Staging the axilla in women with breast cancer: the utility of preoperative ultrasound-guided needle biopsy

Nehmat Houssami, Robin M Turner, Nehmat Houssami, Robin M Turner

Abstract

Preoperative staging of the axilla in women with invasive breast cancer using ultrasound-guided needle biopsy (UNB) identifies approximately 50% of patients with axillary nodal metastases prior to surgical intervention. Although moderately sensitive, it is a highly specific staging strategy that is rarely falsely-positive, hence a positive UNB allows patients to be triaged to axillary lymph-node dissection (ALND) avoiding potentially unnecessary sentinel node biopsy (SNB). In this review, we extend our previous work through an updated literature search, focusing on studies that report data on UNB utility. Based on data for 10,934 breast cancer patients, sourced from 35 studies, a positive UNB allowed triage of 1,745 cases (simple proportion 16%) to axillary surgical treatment: the utility of UNB was a median 19.8% [interquartile range (IQR) 11.6%-26.7%] across these studies. We also modelled data from a subgroup of studies, and estimated that amongst patients with metastases to axillary nodes, the odds ratio (OR) for high nodal disease burden for a positive UNB versus a negative UNB was 4.38 [95% confidence interval (95% CI): 3.13, 6.13], P<0.001. From this model, the estimated proportion with high nodal disease burden was 58.9% (95% CI: 50.2%, 67.0%) for a positive UNB, whereas the estimated proportion with high nodal disease burden was 24.6% (95% CI: 17.7%, 33.2%) if UNB was negative. Overall, axillary UNB has good clinical utility and a positive UNB can effectively triage to ALND. However, the evolving landscape of axillary surgical treatment means that UNB will have relatively less utility where surgeons have modified their practice to omission of ALND for minimal nodal metastatic disease.

Keywords: Breast cancer; axillary staging; node metastases; test utility; ultrasound-guided needle biopsy (UNB).

Conflict of interest statement

No potential conflicts of interest are disclosed.

Figures

Figure 1
Figure 1
Bubble plot shows study-specific UNB utility (proportion of subjects triaged to axillary surgery based on UNB result) in relation to underlying prevalence of node metastases.
Figure 2
Figure 2
Estimated OR for high nodal disease burden in patients with a positive UNB vs. those with a negative UNB amongst patients with axillary node metastases. Study-specific and pooled estimates shown in plot; pooled OR=4.38 (95% CI: 3.13, 6.13); a positive UNB refers to positive ultrasound/positive needle biopsy, a negative UNB refers to positive ultrasound/negative needle biopsy amongst patients subsequently shown to have nodal metastases on SNB and/or ALND; high nodal disease burden refers to >3 nodes (relative to 1-3 nodes) however the study from Garcia-Fernandez 2011 used ≥2 nodes to classify higher node disease burden. UNB, ultrasound-guided needle biopsy; SNB, sentinel node biopsy; OR, odds ratio; ALND, axillary lymph-node dissection.

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