Proposed Algorithm for Axillary Ultrasound Evaluation in Breast Cancer Patients Seeks Middle Ground

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Investigators at Massachusetts General Hospital proposed an algorithm for appropriate axillary nodal imaging to better align with changes in treatment algorithms for axillary nodal disease in patients with breast cancer.

Axillary ultrasound evaluation may not be necessary in all patients with breast cancer, and a new article offers an algorithm to help radiologists determine which patients should undergo evaluation and which patients should skip it.

The study, published in the Journal of Breast Imaging, represents a middle-ground approach between two opposing viewpoints -- those arguing for axillary ultrasound in all patients with newly diagnosed breast cancer and those arguing against it for all patients.

“Over the past decade the treatment algorithms for axillary nodal disease in patients with breast cancer have evolved,” Mansi Saksena, MD, of Massachusetts General Hospital told Diagnostic Imaging. “Hence, algorithms for imaging the axilla with ultrasound must also change. Many radiologists have not changed their practice based on recent changes in treatments (my second paper under publication shows data supporting the same). Our paper shows an imaging algorithm that will help radiologists decide which patients should get an axillary ultrasound and which should not.”

The report suggests axillary ultrasound for patients with palpable axillary nodes, T3/T4 tumors, multicentric or multifocal disease, those receiving neoadjuvant chemotherapy or endocrine therapy, and other scenarios as determined through multidisciplinary consultation.

Axillary nodal evaluation is unnecessary for patients with T1/T2 tumors who meet criteria for inclusion in the American College of Surgeons Oncology group Z0011 trial algorithm.

“The biggest challenge is in establishing uniformity in axillary nodal imaging,” Saksena said. “There is a lack of guidelines for axillary imaging, and this leads confusion about appropriate use of axillary ultrasound in patients with breast cancer.”

The report details indications for when axillary ultrasound is always, never or sometimes appropriate. Evaluation is sometimes indicated for patients with positive sentinel lymph node biopsy (SLNB), when breast MRI shows suspicious internal mammary nodes or axillary nodes in clinically node-negative patients, and patients older than 70 who will not undergo SLNB.

“I want practitioners to understand that they must use axillary ultrasound judiciously in patients with breast cancer,” Saksena said. “Doing axillary ultrasound in all patients can lead to unintended harm. Each practice must thoughtfully come up with imaging algorithms in collaboration with treating surgeons and oncologists.”

Potential harmful consequences of unnecessary axillary ultrasound include cost and resource burden on health systems and the potential for unnecessary preoperative biopsies or axillary lymph node dissection on patients.

“Although in many cases imaging plays a crucial role in the assessment of the axilla, it is essential that targeted axillary US and/or image-guided biopsy of an axillary lymph node be performed by the radiologist only when clinically appropriate,” Victoria Mango, MD; Melissa Pilewski, MD; and Maxine Jochelson, MD, wrote in a related editorial. “This decision-making process requires multidisciplinary communication and collaboration among radiologists, surgeons, medical oncologists and radiation oncologists.”

Decisions about axillary imaging should consider local clinical practices and adapt to changes in clinical management of axillary lymph nodes, the authors noted. Indications may change as more clinical trial results become available.

“The next step is to create educational tools and guidelines for axillary nodal evaluation with ultrasound in patients with breast cancer,” Saksena said.

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