DOI: 10.1148/rg.27si075502
RadioGraphics 2007;27:S91-S99
© RSNA, 2007
US-guided Core Needle Biopsy of Axillary Lymph Nodes in Patients with Breast Cancer: Why and How to Do It1
Hiroyuki Abe, MD, PhD,
Robert A. Schmidt, MD,
Charlene A. Sennett, MD,
Akiko Shimauchi, MD, PhD, and
Gillian M. Newstead, MD
1 From the Section of Breast Imaging, Department of Radiology, University of Chicago, 5841 S Maryland Ave, MC 2026, Chicago, IL 60637. Recipient of a Certificate of Merit award for an education exhibit at the 2006 RSNA Annual Meeting. Received February 6, 2007; revision requested March 16 and received April 9; accepted April 18. R.A.S. is a minor stockholder with Hologic/R2 Technology, received research grants from Fuji Medical USA and Konica Minolta, and is a consultant and member of the advisory board for Konica Minolta; G.M.N. received research support from Fuji Medical USA and Philips Medical, is a member of the advisory board for Konica Minolta, and is with the speakers’ bureau of Bayer; all remaining authors have no financial relationships to disclose.
Address correspondence to H.A. (e-mail: habe{at}uchicago.edu).
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Abstract
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Axillary lymph node status is an extremely important prognostic factor in the assessment of new breast cancer patients. Sentinel lymph node biopsy is now often performed instead of axillary dissection for lymph node staging but raises numerous issues of practicality. Sentinel lymph node biopsy can be avoided if lymph node metastasis is documented presurgically, making an alternative staging method desirable. Although not widely performed for axillary lymph node staging, ultrasonography (US)–guided core needle biopsy is a well-established procedure for the breast and other organs, with a higher success rate in terms of tissue diagnosis than fine-needle aspiration biopsy. Improvements in US have established it as a valuable method for evaluating lymph nodes. US findings in abnormal lymph nodes include cortical thickening and diminished or absent hilum. In addition, color Doppler US of abnormal axillary lymph nodes often shows hyperemic blood flow in the hilum and central cortex or abnormal (nonhilar cortical) blood flow. US-guided core needle biopsy of axillary lymph nodes in breast cancer patients can yield a high accuracy rate with no significant complications, given the use of a biopsy device with controllable needle action, a clear understanding of anatomy, and good skills for controlling the needle.
© RSNA, 2007
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Introduction
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Until some future time when it is replaced with noninvasive imaging techniques, tissue diagnosis of axillary lymph nodes will remain one of the most important prognostic factors in the treatment evaluation of patients with newly diagnosed breast cancer (1–3). The standard of reference for axillary lymph node staging is dissection (4,5). However, this procedure can cause numerous postoperative problems, such as lymphedema (2%–18% of cases), pain (16%–56%), impaired shoulder mobility (4%–45%), and arm weakness (19%–35%). Furthermore, in this era of mammographic screening, axillary lymph node dissection yields negative results in 80%–85% of patients with T1 cancer (6–8). Therefore, in recent years, sentinel lymph node biopsy has replaced axillary dissection for lymph node staging at major medical centers in the United States. However, there are some practical issues to be resolved. For example, radiotracer distribution can be slow or faulty, valuable operating room time is expended, and pathologists must make quick decisions based on the analysis of frozen sections (9–12). If nodal positivity could be proved preoperatively, sentinel lymph node biopsy could be bypassed and a decision made to perform axillary dissection, which is the standard of care for staging in most node-positive patients. Minimally invasive determination of preoperative lymph node status in patients with breast cancer is of growing interest in the surgical community. Ultrasonography (US) is currently the main modality used for this purpose (13–17), with advantages over computed tomography and magnetic resonance imaging, including the capacity to help direct biopsy. Although fine-needle aspiration biopsy is helpful when used in combination with US for preoperative lymph node staging, it is known to be more operator dependent than core needle biopsy, necessitating operator expertise and the cooperation of experienced cytologists. Core needle breast biopsy is a standard procedure, is available at most institutions in the United States, is less operator dependent, and yields a higher reproducible success rate in terms of tissue diagnosis than does fine-needle aspiration biopsy. Nevertheless, core needle biopsy is not widely performed for axillary lymph node staging, partly because of the anatomic challenges it presents, and partly due to radiologists’ unfamiliarity with the procedure.
In this article, we review the anatomy of the axillary lymph nodes and the imaging appearances of both normal and abnormal nodes. In addition, we discuss and illustrate US-guided core needle biopsy of axillary lymph nodes in breast cancer patients in terms of the biopsy device used, indications for the procedure, technical considerations, and associated complications.
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Anatomy
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Axillary lymph nodes are divided into three levels relative to the pectoralis minor muscle (18). Level 1 consists of nodes below the lateral border of the muscle, level 2 consists of nodes behind the muscle, and level 3 consists of nodes above the medial border of the muscle.
Most sentinel lymph nodes are level 1 nodes located in the inferior distribution of axillary nodes (1,19). 
In our experience over the past 3 years, abnormal lymph nodes are often seen in the tissues near the axillary tail, where core needle biopsy can be performed safely and easily. Although it has not yet been proved whether we are performing biopsy of a sentinel node when we use US evaluation and guidance, in over 15% of cases of positive US-guided core needle biopsy, the positive node was the only one found at subsequent axillary dissection—by inference, the sentinel node. We have received no reports from surgeons or pathologists that the sentinel node procedure, performed in all cases of negative US-guided core needle biopsy, was compromised or that diagnosis of the sampled nodes was made more difficult.
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Normal Lymph Node
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A normal lymph node has a thin cortex and a relatively large fatty hilum (Figs 1, 2). Blood flow usually passes through a single artery and drains into a single vein, with both vessels being located in the fatty hilum (20,21), much as in a small kidney. This normal blood flow is observed as bidirectional flow in the hilum. Microscopy demonstrates a vascular network within the lymph node cortex (20), but this network is not usually observed in a normal lymph node at color Doppler US. The size of the lymph node is not an indicator of benignity or malignancy, since normal lymph nodes larger than 5 cm can be present in the axilla and lymph nodes as small as 5 mm can contain metastases.
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Figure 1a. (a) US image shows a normal lymph node with a thin cortex (arrowheads) and a large fatty hilum (arrows). (b) Color Doppler US image shows normal bidirectional hilar blood flow (arrow).
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Figure 1b. (a) US image shows a normal lymph node with a thin cortex (arrowheads) and a large fatty hilum (arrows). (b) Color Doppler US image shows normal bidirectional hilar blood flow (arrow).
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Figure 2a. (a) US image shows a normal lymph node with a thin cortex (arrowheads) and a fatty hilum (arrows) (cf Fig 1a). (b) Color Doppler US image demonstrates an adjacent vein (arrow). Lymph nodes are often located near vessels and nerves.
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Figure 2b. (a) US image shows a normal lymph node with a thin cortex (arrowheads) and a fatty hilum (arrows) (cf Fig 1a). (b) Color Doppler US image demonstrates an adjacent vein (arrow). Lymph nodes are often located near vessels and nerves.
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Abnormal Lymph Node
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An abnormal lymph node has a thickened or eccentrically bulging cortex and a diminished or absent hilum (Figs 3–5) (22,23). The thickened cortex should be the target at biopsy. Metastases embed subcortically in the end vasculature. Color Doppler US shows hyperemic blood flow in the hilum and central cortex or abnormal (nonhilar cortical) blood flow (24). In metastatic lymph nodes, this nonhilar cortical blood flow is probably due to angiogenesis of the tumor, and the vascular network of the cortex is enlarged; blood flow in this area becomes visible at US of an abnormal node. However, this abnormal blood flow is not pathognomonic for a metastatic lymph node; it can also be observed in other pathologic conditions such as reactive lymph nodes with inflammation. Maximizing the sampling of the cortex and specifically targeting the peripheral cortex are recommended for biopsy. We usually recommend biopsy when thickened cortex or nonhilar cortical blood flow is seen. We consider cortical thickening to be present if the cortex thickens to more than one-half the thickness of the lymph node in the short axis. We usually obtain two good-quality core samples, one centrally and one peripherally.
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Figure 4a. (a) US image shows an abnormal lymph node with asymmetric cortical thickening (arrow). (b) Color Doppler US image shows normal hilar blood flow as well as abnormal (nonhilar cortical) blood flow (arrow), with the latter finding probably representing enlarged capsular vessels.
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Figure 4b. (a) US image shows an abnormal lymph node with asymmetric cortical thickening (arrow). (b) Color Doppler US image shows normal hilar blood flow as well as abnormal (nonhilar cortical) blood flow (arrow), with the latter finding probably representing enlarged capsular vessels.
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Figure 5a. (a) US image shows an abnormal lymph node with a hypoechoic thickened cortex (arrowheads) but no fatty hilum. (b) Color Doppler US image shows only abnormal (nonhilar cortical) blood flow (arrows); no normal hilar blood flow is seen.
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Figure 5b. (a) US image shows an abnormal lymph node with a hypoechoic thickened cortex (arrowheads) but no fatty hilum. (b) Color Doppler US image shows only abnormal (nonhilar cortical) blood flow (arrows); no normal hilar blood flow is seen.
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Biopsy Device
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With standard spring-loaded 14-gauge biopsy needles, a tissue sample is retrieved by firing a stylet and then a cutting cannula at high speed in rapid sequence to capture the sample with the push of a button. However, this automated action is not desirable when there is a vessel immediately beyond the target, since the track of the needle is difficult to predict and the stroke can damage the vessel. To avoid this possible complication, we use a 14-gauge Achieve biopsy needle (Cardinal Health, Dublin, Ohio). This needle can retrieve a sample without advancing (firing) the tip of the needle beyond its initial placement, thus removing concerns about damaging vessels, nerves, or other tissue beyond the target. Biopsy performed with this needle is illustrated in Figure 6.
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Figure 6a. Biopsy performed with the Achieve needle (Cardinal Health). (a) Photograph shows the biopsy device. Arrow indicates the "A" button, which the operator presses to release the outer cutting cannula. (b) Presampling US image with corresponding drawing shows how, after the needle has been inserted through the target lesion (arrowheads), the outer cutting cannula (black arrows) is cocked (pulled back) and the trough (short white arrows) is opened. At this point, the system is "charged" for releasing the outer cutting cannula. Long white arrow indicates the needle tip. (c) Postsampling US image with corresponding drawing shows how, when the "A" button is pressed, the spring-loaded cannula is released and the trough is covered, thereby retrieving the sample (short arrows). Note that the needle tip (long arrow) remains in the same position between pre- and postsampling (cf b). Arrowheads indicate the target lesion. (d) Color Doppler US image shows how biopsy can be performed even for a lymph node located right next to the axillary vein (large arrow), since the needle tip (small arrow) does not move during sampling. In this case, the distance between the axillary vein and the needle tip is less than 1 mm. Indeed, we have encountered no complications even when performing a biopsy with the needle tip almost touching the wall of a vessel.
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Figure 6b. Biopsy performed with the Achieve needle (Cardinal Health). (a) Photograph shows the biopsy device. Arrow indicates the "A" button, which the operator presses to release the outer cutting cannula. (b) Presampling US image with corresponding drawing shows how, after the needle has been inserted through the target lesion (arrowheads), the outer cutting cannula (black arrows) is cocked (pulled back) and the trough (short white arrows) is opened. At this point, the system is "charged" for releasing the outer cutting cannula. Long white arrow indicates the needle tip. (c) Postsampling US image with corresponding drawing shows how, when the "A" button is pressed, the spring-loaded cannula is released and the trough is covered, thereby retrieving the sample (short arrows). Note that the needle tip (long arrow) remains in the same position between pre- and postsampling (cf b). Arrowheads indicate the target lesion. (d) Color Doppler US image shows how biopsy can be performed even for a lymph node located right next to the axillary vein (large arrow), since the needle tip (small arrow) does not move during sampling. In this case, the distance between the axillary vein and the needle tip is less than 1 mm. Indeed, we have encountered no complications even when performing a biopsy with the needle tip almost touching the wall of a vessel.
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Figure 6c. Biopsy performed with the Achieve needle (Cardinal Health). (a) Photograph shows the biopsy device. Arrow indicates the "A" button, which the operator presses to release the outer cutting cannula. (b) Presampling US image with corresponding drawing shows how, after the needle has been inserted through the target lesion (arrowheads), the outer cutting cannula (black arrows) is cocked (pulled back) and the trough (short white arrows) is opened. At this point, the system is "charged" for releasing the outer cutting cannula. Long white arrow indicates the needle tip. (c) Postsampling US image with corresponding drawing shows how, when the "A" button is pressed, the spring-loaded cannula is released and the trough is covered, thereby retrieving the sample (short arrows). Note that the needle tip (long arrow) remains in the same position between pre- and postsampling (cf b). Arrowheads indicate the target lesion. (d) Color Doppler US image shows how biopsy can be performed even for a lymph node located right next to the axillary vein (large arrow), since the needle tip (small arrow) does not move during sampling. In this case, the distance between the axillary vein and the needle tip is less than 1 mm. Indeed, we have encountered no complications even when performing a biopsy with the needle tip almost touching the wall of a vessel.
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Figure 6d. Biopsy performed with the Achieve needle (Cardinal Health). (a) Photograph shows the biopsy device. Arrow indicates the "A" button, which the operator presses to release the outer cutting cannula. (b) Presampling US image with corresponding drawing shows how, after the needle has been inserted through the target lesion (arrowheads), the outer cutting cannula (black arrows) is cocked (pulled back) and the trough (short white arrows) is opened. At this point, the system is "charged" for releasing the outer cutting cannula. Long white arrow indicates the needle tip. (c) Postsampling US image with corresponding drawing shows how, when the "A" button is pressed, the spring-loaded cannula is released and the trough is covered, thereby retrieving the sample (short arrows). Note that the needle tip (long arrow) remains in the same position between pre- and postsampling (cf b). Arrowheads indicate the target lesion. (d) Color Doppler US image shows how biopsy can be performed even for a lymph node located right next to the axillary vein (large arrow), since the needle tip (small arrow) does not move during sampling. In this case, the distance between the axillary vein and the needle tip is less than 1 mm. Indeed, we have encountered no complications even when performing a biopsy with the needle tip almost touching the wall of a vessel.
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Indications
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Our biopsy technique is useful for those new breast cancer patients in whom suspicious axillary lymph nodes are identified at ipsilateral axillary US, which is now part of our standard evaluation for invasive breast cancer or extensive ductal carcinoma in situ. Although we do not sample palpable lymph nodes at our clinic unless results of clinical fine-needle aspiration or unguided core needle biopsy are negative or equivocal, this technique can be used in patients with palpable lymph nodes if necessary.
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Technique
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Our approach is almost always from inferolateral to superomedial toward the target to avoid major vessels and muscles. To flatten the axilla, a wedge pillow is used to rotate the patient’s body (Fig 7) and elevate the targeted area. The operator should visualize the target lymph node clearly at prebiopsy scanning and use color Doppler US to determine if there are large vessels around the target. The operator should determine the best approach at this time, with all information obtained at immediate prebiopsy scanning taken into account. After the puncture site and optimal needle approach have been determined, a local anesthetic is placed both superficially and deeply (Fig 8). During deep placement of anesthetic, the needle can be used as a probe to detect any sensitive nerves around the target and simulate the best approach. After the patient has been anesthetized, a small skin incision is made with a #11 scalpel blade. The biopsy needle is then advanced manually under real-time US guidance (Fig 9). Note that the outer cannula remains uncocked during manual needle advancement. In some cases, a tougher fascial layer under the superficial tissues necessitates a deeper incision or the use of a diamond-tipped guide cannula, and advancing the needle after cocking the outer cannula leaves a relatively thin and flexible portion of the stylet to withstand the insertion through the fascial tissues, potentially compromising placement accuracy or even bending the needle at the collection trough, the thinnest portion. Thus, we developed our protocol of advancing the entire uncocked needle—including the outer, more rigid cutting cannula—to or through the target (the cortex of the abnormal lymph node) and then cocking the needle to expose the inner collection trough. The operator should take care that the needle tip is visualized at all times, especially when there are large vessels around the target. Liberal use of color Doppler US is encouraged, both to avoid major vessels and to select a portion of the target node that is less likely to bleed. Somewhat surprisingly, targeting the central hilar area, even when considerable vascularity is present, has neither resulted in any significant hematoma nor compromised sampling or pathologic interpretation. At present, Doppler US at low flow rates (approximately 4 cm/sec) is highly sensitive for imaging blood flow and tends to lead to overestimation of the potential for vascular injury.
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Figure 8. Clinical photograph illustrates the injection of anesthetic. The operator can use the needle to probe any sensitive nerves, evaluate the distance and depth of the target, and simulate the appropriate angle of the biopsy needle.
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When the needle tip is just at or within the target, the gun is cocked once, which opens the trough without advancing the needle tip (Fig 10a). After manually adjusting the position of the trough to center on the target (Fig 10b), the operator presses the "A" button (Fig 10c), thereby releasing the outer cutting cannula and closing the trough (Fig 10d). This maneuver requires some practice and a modicum of physical strength but is easily accomplished with experience. We insert the needle with the bevel facing up to facilitate penetration of the superficial tissues and advance the needle with the plastic flanges used to cock the needle optimally positioned so as not to compromise the angle of advancement. The open trough can be positioned with exquisite accuracy just prior to sampling using this technique. It is recommended that a portion of the trough bridge the cortex and surrounding fat, which helps the pathologist see the interface between the target tissue and surrounding normal (usually fatty) tissue and thus more readily identify the target sample as being from a lymph node. Unlike with most other US core needle biopsy procedures, the needle is placed through the lymph node manually rather than by firing the trocar and the cutting cannula automatically. The fatty tissue of the axilla and the relatively soft consistency of both normal and abnormal lymph nodes allows the firing of just the outer cutting cannula to produce a very good core specimen. Use of this procedure prevents inadvertent needle damage, since the needle does not move after placement and the cannula samples only tissue that has already been traversed by the specimen trocar—the same principle involved in stepping in the footprints made by a leader walking through a minefield.
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Figure 10a. (a) Clinical photograph shows the direction (arrow) in which the loading lever (arrowhead) is cocked once the needle tip reaches the target. (b) US image shows the biopsy needle with the loading lever cocked. The trough can now be adjusted manually to center on the target. (c) Clinical photograph shows the operator pressing the "A" button (in direction of arrow) for sampling. (d) On a US image obtained immediately after the "A" button has been pressed, the outer cutting cannula is released and the trough is closed. The tip of the needle (arrow) should not move from its presampling location.
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Figure 10b. (a) Clinical photograph shows the direction (arrow) in which the loading lever (arrowhead) is cocked once the needle tip reaches the target. (b) US image shows the biopsy needle with the loading lever cocked. The trough can now be adjusted manually to center on the target. (c) Clinical photograph shows the operator pressing the "A" button (in direction of arrow) for sampling. (d) On a US image obtained immediately after the "A" button has been pressed, the outer cutting cannula is released and the trough is closed. The tip of the needle (arrow) should not move from its presampling location.
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Figure 10c. (a) Clinical photograph shows the direction (arrow) in which the loading lever (arrowhead) is cocked once the needle tip reaches the target. (b) US image shows the biopsy needle with the loading lever cocked. The trough can now be adjusted manually to center on the target. (c) Clinical photograph shows the operator pressing the "A" button (in direction of arrow) for sampling. (d) On a US image obtained immediately after the "A" button has been pressed, the outer cutting cannula is released and the trough is closed. The tip of the needle (arrow) should not move from its presampling location.
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Figure 10d. (a) Clinical photograph shows the direction (arrow) in which the loading lever (arrowhead) is cocked once the needle tip reaches the target. (b) US image shows the biopsy needle with the loading lever cocked. The trough can now be adjusted manually to center on the target. (c) Clinical photograph shows the operator pressing the "A" button (in direction of arrow) for sampling. (d) On a US image obtained immediately after the "A" button has been pressed, the outer cutting cannula is released and the trough is closed. The tip of the needle (arrow) should not move from its presampling location.
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After sampling and documentation of the needle throw position are achieved under US guidance, the needle is withdrawn, and the operator or an assistant should apply manual pressure on the biopsy site to minimize bleeding. The operator should evaluate the specimen visually both before and after placing the sample into a 10% formalin solution. The specimen should have a white (generally pathologic) or browntan (lymph node tissue) component, possibly with a yellow component representing adjacent fatty tissue (Fig 11). Because the trough of the needle (19 mm) is usually longer than the target lymph node, some adjacent fat (density, 0.9 g/mL) will often accompany the sampled lymph node tissue (density, 1.04–1.07 g/mL), causing the sample to float or partially sink. A lymph node replaced by tumor will usually produce a sample that sinks to the bottom of the container, sometimes after losing a few air bubbles that accompany the core initially (Fig 12). As mentioned earlier, we usually obtain two samples, one through the middle of cortex and one at the periphery. If the samples appear not to contain lymph node tissue (cortex) or tumor at visual assessment, additional sampling is advised. On average, we obtain about 2.2 samples per case. Occasionally, we will target more than one lymph node if another suspicious node is in the immediate vicinity, but this is not common.
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Figure 11. Photograph shows a biopsy specimen on the trough of the needle. The white component (lymph node cortex [arrow]) is metastatic tumor, and the yellow component (arrowheads) is adjacent fatty tissue.
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Figure 12. Photograph shows two core samples, taken from an axillary lymph node, in a jar filled with 10% formalin solution. As is typically the case, the lymph node cortical component (black arrow) or tumor component (white arrow) of the specimen sinks in the formalin solution, whereas the fatty tissue (arrowheads) floats. Because the trough of the biopsy needle is often longer than the lymph node, adjacent fatty tissue is usually sampled together with the target cortex.
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Complications
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The main concern in performing axillary core needle biopsy is to avoid damaging blood vessels or nerves, since lymph nodes are often located near these structures. In our experience with more than 100 biopsies, there have been no major complications. To avoid significant complications, a biopsy device with controllable needle action (such as the Achieve needle) should be used, with a clear understanding of anatomy and good skills for controlling the needle. If, as rarely occurs, the patient complains of a sharp radiating pain on manual insertion of the needle, indicating possible contact with a nerve, choosing a slightly different direction for the approach invariably solves the problem. Use of the inferolateral-to-superomedial approach with the patient’s ipsilateral arm raised but not fully extended allows most sampling to be performed parallel to major vessels.
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Conclusions
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US-guided core needle biopsy of axillary lymph nodes in patients with breast cancer can yield a high accuracy rate with no significant complications. Our positive biopsy yield is over 50%, with only three false-negative core needle biopsies to date: one due to mistargeting of the lesion and two in cases involving very small metastatic deposits (2 and 3 mm, respectively). Because many sentinel lymph nodes are located in the lower axillary region, core needle biopsy of these nodes can be performed safely. Core needle biopsy can be performed even for axillary lymph nodes located immediately adjacent to major vessels by choosing the approach with care and using a biopsy device with controllable needle action. If nodal positivity is confirmed with this procedure, time-consuming sentinel lymph node biopsy can be avoided. To obtain sufficient samples, accurate targeting of the thickened cortex and visual assessment of the sample are crucial. Use of an appropriate device, a clear understanding of anatomy, and good skills for controlling the needle are important for avoiding significant complications.
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References
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|---|
- Krag D, Weaver D, Ashikaga T, et al. The sentinel node in breast cancer: a multicenter validation study. N Engl J Med 1998;339:941–946.[Abstract/Free Full Text]
- Banerjee M, George J, Song EY, Roy A, Hryniuk W. Tree-based model for breast cancer prognostication. J Clin Oncol 2004;22:2567–2575.[Abstract/Free Full Text]
- Cianfrocca M, Goldstein LJ. Prognostic and predictive factors on early-stage breast cancer. Oncologist 2004;9:606–616.[Abstract/Free Full Text]
- Reynolds C, Mick R, Donohue JH, et al. Sentinel lymph node biopsy with metastasis: can axillary dissection be avoided in some patients with breast cancer? J Clin Oncol 1999;17:1720–1726.[Abstract/Free Full Text]
- Lovrics PJ, Chen V, Coates G, et al. A prospective evaluation of positron emission tomography scanning, sentinel lymph node biopsy, and standard axillary dissection for axillary staging in patients with early stage breast cancer. Ann Surg Oncol 2004;11:846–853.[Abstract/Free Full Text]
- Siegel BM, Mayzel KA, Love SM. Level I and II axillary dissection in the treatment of early-stage breast cancer: an analysis of 259 consecutive patients. Arch Surg 1990;125:1144–1147.[Abstract]
- Swenson KK, Nissen MJ, Ceronsky C, Swenson L, Lee MW, Tuttle TM. Comparison of side effects between sentinel lymph node and axillary lymph node dissection for breast cancer. Ann Surg Oncol 2002;9:745–753.[Abstract/Free Full Text]
- Mincey BA, Bammer T, Atkinson EJ, Perez EA. Role of axillary node dissection in patients with T1a and T1b breast cancer: Mayo Clinic experience. Arch Surg 2001;136:779–782.[Abstract/Free Full Text]
- McMasters KM, Giuliano AE, Ross MI, et al. Sentinel-lymphnode biopsy for breast cancer: not yet the standard of care. N Engl J Med 1998;339: 990–995.[Free Full Text]
- de Kanter AY, van Eijck, van Geel AN, et al. Multicentre study of ultrasonographically guided axillary node biopsy in patients with breast cancer. Br J Surg 1999;86:1459–1462.[CrossRef][Medline]
- Fraile M, Rull M, Julian FJ, et al. Sentinel node biopsy as a practical alternative to axillary lymph node dissection in breast cancer patients: an approach to its validity. Ann Oncol 2000;11:701–705.[Abstract/Free Full Text]
- Kumar R, Jana S, Heiba S, et al. Retrospective analysis of sentinel node localization in multifocal, multicentric, palpable, or nonpalpable breast cancer. J Nucl Med 2003;44:7–10.[Abstract/Free Full Text]
- de Freitas R Jr, Costa MV, Schneider SV, Nicolau MA, Marussi E. Accuracy of ultrasound and clinical examination in the diagnosis of axillary lymph node metastases in breast cancer. Eur J Surg Oncol 1991;17:240–244.[Medline]
- Yang WT, Ahuja A, Tang A, Suen M, King W, Metreweli C. High resolution sonographic detection of axillary lymph node metastasis in breast cancer. J Ultrasound Med 1996;15:241–246.[Abstract]
- Vaidya JS, Vyas JJ, Thakur MH, et al. Role of ultrasonography to detect axillary node involvement in operable breast cancer. Eur J Surg Oncol 1996; 22:140–143.[CrossRef][Medline]
- Tate JJ, Lewis V, Archer T, Guyer PG, Royle GT, Taylor I. Ultrasound detection of axillary lymph node metastases in breast cancer. Eur J Surg Oncol 1989;15:139–141.[Medline]
- Deurloo EE, Tanis PJ, Gilhuijs KG, et al. Reduction in the number of sentinel lymph node procedures by preoperative ultrasonography of the axilla in breast cancer. Eur J Cancer 2003;39:1068–1073.[CrossRef][Medline]
- Berg JW. The significance of axillary node levels in the study of breast carcinoma. Cancer 1955;8: 776–778.[CrossRef][Medline]
- Suga K, Yuan Y, Okada M, et al. Breast sentinel lymph node mapping at CT lymphography with iopamidol: preliminary experience. Radiology 2004;230:543–552.[Abstract/Free Full Text]
- Belz GT, Heath TJ. Pathways of blood flow to and through superficial lymph nodes in the dog. J Anat 1995;187:413–421.[Medline]
- Hay JB, Hobbs BB. The flow of blood to lymph nodes and its relation to lymphocyte traffic and the immune response. J Exp Med 1977;145:31–44.[Abstract/Free Full Text]
- Feu J, Tresserra F, Fabregas R, et al. Metastatic breast carcinoma in axillary lymph nodes: in vitro US detection. Radiology 1997;205:831–835.[Abstract/Free Full Text]
- Vassallo P, Wernecke K, Roos N, Peters PE. Differentiation of benign from malignant superficial lymphadenopathy: the role of high-resolution US. Radiology 1992;183:215–220.[Abstract/Free Full Text]
- Yang WT, Chang J, Metreweli C. Patients with breast cancer: differences in color Doppler flow and gray-scale US features of benign and malignant axillary lymph nodes. Radiology 2000;215: 568–573.[Abstract/Free Full Text]
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H. Abe, R. A. Schmidt, K. Kulkarni, C. A. Sennett, J. S. Mueller, and G. M. Newstead
Axillary Lymph Nodes Suspicious for Breast Cancer Metastasis: Sampling with US-guided 14-Gauge Core-Needle Biopsy--Clinical Experience in 100 Patients
Radiology,
October 27, 2008;
(2008)
2493071483.
[Abstract]
[Full Text]
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Abstract
Introduction
