TAULA RODONA: QUE FEM AMB ELS GANGLIS?

TAULA RODONA: QUE FEM AMB ELS GANGLIS? Dr. Javier del Riego Área de Radiología Mamaria y Ginecológica UDIAT CD. InsFtut Universitari Parc Tauli – UAB. Sabadell, Barcelona. Manejo axilar BI-­‐RADS 6 EcograNa Axilar STOP INESPECÍFICO SOSPECHOSO BSGC PAAF LINFADENECTOMIA Manejo axilar BI-­‐RADS 6 EcograNa Axilar STOP INESPECÍFICO SOSPECHOSO BSGC PAAF LINFADENECTOMIA Manejo axilar BI-­‐RADS 6 EcograNa Axilar INESPECÍFICO STOP SOSPECHOSO BSGC PAAF LINFADENECTOMIA ¡¡Evitar un 2do Bempo quirúrgico!! Manejo axilar ¿Hay cáncer en la axila? NO SI BSGC LINFADENECTOMIA Manejo axilar 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 – LIMITACIONES
• 
No concluyó en reclutamiento (891 de 1900 previstas). • 
Baja representación de la muestra (bajo reclutamiento en 50% de centros). • 
Baja esFmación de supervivencia para grupo control (75% a 5 años). • 
Tumores pequeños •  Pacientes grandes (> 50 años) • 
80% Rc Estrogenicos + (tumores de buen comportamiento biológico) • 
No información del Her2 y Ki67 •  Alto % de micrometástasis (LA: 48.8%; BGSC: 37,5%) Sesgo de inclusión! • 
Casos avanzados en Grupo de LA (mayor tamaño, mayor invasion A-­‐L, mayor ganglio afectos). Sesgo de aleatorizacion. • 
No describe la Radioterapia •  Pérdida del seguimiento del 19,4%. •  Escaso Fempo de seguimiento (6.3 años). TRIAL ACOSOG Z0011 TRIAL ACOSOG Z0011 -­‐ IMPACTO Printed by Javier Horacio del Riego Ferrari on 6/14/2016 10:35:47 AM. For personal use only. Not approved for distribution. Copyright © 2016 National Comprehensive Cancer Network, Inc., All Rights Reserved.
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8&RQVLGHUSDWKRORJLFFRQILUPDWLRQRIPDOLJQDQF\LQFOLQLFDOO\SRVLWLYHQRGHVXVLQJXOWUDVRXQGJXLGHG)1$RUFRUHELRSV\LQGHWHUPLQLQJLIDSDWLHQWQHHGVD[LOODU\O\PSK
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 BI-­‐RADS 6 EcograNa Axilar/PAFF NO ACOSOG Z11 ¿Hay cáncer en la axila? ACOSOG Z11 ¿Cuánto cáncer hay en la axila? Valor actual de la EcograNa/PAAF Axilar ¿EcograNa axilar? Valor actual de la EcograNa/PAAF Axilar Baja carga axilar vs Alta carga axila ECOGRAFIA/PAAF Alto Valor PredicFvo NegaFvo Alto Valor PredicFvo PosiFvo BAJA Carga Axilar (LN+ ≤ 2) ALTA Carga Axilar (LN+ > 2) Control por BSGC LINFADENECTOMÍA Valor actual de la EcograNa/PAAF Axilar Author's personal copy
Eur Radiol
DOI 10.1007/s00330-015-3901-2
ABRIL 2016 BREAST
The impact of preoperative axillary ultrasonography in T1
breast tumours
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
Received: 26 February 2015 / Revised: 8 June 2015 / Accepted: 23 June 2015
# European Society of Radiology 2015
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 % sensiultrasound (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
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
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
MULTICENTRICO. RETROSPECTIVO §  N: 355 (pT1) §  N+: 81/255 (22.8%) §  AUS: S: 66.7%; E: 91.1% VPN: 94.2% §  N= 288 pT1 (ACOSOG) §  VPN (Cutoff > 2 LN+): 99.2% § 
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-
Valor actual de la EcograNa/PAAF 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) EcograNa 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 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
cT1: 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% loco(%)
(%)
(%)
node (SLN), additional (%)
lymph node (%)
dissection is still
regional control or§  overall
survival
with completion
pT1: V
PN (>2LN+): 99.1% warranted for regional control, although 40–65 % have no
35
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.
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
§  cT2: PN metastases
(<2LN+): and,
93% value of ALND in patients
withVSLN
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.
§  pT2: VPN (<2LN+): 95% (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
Valor actual de la EcograNa/PAAF Axilar Ann Surg Oncol
DOI 10.1245/s10434-015-4717-7
ORIGINAL ARTICLE – BREAST ONCOLOGY
§ 
Normal Axillary Ultrasound Excludes Heavy Nodal Disease
Burden in Patients with Breast Cancer
§ 
Rubie Sue Jackson, MD, MPH, Charles Mylander, PhD, Martin Rosman, MD, Reema Andrade, MBBS,
Kristen Sawyer, MS, Thomas Sanders, PhD, and Lorraine Tafra, MD, FACS
§ 
§ 
RETROSPECTIVO. UNICÉNTRICO N= 513 (pT1 – pT4; cN0) AUS -­‐: 400; AUS +: 113 VPN (> 2 LN+): 96% (FNR 4% The Breast Center, Anne Arundel Medical Center, Annapolis, MD
Octubre 2015 § 
VPN (> 2 LN+): pT1 98.3% (FNR: 1,7 %) disease burden preoperatively and as such is a powerful
ABSTRACT
tool to individualize treatment plans.
Background. Axillary lymph node stage is important in
guiding adjuvant treatment for breast cancer. The role of
axillary ultrasound (AUS) in axillary staging is uncertain.
Methods. From an institutional database, all newly diagAxillary lymph node stage is the single most important
nosed invasive breast carcinomas from February 1, 2011 to
factor to determine breast cancer prognosis and has an
October 31, 2014 were identified; exclusions were for stage
important role in guiding treatment for breast cancer.1,2
IV disease, palpable adenopathy, or receipt of neoadjuvant
Axillary lymph node dissection (ALND) was the ‘‘gold
chemotherapy. AUS findings, categorized as suspicious
standard’’ for diagnosis and treatment of axillary lymph node
versus not suspicious, were correlated with the number of
metastasis for decades. In 2003, Veronesi et al. demonstrated
nodal metastasis from surgical pathology. The false-negathat, despite a false-negative rate of 8.8 %, sentinel lymph
tive rate of nonsuspicious AUS for identifying C3 lymph
node biopsy (SLNB), followed by ALND only if the sentinel
nodes positive on final pathology was calculated.
lymph node contained metastasis, resulted in a similar breast
Results. A total of 513 cancers were included. Overall,
cancer-related
eventTrate
compared
Jackson 400
RS, AUSs
Mylander C
, R
osman M
, A
ndrade R
, S
awyer K, Sanders , et and
al. short-term
Normal survival
Axillary Ultrasound Excludes Heavy Nodal Disease Burden in PaFents with Breast Cancer. Ann were not suspicious (78 %), and 113 were suswith routine ALND.3 SLNB was widely adopted on the basis
picious
(22 %).
The sensitivity and specificity of AUS for
Surg Oncol 2015. Oct;22(10):3289-­‐95. of these findings, which were later updated to show similar
predicting C3 nodal metastasis were 71 and 83 %,
breast cancer-related events and overall survival at 10 years
respectively. The false-negative rate for detecting C3 nodal
in the two trial arms.4,5
metastasis was 4 %. False-negative rate was higher for
In 2011, the American College of Surgeons Oncology
lobular versus nonlobular carcinomas (12.0 vs. 2.3 %,
Group (ACOSOG) Z0011 trial results suggested that select
p = 0.004) and for pT2–pT4 tumors versus pT1 tumors
patients with metastasis in one or two sentinel lymph nodes
(8.2 vs. 1.7 %, p = 0.005).
Valor actual de la EcograNa/PAAF Axilar Valor actual de la EcograNa/PAAF Axilar Valor actual de la EcograNa/PAAF Axilar Reemplazar la BSGC por una técnica de imágenes (cN0). Valor actual de la EcograNa/PAAF Axilar Octubre 2012 cT1 N0 AUS negaFva STOP 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. 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). ACCEPTED MANUSCRIPT
Successful Completion of the Pilot Phase of a Randomized Controlled Trial Comparing
Sentinel Lymph Node Biopsy to No Further Axillary Staging in Patients with Clinical T1ACCEPTED
MANUSCRIPT
T2 N0 Breast Cancer
and Normal Axillary Ultrasound
Amy E Cyr, MD, FACS,1 Natalia Tucker, MD,1 Foluso Ademuyiwa, MD,2 Julie A
Margenthaler, MD, FACS,1 Rebecca L Aft, MD, FACS,1 Timothy J Eberlein, MD, FACS,1
Catherine M Appleton, MD,3 Imran Zoberi, MD,4 Maria A Thomas, MD, PhD,4 Feng Gao,
1
MANUSCRIPT
PhD,1,5 William E ACCEPTED
Gillanders, MD, FACS
ACCEPTED MANUSCRIPT
IP
T
ACCEPTED MANUSCRIPT
JUNIO 2016 1
Department of Surgery, Washington University School of Medicine, St Louis, MO
Department of Medicine, Washington University School of Medicine, St Louis, MO
3
Department of Radiology, Washington University School of Medicine, St Louis, MO
4
Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO
5
Division of Biostatistics, Washington University School of Medicine, St Louis, MO
ME D
ANMMA
UASNNUUM
SS
C RCARCNIRU
P TSI
IP PCTR
T
2
§ 
Disclosure Information: Nothing to disclose.
§ 
Disclosures outside the scope of this work: Dr Cyr is a paid consultant to Nanostring. Dr
Margenthaler receives payment for lectures from Myriad Genetics and Genentech. Dr § 
Appleton is a paid consultant to Hologic, Inc. and has provided expert trial testimony for
§ 
Crivello Carlson law firm in Wisconsin, and Rensch and Rensch in Omaha, Nebraska.
§ 
Support: This study is funded by a grant from the Longer Life Foundation. Dr Tucker was
supported by NCI grant T32 CA 009621. Dr Ademuyiwa was supported by an NCI grant 1K12
CA167540. Biostatistics services were provided by the Alvin J Siteman Cancer Center at
Washington University School of Medicine and Barnes-Jewish Hospital in St Louis, MO. The§ 
Siteman Cancer Center is supported in part by NCI Cancer Center Support Grant #P30
§ 
CA91842.
§ 
Presented at the American Society of Breast Surgeons 16th Annual Meeting, Orlando, Florida,
May 2015.
CE
PT
Address correspondence to:
Amy E Cyr, MD
Assistant Professor of Surgery
Washington University
Box 8109, 660 South Euclid Avenue
St. Louis, MO 63110
Phone (314) 747-8708
Fax (314) 222-6260
[email protected]
Running Title: Axillary Ultrasound for Breast Cancer Staging
!
!
!
PROSPECTIVO. UNICÉNTRICO RANDOMIZADO (fase piloto). N= 68 (c T1 – T2 cN0) + ECO NEGATIVA Brazo 1 (no estadiaje Qx): 34 Brazo 2 (SLNB): 32 VPN (cN0): 90.6% VPN (>2LN+): 96.9% Recurrencias 0 ( 17 meses de seguimiento) Valor actual de la EcograNa/PAAF Axilar ¿BIOPSIA (Core o PAAF)?? Valor actual de la EcograNa/PAAF Axilar 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 Valor actual de la EcograNa/PAAF Axilar 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
in Node
Positive
Cancer
Patients
StagingDifferences
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
413
TABLE 2 Univariate analysis of characteristics of axillary lymph
nodes showing significant differences between axillary node
positive
Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands; Department
of Radiology,
Máxima
Febrero 2015 Medical Center,
Veldhoven,
The Netherlands;
Comprehensive
Cancersentinel
Center Netherlands,
Eindhoven, The Netherlands;
patients
identified
by ultrasound
versus
node biopsy
2
1
3
4
RETROSPECTIVO. UNICENTRICO (5años) §  N: 1281 tumores Survival
§  1.0 N= 302 (pN+). Incluidos § 
School GROW, Maastricht University Medical Center, Maastricht, The Netherlands
Axillary lymph nodes Ultrasound
Sentinel node
p value
§ 
Dos ramas Grupo PAAF (AUS+ PAAF +): 139 0.8
(46%) Grupo BSGC (AUS + PAAF -­‐ BSGC +; AUS-­‐ BSGC +): 163 (54%) 0.6
lymph nodes with macrometastases (p \ 0.001), extranodal
ABSTRACT
1 
extension (p \ 0.001), and involvement of level-III-lymph
Background. Axillary status in invasive breast cancer,
node (p \ 0.001). Finally, they showed a worse disease-free
established by sentinel lymph node biopsy (SLNB) or
survival [hazard ratio (HR) = 2.71; 95 % confidence interval
ultrasound-guided lymph node biopsy, is an important
(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
tive patients have less favorable disease characteristics and
applicability of these conclusions on ultrasound positive
a worse prognosis than SN-positive patients. Therefore, we
patients. The purpose of this study was to evaluate potenconclude that omitting an ALND is as yet only applicable,
tial differences in patient and tumor characteristics and
as concluded in the Z0011, in patients with a positive
survival between axillary node positive patients after
SLNB.
ultrasound (US group) or sentinel lymph node procedure
(SN group).
Methods. Patients diagnosed with invasive breast cancer
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
Results. In total, 302 node-positive cases were included: 139
be determined by ultrasound-guided lymph node biopsy
and 163 cases in the US and SN groups, respectively. Patients
(UGLNB) or sentinel lymph node biopsy (SLNB).1,2 There
Axillary
staging
in the US group were older at diagnosis (p \ 0.001), more
are
in European
versus
American
guidelines
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. US
group
(p \ 0.001), larger tumors (p \ 0.001), higher tumor grade
guidelines dictate to perform the UGLNB only in patients
(p = 0.001), lymphovascular invasion (p = 0.035), a posiSN group
with palpable lymphadenopathy, although clinical palpation
tive Her2Neu (p = 0.006), and a negative hormonal receptor
has a false-negative rate of 30–50 %.6,7 In European guideUS group-censored
status (p = 0.003). Also, they were more likely to have more
lines, however, the axillary ultrasound is a routine element in
SN group-censored
all breast cancer patients with or without palpable lymph
3,4
nodes.
(n = 139)
(n = 163)
Median [range]
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
0.4
0.000
Macro
Micro
126 (90.5 %) 109 (66.9 %)
4
(2.9 %) 54 (33.1 %)
Unknown
9
(6.5 %)
0
(0 %)
0.2
Valor actual de la EcograNa/PAAF Axilar ACOSOG Z0011 PAAF + LA Baja carga axilar SOBRETRATAMIENTO Valor actual de la EcograNa/PAAF Axilar EcograWa cuanBtaBva vs Carga axilar final EcograNa cuanFtaFva vs Carga axilar EcograWa cuanBtaBva vs vs Carga axilar final EcograWa cuanBtaBva Carga axilar final 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 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
Farrell TPJ, Adams C, Stenson M, Carroll The Zof
0011 Trial : Is this the end of adisease
xillary uburden.
ltrasound in the pre-­‐operaFve assessment of breast cancer paFents ? Eur Radiol 2015. axillary
node
purpose
of thisNstudy
was to correlate
thePA. number
abnormal
Sep;25(9):2682-­‐7. • 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 of axillary ultrasound in breast cancer staging
staging.
Methods Six hundred and seventy-nine patients underwent
continues to evolve.
pre-operative AxUS. Suspicious nodes were sampled. Nega-
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
EcograNa 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
EcograNa 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
EcograNa 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 ecograNa 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. EcograNa cuanFtaFva vs Carga axilar 322 (ACOSOG Z11) EcograNa 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. EcograNa cuanFtaFva vs Carga axilar 322 (ACOSOG Z11) EcograNa INESPECÍFICO SOSPECHOSO 228/322 (70,8%) 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. EcograNa 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 Eco + 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. Manejo axilar actual ¿ECO AXILAR? ¿PAAF? ¿CUÁNDO? SI! Depende! Manejo axilar actual BI-­‐RADS 6 RM • 
• 
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] EcograNa cuanFtaFva vs Carga axilar En proceso de publicación EcograNa 288 (ACOSOG) 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 EcograNa cuanFtaFva vs Carga axilar En proceso de publicación EcograNa (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%) EcograNa cuanFtaFva vs Carga axilar ESQUEMA ACTUAL VS NUEVO (ACOSOG Z0011) SOBRETRATAMIENTO
(PAAF + ≤ 2 LN+)
ACTUAL NUEVO Total PAAF + 6/11 (55%) 1/11 (9.1%) Total Eco + 6/37 (16.2%) 1/37 (2.7%)