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The approach could be particularly useful in women at higher risk of metastases, such as those with tumors of at least 20 mm, said coauthors Dr. Nehmat Houssami of the University of Sydney, Australia and colleagues.
These women typically have sentinel-node biopsies (SNB). While preoperative ultrasound-guided needle biopsy (UNB) has been advocated for triaging women directly to axillary node dissection, it isn't widely used, and the researchers note that only a single clinical cancer guideline recommends it. They attribute this to beliefs that UNB isn't sensitive enough, or that it won't change treatment in most cases. Finally, they say, most studies of the approach have included small numbers of patients.
Dr. Houssami and colleagues wanted to know the proportion of women for whom SNB could be avoided if UNB were used systematically. They looked at 31 studies with data on 6,166 patients with invasive breast cancer, including 2,874 who had UNB. The median percentage of patients with metastatic nodes was 47.2%.
As reported online May 18th in Annals of Surgery, data from 21 studies showed that with systematic use of UNB, the median proportion of patients who were, or would have been, triaged directly to axillary node dissection was 19.8%. Among women with positive axillary nodes, 55.2% could have gone directly to nodal dissection. The same was true for 65.6% of women in the 11 studies where median tumor size was at least 21 mm.
UNB had a pooled sensitivity of 79.6%, a specificity of 98.3%, and a positive predictive value of 97.1%, based on a 47% prevalence of node metastases. The median insufficiency rate for UNB was 4.1%.
Sensitivity was heterogeneous among the studies, the researchers note, and was strongly linked to ultrasound sensitivity and ultrasound true-positive fraction. Ultrasound sensitivity should be at least 60% to 65%, they say, and "ideally higher," to maximize the accuracy of preoperative UNB for axillary staging.
The researchers also say the 47% figure for node metastases is higher than the 30% typically seen in practice.
They conclude: "On the basis of the evidence reported in this meta-analysis, preoperative UNB is an accurate test and should be considered for staging the axilla in women with newly diagnosed invasive breast cancer, except in those who require upfront (axillary node dissection) on clinical grounds."
SOURCE: http://bit.ly
This post was edited by Cynthia at July 19, 2011 1:15:30 PM WATime"the Click Researcher 
More Research Info
NEW YORK (Reuters Health) Jun 27 - Changes in breast density in response to sex hormone levels are greater in women who later develop breast cancer, a new study shows.
If the findings are confirmed, this "functional information" could be used to improve breast cancer risk prediction based on mammographic density, according to lead author Dr. Norman F. Boyd of the Ontario Cancer Institute in Toronto and colleagues.
More extensive breast density as detected by mammography is linked with an increased breast cancer risk. To see if the same might be true for greater density in response to hormonal changes, the researchers analyzed data from three case-control studies involving 1,164 breast cancer patients and 1,155 controls.
They reported their findings in a paper published online today in the Journal of Clinical Oncology.
In all three analyses, Dr. Boyd and his team note, the differences were seen in the dense area of the mammogram, which contains the sex-hormone-receptor-bearing stromal and epithelial tissues. "The data are consistent with an effect of exogenous and endogenous sex hormones acting as mitogens on these tissues," they write.
At baseline, everyone was cancer-free. Mammographic density averaged 5.7% higher among the women who went on to develop cancer during the next one to eight years, compared to the controls.
In case subjects who were premenopausal at enrollment, baseline adjusted percent mammographic density (PMD) was 5.3% greater in women who had ever used oral contraceptives compared to women who had never used them (p=0.06). Among controls, however, birth control pill users had a 2% lower PMD than women who never used them (p=ns).
Among women who never used hormone therapy and later developed breast cancer, those who were premenopausal at baseline had an 8.5% higher PMD, on average, than those who were postmenopausal at baseline. Among controls, the mean difference was 3.9%.
The third analysis, entirely of postmenopausal women, found that among cases, adjusted PMD was 6% higher for women currently using hormone therapy compared to never-users, while the difference between past users and never-users was 3.4%. For controls, current hormone therapy users had a slightly but not significantly higher PMD than never-users, while the past hormone therapy users had a 3.8% lower PMD than never-users. Average PMD rose as hormone therapy duration increased among the cases, but not among the controls.
"The present findings that the responses of mammographic density to changes in hormone exposure are related to later risk of breast cancer require confirmation in longitudinal studies," the researchers write. "If confirmed, it may be possible to improve risk prediction by supplementing the information about risk provided by a single measure of mammographic density with this functional information."
SOURCE: http://bit.ly/jIhdSe
J Clin Oncol 2011.
This post was edited by Cynthia at July 22, 2011 10:37:50 AM WATime"the Click Researcher
Sentinel Lymph Node Biopsy
September 28, 2010 — In women with breast cancer and clinically negative lymph nodes, a less invasive approach to lymph node surgery provides the same survival and regional control as a more aggressive approach.
This is the most definitive word to date on the subject of sentinel lymph node (SLN) biopsy vs axillary lymph node dissection (ALND) in these women, according to the authors of the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-32 trial.
The results from this study, the largest-ever randomized surgical trial of breast cancer, which were presented earlier this year at the American Society of Clinical Oncology annual meeting, were published online September 20 in the Lancet Oncology.
The trial enrolled 5611 women with invasive breast cancer, and randomly assigned them to either SLN biopsy plus ALND or to SLN biopsy alone (with ALND only if the SLNs were
SLN surgery is the "highly targeted removal of the lymph nodes that receive direct drainage from a solid tumor in the breast," explain the study authors, led by David Krag, MD, from the University of Vermont in Burlington.
Anytime that SNL surgery is performed without follow-up ALND, there is the chance that there is residual disease in the nonsentinel nodes, according to an editorial that accompanies the study.
"It is of crucial importance to ascertain whether the finite proportion of patients with residual disease in nonsentinel nodes have impaired overall survival," writes editorialist John Benson, MD, from Cambridge University Teaching Hospitals Trust in the United Kingdom.
There was a slight difference in survival among patients assigned to SLN biopsy plus ALND and those assigned to SLN alone. But the difference was not statistically significant and, thus, could have been due to chance.
The 8-year Kaplan–Meier estimates for overall survival were 91.8% (95% confidence interval [CI], 90.4 - 93.3) for SLN biopsy plus ALND and 90.3% (95% CI, 88.8 - 91.8) for SLN biopsy alone.
The new data vindicate the "contemporary practice of SLN biopsy and provide support for a reduction in extent of axillary surgery for most patients with breast cancer," writes Dr. Benson.
However, this is not the final word on the subject — more follow-up is needed, says Dr. Benson.
For instance, there were more regional recurrences with SLN biopsy alone (14 vs 8 events). "Low volume axillary disease might arguably be clinically relevant if it translates into overall survival differences with longer-term follow-up," he points out.
However, the study authors placed a different emphasis on these data.
Dr. Krag and his coauthors say the results confirm the low rate of regional node recurrences after SLN surgery. Furthermore, the trial shows that in patients with negative SLNs, "the number of regional node recurrences does not differ significantly between patients who have axillary dissection or SLN resection only," they write.
"SLN surgery represents the next major step in reducing the extent of surgical procedures to treat breast cancer," the authors conclude, citing breast-conserving surgery as the previous major step.
Adverse Effect Advantage Too
In the editorial, Dr. Benson points out that this study is a step forward in understanding how SLN influences outcomes in clinical node-negative breast cancer, where disease in the nodes cannot be palpably detected in the clinic.
"Most published data on [SLN] biopsy come from validation studies in which clinically node-negative patients have undergone SLN biopsy and then immediate complete [ALND]," he writes.
What's been missing is comparative data for SLN biopsy alone without concomitant ALND, he adds.
There are actually 5 randomized controlled trials currently comparing SLN biopsy with conventional ALND in clinically node-negative patients. Notably, 3 of the trials have the exact same design: SLN biopsy plus ALND vs SLN biopsy alone. But the NSABP B-32 trial is the biggest.
In the B-32 trial, which is taking place at 80 centers in Canada and the United States, SLN biopsy was done in the more than 5000 patients with a blue dye and radioactive tracer, note the authors.
Previously reported results from the B-32 trial showed that morbidity related to range of motion, edema, pain, and sensory defects is lower in the SLN group than in the ALND group (J Clin Oncol. 2010;28:3929-3936; J Surg Oncol 2010;102:111-118).
This is key because the whole point of SLN surgery is to reduce morbidity.
However, as Dr. Krag and colleagues point out, SLN surgery is not without complications. There is a small increase over baseline of extremity edema and functional and neurologic deficits, they note.
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The authors have disclosed no relevant financial relationships.
Lancet Oncol. Published online September 20, 2010.
This post was edited by Cynthia at September 9, 2011 9:54:12 AM WATime"the Click Researcher
