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5/10/17 1 Radiologic Management of the Axilla Janice S. Sung, MD Breast Imaging Section Department of Radiology Memorial Sloan-Kettering Cancer Center New York, NY Outline Normal anatomy Normal vs abnormal nodes Differential diagnosis Management in CA patient Lymph Node Levels Level I – Lateral to pectoralis minor Level II – Behind pectoralis minor Level III – Medial to pectoralis minor Normal vs Abnormal Nodes Normal LN on Mammography Seen on >50% of screening MG – Location: axilla, axillary tail, UOQ – Shape: oval, reniform – Morphology: circumscribed, fatty hilum

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Page 1: Radiologic managment of axilla toronto 2017

5/10/17

1

Radiologic Management of the Axilla

Janice S. Sung, MD Breast Imaging Section

Department of Radiology Memorial Sloan-Kettering Cancer Center

New York, NY

Outline

•  Normal anatomy •  Normal vs abnormal nodes •  Differential diagnosis •  Management in CA patient

Lymph Node Levels

•  Level I – Lateral to pectoralis minor

•  Level II – Behind pectoralis minor

•  Level III – Medial to pectoralis minor

Normal vs Abnormal Nodes

Normal LN on Mammography

•  Seen on >50% of screening MG –  Location: axilla, axillary tail, UOQ –  Shape: oval, reniform – Morphology: circumscribed, fatty hilum

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Normal LN on US

Normal/Benign

Abnormal

Shape Oval, lobulated Round

Cortex Uniformly ≤ 3 mm

> 3mm, focal thickening

Echogenic fatty hilum

Present Absent or displaced

Vascularity Single hilar vessel

Peripheral vascularization

Echogenicity Homogeneous Heterogeneous, hypoechoic Net J Radiographics

Approach to Axillary LAD

•  Unilateral vs bilateral?

•  Does the patient have known breast CA?

Bilateral Axillary Adenopathy: Benign •  Autoimmune:

– RA, SLE, scleroderma, dermatomyositis, psoriasis, Sjogrens syndrome

•  Granulomatous: –  Sarcoid, TB, silicone, gold

•  HIV •  Lymphoid hyperplasia:

–  infectious mono, cat scratch

•  Diabetic mastopathy

Bilateral Axillary Adenopathy: Malignant

•  Lymphoma •  Leukemia •  Metastases:

– Breast: uncommon –  Lung, melanoma

•  HIV associated malignancy

Unilateral Axillary Adenopathy

•  Metastatic breast CA •  Axillary metastases from non-breast primary:

– melanoma, lung, ovarian, gastric –  lymphoma

•  Benign – Reactive, dermatopathic, etc

•  All causes of bilateral adenopathy

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Axillary LAD on Screening MG

•  59 women with LAD •  Benign: 45 (76%)

– Reactive (22), arthritis (11), skin/viral condition (5), Tb (3)

•  Malignancy: 13 (22%) – Breast primary: 4 –  Lymphoma/leukemia: 9

•  Unknown: 1

Patel et al Clin Rad 2005

Reactive vs Metastatic?

•  Shape: – Reactive: inflammation usually enlarges LN

proportionally in all planes – CA: usually enlarges disproportionately in same

plane (round)

•  Adjacent nodes: – Reactive: affects all nodes in regional chain – CA often involves step by step

“Calcifications” in Axillary Nodes

•  Granulomatous infection •  Silicone •  Gold deposits •  Tattoos •  Metastatic disease

Calcifications in LN

Gold Therapy

CALCIFICATIONS IN AXILLARY LYMPH NODES

Metastatic ovarian carcinoma

Pitfalls of LN on Mammography

•  Not everything in the axilla is a lymph node

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Pitfalls of LN on Mammography

•  Not everything in the axilla is a lymph node •  Don’t overlook enlarging nodes

Pitfalls of LN on Mammography

•  Not everything in the axilla is a lymph node •  Don’t overlook enlarging nodes •  Don’t assume a mass is a node unless

completely typical

Biopsy of Axillary Nodes

•  Comparable sensitivity of FNA and core bx •  FNA: 75% •  Core bx: 82%

•  FNA: 18 or 22 g needles –  Send for flow cytometry if DDx includes

lymphoma

Approach to LN

•  Be familiar with normal appearance •  History •  Comparison to priors •  Not everything in the axilla is a node •  Ultrasound and biopsy

–  FNA +/- flow cytometry or core

•  Follow-up low-suspicion nodes thought to be reactive

History of Management of the Axilla in Breast Cancer

•  ALND in all women w/invasive breast CA

•  Sentinel lymph node biopsy followed by ALND for positive nodes

•  ACOSOG Z0011

•  Post-NAC setting

Can Imaging Detect Axillary Nodal Metastases?

•  425 patients with nodal metastases •  All had mammo

– abnormal nodes in 7% •  US in 242

– abnormal nodes in 25% •  MRI in 172

– abnormal nodes in 30%

Pilewski et al J Am Coll Surg 2016;222:138

Page 5: Radiologic managment of axilla toronto 2017

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Biopsy of Axillary Nodes in CA

•  Insufficient NPV to avoid sentinel node bx – Node on US may not represent sentinel node – Overall accuracy 70%

•  PPV: 97%, NPV: 84%

Holwitt et al. Am J Surg 2008; 196:477-82

Early Breast Sentinel Node Single Institution Trials

Giuliano 1994 krag 1993 Reintgen 1996 Veronesi 1997

Pts.

174 22 62

163

Success %

66

82

92

98

Method

Blue

Tc99

Tc99 & Blue

Tc99* skin

False Negs %

11 0 0 5

*Subdermal above the lesion

Breast Sentinel Node Multi-Center Trials

Krag 1998 Tafra 2001 McMasters 2001

Pts.

443

535

2206

Method

Tc99

Tc99 & Blue

Tc99 & Blue

Success %

93

87

92

False Negs %

11 13 8

US Guided FNA of Axillary Nodes

•  Women with negative FNA would have sentinel node procedure

•  Women with positive FNA would go directly to axillary node dissection

ACOSOG Z0011

•  813 pts with T1-T2 invasive CA, no palpable LAD, and <3 SLN mets

•  Randomized to either ALND vs no dissection •  All tx with whole breast RT and chemotherapy •  Equivalent results for LRR and overall survival at 6

years •  US guided FNA not necessary for T1 or T2 tumors

and clinically negative axilla

Giuliano et al JAMA 2011;305 (6):569-575

Neoadjuvant Chemotherapy

•  Locally advanced disease prior to mastectomy •  Downstage extensive disease to allow BCT •  Triple negative, HER2+ •  Downstage the axilla

– Anthracycline and taxanes can eradicate nodal disease in 30-40%

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Management of the Axilla After Neoadjuvant Chemotherapy

•  Do women with positive nodes before NAC need full ALND or is sentinel node sufficient?

•  What is the role of ultrasound of the axilla after NAC?

•  How can imaging help improve the accuracy of lymph node evaluation after NAC?

ACOSOG Z1071

•  What is the false negative rate of sentinel node biopsy in women with initially positive nodes who undergo neoadjuvant chemotherapy?

•  525 patients had both SLND with ≥2 sentinel nodes retrieved and full ALND –  False negative rate of SLND 13%

•  SLND not supported as alternative to ALND in these patients

Boughey et al. JAMA 2013;310:1455

ACOSOG Z1071

•  Decreased FNR if ≥3 sentinel nodes retrieved (p=.007) – 2 SLNs: 21% – ≥3 SLNs: 9%

Boughey et al. JAMA 2013;310:1455

ACOSOG Z1071: Axillary Ultrasound After NAC

•  Women with negative axillary US and sentinel node with > 2 nodes recovered –  False neg rate: 9.8%

•  Conclusion: Axillary US should be done after NAC –  Full ax dissection may not be necessary in women

who have a negative post NAC US and at least 2 negative sentinel nodes

Boughey et al J Clin Onc 2015;33

Clipping Axillary Nodes Prior to NAC

•  191 patients with positive axillary node, clip placed at time of biopsy

•  Targeted axillary dissection of clipped node and sentinel node vs ALND – Clipped node not among sentinel node in 23% –  SLN negative and mets in clipped node in 6 women

Caudle et al. J Clin Onc 2016;34

Clipping Axillary Nodes Prior to NAC

•  False negative rate –  Sentinel node 10.1% – Clipped node 4.2% –  Sentinel node + clipped node 1.4%

•  Conclusion: Marking positive nodes allows for selective removal and improves pathologic evaluation for residual disease after NAC

Caudle et al. J Clin Onc 2016;34

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Conclusion

•  US primary modality for evaluating axilla – Morphology most important – Distribution and clinical history important in

determining differential and management

•  Management of axilla in women with breast CA evolving to less invasive measures

Radiologic Management of the Axilla

Janice S. Sung, MD Breast Imaging Section

Department of Radiology Memorial Sloan-Kettering Cancer Center

New York, NY