Axillary US: The Pits

Andrea A. Birch, MD

Disclosures

• I have no disclosures to acknowledge

OUTLINE

We’ve Come a Long Way, Baby…

• Halstead-remove it all

• Minimal Operative Surgery

• But what about the axilla

Post ALND sequelae

• Lymphedema-2-18%

• Pain-16-56%

• Impaired shoulder mobility 4-45%

• Arm weakness 19-35%

Early Stage Breast Cancer

• T1 N0 M0

• T2 N0 M0

• T1 N1 M0

• T2 N1 M0

40% PTS NEWLY DXED

• HAVE AX METS

• NEG US INSUFFICIENT TO EXCLUDE AX METS

Management Decisions

• Surgery

• Axill staging, how, when

• Neoadj therapy, pre or post ax staging

Mets to Axillary Lymph Nodes </=2cm

• Level 1-69.9%

• Level II-13.2%

• All Levels-11.3%

• Skip mets to levels II and III- 5.6%

• Veronesi et al.

Extent of Scan Documentation

• Level 1

• Level 1, 2, and 3

• Locoregional Nodal basins, ie Supraclavicular, Internal Mammary (medial mass/es)

Indications for Axillary US

Staging for Early Breast Cancer

Palpable Abnormality

Mammographic Finding

Postsurgical Concern

US Inclusion Criteria to Look

• Any person, any age, BIRADS 5, with sonographicindex breast mass

• Any person, any age, BIRADS 4, with sonographicindex breast mass, and risk estimated to be >/= 4c

• Any person, any age, BIRADS 3, with sonographicindex breast mass and special circumstances ietransplant pt, not surgical candidate

• Mg Ax abnormality or clin palp AX abnormality• EXTENSIVE DCIS>4 CM

Selection Exclusion Criteria for AU

• Suspected Inflammatory Breast Cancer

• Suspected Mg DCIS < 4cm

• Previous tx’ed ipsilateral breast cancer with axillary lymph node dissection (ALND)

• Prev Hyperpl Ipsil Ax Lymph Node Disease

• Pregnancy

• PREVIOUS IPSILATERAL AXILLARY SURGERY

• Susp bilateral breast disease

Axillary Trials

• NSABP B-04, 1977

• B-32

• ACOSOG –American College of Surgeons Oncology Group Z0011 trial , 2011

• ACOSOG Z1071

Z011 trial

• Randomized clinical trial that demonstrated subset pts with early breast cancer that do not benefit from axillary lymph node dissection( ALND)

• ie doesn’t alter recurrence rate, longtermsurvival, or treatment plan

ACOSOG Z0011 trial

• Randomized inferiority trial that compared outcomes of patients with T1 or T2 invasive breast cancers and positive SLNB findings who underwent completion ALND vs the outcome of those who did not

• Cohort-T1/T2 IMC, no clinically palp adenopathy, and 1 or 2 metastases within sentinel nodes

• Randomized to ALND or no further axillary tx ieSLNB alone

Z0011 Cohort Exclusions

• 3 or more positive sentinel nodes

• Matted nodes

• Gross extranodal disease

• Completed /undergone hormonal neoadjuvant chemotherapy

• Palp axillary adenopathy

Z0011 Trial

• All patients underwent lumpectomy

• Negative margins achieved on ALL patients

• All patients received tangential whole breast irradiation- BUT NOT SAME RADIATION

Z0011 Trial Survival/Local Recur

• SURVIVAL

• ALND-91.8%

• SLNB ALONE-92.5

• LOCAL RECURRANCE 5 YR

• ALND-3.1%

• SLNB-1.6%

Z0011 TRIAL CONCLUSIONS

• Survival of SLNB alone not inferior to ALND among patients with limited sln mets tx’edwith breast conservation and systemic therapy

• ALND may not be justified in this cohort

• Conclusions controversial-f/u limited to 6 years

Nodal Extraction

• SLND –median of 2 nodes removed

• ALND-median of 17 nodes removed

• 17% ALND-3 or > involved nodes

• 5% SLND-3 or > involved nodes

• 27% ALND addn positive positive nodes removed beyond sentinel node(s)

9.25 yr Median Followup Z0011

• No statistically significant differences in local or regional recurrence

• 2 nodal regional recurr ALND

• 5 nodal regional recurr SLND

10 yr Z0011 Survival Conclusion

• 2016 American Society of Clinical Oncology (ASCO) Annual Meeting

• “Routine use of axillary lymph node dissection (ALND) should be abandoned.” Guiliano, AE., oral presentation

ACOSOG Z11

• Taking cancerous nodes out has no advantage

• It does not alter treatment plan

• Does not improve survival

• Does not make cancer less likely to recurr

10 yr Locoregional Recurrence-Free Survival

• 93.8% ALND

• 94.7% SLND

Locoregional recurrence

• Hormone receptor status

• Bloom-Richardson score

• Tumor size

• NOT THE OPERATION ITSELF

Radiology Assessment of Axilla

• Mammogram

• Ultrasound

• MRI

Mammographic Assessment

MG NODAL CHANGE

SIZE-increase > than 25%

DENSITY

MORPHOLOGY

INTERVAL CALCS

LOSS FATTY HILUM

US Features of Abnormal Node

• Cortical thickening- diffuse and/or focal

• Hilar effacement

• Nonhilar cortical blood flow

• Cortical irregularity

• Size-greater than 1 cm

• Matted nodes

Lee et al. AJR200:2013

• US features: size, morphology, hilum, cortical thickness ipsilat nodes

• Us data collected over 3 yrs-224 cases

• 50.4% nodal involvement p ALND- 113 CASES

• OF 113 + US for 59 cases-52.2%

• Overall US PPV 0.81 for detecting nodal inv

• Negative PV 0.60

• Sensitivity 53.7, Specificity-85.1%

Best predictive morphologic features

• Absence fatty hilum ( p=0.003 )

• Increased cortical thickness ( p= 0.03 )

• Metastatic nodal burden at least 20% more likely to have findings on US

LEE ET AL

• Size criteria-greater than 10 mm short axis diameter

• Height length ratio > 0.5

• Cortical thickness > 3mm maximum trans dimen or at the focally widest dimen if asymm thickening

• Lobulation

• “presence or effacement” of normal central fatty hilum

• Documentation of abn vascularity- mult periphneoangiogenic vessels

Future Direction

• Can imaging assume primary role in assessing axilla vs gold standard ALND

• IF ALND performed only on pts with advanced nodal dz-N2 and N3

• IF tx decisions can be made based on nonnodal criteria in cases with limited dz

US-NEG PREDICTIVE VALUE

• 96% for excluding N2 and N3 mets in pts with IMC

• 83% for excluding N2 and N3 mets in pts with ILC

• IN FUTURE, pts with IMC undergo imaging to exclude N2 or N3 dz, rather than dx axillary mets

• Dx value of ax imaging increase, accuracy > with mult modalities-US and MRI

Current Criteria for ALND

• RESTRICTED TO MORE ADVANCED DZ

• MORPHOLOGIC CRITERIA MORE IMPT THAN SIZE CRITERIA

FNA AXILLARY NODE

• HIGH FALSE NEGATIVE RATE 12-23%

• NO RECEPTOR INFO

• RELIABLE CYTOLOGY

• CYTOLOGIST ON SITE

Axillary Node Core BX

Imaging Strategies for Identifying Ax ND prior to surgery

• Inconclusive findings on clinical exam

• Established IMC

• T size greater than 1CM

• Angiolymphatic invasion

• Prestaging –reflex axillary US -allows direct route to ALND, avoiding SLNB and poss 2nd

surgical procedure for ALND

US SIGNS AX NODAL METS

• Focal cortical bulge/thickening-earliest sign but non specific, and low PPV

• Eccentric cortical thickening

• Hilar effacement

• Round hypoechoic mass

• Nodal calcs

• Replacement of the entire node or portion of a node by ill-defined mass

AXILLARY NODE BX

• Safely performed using 12-18 gauge spring loaded or vacuum assisted device

• No throw technique-decreases hematoma risk and unintended nerve damage

US AXILLARY NODES

• Topal et al. Eur J Radiol. 2005

• 90% sensitivity

• 100% specificity

• 92% accuracy

Second Look Axillary US (SLAUS) p MRI

Exhibit 2016-MRI performed to assess extent of dx p DxMg, Breast US, and nl AUS p cancer dx

No consensus criteria using MRI for reporting of axillary nodal appearance

All cases of MRI detected susp nodes underwent SLAUS within 7 days

191/200 breast MRI- normal nodes

29/220 addn nodes

• Breast MRI detected 29/220 addn cases suspax nodes

• SLAUS identified 28/29

• 12/29 fna/cbx – positive

• 1/29 SLAUS discordant with MRI, neg also with fna and confirmed with SLNB

• Conclusion: SLAUS improves detection of metastatic nodes and could diminish FP from MRI alone-more studies needed

Other Axillary Masses

• Assessory Breast related masses- FAs, hamartomas, fat necrosis, carcinoma

• Primary Soft Tissue Masses- lipomas, hemangiomas, schwannomas, Fibromatosis(desmoid), Epidermal Inclusion cysts, Malignant Fibrous Histiocytomas

• Surgery Related masses-seroma, hematoma

Axillary anatomy

• 20-30 nodes in axilla

• Rotter’s nodes-level 2