AFECTACIÓN GANGLIONAR: ¿CONSENSO O DISENSO?

AFECTACIÓN GANGLIONAR: ¿CONSENSO O DISENSO? Estadificación de la enfermedad ganglionar: valor de la imagen Dr. Javier del Riego Área de Radiología Mamaria y Ginecológica UDIAT CD. InsFtut Universitari Tauli – UAB. Sabadell, Barcelona. Reemplazar la BSGC por una técnica de imágenes (cN0). Técnicas de Imagen Downloaded from www.ajronline.org by SERAM on 10/20/15 from IP address 176.31.224.175. Copyright ARRS. For personal use only; all rights reserved
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Fig. 1—Reactive axillary lymph node in 57-year-old woman with invasive ductal carcinoma of right breast. In this case, elastogram finding was false-positive. Dotted
lines show measurements used to calculate
ratio of size of node on strain elastography
and ultrasound.
Ultrasound
in Medicine
and Biology
A, On gray-scale ultrasound image, lymph node (arrow) appears indeterminate; lymph node shows evenly thickened, isoechoic cortex and has long-axis–to–short-axis
ratio cancer.
of 2.
newly diagnosed with right breast
B, Strain elastogram of node shows black area is covering 100% of lymph node (arrow). Ultrasound-guided fine-needle aspiration biopsy of node and sentinel lymph node
DCE MRI (performed to evaluate biopsy
thewere
extent
negative for malignancy.
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Volume -, N
FIG 6. Example of a morphologically abnormal level 1 right axillary lymph node on MRI in a patient
Axial (A) and sagittal (B) postcontrast T1-weighted images with fat saturation from the patient’s clinical
of disease) demonstrate that the lymph node (blue arrows) has a rounded shape with a thickened cortex and no perceptible fatty hilum.
Ultrasound-guided core needle biopsy confirmed the presence of metastatic disease. (Color version of figure is available online.)
BREAST IMAGING: Axillary T2- and Diffusion-weighted MR Imaging for Nodal Staging in Breast Cancer
Schipper et al
Figure 6
Fig. 2—Metastatic axillary lymph node in 63-year-old woman with invasive ductal carcinoma of left breast. In this case, elastogram finding was true-positive. Dotted
lines show measurements used to calculate ratio of size of node on strain elastography and ultrasound.
FIG 7. 18F-FDG-PET appearance of a metastatic left axillary lymph node in a patient with newly diagnosed breast cancer. 18F-FDG-PET image
(A)
A, Lymph node (arrow) appears suspicious on gray-scale ultrasound; lymph node shows eccentric, hypoechoic cortical thickening.
demonstrates focally increased radiotracer activity in the left axilla (blue arrow). 18F-FDG-PET/CT fusion image (B) demonstrates the radiotracer
B, Strain elastogram of node shows black area is covering 100% of lymph node (arrow). Ultrasound-guided fine-needle aspiration biopsy of node and sentinel lymph node
biopsy revealed metastatic carcinoma.
activity correlates to a left level 1 axillary lymph node (blue arrow). Ultrasound-guided core needle biopsy confirmed the presence of metastatic
disease. (Color version of figure is available online.)
95*:)"*
and axillary node dissection after neoadju- lobular carcinoma (n = 8), invasive mam-
The 101 patients included 99 women and vant chemotherapy was performed in 57 pa- mary carcinoma (n = 3), ductal carcinoma
men with a total of 104 nodes. The medi- tients with metastatic lymph nodes. Surgery in situ (n = 3), mucinous carcinoma (n = 1),
Fig. 3. False positive of PET/CT. The primary lesion was detected on the outer part of right breast (upper row axial fused and twoPET
an age of all patients was 55 years (age range, was not performed after ultrasound-guided papillary carcinoma (n = 1), tubular carcinomages and on the right side MIP-image, thick arrows). A lymph node with mild FDG uptake about 1 cm in diameter was reported
31–91asyears). Sixty-nine of 104 (66.3%) FNAB in five nodes: two nodes of benign hy- ma (n = 1), metaplastic carcinoma (n = 1),
DCE breast MRI for staging the axilla. Baltzer et al.
Fig. of
2. Generation
ofand 35NSD
features
from
hilum
and lym
the
increased
metabolic
activity
malignancies
(n = 1), malignant
phyllodes(yellow)
tuperplasia, two nodes of metastasis
that had lymphoma
nodes were malignant
(33.7%), be- transform
metastatic (bottom row
fused
andwoman
PET
images,
Figure axial
6: Images
in a 64-year-old
with invasive
ductal thin arrows), however there was no evidence of metastasis to the axillary lymph
(n = 1).distance.
nign. Ultrasound-guided
FNAB was per- undergone chemoradiation, and one recurrent mor (n = 1), and leiomyosarcoma
signed
further evaluated
specific
MRI
lymph
node findings
relative to normal
tissue
for
detecting
metastatic
discarcinoma in the right breast,
which was treated
with mastectomy
metastatic lymph
node in a
a patient
who had
formed after
SE on the same
day in all nodes.patient
Fig. 1. US images of a 40-year-old
breast
cancer
with
multifocal
breast tumour BI-RADS 5. (a) An
nodes in pathology.
and ALND (stage pT2N1). (a) Coronal T2-weighted ( T2W ) MR image
18
(including
presence of irregular margins, cortical
was is
identified
in CEUS. with
(c) This
was
the first
and
enhancing
LN which in the grey scale US had
often performed
computed
ease. F-FDG-PET
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wasonly
final
histopathology,
3/15
LNs after ax
biopsy (arrow heads) and confirmed
The characteristics
of metastatic
the examined
cases of benignshowed
on 87at
of the
104 axillary
nodes. earlier. Twelve cases, fourwhich
nodularity, or thickening, replaced fatty hilum, peritomography (CT) to provide We
anatomic
detail performed
and
to
hypothesized
that
3-D
histograms
consisting
difference
Table 1. The longSLNB revealed benign lymph nodes in 17 hyperplasia and eight metastases, were lost lymph nodes are listed in of
nodal
edema,
rim
enhancement,
and
lymph
node
and short-axis diameters
of the metastatic ical
ultrasound-guided FNAB. from
patients, axillary nodecalculated
dissection performed to follow-up after
improve but
image
quality
with image
attenuation
correction.
Table
1 (i)
intensity
directly
the
with
an im
staining
poor
specificity;
we
in fact observed
additional non-sentinel node biopsy tests, based on high sensitivity
!
demonstrates the absence of the fatty hilum of the lymph node.
(b) Coronal DW MR image (b value of 800 sec/mm2) demonstrates
the same lymph node depicted in a with low diffusivity, reflected by
relatively high signal intensity. (c) Corresponding coronal ADC map
shows a low mean ADC value (0.624 3 10–3 mm2/sec), reflected
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EcograSa axilar v 
Alta disponibilidad v 
No invasiva v 
Rápida v 
Eficiente v 
RelaFvo Bajo Coste York, USA.
META-ANALYSIS
Studies with any of the following features were not eligible for
Reprints: Nehmat Houssami, MBBS, PhD, School of Public Health (A27), Sydinclusion:
reported only as abstracts; index test performed in fewer
ney Medical School, University of Sydney, Sydney 2006, Australia. E-mail:
than 20 subjects; axillary needle biopsy from various primary cancers;
[email protected]
This work was partly funded by National Health and Medical Research Council
or clinical (manual) axillary needle biopsy in the majority of subjects.
(NHMRC) program grant 402764 to the Screening & Test Evaluation Program.
Supplemental digital contents are available for this article. Direct URL citations
Literature Search and Data Extraction
appear in the printed text and are provided in the HTML and PDF version of
Systematic searches of the literature (MEDLINE, and EBM
this article on the journal’s web file (www.annalsofsurgery.com).
Financial disclosures:
None to declare.of Its Accuracy and Utility in Staging
reviews including
Cochrane databases, from 1965 to April 2010)
Meta-Analysis
the Axilla
Commercial Sponsorships: None.
were
performed
to
identify studies that met eligibility criteria, usC 2011 by Lippincott Williams & Wilkins
Copyright #
Nehmat
Houssami, MBBS, PhD,∗ Stefano Ciatto, MD,† Robin M. Turner, PhD,
Hiram
S. strategy
Cody, III,summarized
MD,‡ and in the Appendix (see Appendix,
ing ∗the
search
ISSN:
0003-4932/11/25402-0243
Petra Macaskill, PhD∗
DOI: 10.1097/SLA.0b013e31821f1564
Supplemental Digital Content 1 at http://links.lww.com/SLA/A139,
Preoperative Ultrasound-Guided Needle Biopsy of Axillary
Nodes in Invasive Breast Cancer
!
Volume
254, Number
August 2011
www.annalsofsurgery.com
AnnalsSystematic
of Surgery
Objective:
evidence synthesis
of ultrasound-guided
needle2,
biopsy
dard initial surgical approach for staging the axilla in most women;
(UNB) of axillary nodes in breast cancer.
those found to have sentinel node metastases will generally undergo
Summary Background Data: Women affected by invasive breast cancer
further surgery, a completion axillary node dissection (AND). The
undergo initial staging with sentinel node biopsy, generally progressing to axpast
decade has
seen the introduction
of ultrasound-guided
needle is prohibited.
Copyright
© 2011
Lippincott
Williams
& Wilkins.
Unauthorized
reproduction
of this article
illary node dissection (AND)
if metastases
are found.
Preoperative
UNB
biopsy (UNB) in preoperative evaluation of axillary nodes to pocan potentially identify and triage women with node metastases directly
tentially identify and triage women with node metastases on UNB
to AND.
directly to AND.1–7 Although studies have examined, and in some
Methods: Review and meta-analysis of studies reporting UNB accuracy: we
instances advocated,1–6 the adoption of preoperative UNB of the axestimated sensitivity, specificity, and PPV, using bivariate random-effects modilla, the routine use of axillary UNB is not very widely adopted and
els and examined the effect of covariates; we calculated UNB utility (effect
has been recommended in only 1 cancer clinical guideline to date.8
on axillary surgery).
This may, in part, be due to perceptions that UNB has limited senResults: Thirty-one studies provided 2874 UNB data from 6166 subjects
sitivity, or due to perceptions that the test will not alter the standard
(median proportion with metastatic nodes 47.2%; IQR 39.5%, 61.2%).
surgical approach to axillary staging in the majority of women with
Modeled estimates for UNB were: sensitivity 79.6% (95% confidence inbreast cancer. In addition, most research into axillary needle biopsy
tervals [CI] 74.1–84.2), specificity 98.3% (95%CI 97.2–99.0), PPV 97.1%
has been based on relatively small series, limiting the precision of
(95%CI 95.2–98.3); median UNB insufficiency was 4.1% (IQR0%–10.9%).
estimates of accuracy reported in individual studies.
UNB sensitivity increased with increasing ultrasound sensitivity, and was
We systematically examined the evidence on ultrasoundhigher in studies performing UNB for “suspicious” than for “visible” nodes.
guided fine needle aspiration biopsy (FNAB) or core needle biopsy
Specificity was higher in studies of consecutive (vs. selected) subjects, in
(CNB; collectively referred to as UNB) of axillary nodes, to destudies reporting ultrasound data, and in more recent studies. Median protermine whether UNB is effective as a triage test9 in preoperative
portion of women triaged directly to AND (attributed to UNB) was 19.8%
staging of the axilla in women with breast cancer. We aimed to es(IQR11.6%–28.1%) or 17.7% (IQR11.6%–27.1%) if restricted to clinically
tablish the effectiveness of UNB in staging the axilla by estimating in
node-negative series. Median proportion of women with metastatic axillary
meta-analysis: (a) test-related measures, including accuracy and (b)
nodes potentially triaged to AND was 55.2% (IQR41.8%–68.2%) and was
patient-related outcomes, specifically test utility defined in terms of
higher (65.6%; IQR48.9%–69.7%) in the subgroup of studies with median
the proportion of women potentially triaged directly to AND, and in
tumor size ≥21 mm.
whom (unnecessary) SNB could be avoided through systematic use
Conclusions: Preoperative UNB of the axilla is accurate for initial staging
of preoperative UNB.
of women with invasive breast cancer. Meta-analysis indicates that UNB provides better utility in women with average or higher underlying risk of node
METHODS
metastases.
on the use of systemic therapy. Sentinel node biopsy (SNB) is the stan-
| 243
Agosto 2011 EcograSa axilar v 
31 estudios, 6167 pacientes (T1-­‐T4), Prevalencia N+: 47.2% v 
Sensibilidad: 61.4 % (51.2%. – 79.4%); Especificidad: 82% (77%– 89%) Eco + Biopsia (PAAF/BAG) v 
21 estudios, 1733 pacientes (T1-­‐T4). S
Criteria for Study Eligibility
were included in our systematic review if they reported
Sensibilidad: 79.4 % (68.3%. –Studies
8.9%); Especificidad: 100% (100%– 100%) on ultrasound-guided FNAB or CNB of axillary nodes (index test,
(Ann Surg 2011;254:243–251)
v 
taging of the axilla in women affected by invasive breast cancer
provides prognostic information and helps in guiding decisions
UNB) in women with newly diagnosed invasive breast cancer, and
provided data on FNAB or CNB accuracy: data on true and false
positives were the minimum data criteria for study eligibility. We
also examined data on insufficient test results, and the number of
From the *Screening and Test Evaluation Program (STEP), School of Public Health,
subjects triaged to AND on the basis of UNB. Node histology (based
Sydney Medical School, University of Sydney, Sydney, Australia; †Breast
onusurgery)
was the referencenstandard
ascertaining
the presence
‡reoperaFve Breast SerCancer
Screening
Program,
Padua,H
Veneto
Region,
Italy;Pand
Houssami N, Ciaho S
, T
urner R
M, C
ody S, M
acaskill . P
ltrasound-­‐guided eedle for
biopsy of axillary nodes in invasive breast cancer: meta-­‐analysis of its accuracy vice, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New
or absence of node metastases.
York,the USA.axilla. Ann Surg 2011;254:243–51. and uFlity in staging Studies with any of the following features were not eligible for
Reprints: Nehmat Houssami, MBBS, PhD, School of Public Health (A27), Sydinclusion: reported only as abstracts; index test performed in fewer
ney Medical School, University of Sydney, Sydney 2006, Australia. E-mail:
than 20 subjects; axillary needle biopsy from various primary cancers;
[email protected]
This work was partly funded by National Health and Medical Research Council
or clinical (manual) axillary needle biopsy in the majority of subjects.
(NHMRC) program grant 402764 to the Screening & Test Evaluation Program.
Supplemental digital contents are available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF version of
this article on the journal’s web file (www.annalsofsurgery.com).
Literature Search and Data Extraction
Systematic searches of the literature (MEDLINE, and EBM
Manejo axilar BI-­‐RADS 6 EcograSa Axilar STOP INESPECÍFICO SOSPECHOSO BSGC PAAF LINFADENECTOMIA Manejo axilar BI-­‐RADS 6 EcograSa Axilar INESPECÍFICO STOP SOSPECHOSO BSGC PAAF LINFADENECTOMIA ¡¡Evitar un 2do Rempo quirúrgico!! Manejo axilar ¿Hay cáncer en la axila? NO SI BSGC LINFADENECTOMIA TRIAL ACOSOG Z0011 Febrero 2011 Giuliano AE, Hunt KK, Ballman K V, Beitsch PD, Whitworth PW, Blumencranz PW, et al. Axillary dissecFon vs no axillary dissecFon in women with invasive breast cancer and senFnel node metastasis: a randomized clinical trial. JAMA 2011;305:569–75. TRIAL ACOSOG Z0011 TRIAL ACOSOG Z0011 BSGC NO LINFADENECTOMIA v 
cT1 – T2; N0 v 
BSGC ≤ 2 macrometástasis v 
Tratamiento conservador v 
Radioterapia v 
Tratamiento adyuvante sistémico (97%) TRIAL ACOSOG Z0011 TRIAL ACOSOG Z0011 TRIAL ACOSOG Z0011 TRIAL ACOSOG Z0011 -­‐ IMPACTO Printed by Javier Horacio del Riego Ferrari on 6/12/2015 7:50:34 AM. For personal use only. Not approved for distribution. Copyright © 2015 National Comprehensive Cancer Network, Inc., All Rights Reserved.
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elephone system when frozen section or touch preparation analysis
documented a tumor-involved SN. Although some of these patients
were subsequently found to have 3 or more tumor-involved SNs, they
were included in the analyses. All patients gave written informed
onsent, and all institutions obtained approval by their institutional
eview board. There were 165 investigators and 177 institutions particpating in this study. Figure 1 illustrates the study schema.
variables between groups. Cox proportional hazards models were used
to assess the univariable and multivariable association between prognostic variables, treatment, and locoregional recurrence. All statistical
tests were 2-sided and a P value of 0.05 or less was considered
statistically significant. Analyses were performed with SAS statistical
analysis software, version 9.1 (SAS Institute, Cary, NC).
TRIAL ACOSOG Z0011 RESULTS
Enrollment to Z0011 began in May 1999 with a planned
accrual of 1900 patients. The trial was closed in December 2004 due
to lower than expected accrual and event rates. There were 891
patients randomized with 35 patients (25 on the ALND arm and 10
on the SLND alone arm) excluded because they withdrew consent
from the study. Eligible patients underwent lumpectomy and SLND
alone or lumpectomy with SLND and completion ALND. Statistical
analyses were performed on an intent-to-treat basis with 420 patients in
the SLND " ALND arm and 436 in the SLND only arm. There were
43 (5.0%) patients who did not undergo their assigned treatment. Of the
420 patients assigned to the ALND arm, 32 (7.6%) did not undergo
ALND and, of the patients who were assigned to the SLND alone arm,
11 (2.5%) had ALND. Figure 2 shows the trial participants by study
arm (the intent-to-treat sample) and the number of patients who received ALND (388 patients) and SLND alone (425 patients) as originally assigned (the treatment received sample). The primary analyses
were performed on the intent-to-treat sample, and all were repeated for
the treatment received sample. Both analyses yielded similar results
with no significant change in outcomes.
Within the intent-to-treat sample, there were 103 ineligible
patients: 47 on the ALND arm and 56 on the SLND only arm. Reasons
for ineligibility were incorrect number of positive SNs (16 ALND arm
and 32 SLND only arm), SNs positive by IHC only (4 ALND arm and
4 SLND only arm), positive lumpectomy margins (6 ALND arm and 7
SLND only arm), gross extracapsular extension in the SNs (8 ALND
arm and 7 SLND only arm), and other (13 ALND arm and 6 SLND
only arm). In both the intent-to-treat and treatment received samples,
the 2 treatment arms were well balanced in terms of baseline patient and
tumor characteristics (Table 1).
The number of lymph nodes removed and the extent of metastatic involvement for each study arm is presented in Table 2 with
interquartile range (IQR), which reports the 25th and 75th percentile
range.
the
patients randomized
to the
ALND
arm,lymph the median
FIGURE
1.AStudy
design
showing
randomization
process. P, Leitch Giuliano E, McCall L, Beitsch P, Whitworth PW, Blumencranz a M, eFor
t al. Locoregional recurrence auer senFnel node total
dissecFon with or without axillary dissecFon in paFents with senFnel lymph node metastases: the American College of Surgeons Oncology Group Z0011 randomized trial. Ann Surg 2010;252:426–32. © 2010 Lippincott Williams & Wilkins
www.annalsofsurgery.com | 427
v 
BSGC A TODOS!! v 
NO ECO/PAAF!! TRIAL ACOSOG Z0011 ¿Hay cáncer en la axila? NO SI BSGC LINFADENECTOMIA TRIAL ACOSOG Z0011 ¿Hay cáncer en la axila? NO SI BSGC LINFADENECTOMIA TRIAL ACOSOG Z0011 ¿CUANTO cáncer hay en la axila? ≤ 2 OBSERVACIÓN > 2 LINFADENECTOMIA Manejo axilar actual BI-­‐RADS 6 EcograSa Axilar/PAFF NO ACOSOG Z0011 ACOSOG Z0011 Valor actual de la EcograSa/PAAF Axilar Valor actual de la EcograSa/PAAF Axilar ①  Baja carga axilar vs Alta carga axilar ②  Perfil tumoral/ PronósFco ③  EcograSa cuanFtaFva vs Carga axilar final Valor actual de la EcograSa/PAAF Axilar ①  Baja carga axilar vs Alta carga axilar ②  Perfil tumoral/ PronósFco ③  EcograSa cuanFtaFva vs Carga axilar final ①  Baja Carga Axilar vs Alta Carga axilar ECOGRAFIA/PAAF Alto Valor PredicFvo NegaFvo (Baja Tasa de Falsos NegaFvos) Alto Valor PredicFvo PosiFvo BAJA Carga Axilar (LN+ ≤ 2) ALTA Carga Axilar (LN+ > 2) Control por BSGC LINFADENECTOMÍA ①  Baja Carga Axilar vs Alta Carga axilar Author's personal copy
Eur Radiol
DOI 10.1007/s00330-015-3901-2
BREAST
The impact of preoperative axillary ultrasonography in T1
breast tumours
MULTICENTRICO. RETROSPECTIVO §  N: 355 (pT1) Julio 2015 §  N+: 81/255 (22.8%) §  AUS: Received: 26 February 2015 / Revised: 8 June 2015 / Accepted: 23 June 2015
# European Society of Radiology 2015
S: 66.7%; E: 91.1% VPN: 94.2% sensitivity: 52.6 % (pNmic positive)/72.0 % (pNmic negaAbstract
Objectives To (a) determine the diagnostic validity of axillary
tive). In the simulation environment, AUS had 75.0 % sensi ultrasound (AUS) in pT1 tumours and whether fine-needle
tivity, 88.9 % specificity and 99.2 % NPV.
Conclusion AUS has moderate sensitivity in T1 tumours. As
aspiration (FNA) improves its diagnostic performance, and
§  N= 288 pT1 (ACOSOG) ALND is unnecessary in micrometastases, considering
(b) determine the negative predictive value (NPV) of AUS
micrometastases ‘N negative’ increases the practical impact
in a simulation environment (cutoff: two lymph nodes with
§  VPN (Cutoff > 2 LN+): 99.2% Javier del Riego 1 & María Jesús Diaz-Ruiz 2 & Milagros Teixidó 3 & Judit Ribé 4 &
6
Mariona Vilagran 1,5 & Lydia Canales
& Melcior
Sentís 7 & copy
Author's
personal
Grup de Mama Vallès-Osona-Bages (GMVOB; Cooperative Breast Workgroup Vallés-Osona-Bagés)
§ 
Eur Radiol
of AUS.
macrometastases) in patients fulfilling American College of
In patients fulfilling ACOSOG Z0011 criteria, AUS alone
Surgeons Oncology Group (ACOSOG) Z0011 criteria.
Materials and methods This retrospective multicentre crosscan predict cases unlikely to benefit from ALND.
Key Points
sectional study analysed diagnostic accuracy in 355 pT1
• AUS+FNA can predict axillary involvement, thus avoiding
breast cancers. All patients underwent AUS; visible nodes
SNB.
underwent FNA regardless of their AUS appearance. Sentinel
• Not all patients with axillary involvement need ALND.
node biopsy and axillary lymph node dissection (ALND) were
• Axillary tumour load determines axillary management.
gold standards. Data were analysed considering
• AUS could classify patients according to axillary load.
micrometastases ‘positive’ and considering micrometastases
‘N negative’. The simulation environment included all patients fulfilling ACOSOG Z0011 criteria.
Fig.
1 Flow Axillary
diagram for the
entire series. NVLN 22.8
nonvisible
node;sensitivity:
NGS non-gold-standard;
NCT neoadjuvant
chemotherapy
Results
involvement:
%;lymph
AUS
Keywords
Breast
cancer . Axillary ultrasound . Percutaneous
46.9 % (Nmic positive)/66.7 % (Nmic negative); AUS+FNA
biopsy . Sentinel lymph node biopsy . Axillary surgery
Del Riego J, Diaz-­‐Ruiz MJ, Teixidó M, Ribé J, Vilagran M, Canales L, et al. The impact of preoperaFve axillary ultrasonography in T1 breast tumours. Eur Radiol 2015 Jul 12. transducers with various US scanners. US studies examined
The flowchart in Fig. 1 shows the tumours and data includElectronic
supplementary
The online
axilla ipsilateral to the tumour craniocaudally, reviewing
ed
in the first
substudy. The material
analyses included
355version
pT1 tu-of thisthearticle
(doi:10.1007/s00330-015-3901-2)
contains
supplementary
Berg levels I, II and III [39].
mours
studied by AUS (in 349 patients;
six patients
had syn- material,
which is available
to authorized
We classified lymph nodes according to their morphologichronous
bilateral pT1
tumours). users.
In 55/355 (15.5 %), FNA
cal criteria and we defined:
was not done: 43 because AUS detected no nodes and 12
4
because patient and/or technical factors precluded FNA. Fi-
①  Baja Carga Axilar vs Alta Carga axilar Ann Surg Oncol
DOI 10.1245/s10434-014-3674-x
ORIGINAL ARTICLE – BREAST ONCOLOGY
Axillary Ultrasonography in Breast Cancer Patients Helps in
Identifying Patients Preoperatively with Limited Disease of the
Axilla
§ 
A. M. Moorman, MD1, R. L. J. H. Bourez, MD2, H. J. Heijmans, MD1, and E. A. Kouwenhoven, MD, PhD1
Ultrasonography
forGroup
Limited
Disease
of Netherlands;
the Axilla2Departments of Radiology, Hospital Group
Departments
of Surgery, Hospital
Twente,
Almelo, The
Twente, Almelo, The Netherlands
1
§ 
RETROSPECTIVO. UNICÉNTRICO N= 851 (c T1 – T2 cN0) EcograSa negaFva § 
SepFembre ALND in case of a positive SLN, in which case the treatTABLE 3 Subdivision by clinical and pathologic tumor status
Conclusions. The risk of more than 2 positive axillary
ABSTRACT
ment
nodes is relatively
breaststrategy includes whole-breast radiation alone or
Background. The sentinel
lymph node
biopsy (SLNB)
Clinical
T status
Pathologic
T statussmall in patients with cT1–2 2014 §  cT1: VPN (>2LN+): 99% cancer. US of the axilla helps in further identifying
patients
procedure is the method of choice for the identification and
combined
with
adjuvant
therapy after lumpectomy of T1–2
with a minimal risk of additional axillary disease, putting
monitoring of regional lymph node metastases in patients
cT1,
n
cT2,
n
pT1,
n
pT2,
n
pT3,
n
pT1: PN (>2LN+): ALND up for discussion.
with breast cancer. In the case of a positive sentinel lymph
breast cancer. They§ found
no V
significant
benefit 9
in9.1% loco(%)
(%)
(%)
node (SLN), additional (%)
lymph node (%)
dissection is still
regional control or overall survival with completion
warranted for regional control, although 40–65 % have no
Sentinel
lymph
node
biopsy
(SLNB)
has
revolutionized
additional
axillary
disease.
Recent
studies
show
that
after
B2
617 (99) 212 (93.0) 568 (99.1) 247 (95.0) 14 (77.8)
ALND.35
the management of clinically node-negative women with
breast-conserving surgery, SLNB, and adjuvant systemic
Positive
breast cancer. It is a safe and accurate method for axillary
Other recent studies have also questioned the additional
therapy, there
is no significant difference between recurstaging, and it causes substantially less postoperative
rence-free lymph
period and overall survival if there are B2
value of ALND in patients with SLN metastases and, more
positive axillary
nodesnodes. The purpose of this study was morbidity than axillary lymph node dissection (ALND).
The recommended management for patients with
sentinel
preoperative identification of patients with limited axillary
importantly,
proposed a routine ALND after positive SLN.
(SLN)
metastases4 is(22.2)
still ALND in cases of
6 by
(1.0)
16 (7.0)
5 lymph
(0.9) node 13
(5.0)
disease[2
(B2 macrometastases)
using ultrasonography.
SLN metastases larger than 0.2 mm. However,First,
the need ALND is associated with considerable morbidity
Methods. Positive
Data from 1,103 consecutive primary breast
for ALND has recently been questioned
because the
cancer patients with tumors smaller than 50 mm, no pal4,24,41,42
when
Second, several
lymph and a maximum of 2 SLNs with SLN has shown to be the only positive lymph node
in 40–compared with SLNB alone.
pable adenopathy,
For these patients,
ALND
nodeswere collected. The variable of interest 65 % of these patients.
macrometastases
retrospective studies have been published reporting low
offers no additional diagnostic, prognostic, or therapeutic
was US of the axilla.
axillary
benefit while
subjecting
risk of recurrence rates in patients with positive SNs who
Results.
the 1,103
included,
remained
T Of
tumor,
cT patients
clinical
tumor1,060
size,
pT pathologic
tumor
size them to a significant
additional morbidity. The incidence of nodal metastases is
after exclusion criteria. Of these, 102 (9.6 %) had more
didmamnot have ALND. The axillary recurrence rate was less
lower since the introduction of routine screening
than 2 positive axillary nodes on ALND. Selected by
Moorman M, the
Bourez RofLJH, Hnodes,
eijmans HJ, Kouwenhoven . Axillary Ultrasonography in Breast ancer PaFents in IdenFfying PaFents Pthe
reoperaFvely mography. E aThe
widespread
use of chemotherapy,
unsuspected
US,
chance
having
[2 positive
lymph
of aaxillary
lymph
being
moderately
sensitive
(48.8–
than
2 %.C8,11–14,16,17
InHelps a review
by Rutgers,
2- to 3-with Limited Disease radiation therapy, and endocrine therapy may also dimin%). S
This
is signifof nodes
the A(LNs)
xilla. isAsubstantially
nn Surg Olower
ncol (4.2
2014. ep;21(9):2904-­‐10. 87.1
%) and
specific
depending
of theIn addition,
year the
risk of axillary recurrence was even lower: 0–1.4 % in
ish the%),
added
benefit of ALND.
icant on
univariate
and fairly
multivariate
analysis.(55.6–97.3
After
AMAROS
trial
showed
that
the
absence
of
knowledge
of
excluding
the
patients
with
extracapsular
extension
of
the
reference standard. With the use of
US-guided biopsy, the
untreated
axilla.43 Because the recurrence rates in these
axillary status did not modify postoperative the
treatment
SLN, the chance of having [2 positive LNs is only 2.6 %.
38–40
planning.
For pT1–2,
this is 2.2 %.increases to 100 %.
specificity
studies were similar between groups, this also suggests that
A number of reports have suggested that in selected
By implementing routine US of the axilla in the selec1–5
6
7–17,25
10,18–23
24
12
25
①  Baja Carga Axilar vs Alta Carga axilar Octubre 2012 GenFlini O, Veronesi U. Abandoning senFnel lymph node biopsy in early breast cancer? A new trial in progress at the European InsFtute of Oncology of Milan (SOUND: SenFnel node vs ObservaFon auer axillary UltraSouND). Breast 2012;21:678–81. ①  Baja Carga Axilar vs Alta Carga axilar Octubre 2012 ¿Todos los tumores con ecograSa negaFva podrían evitar la BSGC? GenFlini O, Veronesi U. Abandoning senFnel lymph node biopsy in early breast cancer? A new trial in progress at the European InsFtute of Oncology of Milan (SOUND: SenFnel node vs ObservaFon auer axillary UltraSouND). Breast 2012;21:678–81. ①  Baja Carga Axilar vs Alta Carga axilar Ann Surg Oncol
DOI 10.1245/s10434-014-3674-x
ORIGINAL ARTICLE – BREAST ONCOLOGY
Axillary Ultrasonography in Breast Cancer Patients Helps in
Identifying Patients Preoperatively with Limited Disease of the
Axilla
§ 
A. M. Moorman, MD1, R. L. J. H. Bourez, MD2, H. J. Heijmans, MD1, and E. A. Kouwenhoven, MD, PhD1
Ultrasonography
forGroup
Limited
Disease
of Netherlands;
the Axilla2Departments of Radiology, Hospital Group
Departments
of Surgery, Hospital
Twente,
Almelo, The
Twente, Almelo, The Netherlands
1
§ 
RETROSPECTIVO. UNICÉNTRICO N= 851 (c T1 – T2 cN0) EcograSa negaFva § 
SepFembre ALND in case of a positive SLN, in which case the treatTABLE 3 Subdivision by clinical and pathologic tumor status
Conclusions. The risk of more than 2 positive axillary
ABSTRACT
ment
nodes is relatively
breaststrategy includes whole-breast radiation alone or
Background. The sentinel
lymph node
biopsy (SLNB)
Clinical
T status
Pathologic
T statussmall in patients with cT1–2 2014 §  cT2: VPN (>2LN+): 93% cancer. US of the axilla helps in further identifying
patients
procedure is the method of choice for the identification and
combined
with
adjuvant
therapy after lumpectomy of T1–2
with a minimal risk of additional axillary disease, putting
monitoring of regional lymph node metastases in patients
cT1,
n
cT2,
n
pT1,
n
pT2,
n
pT3,
n
pT2: PN (>2LN+): ALND up for discussion.
with breast cancer. In the case of a positive sentinel lymph
breast cancer. They§ found
no V
significant
benefit 9
in5% loco(%)
(%)
(%)
node (SLN), additional (%)
lymph node (%)
dissection is still
regional control or overall survival with completion
warranted for regional control, although 40–65 % have no
Sentinel
lymph
node
biopsy
(SLNB)
has
revolutionized
additional
axillary
disease.
Recent
studies
show
that
after
B2
617 (99) 212 (93.0) 568 (99.1) 247 (95.0) 14 (77.8)
ALND.35
the management of clinically node-negative women with
breast-conserving surgery, SLNB, and adjuvant systemic
§  pT3: VPN (>2LN+): 78% Positive
breast cancer. It is a safe and accurate method for axillary
Other recent studies have also questioned the additional
therapy, there
is no significant difference between recurstaging, and it causes substantially less postoperative
rence-free lymph
period and overall survival if there are B2
value of ALND in patients with SLN metastases and, more
positive axillary
nodesnodes. The purpose of this study was morbidity than axillary lymph node dissection (ALND).
The recommended management for patients with
sentinel
preoperative identification of patients with limited axillary
importantly,
proposed a routine ALND after positive SLN.
(SLN)
metastases4 is(22.2)
still ALND in cases of
6 by
(1.0)
16 (7.0)
5 lymph
(0.9) node 13
(5.0)
disease[2
(B2 macrometastases)
using ultrasonography.
SLN metastases larger than 0.2 mm. However,First,
the need ALND is associated with considerable morbidity
Methods. Positive
Data from 1,103 consecutive primary breast
for ALND has recently been questioned
because the
cancer patients with tumors smaller than 50 mm, no pal4,24,41,42
when
Second, several
lymph and a maximum of 2 SLNs with SLN has shown to be the only positive lymph node
in 40–compared with SLNB alone.
pable adenopathy,
For these patients,
ALND
nodeswere collected. The variable of interest 65 % of these patients.
macrometastases
retrospective studies have been published reporting low
offers no additional diagnostic, prognostic, or therapeutic
was US of the axilla.
axillary
benefit while
subjecting
risk of recurrence rates in patients with positive SNs who
Results.
the 1,103
included,
remained
T Of
tumor,
cT patients
clinical
tumor1,060
size,
pT pathologic
tumor
size them to a significant
additional morbidity. The incidence of nodal metastases is
after exclusion criteria. Of these, 102 (9.6 %) had more
didmamnot have ALND. The axillary recurrence rate was less
lower since the introduction of routine screening
than 2 positive axillary nodes on ALND. Selected by
Moorman M, the
Bourez RofLJH, Hnodes,
eijmans HJ, Kouwenhoven . Axillary Ultrasonography in Breast ancer PaFents in IdenFfying PaFents Pthe
reoperaFvely mography. E aThe
widespread
use of chemotherapy,
unsuspected
US,
chance
having
[2 positive
lymph
of aaxillary
lymph
being
moderately
sensitive
(48.8–
than
2 %.C8,11–14,16,17
InHelps a review
by Rutgers,
2- to 3-with Limited Disease radiation therapy, and endocrine therapy may also dimin%). S
This
is signifof nodes
the A(LNs)
xilla. isAsubstantially
nn Surg Olower
ncol (4.2
2014. ep;21(9):2904-­‐10. 87.1
%) and
specific
depending
of theIn addition,
year the
risk of axillary recurrence was even lower: 0–1.4 % in
ish the%),
added
benefit of ALND.
icant on
univariate
and fairly
multivariate
analysis.(55.6–97.3
After
AMAROS
trial
showed
that
the
absence
of
knowledge
of
excluding
the
patients
with
extracapsular
extension
of
the
reference standard. With the use of
US-guided biopsy, the
untreated
axilla.43 Because the recurrence rates in these
axillary status did not modify postoperative the
treatment
SLN, the chance of having [2 positive LNs is only 2.6 %.
38–40
planning.
For pT1–2,
this is 2.2 %.increases to 100 %.
specificity
studies were similar between groups, this also suggests that
A number of reports have suggested that in selected
By implementing routine US of the axilla in the selec1–5
6
7–17,25
10,18–23
24
12
25
①  Baja Carga Axilar vs Alta Carga axilar Ann Surg Oncol
DOI 10.1245/s10434-014-3674-x
ORIGINAL ARTICLE – BREAST ONCOLOGY
Axillary Ultrasonography in Breast Cancer Patients Helps in
Identifying Patients Preoperatively with Limited Disease of the
Axilla
§ 
A. M. Moorman, MD1, R. L. J. H. Bourez, MD2, H. J. Heijmans, MD1, and E. A. Kouwenhoven, MD, PhD1
Ultrasonography
forGroup
Limited
Disease
of Netherlands;
the Axilla2Departments of Radiology, Hospital Group
Departments
of Surgery, Hospital
Twente,
Almelo, The
Twente, Almelo, The Netherlands
1
§ 
RETROSPECTIVO. UNICÉNTRICO N= 851 (c T1 – T2 cN0) EcograSa negaFva § 
SepFembre ALND in case of a positive SLN, in which case the treatTABLE 3 Subdivision by clinical and pathologic tumor status
Conclusions. The risk of more than 2 positive axillary
ABSTRACT
ment
nodes is relatively
breaststrategy includes whole-breast radiation alone or
Background. The sentinel
lymph node
biopsy (SLNB)
Clinical
T status
Pathologic
T statussmall in patients with cT1–2 2014 §  cT2: VPN (>2LN+): 93% cancer. US of the axilla helps in further identifying
patients
procedure is the method of choice for the identification and
combined
with
adjuvant
therapy after lumpectomy of T1–2
with a minimal risk of additional axillary disease, putting
monitoring of regional lymph node metastases in patients
cT1,
n
cT2,
n
pT1,
n
pT2,
n
pT3,
n
pT2: PN (>2LN+): ALND up for discussion.
with breast cancer. In the case of a positive sentinel lymph
breast cancer. They§ found
no V
significant
benefit 9
in5% loco(%)
(%)
(%)
node (SLN), additional (%)
lymph node (%)
dissection is still
regional control or overall survival with completion
warranted for regional control, although 40–65 % have no
Sentinel
lymph
node
biopsy
(SLNB)
has
revolutionized
additional
axillary
disease.
Recent
studies
show
that
after
B2
617 (99) 212 (93.0) 568 (99.1) 247 (95.0) 14 (77.8)
ALND.35
the management of clinically node-negative women with
breast-conserving surgery, SLNB, and adjuvant systemic
§  pT3: VPN (>2LN+): 78% Positive
breast cancer. It is a safe and accurate method for axillary
Other recent studies have also questioned the additional
therapy, there
is no significant difference between recurstaging, and it causes substantially less postoperative
rence-free lymph
period and overall survival if there are B2
value of ALND in patients with SLN metastases and, more
positive axillary
nodesnodes. The purpose of this study was morbidity than axillary lymph node dissection (ALND).
The recommended management for patients with
sentinel
preoperative identification of patients with limited axillary
importantly,
proposed a routine ALND after positive SLN.
(SLN)
metastases4 is(22.2)
still ALND in cases of
6 by
(1.0)
16 (7.0)
5 lymph
(0.9) node 13
(5.0)
disease[2
(B2 macrometastases)
using ultrasonography.
SLN metastases larger than 0.2 mm. However,First,
the need ALND is associated with considerable morbidity
Methods. Positive
Data from 1,103 consecutive primary breast
for ALND has recently been questioned
because the
cancer patients with tumors smaller than 50 mm, no pal4,24,41,42
when
Second, several
lymph and a maximum of 2 SLNs with SLN has shown to be the only positive lymph node
in 40–compared with SLNB alone.
pable adenopathy,
For these patients,
ALND
nodeswere collected. The variable of interest 65 % of these patients.
macrometastases
retrospective studies have been published reporting low
offers no additional diagnostic, prognostic, or therapeutic
was US of the axilla.
axillary
benefit while
subjecting
risk of recurrence rates in patients with positive SNs who
Results.
the 1,103
included,
remained
T Of
tumor,
cT patients
clinical
tumor1,060
size,
pT pathologic
tumor
size them to a significant
additional morbidity. The incidence of nodal metastases is
after exclusion criteria. Of these, 102 (9.6 %) had more
didmamnot have ALND. The axillary recurrence rate was less
lower since the introduction of routine screening
than 2 positive axillary nodes on ALND. Selected by
Moorman M, the
Bourez RofLJH, Hnodes,
eijmans HJ, Kouwenhoven . Axillary Ultrasonography in Breast ancer PaFents in IdenFfying PaFents Pthe
reoperaFvely mography. E aThe
widespread
use of chemotherapy,
unsuspected
US,
chance
having
[2 positive
lymph
of aaxillary
lymph
being
moderately
sensitive
(48.8–
than
2 %.C8,11–14,16,17
InHelps a review
by Rutgers,
2- to 3-with Limited Disease radiation therapy, and endocrine therapy may also dimin%). S
This
is signifof nodes
the A(LNs)
xilla. isAsubstantially
nn Surg Olower
ncol (4.2
2014. ep;21(9):2904-­‐10. 87.1
%) and
specific
depending
of theIn addition,
year the
risk of axillary recurrence was even lower: 0–1.4 % in
ish the%),
added
benefit of ALND.
icant on
univariate
and fairly
multivariate
analysis.(55.6–97.3
After
AMAROS
trial
showed
that
the
absence
of
knowledge
of
excluding
the
patients
with
extracapsular
extension
of
the
reference standard. With the use of
US-guided biopsy, the
untreated
axilla.43 Because the recurrence rates in these
axillary status did not modify postoperative the
treatment
SLN, the chance of having [2 positive LNs is only 2.6 %.
38–40
planning.
For pT1–2,
this is 2.2 %.increases to 100 %.
specificity
studies were similar between groups, this also suggests that
A number of reports have suggested that in selected
By implementing routine US of the axilla in the selec1–5
6
7–17,25
10,18–23
24
12
25
A mayor tamaño, menor VPN (mayor TFN) cT1-­‐T2 N0 AUS negaFva STOP BSGC Prospec(vo. Randomizado Comienzo : Abril 2013 Finaliza: Julio 2020 N es%mada: 460 casos. Primer objeFvo: Recurrencia (5 años desde la intervención). ObjeFvo secundario: Tiempo libre de enfermedad (5 años desde la intervención) Supervivencia Overall survival (5 años desde la intervención). Valor actual de la EcograSa/PAAF Axilar ①  Baja carga axilar vs Alta carga axilar ②  Perfil tumoral/ PronósRco ③  EcograSa cuanFtaFva vs Carga axilar final ②  Perfil tumoral/ PronósFco Pacientes con afectación axilar (pN+) AUS + PAAF -­‐ BSGC + AUS -­‐ BSGC + AUS + PAAF + v 
v 
v 
v 
v 
v 
Mayor carga axilar Mayor tamaño Mayor grado Histológico Mayor invasión angio-­‐linfáFca Mayor extensión extra nodal Mas mastectomía ②  Perfil tumoral/ PronósFco Ann Surg Oncol (2015) 22:409–415
DOI 10.1245/s10434-014-4071-1
ORIGINAL ARTICLE – BREAST ONCOLOGY
The Role of Ultrasound-Guided Lymph Node Biopsy in Axillary
Staging of Invasive Breast Cancer in the Post-ACOSOG Z0011
Trial Era
N. C. Verheuvel, MSc, MD1, I. van den Hoven, MD1, H. W. A. Ooms, MD, PhD2, A. C. Voogd, PhD3,4, and
R. M. H. Roumen, MD, PhD1,4
Differences in Node Positive Cancer Patients
411
Febrero 2015 Department of Surgery, Máxima Medical
Center, Veldhoven, The Netherlands; 2Department of Radiology, Máxima
1281
3
Invasive
Medical Center, Veldhoven, The Netherlands;
Comprehensive Cancer Center Netherlands, Eindhoven, The Netherlands;
breast cancer
4
School GROW, Maastricht University Medical Center, Maastricht, The Netherlands
1
431
Node positive
axillary status
§ 
§ 
§ 
§ 
RETROSPECTIVO. UNICENTRICO (5años) N: 1281 tumores N= 302 (pN+). Incluidos Dos ramas Grupo PAAF (AUS+ PAAF +): 139 (46%) Grupo BSGC (AUS + PAAF -­‐ BSGC +; AUS-­‐ BSGC +): 163 (54%) lymph nodes with macrometastases (p \ 0.001), extranodal
ABSTRACT
78
neo-adjuvant treatment
1 
Background. Axillary status in invasive breast cancer, 17extension (p \ 0.001), and involvement of level-III-lymph
axillary
lymph
node
(p \ 0.001). Finally, they showed a worse disease-free
established by sentinel lymph node biopsy (SLNB) Immediate
ornode dissection
5
survival [hazard ratio (HR) = 2.71; 95 % confidence interval
ultrasound-guided
lymph
node biopsy, is an important
Clinical stage N
(CI) = 1.49–4.92] and overall survival (HR = 2.67; 95 %
prognostic indicator. The ACOSOG Z0011 trial showed
2 
CI = 1.48–4.84) than the SN group.
that axillary dissection may be redundant in selected senConclusions. These results suggest that ultrasound-positinel node-positive patients, raising questions on the
180
151
tive patients have less favorable disease characteristics and
applicability of these conclusions
on ultrasound
SN procedure
Axillary positive
ultrasound
a worse prognosis than SN-positive patients. Therefore, we
patients. The purpose of this study was to evaluate potenthat omitting an ALND is as yet only applicable,
tial differences in patient and tumor characteristics and 12conclude
Exclusion:
17 Exclusion:
diagnosis
as concluded
in the Z0011, in patients with a positive
survival- between
axillary node positive patients after- 8 inconclusive
8 non-retrieved SN
- 1 missing pathological
- 7 recurrent
breast
reportSLNB.
ultrasound
(US
group)
or
sentinel
lymph
node
procedure
cancer
- 1 MRI-guided biopsy
(SN group).
- 2 false negative SN
- 1 false positive biopsy
recurrent breast
Methods. Patients diagnosed with invasive breast cancer- 1cancer
at the Máxima Medical Center between January 2006 and
Axillary lymph node status in patients with invasive
December 2011 were studied.
breast cancer is still an important prognostic indicator. It can
163
139
Results. In total, 302 node-positive
cases were included:
139
be determined by ultrasound-guided lymph node biopsy
SN Group
US Group
and 163 cases in the US and SN groups, respectively. Patients
(UGLNB) or sentinel lymph node biopsy (SLNB).1,2 There
FIG. 1 Flowchart of patient selection showing the inclusion of 163 cases in the sentinel node group and 139 cases in the ultrasound group. SN
in
the US group were older at diagnosis (p \ 0.001), more
are
in European
versus
American
guidelines
group = sentinel node-positive patients; US group = patients with a positive ultrasound-guided lymph node biopsy
Verheuvel NC, van den Hoven I, Ooms HW a., Voogd a. differences
C, Roumen RMH. The Role of Ultrasound-­‐Guided Lymph Node Biopsy in Axillary Staging of Invasive Breast Cancer in the often had palpable nodes (p \ 0.001), mastectomy
concerning the axillary workup.3–5 Current American
Post-­‐ACOSOG Z
0011 T
rial E
ra. A
nn S
urg O
ncol 2
015;22:409–15. group).
Subsequently,
another
29
cases
were
excluded
for
having
a
new
appointment
in
the
near
future
at
the
breast
(p \ 0.001), larger tumors (p \ 0.001), higher tumor grade
guidelines dictate to perform the UGLNB only in patients
various reasons listed in Fig. 1.
center. Thirteen patients were considered lost to follow-up.
(p = 0.001), lymphovascular invasion (p =Hence,
0.035),
a totalaofposi302 cases, representing
301 patients,
with palpable
lymphadenopathy, although clinical palpation
were analysed including
139 cases in the US group and 163
RESULTS
tive
Her2Neu (p = 0.006), and a negative hormonal
receptor
has a false-negative rate of 30–50 %.6,7 In European guidecases, equalling 162 patients, in the SN group. The median
status
(p = 2006
0.003).
Also, they
werecases
more
more
age wasto
60 have
years; all
patients, except
one in
the SN group,
From January
until December
2011, 1,281
of likely
lines,
however,
the axillary ultrasound is a routine element in
were female.
invasive breast cancer without metastatic disease were
all breast cancer patients with or without palpable lymph
treated. In 431 (33.6 %) cases axillary metastases were
3,4
Univariate Analyses on Differences
in Characteristics
found. Of these, 78 cases receiving neoadjuvant systemic
nodes.
2-3
2006–2008
75
(54.0 %)
78
(47.9 %)
412
2009–2011
64
(46.0 %)
85
(52.1 %)
ER estrogen receptor, PR progesterone receptor
Differences in Node Positive Cancer Patients
N.C. Verheuvel et al.
\0.001
Palpability of axillary nodes
②  Perfil tumoral/ PronósFco stics
itive
alue
stics
itive
.001
alue
.001
.859
.859
.290
.001
.290
Side
of characteristics
tumor
Patient
Right
Left
Ultrasound
61
(43.9 %)
78
(56.1 %)
(n = 139)
Sentinel node
80
(49.1 %)
83
(50.9 %)
(n = 163)
\0.001
\0.001
Type
Age of surgery
Breast
Medianconserving
[range]
49
64
(35.3
%)
[23–89]
112
57
(68.7
%)
[27–89]
Mastectomy
\50 year
90
38
(64.7 %)
(27.3 %)
51
38
(31.3 %)
50–69 year
48
(34.5 %)
92
(56.4 %)
Tumor size in mm
(23.3 %)
Median [range]
25
[5–79]
18
[2–76]
\20 mm
23
(16.5 %)
95
(58.3 %)
20–30 mm
64
(46.0 %)
49
(30.1 %)
[30 mm
52
(37.0 %)
19
(11.7 %)
C70 year
BMI
Normal weight
p 0.367
value
53
62
(38.1 %)
(43.4 %)
33
\0.001
(20.2 %)
0.859
Verheuvel
68N.C.(41.5
%) et al.
Overweightof tumor 49
(35.3 %)
62 (38.0 %)
Morphology
0.635
(Morbid)
obesity
28
(20.2
%)
33 (74.8
(20.2 %)
%)
TABLE
continued
Ductal 1carcinoma
108 (77.7 %) 122
Year
of diagnosis
0.290
Lobular
carcinoma Ultrasound
23
(16.5 %) Sentinel
27 (16.6
Patient
characteristics
node %) p value
2006–2008
75
(54.0%)
%)
78 (8.6
(47.9%)
%)
Other
types
8
(5.8
14
N.C.
Verheuvel et al.
(n
=
139)
(n
=
163)
2009–2011
64
(46.0 %)
85 (52.1 %)
Tumor
grade
0.001
Gradenegative
1 of axillary nodes
23
(16.5 %)
58 (35.6 %) \0.001
Palpability
Triple
0.080
TABLE
1 continued
Grade
2
75
(54.0
%)
74 (45.4
No
54 (84.2
(38.8%) 148
130
(79.8%)%)
No
117
(90.8
Patient
characteristics Ultrasound
Sentinel (18.4
node %) p value
Grade
38
(27.3
%)
Yes 3
82 (15.8
(61.2%)
%) 1530
18 (9.2
(11.0
Yes
22
%) %)
(n
=
139)
(n
=
163)
Unknown
3
(2.2
%)
1
(0.6
Unknown
3
(2.2 %)
15 (9.2 %)
%)
Multifocality
0.087
ER
status
\0.001
Side
of
tumor
0.367
Triple
0.080
No negative
111 (79.8 %) 119 (73.0 %)
Negative
39
(28.1 %)
17 (10.4 %)
Right
61 (84.2
(43.9%)
%) 148
(49.1%)
No
117
Yes
24
(17.3
%)
4280 (90.8
(25.8
%)%)
Positive
100 (71.9 %) 146 (89.6 %)
Yes
22
%)
%)
Left
(56.1
%) 15283 (9.2
(50.9
Unknown
478 (15.8
(2.9
%)
(1.2
%) %)
PR
status
0.001
Multifocality
0.087
Type of surgery invasion
\0.001
Lymphovascular
Negative
59
(42.4 %)
41 (25.2 %) 0.035
No
111
Breast conserving
49 (79.8
(35.3%)
%) 119
112 (73.0
(68.7%)%)
No
80
Positive
80 (57.5
(57.6%)
%) 118
122 (72.4
(74.8%)%)
Yes
24
(17.3
%)
42
(25.8
Mastectomy
90 (24.5
(64.7%)
%) 2751 (16.6
(31.3%)
Yes
34
%)%)
Her2Neu
status
0.006
Unknown
4
(2.9 %)
2 (1.2 %)
Tumor
size
in
mm
\0.001
Negative
113 (18.0
(81.3%)
%) 18
149 (11.0
(91.4%)%)
Unknown
25
Lymphovascular invasion
0.035
Median
[range]
25
[5–79]
18
[2–76]
Positive
26
(18.7 %)
13 (8.0
%)
Noestrogen receptor, PR80progesterone
(57.5 %)receptor
118 (72.4 %)
ER
\20
mm
23
(16.5
%)
95 (0.6
(58.3%)
%)
Unknown
0
(0
%)%)
Yes
34
(24.5
27 1 (16.6
%)
20–30 mm
64 (18.0
(46.0%)
%) 1849 (11.0
(30.1%)%)
Unknown
25
[30 mm
52
(37.0 %)
19 (11.7 %)
estrogen
receptor
status (38 vs.
10 %,lymph
TABLE 1 and/or
continued
TABLEprogesterone
2 Univariate analysis
of characteristics
of axillary
respectively)
a significant
positivedifferences
Her2Neu
receptor
status
nodes and
showing
between
axillarypnode
positive
Patient characteristics
Ultrasound
Sentinel the
nodenumber
value
(Table
1).patients
Furthermore,
in
the
US
group,
identified by ultrasound versus sentinel node biopsyof
lymph nodes removed
higher, as were
(n from
= 139)the axilla
(n was
= 163)
Axillary
lymph nodes
Sentinel node
p value
the number
of positive
lymphUltrasound
nodes with macrometastases,
Triple
negative
0.080
the risk of extranodal extension and level-III lymph node
(n = 139)
(n = 163)
No
(84.2
148(Table
(90.82).
%) Multifometastases
compared117
to the
SN%)
group
Yes and Lymph
22
%) status
15 (9.2
%)borderline 0.001
cality
a triple
negative
receptor
were
nodes
removed(15.8
not significantly different between the groups. When
Multifocality
0.087
Median [range]
15 [3–41]
13 [3–27]
selecting
only patients
without
No
111
(79.8 palpable
%) 119 lymphadenopathy,
(73.0 %)
lymph
nodes
\0.001
a Yes
total of Total
184 positive
cases, 24
all differences
presented
(17.3 %)
42 (25.8 in
%) Tables 1
Median
4receptor
[1–41]status,
1 progesterone
[1–16]
and
2, except
for[range]
Her2Neu
Unknown
4
(2.9 %)
2 (1.2 %)
receptor status
and the presence
lymphovascular
inva1–2 nodes
51 of
(36.7
%) 126 (77.3 %)
Lymphovascular
invasion
0.035
sion, remained statistically significant. In addition, a
3
or
more
nodes
88
(63.3
%)
37
(22.7
%)
No
80
(57.5 %) 118 (72.4 %)
significant difference in the proportion of patients with
Size
of
axillary
metastasis
Yes
34
%)
27 =(16.6
%) between 0.000
triple negative disease was(24.5
observed
(p
0.043)
Unknown
(18.0
Macro
126%) (90.518%) (11.0
109 %)
(66.9 %)
the
US versus
the SN25group.
Micro PR progesterone
4
(2.9 %)
ER estrogen receptor,
receptor
54
(33.1 %)
Survival Analysis
Unknown
0
(0 %)
9
(6.5 %)
1.0
0.8
Cum Survival
No
54
(38.8
%) 130
(79.8characteristics
%)
TABLE
1 Univariate analysis
of patient
and tumor
Yes
82
(61.2
%)
18
(11.0node
%) positive
showing
significant differences
between
axillary
patients
identified
by
ultrasound
versus
sentinel
node
biopsy
Unknown
3
(2.2 %)
15 (9.2 %)
0.6
0.4
0.2
0.0
Extranodal extension
\0.001
The median follow-up time was 4 years. During followestrogen
and/or progesterone 74
receptor
status
(38 (87.1
vs.%)
10
%) 142
%)as%,a
up, a total ofNo54 patients (18 %)
died(53.2
of whom
33 (61
.0
respectively)
a and
positive
receptor
status
result of breast
cancer
12 (22
%)(46.8
due%)
to unrelated
Yes and
65 Her2Neu
21 (12.9causes.
%)
(Table
Furthermore,
US was
group,
the number
of
In nine 1).
patients,
causeinofthe
death
unknown.
LocoreMetastasisthe
level-III-node
\0.001
lymph
nodes removed
the
was higher,
as were
gional relapse,
solely orfrom
before
theaxilla
occurrence
of metastases,
FIG. 3 Kapl
No positive lymph89nodes
(64.0
%) macrometastases,
151 (92.6 %)
the
number
with
occurred
in of
seven patients: five patients
(three in US group
positive SLN
Yes
40 recurrence
(28.8level-III
%) in
12the
(7.4
%)node
the
ofSN
extranodal
extension
and
lymph
and risk
two in
group) had
a local
breast
and
group = sent
10 group
(7.2
%)(Table
0 2).
(0 Multifo%)
two patientsUnknown
had a regional
(one
in both
groups).
metastases
compared
to therelapse
SN
positive ultra
In and
the aUS
group,
33 patients
from
distant
cality
triple
negative
receptor suffered
status were
borderline
metastases
and/or
locoregional
relapse
compared
to 16
not
significantly
different
groups.
When
Verheuvel NC, van den Hoven I, Obetween
oms HW a., the
Voogd a. C, Roumen RMH. The Role of patients
with
positive
Survival
analysis
the Breast Cancer Disease-free
Survival
Furtherm
selecting
only apatients
without
palpable
lymphadenopathy,
Ultrasound-­‐Guided Lymph NSLNB.
ode Biopsy in Axillary Staging of on
Invasive in the included
showed
aA5-year
disease-free
survival
0011 Trial nn Surg O
ncol 2015;22:409–15. a Post-­‐ACOSOG total ofpatients
184Z1.0
cases,
allEra. differences
presented
in
Tablesof1
(95 % CI, 7
72.6
% except
(95 % for
CI,Her2Neu
71.8–73.4)
in thestatus,
US group
versus
and 2,
receptor
progesterone
CI, 81.7–83
87.7 % (95 % CI, 87.2–88.2) in the SN group
receptor status and the presence of lymphovascular invasion, remained statistically significant. In addition, a
sion, adjust
(95 % CI, 1
3 or more nodes
88
(63.3 %)
37
(22.7 %)
Micro
4
(2.9 %)
54
(33.1 %)
Unknown
9
(6.5 %)
0
(0 %)
1
1
N. C. Verheuvel,Size
MSc,
MD
, I. van den Hoven, MD
PhD2, A. C. Voogd, PhD3,4, and
of axillary
metastasis
0.000 , H. W. A. Ooms, MD,
Axillary staging
1,4
0.2
US group
Macro
R. M. H. Roumen,
MD, PhD 126 (90.5 %) 109 (66.9 %)
SN group
②  Perfil tumoral/ PronósFco US group-censored
SN group-censored
2
Department of Surgery,
Máxima Medical Center, \0.001
Veldhoven,
0.0 The Netherlands; Department of Radiology, Máxima
Extranodal extension
3
Medical Center, Veldhoven,
The
Cancer
Center 4.00
Netherlands,
Eindhoven,
The Netherlands;
No
74 Netherlands;
(53.2 %) 142 (87.1Comprehensive
%)
.00
6.00
8.00
2.00
4
Yes
65
(46.8 %) Medical
21
(12.9 %)
School GROW, Maastricht
University
Center, Maastricht, The Netherlands
Follow-up (years)
1
\0.001
Metastasis level-III-node
No
89
(64.0 %)
151
(92.6 %)
Yes
40
(28.8 %)
12
(7.4 %)
Unknown
10
(7.2 %)
0
(0 %)
FIG. 3 Kaplan–Meier curve of overall survival of patients with a
positive SLNB and patients with a positive UGLNB (p \ 0.001). SN
group = sentinel node-positive patients; US group = patients with a
positive ultrasound-guided lymph node biopsy
8.00
node characteristics and differences in survival between
patients with a positive UGLNB and patients with a positive SLNB. The results show that US-positive patients
more often had clinically palpable lymphadenopathy and
Cum Survival
Cum Survival
413
lymph nodes with macrometastases (p \ 0.001), extranodal
ABSTRACT
extension (p \ 0.001), and involvement of level-III-lymph
Background. Axillary status in invasive breast cancer,
Disease-free Survival
Furthermore, the 5-year overall survival rate was 73.0 %
Survival
y lymph
node (p \ 0.001). Finally, they showed a worse disease-free
established
by
sentinel
lymph
node
biopsy
(SLNB)
or
positive
(95 % CI, 72.3–73.8) in the US group versus 82.4 % (95 %
1.0
1.0
survival
[hazard
(HR)Cox
= regres2.71; 95 % confidence interval
ultrasound-guided lymph node biopsy, is an importantCI, 81.7–83.1)
in the
SN groupratio
(p \ 0.001).
at diagnosis, resulted
a HR of 2.67
p value
(CI) for
=age
1.49–4.92]
and inoverall
survival (HR = 2.67; 95 %
prognostic indicator. The ACOSOG Z0011 trial showedsion, adjusted
for the US group compared with the
0.8 may be redundant in selected sen-(95 % CI,
0.8
CI1.48–4.84)
= 1.48–4.84)
than the SN group.
that axillary dissection
SN group (Fig. 3).
These
results
suggest that ultrasound-positinel node-positive patients, raising questions on the WhenConclusions.
excluding patients with
palpable
lymphadenopa0.001
thy,
both
overall
survival
and
disease-free
survival
tive
patients
have
less
favorable
disease characteristics and
applicability
of
these
conclusions
on
ultrasound
positive
0.6
0.6
significantly worse for patients of the US group
\0.001
a worse
prognosis than SN-positive patients. Therefore, we
patients. The purpose of this study was to evaluate poten-remained
compared with the SN group (HR = 2.84; 95 %
conclude
an ALND
tial differences in patient and tumor characteristics andCI = 1.13–7.17)
with that
respectomitting
to the disease-free
survival is as yet only applicable,
0.4
0.4
for age at
a HR of 3.36
as adjusting
concluded
indiagnosis,
the Z0011,
in patients with a positive
survival between axillary node positive patients afterand, after
(95 % CI,
1.45–7.77) for overall survival.
0.000
SLNB.
ultrasound (US group) or sentinel Axillary
lymph
node
procedure
Axillary staging
staging
0.2
0.2
US group
US group
(SN group).
SN group
DISCUSSION
SN group
US group-censored
US group-censored
SN group-censored Methods. Patients diagnosed with invasive
SN group-censored breast cancer
study compared patient, tumor, and lymph
0.0
0.0
at the Máxima Medical
Center between January 2006 and The present
\0.001
Axillary
lymph node status in patients with invasive
node characteristics and differences in survival between
December
2011
were
studied.
breast
cancer
is still
important
.00
6.00
8.00
2.00
4.00
patients with a positive UGLNB
and an
patients
with a posi-prognostic indicator. It can
.00
2.00
4.00
6.00
8.00
Follow-up (years) Results. In total, 302 node-positive
cases (Years)
were included: 139tive SLNB.
The results show by
that ultrasound-guided
US-positive patients
Follow-up
be
determined
lymph node biopsy
\0.001
more often had clinically palpable lymphadenopathy and
163with
cases
in the
US
and
SN
groups,
respectively.
Patients
(UGLNB)
or
sentinel
lymph
node
biopsy
(SLNB).1,2 There
FIG. 3 Kaplan–Meier curve of overall survival and
of patients
a
FIG. 2 Kaplan-Meier curve of disease-free survival of patients with
larger tumors with worse prognostic factors, such as a
positive SLNB and patients with a positive UGLNB
(p
\
0.001).
SN
a positiveolder
SLNB and
with a positive
UGLNB
(p = 0.001).
in the US group were
atpatients
diagnosis
(p \
0.001),
morehigher tumor
are differences
in European
versus American guidelines
grade and lymphovascular
invasion. Consegroup = sentinel node-positive patients; US group = patients with a
SN group = sentinel node-positive patients; US group = patients
3–5
had palpable
nodes
(p \lymph
0.001),
positive ultrasound-guided lymph node biopsy often
these differences
explain theworkup.
higher
themayaxillary
Current American
with a positive
ultrasound-guided
node biopsymastectomyquently,concerning
proportion
of
radical
mastectomies
and
the
larger
tumor
(p \ 0.001), larger tumors (p \ 0.001), higher tumor grade
guidelines dictate to perform the UGLNB only in patients
burden in the axilla, resulting in a worse disease-free and
(p \ 0.0001). Subsequent Cox regression analysis resulted
Furthermore, the 5-year overall survival(p
rate=
was0.001),
73.0 % lymphovascular invasion (p = 0.035), a posilymphadenopathy,
overall with
survivalpalpable
in patients diagnosed
by ultrasound. Sim-although clinical palpation
in a hazard ratio (HR) of 2.71 (95 % CI, 1.49–4.92) for the
(95 % CI, 72.3–73.8) in the US group versus
82.4
%
(95
%
6,7
tive Her2Neu (p =US0.006),
and awith
negative
hormonal
were observed after exclusion
patients %.
has a false-negative
rate ofof30–50
In European guidegroup compared
the SN group
(Fig. 2). receptorilar differences
CI, 81.7–83.1) in the SN group (p \ 0.001). Cox regresstatus (p = 0.003). Also, they were more likely to have more
lines, however, the axillary ultrasound is a routine element in
sion, adjusted for age at diagnosis, resulted in a HR of 2.67
(95 % CI, 1.48–4.84) for the US group compared with the
all breast cancer patients with or without palpable lymph
SN group (Fig. 3).
nodes.3,4
When excluding patients with palpable lymphadenopaMultiple studies have shown that in 40–70 % of sentinel
The contents
thy, both overall survival and disease-free
survival of this article have been presented in an oral presentation
at the
theUS
9th
European Breast Cancer Conference 2014 in Glasgow.
node positive patients additional lymph nodes do not
remained significantly worse for patients of
group
compared with the SN group (HR = 2.84; 95 %
contain any metastases.8–11 The ACOSOG Z0011 trial
CI = 1.13–7.17) with respect to the disease-free survival
showed that an axillary lymph node dissection (ALND)
! Society of Surgical Oncology 2014
and, after adjusting for age at diagnosis, a HR of 3.36
may be safely omitted in selected patients with a positive
(95 % CI, 1.45–7.77) for overall survival.First Received: 29 April 2014;
12Biopsy in Axillary Staging of Invasive Breast Cancer in the Verheuvel NC, van den Hoven I, Ooms Published
HW a., Voogd a. C10
, Roumen RMH. The Role of Ultrasound-­‐Guided Lymph Node SLNB.
However, questions are raised whether these
Online:
September
2014
DISCUSSION
Post-­‐ACOSOG Z0011 Trial Era. Ann Surg ncol 2015;22:409–15. criteria can be applied to patients with a positive UGLNB.
N.OC.
Verheuvel,
MSc, MD
This may be the case if no clinically relevant differences
e-mail:
The present study compared patient, tumor,
and [email protected]
lymph
3 or more nodes
88
(63.3 %)
37
(22.7 %)
Micro
4
(2.9 %)
54
(33.1 %)
Unknown
9
(6.5 %)
0
(0 %)
1
1
N. C. Verheuvel,Size
MSc,
MD
, I. van den Hoven, MD
PhD2, A. C. Voogd, PhD3,4, and
of axillary
metastasis
0.000 , H. W. A. Ooms, MD,
Axillary staging
1,4
0.2
US group
Macro
R. M. H. Roumen,
MD, PhD 126 (90.5 %) 109 (66.9 %)
SN group
②  Perfil tumoral/ PronósFco US group-censored
SN group-censored
2
Department of Surgery,
Máxima Medical Center, \0.001
Veldhoven,
0.0 The Netherlands; Department of Radiology, Máxima
Extranodal extension
3
Medical Center, Veldhoven,
The
Cancer
Center 4.00
Netherlands,
Eindhoven,
The Netherlands;
No
74 Netherlands;
(53.2 %) 142 (87.1Comprehensive
%)
.00
6.00
8.00
2.00
4
Yes
65
(46.8 %) Medical
21
(12.9 %)
School GROW, Maastricht
University
Center, Maastricht, The Netherlands
Follow-up (years)
1
\0.001
Metastasis level-III-node
No
89
(64.0 %)
151
(92.6 %)
Yes
40
(28.8 %)
12
(7.4 %)
Unknown
10
(7.2 %)
0
(0 %)
FIG. 3 Kaplan–Meier curve of overall survival of patients with a
positive SLNB and patients with a positive UGLNB (p \ 0.001). SN
group = sentinel node-positive patients; US group = patients with a
positive ultrasound-guided lymph node biopsy
Cum Survival
Cum Survival
413
lymph nodes with macrometastases (p \ 0.001), extranodal
ABSTRACT
extension (p \ 0.001), and involvement of level-III-lymph
Background. Axillary status in invasive breast cancer,
Disease-free Survival
Furthermore, the 5-year overall survival rate was 73.0 %
Survival
y lymph
node (p \ 0.001). Finally, they showed a worse disease-free
established
by
sentinel
lymph
node
biopsy
(SLNB)
or
positive
(95 % CI, 72.3–73.8) in the US group versus 82.4 % (95 %
1.0
1.0
survival
[hazard
(HR)Cox
= regres2.71; 95 % confidence interval
ultrasound-guided lymph node biopsy, is an importantCI, 81.7–83.1)
in the
SN groupratio
(p \ 0.001).
at diagnosis, resulted
a HR of 2.67
p value
(CI) for
=age
1.49–4.92]
and inoverall
survival (HR = 2.67; 95 %
prognostic indicator. The ACOSOG Z0011 trial showedsion, adjusted
for the US group compared with the
0.8 may be redundant in selected sen-(95 % CI,
0.8
CI1.48–4.84)
= 1.48–4.84)
than the SN group.
that axillary dissection
SN group (Fig. 3).
These
results
suggest that ultrasound-positinel node-positive patients, raising questions on the WhenConclusions.
excluding patients with
palpable
lymphadenopa0.001
thy,
both
overall
survival
and
disease-free
survival
tive
patients
have
less
favorable
disease characteristics and
applicability
of
these
conclusions
on
ultrasound
positive
0.6
0.6
significantly worse for patients of the US group
\0.001
a worse
prognosis than SN-positive patients. Therefore, we
patients. The purpose of this study was to evaluate poten-remained
compared with the SN group (HR = 2.84; 95 %
conclude
an ALND
tial differences in patient and tumor characteristics andCI = 1.13–7.17)
with that
respectomitting
to the disease-free
survival is as yet only applicable,
0.4
0.4
for age at
a HR of 3.36
as adjusting
concluded
indiagnosis,
the Z0011,
in patients with a positive
survival between axillary node positive patients afterand, after
(95 % CI,
1.45–7.77) for overall survival.
0.000
SLNB.
ultrasound (US group) or sentinel Axillary
lymph
node
procedure
Axillary staging
staging
0.2
0.2
US group
US group
(SN group).
SN group
DISCUSSION
SN group
US group-censored
US group-censored
SN group-censored Methods. Patients diagnosed with invasive
SN group-censored breast cancer
study compared patient, tumor, and lymph
0.0
0.0
at the Máxima Medical
Center between January 2006 and The present
\0.001
Axillary
lymph node status in patients with invasive
node characteristics and differences in survival between
December
2011
were
studied.
breast
cancer
is still
important
.00
6.00
8.00
2.00
4.00
patients with a positive UGLNB
and an
patients
with a posi-prognostic indicator. It can
.00
2.00
4.00
6.00
8.00
Follow-up (years) Results. In total, 302 node-positive
cases (Years)
were included: 139tive SLNB.
The results show by
that ultrasound-guided
US-positive patients
Follow-up
be
determined
lymph node biopsy
\0.001
more often had clinically palpable lymphadenopathy and
163with
cases
in the
US
and
SN
groups,
respectively.
Patients
(UGLNB)
or
sentinel
lymph
node
biopsy
(SLNB).1,2 There
FIG. 3 Kaplan–Meier curve of overall survival and
of patients
a
FIG. 2 Kaplan-Meier curve of disease-free survival of patients with
larger tumors with worse prognostic factors, such as a
positive SLNB and patients with a positive UGLNB
(p
\
0.001).
SN
a positiveolder
SLNB and
with a positive
UGLNB
(p = 0.001).
in the US group were
atpatients
diagnosis
(p \
0.001),
morehigher tumor
are differences
in European
versus American guidelines
grade and lymphovascular
invasion. Consegroup = sentinel node-positive patients; US group = patients with a
SN group = sentinel node-positive patients; US group = patients
3–5
had palpable
nodes
(p \lymph
0.001),
positive ultrasound-guided lymph node biopsy often
these differences
explain theworkup.
higher
themayaxillary
Current American
with a positive
ultrasound-guided
node biopsymastectomyquently,concerning
proportion
of
radical
mastectomies
and
the
larger
tumor
(p \ 0.001), larger tumors (p \ 0.001), higher tumor grade
guidelines dictate to perform the UGLNB only in patients
burden in the axilla, resulting in a worse disease-free and
(p \ 0.0001). Subsequent Cox regression analysis resulted
Furthermore, the 5-year overall survival(p
rate=
was0.001),
73.0 % lymphovascular invasion (p = 0.035), a posilymphadenopathy,
overall with
survivalpalpable
in patients diagnosed
by ultrasound. Sim-although clinical palpation
in a hazard ratio (HR) of 2.71 (95 % CI, 1.49–4.92) for the
(95 % CI, 72.3–73.8) in the US group versus
82.4
%
(95
%
6,7
tive Her2Neu (p =US0.006),
and awith
negative
hormonal
were observed after exclusion
patients %.
has a false-negative
rate ofof30–50
In European guidegroup compared
the SN group
(Fig. 2). receptorilar differences
CI, 81.7–83.1) in the SN group (p \ 0.001). Cox regresstatus (p = 0.003). Also, they were more likely to have more
lines, however, the axillary ultrasound is a routine element in
sion, adjusted for age at diagnosis, resulted in a HR of 2.67
(95 % CI, 1.48–4.84) for the US group compared with the
all breast cancer patients with or without palpable lymph
SN group (Fig. 3).
nodes.3,4
When excluding patients with palpable lymphadenopaMultiple studies have shown that in 40–70 % of sentinel
The contents
thy, both overall survival and disease-free
survival of this article have been presented in an oral presentation
at the
theUS
9th
European Breast Cancer Conference 2014 in Glasgow.
node positive patients additional lymph nodes do not
remained significantly worse for patients of
group
compared with the SN group (HR = 2.84; 95 %
contain any metastases.8–11 The ACOSOG Z0011 trial
CI = 1.13–7.17) with respect to the disease-free survival
showed that an axillary lymph node dissection (ALND)
! Society of Surgical Oncology 2014
and, after adjusting for age at diagnosis, a HR of 3.36
may be safely omitted in selected patients with a positive
(95 % CI, 1.45–7.77) for overall survival.First Received: 29 April 2014;
12Biopsy in Axillary Staging of Invasive Breast Cancer in the Verheuvel NC, van den Hoven I, Ooms Published
HW a., Voogd a. C10
, Roumen RMH. The Role of Ultrasound-­‐Guided Lymph Node SLNB.
However, questions are raised whether these
Online:
September
2014
DISCUSSION
Post-­‐ACOSOG Z0011 Trial Era. Ann Surg ncol 2015;22:409–15. criteria can be applied to patients with a positive UGLNB.
N.OC.
Verheuvel,
MSc, MD
This may be the case if no clinically relevant differences
e-mail:
The present study compared patient, tumor,
and [email protected]
lymph
BSGC PAAF + 8.00
node characteristics and differences in survival between
patients with a positive UGLNB and patients with a positive SLNB. The results show that US-positive patients
more often had clinically palpable lymphadenopathy and
NO LINFADENECTOMIA LINFADENECTOMIA ②  Perfil tumoral/ PronósFco ¿TODOS los tumores con PAAF axilar posiFva se beneficiarían del vaciamiento axilar? ¿Realizar PAAF axilar a todos los tumores con ecograSa posiFva no conlleva al SOBRETATAMIENTO axilar? Verheuvel NC, van den Hoven I, Ooms HW a., Voogd a. C, Roumen RMH. The Role of Ultrasound-­‐Guided Lymph Node Biopsy in Axillary Staging of Invasive Breast Cancer in the Post-­‐ACOSOG Z0011 Trial Era. Ann Surg Oncol 2015;22:409–15. ②  Perfil tumoral/ PronósFco ¿TODOS los tumores con PAAF axilar posiFva se beneficiarían del vaciamiento axilar? Differences in Node Positive Cancer Patients
¿Realizar PAAF axilar a todos los tumores con ecograSa posiFva no conlleva al SOBRETATAMIENTO axilar? Survival
TABLE 2 Univariate analysis
of characteristics of axillary lymph
nodes showing significant differences between axillary node positive
patients identified by ultrasound versus sentinel node biopsy
Axillary lymph nodes Ultrasound
(n = 139)
Sentinel node
p value
0.8
(n = 163)
0.001
15
[3–41]
13
[3–27]
\0.001
Total positive lymph nodes
Median [range]
4
[1–41]
1
[1–16]
1–2 nodes
51
(36.7 %) 126 (77.3 %)
3 or more nodes
88
(63.3 %) 37
(22.7 %)
Size of axillary metastasis
Cum Survival
Lymph nodes removed
Median [range]
1.0
0.6
0.4
0.000
Axillary staging
0.2 Node Biopsy in Axillary Staging Verheuvel NC, van Macro
den Hoven I, Ooms HW a., 126
Voogd (90.5
a. C, Roumen RMH. The Role %)
of Ultrasound-­‐Guided Lymph f Invasive Breast Cancer in the USogroup
%) 109
(66.9
Post-­‐ACOSOG Z0011 Trial Era. Ann Surg Oncol 2015;22:409–15. SN group
Micro
4
(2.9 %)
54
(33.1 %)
Unknown
9
(6.5 %)
0
(0 %)
Extranodal extension
US group-censored
SN group-censored
\0.001
0.0
②  Perfil tumoral/ PronósFco ¿TODOS los tumores con PAAF axilar posiFva se beneficiarían del vaciamiento axilar? Differences in Node Positive Cancer Patients
¿Realizar PAAF axilar a todos los tumores con ecograSa posiFva no conlleva al SOBRETATAMIENTO axilar? Survival
TABLE 2 Univariate analysis
of characteristics of axillary lymph
nodes showing significant differences between axillary node positive
patients identified by ultrasound versus sentinel node biopsy
Axillary lymph nodes Ultrasound
(n = 139)
Sentinel node
p value
0.8
(n = 163)
0.001
15
[3–41]
13
[3–27]
\0.001
Total positive lymph nodes
Median [range]
4
[1–41]
1
[1–16]
1–2 nodes
51
(36.7 %) 126 (77.3 %)
3 or more nodes
88
(63.3 %) 37
(22.7 %)
Size of axillary metastasis
Cum Survival
Lymph nodes removed
Median [range]
1.0
6 % de PAAF + podrían evitar el vaciamiento axilar 0.6
0.4
0.000
Axillary staging
0.2 Node Biopsy in Axillary Staging Verheuvel NC, van Macro
den Hoven I, Ooms HW a., 126
Voogd (90.5
a. C, Roumen RMH. The Role %)
of Ultrasound-­‐Guided Lymph f Invasive Breast Cancer in the USogroup
%) 109
(66.9
Post-­‐ACOSOG Z0011 Trial Era. Ann Surg Oncol 2015;22:409–15. SN group
Micro
4
(2.9 %)
54
(33.1 %)
Unknown
9
(6.5 %)
0
(0 %)
Extranodal extension
US group-censored
SN group-censored
\0.001
0.0
Valor actual de la EcograSa/PAAF Axilar ①  Baja carga axilar vs Alta carga axilar ②  Perfil tumoral/ PronósFco ③  Ecogra_a cuanRtaRva vs Carga axilar final ③  EcograSa cuanFtaFva vs Carga axilar Eur Radiol
DOI 10.1007/s00330-015-3683-6
§ 
BREAST
The Z0011 Trial: Is this the end of axillary ultrasound
in the pre-operative assessment of breast cancer patients?
T. P. J. Farrell & N. C. Adams & M. Stenson & P. A. Carroll &
M. Griffin & E. M. Connolly & S. A. O’Keeffe
§ 
§ 
§ 
RETROSPECTIVO. UNICENTRICO (3años) N = 679 (T1-­‐T4) N+: 43.6% AUS posiFva= 265. Biopsia + 169 SepFembre 2015 Received: 24 November 2014 / Revised: 5 February 2015 / Accepted: 18 February 2015
# European Society of Radiology 2015
Key Points
Abstract
• Axillary ultrasound +/- sampling is an essential technique in
Objectives The Z0011 trial questioned the role of axillary ulpreoperative axillary staging.
trasound (AxUS) in preoperative staging of breast cancer in
• Axillary ultrasound findings correlate with final histological
patients with ≤2 positive sentinel lymph nodes (SLN). The
axillary node disease burden.
purpose of this study was to correlate the number of abnormal
• Axillary ultrasound can help triage patients who require
nodes on AxUS with final nodal burden and determine the
axillary lymph node dissection.
utility of AxUS with sampling (AxUS+S) in preoperative
The
role
cancer staging
staging.
Farrell TPJ, Adams NC, Stenson M, Carroll PA. The Z0011 Trial : Is t•his the end ofof axillary
axillary ultrasound
ultrasound in
in breast
the pre-­‐operaFve assessment of breast cancer paFents ? Eur Radiol 2015. Methods Six hundred and seventy-nine patients underwent
continues to evolve.
Sep;25(9):2682-­‐7. pre-operative AxUS. Suspicious nodes were sampled. Negative axillae proceeded to SLN biopsy. The number of abnorKeywords Breast cancer . Axillary staging . Ultrasound .
mal nodes identified on ultrasound and final histology as well
Percutaneous biopsy . Histology
as sensitivity and specificity for AxUS+S were calculated.
final histology (Range 1-28, SEM=1.3, 95 % CI=3.8-9.3)
ALND in a sub-population of breast cancer patients with ≤2
final histology (Range 1-28, SEM=1.3, 95 % CI=3.8-9.3)
ALND in a sub-population of breast cancer patients with ≤2
with correlation noted between AxUS-S and final histology
positive SLNs. In patients fulfilling the trial’s inclusion
with correlation noted between AxUS-S and final histology
positive SLNs. In patients fulfilling the trial’s inclusion
node numbers (rs = 0.68, 95 % CI = 0.42-0.84, p-value <
criteria, proceeding to ALND did not lead to a difference in
node numbers (rs = 0.68, 95 % CI = 0.42-0.84, p-value <
criteria, proceeding to ALND did not lead to a difference in
0.0001).
overall
and disease free survival or locoregional recurrence
0.0001).
overall and disease free survival or locoregional recurrence
In In
thisthis
subgroup,
the the
mean
finalfinal
metastatic
nodal
burden
12].12].
ThisThis
would
suggest
that that
AxUS
no longer
has ahas
role
subgroup,
mean
metastatic
nodal
burden [11,[11,
would
suggest
AxUS
no longer
a role
based
on on
thethe
number
of abnormal
nodes
identified
on AxUS
is is in these
patients,
as itas
cannot
determine
the number
of sentinel
based
number
of abnormal
nodes
identified
on AxUS
in these
patients,
it cannot
determine
the number
of sentinel
③  EcograSa cuanFtaFva vs Carga axilar Table
2 2Number
of abnormal
nodes
identified
on AxUS
compared
3 3Z0011
eligible
patients:
Number
of abnormal
nodesnodes
identified
Table
Number
of abnormal
nodes
identified
on AxUS
compared Table
Table
Z0011
eligible
patients:
Number
of abnormal
identified
withwith
finalfinal
nodal
burden
on
histology
on
AxUS
compared
with
final
nodal
burden
on
histology
nodal burden on histology
on AxUS compared with final nodal burden on histology
Number
of ofMedian
Mean
number
of of95 %
Number
Median
Mean
numberRange
Range
95CI% CI
abnormal
of of of metastatic
abnormal number
number
of metastatic metastatic
metastaticfor mean
for mean
nodes
metastatic
on final
on onnumber
of of
nodes
metastatic nodes
nodes
on finalnodes
nodes
number
identified nodes
nodes
on finalhistology
histology
metastatic
identified
on final
finalfinal
metastatic
on AxUS histology
histology
histologynodes
nodes
on AxUS
histology
Number
of of
Median
MeanMean
number
Range
of of 95 %95
CI% CI
Number
Median
number
Range
abnormal
of of of metastatic
metastatic
abnormalnumber
number
of metastatic
metastatic for mean
for mean
nodes
on final
nodesnodes
on final
number
of of
nodes metastatic
metastatic nodes
nodes
on final
on final
number
identifiednodes
nodes
on final
histology histology
histology metastatic
metastatic
identified
on final
histology
on AxUShistology
histology
on AxUS
nodesnodes
1 node
1 node
3
2
nodes
2 nodes
5
>2
nodes
>2 nodes
7
All
patients
All patients 5
1 node 2
1 node
2 nodes 5
2 nodes
>2 nodes9
>2 nodes
All patients
All patients
4
3
5
7
5
5.2 5.2
7.5 7.5
10.110.1
7.3 7.3
1–211–21
1-281-28
1-411-41
1-411-41
4–6.4
4–6.4
1.9–13.1
1.9–13.1
7.8–12.5
7.8–12.5
6.1–8.5
6.1–8.5
2
5
9
4
2.6
9.5
9.6
6.6
2.6
9.5
9.6
6.6
1–101–10
2–282–28
3–203–20
1–281–28
1.4–3.9
1.4–3.9
-10.2–29.2
-10.2–29.2
5.3–13.9
5.3–13.9
3.8–9.3
3.8–9.3
Farrell TPJ, Adams NC, Stenson M, Carroll PA. The Z0011 Trial : Is this the end of axillary ultrasound in the pre-­‐operaFve assessment of breast cancer paFents ? Eur Radiol 2015. Sep;25(9):2682-­‐7. final histology (Range 1-28, SEM=1.3, 95 % CI=3.8-9.3)
ALND in a sub-population of breast cancer patients with ≤2
final histology (Range 1-28, SEM=1.3, 95 % CI=3.8-9.3)
ALND in a sub-population of breast cancer patients with ≤2
with correlation noted between AxUS-S and final histology
positive SLNs. In patients fulfilling the trial’s inclusion
with correlation noted between AxUS-S and final histology
positive SLNs. In patients fulfilling the trial’s inclusion
node numbers (rs = 0.68, 95 % CI = 0.42-0.84, p-value <
criteria, proceeding to ALND did not lead to a difference in
node numbers (rs = 0.68, 95 % CI = 0.42-0.84, p-value <
criteria, proceeding to ALND did not lead to a difference in
0.0001).
overall
and disease free survival or locoregional recurrence
0.0001).
overall and disease free survival or locoregional recurrence
In In
thisthis
subgroup,
the the
mean
finalfinal
metastatic
nodal
burden
12].12].
ThisThis
would
suggest
that that
AxUS
no longer
has ahas
role
subgroup,
mean
metastatic
nodal
burden [11,[11,
would
suggest
AxUS
no longer
a role
based
on on
thethe
number
of abnormal
nodes
identified
on AxUS
is is in these
patients,
as itas
cannot
determine
the number
of sentinel
based
number
of abnormal
nodes
identified
on AxUS
in these
patients,
it cannot
determine
the number
of sentinel
③  EcograSa cuanFtaFva vs Carga axilar Table
2 2Number
of abnormal
nodes
identified
on AxUS
compared
3 3Z0011
eligible
patients:
Number
of abnormal
nodesnodes
identified
Table
Number
of abnormal
nodes
identified
on AxUS
compared Table
Table
Z0011
eligible
patients:
Number
of abnormal
identified
withwith
finalfinal
nodal
burden
on
histology
on
AxUS
compared
with
final
nodal
burden
on
histology
nodal burden on histology
on AxUS compared with final nodal burden on histology
Number
of ofMedian
Mean
number
of of95 %
Number
Median
Mean
numberRange
Range
95CI% CI
abnormal
of of of metastatic
abnormal number
number
of metastatic metastatic
metastaticfor mean
for mean
nodes
metastatic
on final
on onnumber
of of
nodes
metastatic nodes
nodes
on finalnodes
nodes
number
identified nodes
nodes
on finalhistology
histology
metastatic
identified
on final
finalfinal
metastatic
on AxUS histology
histology
histologynodes
nodes
on AxUS
histology
Number
of of
Median
MeanMean
number
Range
of of 95 %95
CI% CI
Number
Median
number
Range
abnormal
of of of metastatic
metastatic
abnormalnumber
number
of metastatic
metastatic for mean
for mean
nodes
on final
nodesnodes
on final
number
of of
nodes metastatic
metastatic nodes
nodes
on final
on final
number
identifiednodes
nodes
on final
histology histology
histology metastatic
metastatic
identified
on final
histology
on AxUShistology
histology
on AxUS
nodesnodes
1 node
1 node
3
2
nodes
2 nodes
5
>2
nodes
>2 nodes
7
All
patients
All patients 5
1 node 2
1 node
2 nodes 5
2 nodes
>2 nodes9
>2 nodes
All patients
All patients
4
3
5
7
5
5.2 5.2
7.5 7.5
10.110.1
7.3 7.3
1–211–21
1-281-28
1-411-41
1-411-41
4–6.4
4–6.4
1.9–13.1
1.9–13.1
7.8–12.5
7.8–12.5
6.1–8.5
6.1–8.5
2
5
9
4
2.6
9.5
9.6
6.6
2.6
9.5
9.6
6.6
1–101–10
2–282–28
3–203–20
1–281–28
1.4–3.9
1.4–3.9
-10.2–29.2
-10.2–29.2
5.3–13.9
5.3–13.9
3.8–9.3
3.8–9.3
Farrell TPJ, Adams NC, Stenson M, Carroll PA. The Z0011 Trial : Is this the end of axillary ultrasound in the pre-­‐operaFve assessment of breast cancer paFents ? Eur Radiol 2015. Sep;25(9):2682-­‐7. final histology (Range 1-28, SEM=1.3, 95 % CI=3.8-9.3)
ALND in a sub-population of breast cancer patients with ≤2
final histology (Range 1-28, SEM=1.3, 95 % CI=3.8-9.3)
ALND in a sub-population of breast cancer patients with ≤2
with correlation noted between AxUS-S and final histology
positive SLNs. In patients fulfilling the trial’s inclusion
with correlation noted between AxUS-S and final histology
positive SLNs. In patients fulfilling the trial’s inclusion
node numbers (rs = 0.68, 95 % CI = 0.42-0.84, p-value <
criteria, proceeding to ALND did not lead to a difference in
node numbers (rs = 0.68, 95 % CI = 0.42-0.84, p-value <
criteria, proceeding to ALND did not lead to a difference in
0.0001).
overall
and disease free survival or locoregional recurrence
0.0001).
overall and disease free survival or locoregional recurrence
In In
thisthis
subgroup,
the the
mean
finalfinal
metastatic
nodal
burden
12].12].
ThisThis
would
suggest
that that
AxUS
no longer
has ahas
role
subgroup,
mean
metastatic
nodal
burden [11,[11,
would
suggest
AxUS
no longer
a role
based
on on
thethe
number
of abnormal
nodes
identified
on AxUS
is is in these
patients,
as itas
cannot
determine
the number
of sentinel
based
number
of abnormal
nodes
identified
on AxUS
in these
patients,
it cannot
determine
the number
of sentinel
③  EcograSa cuanFtaFva vs Carga axilar Table
2 2Number
of abnormal
nodes
identified
on AxUS
compared
3 3Z0011
eligible
patients:
Number
of abnormal
nodesnodes
identified
Table
Number
of abnormal
nodes
identified
on AxUS
compared Table
Table
Z0011
eligible
patients:
Number
of abnormal
identified
withwith
finalfinal
nodal
burden
on
histology
on
AxUS
compared
with
final
nodal
burden
on
histology
nodal burden on histology
on AxUS compared with final nodal burden on histology
Number
of ofMedian
Mean
number
of of95 %
Number
Median
Mean
numberRange
Range
95CI% CI
abnormal
of of of metastatic
abnormal number
number
of metastatic metastatic
metastaticfor mean
for mean
nodes
metastatic
on final
on onnumber
of of
nodes
metastatic nodes
nodes
on finalnodes
nodes
number
identified nodes
nodes
on finalhistology
histology
metastatic
identified
on final
finalfinal
metastatic
on AxUS histology
histology
histologynodes
nodes
on AxUS
histology
Number
of of
Median
MeanMean
number
Range
of of 95 %95
CI% CI
Number
Median
number
Range
abnormal
of of of metastatic
metastatic
abnormalnumber
number
of metastatic
metastatic for mean
for mean
nodes
on final
nodesnodes
on final
number
of of
nodes metastatic
metastatic nodes
nodes
on final
on final
number
identifiednodes
nodes
on final
histology histology
histology metastatic
metastatic
identified
on final
histology
on AxUShistology
histology
on AxUS
nodesnodes
1 node
1 node
3
2
nodes
2 nodes
5
>2
nodes
>2 nodes
7
All
patients
All patients 5
1 node 2
1 node
2 nodes 5
2 nodes
>2 nodes9
>2 nodes
All patients
All patients
4
3
5
7
5
5.2 5.2
7.5 7.5
10.110.1
7.3 7.3
1–211–21
1-281-28
1-411-41
1-411-41
4–6.4
4–6.4
1.9–13.1
1.9–13.1
7.8–12.5
7.8–12.5
6.1–8.5
6.1–8.5
2
5
9
4
2.6
9.5
9.6
6.6
2.6
9.5
9.6
6.6
1–101–10
2–282–28
3–203–20
1–281–28
1.4–3.9
1.4–3.9
-10.2–29.2
-10.2–29.2
5.3–13.9
5.3–13.9
3.8–9.3
3.8–9.3
PAAF en ACOSOG Z0011: tener en cuenta el número de adenopa•as visibles en ecograSa 1 AdenopaFa = NO PAAF ≥ 2 Adenopa•as = PAAF Farrell TPJ, Adams NC, Stenson M, Carroll PA. The Z0011 Trial : Is this the end of axillary ultrasound in the pre-­‐operaFve assessment of breast cancer paFents ? Eur Radiol 2015. Sep;25(9):2682-­‐7. ③  EcograSa cuanFtaFva vs Carga axilar 322 (ACOSOG Z11) EcograSa INESPECÍFICO SOSPECHOSO 228/322 (85,5%) 94/322 (29.2%) BSGC PAAF 62 32 BSGC LA >2 : 20 (63%) ≤2 : 12 (37%) SOBRETRATAMIENTO Farrell TPJ, Adams NC, Stenson M, Carroll PA. The Z0011 Trial : Is this the end of axillary ultrasound in the pre-­‐operaFve assessment of breast cancer paFents ? Eur Radiol 2015. Sep;25(9):2682-­‐7. ③  EcograSa cuanFtaFva vs Carga axilar 322 (ACOSOG Z11) EcograSa INESPECÍFICO SOSPECHOSO 228/322 (85,5%) 94/322 (29.2%) BSGC PAAF 62 32 BSGC LA >2 : 20 (63%) ≤2 : 12 (37%) Nº AdenopaFas en Eco Ax 1 = 11/12 (91.6%) 2 = 1/12 (8.3%) Farrell TPJ, Adams NC, Stenson M, Carroll PA. The Z0011 Trial : Is this the end of axillary ultrasound in the pre-­‐operaFve assessment of breast cancer paFents ? Eur Radiol 2015. Sep;25(9):2682-­‐7. ③  EcograSa cuanFtaFva vs Carga axilar ESQUEMA ACTUAL VS NUEVO (ACOSOG Z0011) SOBRETRATAMIENTO
(PAAF + ≤ 2 LN+)
ACTUAL NUEVO Total PAAF + 12/32 (37.5%) 1/32 (3.12%) Total PAAF 12/94 (12.7%) 1/94 (1.1%) Farrell TPJ, Adams NC, Stenson M, Carroll PA. The Z0011 Trial : Is this the end of axillary ultrasound in the pre-­‐operaFve assessment of breast cancer paFents ? Eur Radiol 2015. Sep;25(9):2682-­‐7. ③  EcograSa cuanFtaFva vs Carga axilar En proceso de publicación EcograSa (288) INESPECÍFICO SOSPECHOSO 251/288 (85,5%) 37/288 (14,5%) BSGC PAAF >2 : 2 (0,8%) ≤2 : 249 (99,2%) 26 11 BSGC LA >2 : 1 (3.9%) ≤2 : 25(96.1%) >2 : 5 (45%) ≤2 : 6 (55%) SOBRETRATAMIENTO Del Riego J, Diaz-­‐Ruiz MJ, Teixidó M, Ribé J, Vilagran M, Canales L, et al. The impact of preoperaFve axillary ultrasonography in T1 breast tumours. Eur Radiol 2015 Jul 12. ③  EcograSa cuanFtaFva vs Carga axilar En proceso de publicación EcograSa (288) INESPECÍFICO SOSPECHOSO 251/288 (85,5%) 37/288 (14,5%) BSGC PAAF >2 : 2 (0,8%) ≤2 : 249 (99,2%) 26 11 BSGC LA >2 : 1 (3.9%) ≤2 : 25(96.1%) >2 : 5 (45%) ≤2 : 6 (55%) Nº AdenopaFas en Eco Ax 1 = 5/6 (83.3%) 2 = 1/6 (16.6%) Del Riego J, Diaz-­‐Ruiz MJ, Teixidó M, Ribé J, Vilagran M, Canales L, et al. The impact of preoperaFve axillary ultrasonography in T1 breast tumours. Eur Radiol 2015 Jul 12. ③  EcograSa cuanFtaFva vs Carga axilar En proceso de publicación ESQUEMA ACTUAL VS NUEVO (ACOSOG Z0011) SOBRETRATAMIENTO
(PAAF + ≤ 2 LN+)
ACTUAL NUEVO Total PAAF + 6/11 (55%) 1/11 (9.1%) Total PAAF 6/37 (16.2%) 1/37 (2.7%) Del Riego J, Diaz-­‐Ruiz MJ, Teixidó M, Ribé J, Vilagran M, Canales L, et al. The impact of preoperaFve axillary ultrasonography in T1 breast tumours. Eur Radiol 2015 Jul 12. ③  EcograSa cuanFtaFva vs Carga axilar Manejo axilar actual ¿ECO AXILAR? SI! ¿CUÁNDO? ¿PAAF? Depende! ③  EcograSa cuanFtaFva vs Carga axilar BI-­‐RADS 6 RM • 
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COMITÉ Tamaño tumoral (cT) “Mapa” axilar NO ACOSOG Z11 ACOSOG Z11 ECO Axilar ECO Axilar Inespecífico Inespecífico Sospechoso Sospechoso = 1 S
T
O
P BSGC PAAF pN0 Linf. Ax S
T
O
P
BSGC NO PAAF pN0 ≤ 2 > 2 Linf. Ax ≥ 2 PAAF GRACIAS POR SU ATENCIÓN [email protected]