes some important observations that will contribute to the contemporary management of these patients with regard to the use of sentinel lymph node biopsy procedures.

Today the primary roles of the surgeon managing breast cancer are to ensure optimal local regional disease control, to provide accurate pathologic staging so that appropriate decisions about adjuvant systemic therapies can be made, and to optimize cosmetic and functional outcomes for the individual patient. In recent decades, we have found that less invasive procedures such as breast preservation and sentinel node biopsy techniques, when performed in appropriate patients, can provide disease outcomes similar to those with more radical procedures, with significantly less morbidity and better cosmetic results. The sentinel lymph node biopsy procedure in breast cancer has been in use only a little over a decade, and to date it has been found to be an excellent procedure for staging the regional lymph node basin when performed by a qualified team of surgeons and pathologists. In the event that metastatic disease is found in the sentinel nodes, a completion axillary node dissection is still the recommended treatment to maximize regional disease control. Sentinel lymph node biopsy techniques are highly accurate, but not foolproof, with pathologic inaccuracy rates of 1% to 4%.^2,3 The sentinel node procedure also entails additional time and effort on the part of the surgical and pathology teams, and this will add to the expense of caring for the patient. There is also some level of discomfort for the patient and a small level of risk in relation to allergic reactions to blue dye. All of these factors are quite minor and are well worth the cost, given the obvious benefit of sentinel node biopsy alone compared with axillary node dissection, if the sentinel nodes are negative for metastatic disease. These factors, however, will be additive to the costs and risks of an axillary dissection if the sentinel node biopsy identifies metastatic disease, which it will in 25% to 40% of clinically node-negative breast cancer patients. Techniques that can identify the clinically node-negative but pathologically node-positive patient in an easy, minimally invasive cost-effective manner would therefore be of significant clinical benefit in streamlining the surgical care of these patients, thereby avoiding any potential risk or cost that is not necessary.

The use of ultrasound imaging of the regional lymph nodes and FNA cytology as reported by van Rijk et al. is an excellent demonstration of just such a technique. In this report, 732 clinically node-negative axillae were evaluated by ultrasound imaging. Suspicious lymph nodes were identified and biopsied by FNA in 176 axilllae (24%) and found to contain metastatic disease in 59 axillae (8% of all patients; 1 patient had a false-positive FNA result). More importantly, 21% of patients with metastatic disease in the regional nodes were identified before surgery by the ultrasound-guided FNA technique, bypassed the sentinel node biopsy procedure, and simply had the standard axillary node dissection performed. Preoperative ultrasound evaluation of the axilla may also have the benefit of decreasing the false-negative rate of the sentinel node biopsy procedure itself. It is well known that tumor-replaced lymph nodes may divert the flow of lymphatic fluid to other uninvolved lymph nodes in the nodal basin, thereby potentially leading to a false-negative sentinel node biopsy result. In general, these tumor-replaced lymph nodes are readily identified by experienced sonographers, thus alerting the surgeon to this possibility, allowing an FNA biopsy, and possibility averting a false-negative sentinel node biopsy result. This thesis that large metastases are readily seen by ultrasonography is supported by the results of this study as well, in that 58 of the 59 axillae that had a tumor-positive FNA biopsy had tumor metastases larger than 2 mm. These patients also had significantly more positive lymph nodes than patients whose metastases were not found by ultrasound-guided FNA (4.3 vs. 2.2 on average), again indicating the importance of a complete axillary dissection in these patients.

Although the sonographer, as in this study, may be a radiologist, more and more surgeons are now being adequately trained in breast and soft tissue ultrasound interpretation and biopsy techniques and are capable of performing these evaluations themselves. The surgeon trained in ultrasound techniques can perform detailed preoperative evaluation of the patient’s breast cancer as well as the regional lymph nodes in the office, thereby expediting patient care and better defining the best surgical option for the individual patient. This article is yet another example of the important clinical utility of ultrasonography in the management of the patient with breast cancer. Its uses include evaluating the size and location of the primary breast cancer, detecting the presence of additional foci of disease within the breast, and facilitating the biopsy of nonpalpable lesions. Ultrasonography can also be used by the surgeon during surgery to localize nonpalpable breast cancers for excision, and it is being evaluated for the guidance of nonsurgical ablations of breast cancers in selected patients. Given all of these benefits, it behooves surgeons caring for these patients to become facile with these techniques so that they are able to extend these benefits to the patients under their care.

Received for publication October 24, 2005. Accepted for publication October 27, 2005.

REFERENCES

1. van Rijk MC, Deurloo EE, Nieweg OE, et al. Ultrasonography and fine-needle aspiration cytology can spare breast cancer patients unnecessary sentinel lymph node biopsy. Ann Surg Oncol (in press).
2. Krag D, Weaver D, Ashikaga T, et al. The sentinel lymph node in breast cancer: a multicenter validation study. N Engl J Med 1998; 339:941–6.[Abstract/Free Full Text]
3. Tafra L, Lannin DR, Swanson MS, et al. Multicenter trial of sentinel node biopsy for breast cancer using both technetium sulfur colloid and isosulfan blue dye. Ann Surg 2001; 233:51–9.[CrossRef][Medline]

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