CT localization of axillary lymph nodes in relation to the humeral head: significance of arm position for radiation therapy planning.

Irradiation of the axillary nodes is often indicated in the clinical radiotherapy of patients with lymphoma and breast cancer. The relative location of the axillary nodes and the humeral head has historically been estimated based on lymphangiographic data. Since CT offers more precise definition, the axillary nodal region in relation to the humeral head was systematically studied in 61 patients undergoing CT simulation for breast conservation therapy. Differences in arm position (degree of abduction) significantly affected the location of the axillary nodal region in relation to the humeral head. With the arm abducted beyond 55 degrees, humeral head blocking would result in blocking of some of the axillary nodes.     

Enlarged axillary nodes and position of the arms in axillary irradiation--a computed tomography and magnetic resonance imaging evaluation

The purpose of this study was to evaluate the axillary node displacement away from chest wall and their anatomical location in relation to the humeral head, according to the position of the arms, when the axilla is the site of enlarged nodes. In 13 patients with enlarged axillary nodes, the anatomical span of the nodes according to two arms positions, akimbo (A) and up over the head (U), was prospectively evaluated using computed tomography (CT) and magnetic resonance imaging (MRI). The nodes were classified into two groups, i.e. the lower and upper groups. The mean distances of the lower node group from the chest wall when the patients were in A, and U positions were 3 cm and 6.4 cm, respectively (p=0.002). The upper group nodes showed a smaller difference in the distance from the chest wall: in A position, mean 2.1 cm; in U position 2.8 cm (p=0.03). In U position, there was always a node of the lower group that was displaced in front of the humeral head. This study demonstrates the displacement of enlarged axillary nodes according to the position of the arms. In patients with axillary node involvement, CT planning should be considered when they have their arms held up over their heads.     

Management of the axillary nodes

The increasing use of screening mammography has resulted in the identification of smaller breast cancers with a lower risk of axillary node metastases than those seen in the past. In spite of this, imaging studies and currently availability prognostic markers cannot reliably identify those patients with axillary node disease. Although, in many cases, the need for adjuvant systemic therapy can be determined on the basis of primary tumor characteristics, knowledge of axillary node status remains the best predictor of the risk of breast cancer recurrence. Axillary dissection provides excellent local control, and may have a survival benefit for some patients, but these benefits are limited to patients with nodal involvement. Sentinel node biopsy has the potential to allow axillary dissection to be limited to patients with nodal involvement who will benefit from the procedure. The initial studies have proved that the status of the sentinel node reliably predicts the status of the remainder of the axillary nodes. The challenge for the future is to determine how to teach this procedure to large numbers of surgeons and to define its accuracy in a wider variety of clinical circumstances.     

Imaging of axillary lymph nodes

There is increasing interest in the radiological diagnosis of axillary lymph nodes in patients with breast cancer, especially in the preoperative diagnosis of metastatic nodes. Both CT (computed tomography) and MRI (magnetic resonance imaging) are cross-sectional imaging methods that produce high-quality images of the axilla. MRI also uses contrast enhancement profile, for example in imaging of breast lesions. Few studies have been published on this subject, but the latest have shown high sensitivity and specificity (CT 93.8 and 82.1%, respectively; MRI 90 and 82%, respectively), although, both CT and MRI are restricted to imaging only. US (ultrasound) is widely spread and is fast and accurate with high resolution. Sensitivity and specificity vary (68.2-92% and 90-100%, respectively). Most importantly, there is the possibility of US-guided FNAB (fine-needle aspiration biopsy) of pathological nodes, which increases the specificity. Initial results with colour Doppler are promising, but a recent study has shown that the presence of colour Doppler flow signal is highly non-specific. Other parameters such as flow pattern and distribution may prove to be of value in this method. Today, the method of choice for the daily routine is US in conjunction with FNAB.     

Fatty changes and metastases in axillary lymph nodes

A variety of pathological changes with clinical and prognostic significance is described in axillary lymph nodes removed at mastectomy. We studied 572 lymph nodes removed from 43 women and 1 man during a radical or modified radical mastectomy performed for carcinoma of the breast. We found that in about one-third of the specimens some degree of fat infiltration, or changes, was present; metastases were found in either fatty or nonfatty lymph nodes. We conclude that the presence of fat in axillary lymph nodes does not influence implantation of tumor cells from a primary carcinoma of the breast and has to be reported as an anatomic variant.     

Mondor's disease associated with metastatic axillary nodes

Mondor's disease, superficial thrombophlebitis of the breast, is customarily associated with benign conditions of the breast. This article reports a patient in whom an early manifestation of recurrent axillary metastasis from carcinoma of the breast was a symptom of ipsilateral superficial thrombophlebitis of the breast, an unusual association.     

Minimal risk of macrometastases in the non-sentinel axillary lymph nodes in breast cancer patients with micrometastatic sentinel lymph nodes and preoperatively ultrasonically uninvolved axillary lymph nodes

Micrometastases in the sentinel lymph node (SLN) carry a considerable risk of macrometastases in the non-sentinel lymph nodes (NSLN), resulting in axillary lymph node dissection (ALND). Preoperative ultrasound (US) examination of the axillary lymph nodes combined with a fine-needle aspiration biopsy (FNAB) has been proved to discover metastases in the axillary lymph nodes. The aim of our study was to assess the risk of macrometastases in NSLN in patients with micrometastatic SLN after a preoperative US examination of the axillary lymph nodes. The study included 36 patients in whom, after preoperative axillary US, micrometastases in the SLN were revealed and ALND was subsequently performed. At final histopathology, no macrometastases were discovered in the NSLN. In four patients, additional micrometastases were discovered in the NSLN. In conclusion, the risk of macrometastases in the NSLN in patients with preoperatively ultrasonically uninvolved axillary lymph nodes is minimal.     

The axillary nodes and tumor size in breast cancer

Summary Study of all lymph nodes removed from the axillary dissection specimens from 37 node-negative and 22 node-positive breast cancer patients showed that the number of nodes present in the specimen increased with the diameter of the primary tumor up to 4 cm. Larger tumors showed fewer nodes. The majority of the tumorbearing nodes were in the middle and lower thirds of the specimen. The mean size of the tumor-bearing nodes was similar to that in the largest nodes from the node-negative patients.     

Intraoperative examination of axillary sentinel lymph nodes in breast carcinoma patients.

BACKGROUND: Routine histologic examination of axillary sentinel lymph nodes predicts axillary lymph node status and may spare patients with breast carcinoma axillary lymph node dissection. To avoid the need for two separate surgical sessions, the results of sentinel lymph node examination should be available intraoperatively. However, routine frozen-section examination of sentinel lymph nodes is liable to yield false-negative results. This study was conducted to ascertain whether extensive intraoperative examination of sentinel lymph nodes by frozen section examination would attain a sensitivity comparable to that obtained by routine histologic examination without intraoperative frozen section examination. METHODS: In a consecutive series of 155 clinically lymph node negative breast carcinoma patients, the axillary sentinel lymph nodes were examined intraoperatively, before complete axillary lymph node dissection. The frozen sentinel lymph nodes were sectioned subserially at 50-microm intervals. For each level, one section was stained with hematoxylin and eosin and the other section immunostained for cytokeratins using a rapid immunocytochemical assay. RESULTS: Sentinel lymph node metastases were detected in 70 of the 155 patients (45%). In 37 cases the sentinel lymph nodes were the only axillary lymph nodes with metastases. Immunocytochemistry did not increase the sensitivity of the examination. Five patients had metastases in the nonsentinel axillary lymph nodes despite having negative sentinel lymph nodes. The general concordance between sentinel and axillary lymph node status was 96.7%; the negative predictive value of intraoperative sentinel lymph node examination was 94.1%. CONCLUSIONS: The intraoperative examination of axillary sentinel lymph nodes is effective in predicting the axillary lymph node status of breast carcinoma patients and may be instrumental in deciding whether to spare patients axillary lymph node dissection.     

Imprint cytology of axillary lymph nodes as an intraoperative diagnostic tool.

AIMS: Frozen section histology of lymph nodes intraoperatively is associated with a false negative rate of twenty-five per cent. Imprint cytology is reported to have greater accuracy than frozen section. Accurate intraoperative examination of lymph nodes could help to prevent some patients from having a second axillary operation in breast cancer. This study assesses the sensitivity of imprint cytology to lymph node metastases using two different staining techniques. METHODS: Imprint cytology of 238 freshly excised axillary lymph nodes in 53 patients with stage T1-2, N0, M0 breast cancer was performed. Imprints were stained using toluidine blue dye and anti-pancytokeratin immunoglobulin to compare the two staining methods. A consultant histopathologist blinded to the routine histology results examined each set of imprints. A non-pathologist also examined each set of imprints to determine whether a technician could be used to screen slides in order to decrease the workload of the pathologist. RESULTS: Sensitivity was 82% with toluidine blue and 36.4% with anti-pancytokeratin immunoglobulin. Positive predictive values were 100% and 57% respectively for toluidine blue and anti-pancytokeratin. The false-negative rate was 18% for toluidine blue and 63.6% for anti-pancytokeratin antibody when examined by a consultant histopathologist. CONCLUSIONS: Imprint cytology using toluidine blue is as sensitive as frozen section in the detection of axillary lymph node metastases. A positive result may be acted upon with acceptable safety. Immunohistochemistry using antibody to pancytokeratin did not improve imprint sensitivity in this study. Imprint cytology could help to prevent a second operation in 80% of breast cancer patients with positive lymph nodes.     

Number of lymph nodes identified at axillary dissection

BACKGROUND:

Several reports have shown a significantly lower number of axillary lymph nodes (AxLNs) found at axillary lymph node dissection (ALND) after neoadjuvant chemotherapy. The objective of the current study was to investigate the factors affecting the number of AxLNs identified at ALND.

METHODS:

Medical records of patients seen at the study institution, a tertiary center, from 2004 to 2007 who underwent ALND for breast cancer were reviewed.

RESULTS:

Among the 698 patients who met study criteria, the mean number of AxLNs resected was 20.4. There were 649 (93%) patients with at least 10 AxLNs recovered. Seventy‐one (10%) patients received neoadjuvant chemotherapy and 627 (90%) underwent surgical resection first. The mean number of AxLNs in the patients treated with neoadjuvant chemotherapy was 21.9 (range, 4‐56 AxLNs) compared with 20.2 (range, 5‐65 AxLNs) in the group treated with surgical resection first (P = .13). The number of patients with <10 AxLNs found at ALND was 44 of 627 (7.0%) in the surgical resection first group and 5 of 71 (7.0%) in the neoadjuvant chemotherapy group (P = 1.0). The mean number of AxLNs was higher in the 599 (86%) ALNDs performed at the study center compared with the 99 cases from outside institutions (21.2 vs 15.2 AxLNs; P <.001). Among the cases performed at the study institution, 367 (61%) were performed by surgeons with oncologic training and 232 (39%) were not. Surgical oncologists recovered an average of 23 AxLNs, which was significantly higher than the 18.4 resected by the remaining surgeons (P <.001).

CONCLUSIONS:

The number of AxLNs recovered at ALND does not appear to be affected by neoadjuvant chemotherapy. Surgeons with oncologic training appear to retrieve more AxLNs. Cancer 2010. © 2010 American Cancer Society.     

Breast tumors: immunoglobulins in axillary lymph nodes

The immunohistochemical determination of immunoglobulins IgA, IgG and IgM in axillary lymph nodes from 50 unselected breast ductal carcinomas disclosed that lymph nodes with IgG-positive lymphoid follicles and/or metastasized lymph nodes with IgM-positive lymphoid cells are statistically related to breast tumors with a high histologic grade and more than 3 lymph node metastases.     

Primary axillary radiotherapy as axillary treatment in breast-conserving therapy for patients with breast carcinoma and clinically negative axillary lymph nodes

BACKGROUND: The objective of the current study was to evaluate the effectiveness and morbidity of primary axillary radiotherapy in breast-conserving therapy for postmenopausal, clinically axillary lymph node negative patients with early stage breast carcinoma. METHODS: Between 1983-1997, 105 patients with clinically negative axillary lymph nodes and breast carcinoma were treated with wide local excision followed by radiotherapy to the breast, and axillary and supraclavicular lymph node areas. Adjuvant treatment with tamoxifen was given to 75 patients. The median follow-up of patients still alive was 41 months (range, 8-137 months). Fifty-five patients with no evidence of disease at last follow-up were examined prospectively with respect to late functional damage. RESULTS: The mean age of the patients was 64 years. Three patients developed a local recurrence. No isolated axillary lymph node recurrence was observed. In two patients, axillary recurrence was accompanied by distant metastases. The 5-year disease free interval and the overall survival were 82% (standard error [SE], 6%) and 83% (SE, 6%), respectively. In five patients, arm edema was reported and impaired shoulder function was reported in seven patients. Prospectively scored, arm edema was reported subjectively by the patient in 4% and objectively measured in 11% of cases. Impaired shoulder function was reported subjectively in 35% and objectively measured in 17% of cases. No brachial plexus neuropathy was noted. CONCLUSIONS: Primary axillary radiotherapy for postmenopausal women with clinically lymph node negative, early stage breast carcinoma was found to result in low axillary lymph node recurrence rates with only limited late complications. Therefore, primary axillary radiotherapy should be considered as axillary treatment in selected patients as an alternative to axillary lymph node dissection.     

Inconsistent radiotherapy effects between primary tumors and axillary lymph nodes

<正>Negative surgical margins are important for patients treated with breast-conserving therapy (BCT)BCT has been a standard practice in breast cancer treatment for more than 2 decades. For patients who receive BCT, a positive surgical margin is defined by the presence of ink at the surfaces of surgical specimens, in either the invasive tumor cells or breast ductal carcinoma in situ,     

Conservation treatment intensified with tamoxifen and CAF chemotherapy without axillary dissection for early breast cancer patients with clinically-negative axillary nodes.

Axillary node dissection has been a routine part of breast cancer treatment for more than 100 years. As so few patients have been shown to have positive nodes, more consideration should be given to eliminating axillary node dissection for duct carcinoma in situ (DCIS) and T1a lesions. And for patients with a T1/2N0M0 cancer of the breast, lumpectomy alone without axillary dissection followed by radiation therapy to the intact breast and regional lymph nodes should be a reasonable treatment method that avoids arm morbidity. Between September 1989 and December 1998, we treated 79 breast cancer patients with this method intensified with tamoxifen and CAF chemotherapy. Before the start of the therapy, we performed a thorough evaluation using helical CT and doppler ultrasonography to exclude patients with significant swelling of axillary lymph nodes (more than 5 mm in short diameter). Through the end of December 1998, the mean follow-up period was 52.6 months. Up to this date, only one patient of the 79 showed local recurrence within 5 years after the start of the treatment. This patient received a second lumpectomy. She then experienced lung metastases 6 months later. She is currently receiving combined chemotherapy with docetaxel and cisplatin. The cause-specific survival rate of these 79 patients maintained 100% at 6 years, and no axillary failure has been experienced so far. The cosmetic results in 50 (65.8%) of the 76 patients who were alive at the end of December 1998 were rated as excellent, 26 (34.2%) as good, and none as fair or poor. Therefore, we have concluded that this method of treatment for early breast cancer could eliminate surgical damage and allow good cosmetic results, and that survival rates with this treatment are excellent.