No TemplateComplete Removal of Small Foci of Breast Cancer Metastases to the Axillary Lymph Node by Core Needle BiopsyGünayRona1MeralArifoğlu1ŞerminKökten2EcemMemişoğlu34Department of Radiology, University of Health SciencesIstanbulTurkeyDepartment of Pathology, University of Health SciencesIstanbulTurkeyDepartment Of General Surgery, University of Health SciencesIstanbulTurkey, Günay Rona, MD Cevizli NeighbourhoodKartal, İstanbul, 34890TurkeyAbstract
The clinical or pathological status of the axilla is an essential component for staging in patients with breast cancer. Since lymph node positivity increases the stage of the disease and changes treatment strategies, lymph node (LN) sampling should be done. 1 Pre-operatively, ultrasound (US) or US-guided biopsy should be performed in clinically suspicious lymph nodes to help determine the axillary surgery method.
In this letter, the authors emphasize the importance of the above-mentioned crucial point by presenting a patient that convinced the treatment team to establish the stage of the disease based on the CNB of the axillary lymph nodes. A 20x17mm spiculated contoured mass was detected in the lower inner quadrant of the left breast in an 82-year-old woman. US examination revealed a 22x9mm LN in the left axilla with a focal bulging of 2.6mm in the middle part. Ultrasonography-guided CNB was performed from the suspected LN and the breast mass with a 14 gauge estacorepro 15mm needle (Geotek Medical, Ankara, Turkey). A single sample of 8x0.1x0.1cm tissue was taken from the LN. After CNB, she was diagnosed with non-specific type invasive breast cancer with a 3mm foci of lymph node metastasis. A metallic marker was placed into both biopsied area. At surgical staging of the axilla, the lymph node with
Keywords
The clinical or pathological status of the axilla is an essential component for staging in patients with breast cancer. Since lymph node positivity increases the stage of the disease and changes treatment strategies, lymph node (LN) sampling should be done. 1 Pre-operatively, ultrasound (US) or US-guided biopsy should be performed in clinically suspicious lymph nodes to help determine the axillary surgery method. 234 In the vast majority of patients, sentinel lymph node dissection (SLND) is the procedure of choice. Axillary Nymph Node Dissection (ALND) may not be indicated if the positive LN number is less than 3 in luminal type breast cancers in this subgroup and if there were more than 3 positive LNs, ALND should be added to the surgery protocol along with radiotherapy (RT) of the lymphatic bed. Having information about the lymph node can also change the plan of surgery in triple-negative and HER2-enriched breast cancers that are a candidate for neoadjuvant chemotherapy. If the LNs are positive and the patient receives neoadjuvant chemotherapy, the lymph nodes are examined intraoperatively. In cases with positive residual LN after NAC, ALND should be applied in addition to radiotherapy. 156 US is the primary modality for the evaluation of axillary LNs in patients with breast cancer. 7 Diffuse cortical thickening of 3mm or more, focal cortical thickening, rounded hypoechoic LN, and complete or partial effacement of the hilum are suspicious for lymph node metastasis. 2347 In case of adequate sampling, core needle biopsy (CNB) and fine needle aspiration biopsy (FNAB) have similar high specificity. 8 FNAB is recommended if there is sufficient radiology and cytology support; otherwise, CNB is recommended. 2 CNB is more sensitive than FNAB as it takes more adequate tissue samples. 8 Meanwhile, if the metastatic foci in the lymph node is so small, it can be completely removed by CNB. In this situation, the gold standard of diagnosis of positive lymph and the precise staging of the disease is changed from the information taken from permanent surgical pathology to the CNB of the lymph node.
In this letter, the authors emphasize the importance of the above-mentioned crucial point by presenting a patient that convinced the treatment team to establish the stage of the disease based on the CNB of the axillary lymph nodes. A 20x17mm spiculated contoured mass was detected in the lower inner quadrant of the left breast in an 82-year-old woman. US examination revealed a 22x9mm LN in the left axilla with a focal bulging of 2.6mm in the middle part. Ultrasonography-guided CNB was performed from the suspected LN and the breast mass with a 14 gauge estacorepro 15mm needle (Geotek Medical, Ankara, Turkey). A single sample of 8x0.1x0.1cm tissue was taken from the LN. After CNB, she was diagnosed with non-specific type invasive breast cancer with a 3mm foci of lymph node metastasis. A metallic marker was placed into both biopsied area. At surgical staging of the axilla, the lymph node with
Letter to Editor
Open Access the clip was detected in specimen mammography, and the pathologist confirmed the existence of a lymph node with a metallic clip; however, no metastases were observed in this LN in precise sections. In the second examination of the lymph node, a negligible number of atypical cells were detected in a limited area of the LN. The present findings were accepted as macrometastasis, considering the area of metastasis in the core biopsy material. Although some studies show that CNB could predict the final histological outcome after the operation in some cases with micrometastases, it is preferable to do the primary staging of the axilla by FNAB. 278 However, they stated that this is not the main purpose of CNB and that the metastasis size information in the LN obtained by CNB should be correlated with imaging findings. 9 In our experience, since we obtained the information on axillary lymph nodes by CNB and the metastatic part of the lymph node was totally removed through this procedure, the surgical pathology failed to detect any lymp node involvement and we planned the treatment based on the information received preoperatively from the USguided CNB.
It can be concluded that when the correct location is targeted, small metastasis foci in the LNs can be completely evaluated in the sample taken. Metastasis may not be detected in the subsequent excision. In case of inconsistency between the core biopsy and excision results, the possibility that the metastasis may have been removed by core biopsy should be kept in mind. It is important to place a clip in the cortex of the LN at the time of biopsy to ensure that the biopsied LN is excised. Pre-operative localization of the clip by the wire of radioactive seed is required prior to surgery. Although the US-guided CNB is a highly sensitive method for detecting axillary lymph node metastasis, its complications and the probability of removing the small metastasis should be kept in mind.
CONFLICTS OF INTEREST
Authors and authors' institutions declare no conflicts of interest.
FUNDING
There is no funding for this work to declare.
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