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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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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
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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