Staging Breast Cancer with Ultrasound - HD

Introduction

Hi, I am Gary Whitman.

I'm a professor of radiology and radiation oncology at the University of Texas, MD Anderson Cancer Center in Houston.

In today's lecture, we're going to talk about the use of ultrasound in staging in patients with breast cancer.

Thank you. We're going to try to appreciate the role of ultrasound in staging in the breast.

Especially looking at multifocal disease in multicentric disease, multifocal disease would be more than one lesion within the same quadrant.

Multicentric disease is if more than one quadrant is involved.

In addition, we'll be examining the use of ultrasound and evaluating the regional lymph nodes, including the axillary in canicular, supra, and internal mammary regions.

Another group of lymph nodes that we should consider as well is the intra mammary lymph nodes.

Those are lymph nodes within the breast.

And as you know, when we're staging breast cancer, we want to evaluate the tumor size and determine if there is involvement of the skin or the pectoralis fascia and the pectoralis muscle.

And in addition, an area where ultrasound can help us quite a bit is in evaluating the regional lymph nodes.

So in this talk, we're going to focus on the breast and the regional lymph nodes.

We're not going to consider distant sites in this lecture.

Evaluating Lesions and Disease Extent

And as you can see here, we have an actuary lymph node.

We can see that the cortex is expanded, the hilum is compressed and flattened, and this was a metastatic axial lymph node.

When we do staging, we want to try to determine how many lesions are present.

Is there evidence of multifocal disease?

Is there evidence of multicentric disease?

And as we stated previously, multifocal disease is more than one lesion in the same quadrant.

Multicentric disease is when more than one quadrant is involved.

So here we have a large mass.

This was an invasive ductal carcinoma.

And notice near the lesion there were two other smaller masses.

These were satellite lesions.

So what we would do in this particular case is we would biopsy the large mass, and then we would biopsy the satellite lesion furthest away from the large mass.

Just to show the extent of disease.

Here, when we do staging, we think of the aga cc staging system, which really is the TNM system, tumor nodes, metastasis.

And on ultrasound, we can do quite well in evaluating the tumor size.

As you can see, there are cutoffs at two to five and greater than five cm.

Furthermore, we can determine if there is involvement of the chest wall or the skin with ultrasound.

Ultrasound is particularly important when we're evaluating the lymph nodes.

For example, we can tell if there are suspicious axial lymph nodes.

One area where we can probably improve is if we determine that there are fixed later axial lymph nodes.

That would make the patient N two if the lymph nodes are fixed.

And another area where we can have an impact is determining if there's evidence of N three disease.

That would be involvement of the infra calor or the supra calor lymph nodes.

And here's just an example.

This is an infra calic or lymph node.

As you can see, we really don't see much of a hilum, the borders or somebody of reor.

And then we did fin needle aspiration.

Here's our needle coming all the way into this lymph node, and we showed that this was positive, making this N three disease.

Another example of N three disease would be scalor lymphadenopathy.

Here we see multiple matted lymph nodes in the supraclavicular region.

This was N three disease.

Here with power doppler, we can see a little bit of flow at the periphery of some of the nodes.

And in the staging system, M zero is no distant metastasis, and M1 is distant metastases.

And we're really not gonna cover that in today's session.

So basically we take our t, our n and m and put those together to come up with what would be the appropriate stage.

And we can see that if we determine N three disease, that would be infra click or a supra or disease, that really does affect the stage here.

That would become a three C.

T four which had skin involvement, that would be a three B.

Here's just an example.

The question here is how many lesions are there?

What is the extent of disease?

This was the main tumor mass.

This was a satellite lesion.

This was an intary lymph node, and this was an axial lymph node.

So just on this one view, mammographically, we can see four areas of disease involvement.

Here's the satellite lesion.

Going back to it here, here's the large axial lymph node involved.

The hilum is displaced.

Notice that the cortex is expanded, and we can see that right at the edge of the mammogram here.

In addition, as we went on, there were inor lymph nodes.

There are actually three of them.

Notice here, these are oval lymph nodes, hypo coic with no discernible internal hilum.

When we're looking for evidence of multifocal disease, what we will do is sample the lesion farthest from the index lesion.

This could be done by FNA if there is good cytology support, or if not, then we would recommend the use of corn needle biopsy.

And here we can see on the specimen radiograph, this is specimen, and then it's sliced in multiple sections.

This was an example of multifocal disease.

We had needle localized one lesion, and here's the second lesion with a quip marker that was also needle localized.

So in general, in our staging, we wanna evaluate the main lesion.

As we can see here, it's hypo coic, it's irregular, and posteriorly situated, but also look in the neighborhood, determine if there are satellites, and give the distance between the two lesions.

And in this particular case, we would biopsy both of these lesions.

In my practice, I would core biopsy this one, and I would do a fin needle aspiration on this one.

If fin needle aspiration cytology was not available, then this one would undergo core biopsy.

Case Examples

So let's take a case here.

This was a palpable abnormality in a dense breast.

We wanna ask ourselves, where is the mass?

How many masses are present?

And is this patient a candidate for breast conservation?

So this is in a bit of a tricky area.

Here's the nipple.

We see a little bit of the nipple here.

There was a palpable abnormality, there was a density here.

But we would like to determine what is going on here?

What is the extent of disease and sonography can be helpful.

Here's the main mass that we saw in the retro A or region right here.

But notice there are a few other satellite lesions, one and two, and even another one.

This would be another satellite lesion.

So we would biopsy the main lesion, which we did with core, the furthest lesion from the main lesion we biopsied.

With FNA, we showed that this was evidence of multifocal invasive labial carcinoma.

And as you know, invasive labo carcinoma is slightly more likely to be multifocal and bilateral than invasive ductal carcinoma.

This is probably due to the way that the cells in the tumor form and opposed to one another, where the cells in invasive labial carcinoma tend to be less mass like and maybe more likely to be dispersed.

As you've sometimes heard in single file type orientation.

Let's take another example.

This is a palpable abnormality in a 60-year-old woman in the retro alar region.

This triangle, palpable abnormality, palpable marker here.

These are skin markers.

Right here you can see the skin lesions.

And notice there was nipple retraction.

This was the area of the palpable abnormality.

We went to ultrasound, and we could see in the retro alar region that there was an area a hypo coic mass.

This corresponded to the palpable area, and this accounted for the nipple retraction.

As we can see here, this was the palpable abnormality in the six o'clock region.

This was shown to be invasive lipo carcinoma and breast conservation was being considered.

Thereafter, the patient underwent MRI and on MRI, we can see a large extent of disease.

Notice this extent of disease.

This was about eight cm.

So where we biopsied under ultrasound was right here.

And we really did not see the distant extent of disease that we see on MRI.

So this was invasive lab carcinoma, very extensive.

This was proven by MRI biopsy, spanning about HCM.

And again, just an illustration to show you that although ultrasound is a very valuable tool, there can be some situations where ultrasound does have some limitations.

And one of those is an ill-defined invasive LO carcinoma.

As we saw in this particular case, an MRI is very valuable for evaluating invasive lab carcinoma, for looking at the morphology and the vascularity, and particularly for demonstrating multifocal and multicentric disease.

In this particular case, MRI was particularly helpful for indicating and demonstrating that the patient would not be a candidate for breast conservation and the patient underwent mastectomy.

Ductal Extension and Calcifications

We're gonna talk a little bit about ductal extension.

This is when we look at the prominent ducts that we see on ultrasound, on mammography, a correl, it would be for looking for suspicious mal microcalcifications.

Sometimes on ultrasound we can see calcifications in a duct like distribution or in ducts.

And here would be just an example.

As we can see, when we follow up our spicules, that they're very extensive.

And we would want to know where they were and the extent of those.

And even biopsy some of the extensive speculations because we wouldn't want the surgeon to be cutting through an area of obviously involved tumor.

Here would be just another similar example.

These are multiple microcalcifications.

And with these microcalcifications, they're in induc like distribution.

This is invasive ductal carcinoma.

A similar example, but a little bit more subtle is we can see that here.

We do have some calcifications with some small cystic spaces.

This was a bit subtle.

We went to the power doppler.

We could see that there's vascularity.

We did biopsy this.

If you're biopsying this, I would use your biggest biopsy instrument and perhaps consider getting a specimen radiograph.

And we show that this was evidence of DCIS ductal carcinoma in situ two.

And here you see, we did a vacuum assisted biopsy in this area to show that this was evidence of DCIS.

Lymph Node Staging

We're gonna talk a bit about lymph node staging, and we can use ultrasound to determine if there's involvement in the axillary infra calic and scalic.

Remember, those are both N three, the internal mammary.

Now we're understanding that there is probably some significance in looking and perhaps biopsying the internal mammary and the interim mammary, which would be a lymph node within the breast.

And we know that if patients have interim mammary involvement, that then their prognosis is worse compared to a cohort that does not have intra memory nodal involvement.

This would be just an example here of calcifications within the lymph node.

Sometimes we can see calcifications in patients with invasive duct carcinoma and similar calcifications within the lymph node as we see here.

Occasionally patients with ovarian carcinoma can undergo sonomas calcification and can have this type of appearance as well.

Now, MRI can be helpful for looking at the lymph nodes, but we have to consider that oftentimes the superior extent of the axi may not be well evaluated by ultrasound.

And sometimes to carefully evaluate the extent of axillary involvement, we may need to do a dedicated axillary scan.

Furthermore, we have to be careful about field of view as you can see here, with the field of view and the signal in homogeneity.

It is somewhat difficult to see the posterior, a large excellent lymph node here in this patient with involved lymph nodes.

This is just an example.

When we're doing sentinel lymph node biopsy, this is Tanium 99 m sulfur colloid.

And you can see that we have the injection site here.

And then we have three lymph nodes posteriorly here.

These would be in the axilla.

Now seeing the lymph nodes with the radiopharmaceutical does not mean that they are involved.

It just means that those are the lymph nodes that are taken up by the radiopharmaceutical.

So the surgeon would be looking for lymph nodes that are hot with counts or those that are blue.

If they did blue dye injection or those that are hot and blue or just hot only or only blue.

And then they'd be examined very carefully by the pathologist.

So just the presence of the radiopharmaceutical uptake does not necessarily indicate evidence of metastatic involvement.

And when we look at ultrasound of the xi, it can be very helpful because we can see that the metastatic disease would come in through the afferent lymphatics set up shop in the cortex, and could really displace or compress the echogenic hilum as we see here.

So this would be our normal lymph node.

We can see that there is a hypo coic cortex and a hyper coic hilum.

And notice how the hypo coic cortex is just a very thin rim around the lymph node.

And this would just be an example here.

We see our central hilum, our very thin rim of the cortex going around the lymph node.

And what we're trying to look at with metastatic lymph nodes is if there's absence or deformity of the echogenic hilum, is that hilum no longer present or is it displaced or flattened?

And also looking for eccentric cortical hypertrophy, is the cortex expanded at the periphery of the lymph node?

And this would be just an example.

Here we see this is all cortex and the hilum has been displaced ecentric right here.

And in terms of measurements, I think a useful measurement is really the short axis measurement or the ratio of the long to short axis, because this is the normal side of the lymph node.

Notice the hilum centrally and the thin cortex.

But notice on the metastatic side, the hilum is really compressed and there's mark cortical hypertrophy as we see here.

This would be just an example of a metastatic lymph node.

And notice that the hilum as we see here is markedly compressed.

And if we were doing a biopsy, we would target the expanded cortex.

As we note here, this is just another example, just showing that this hypo como cystic region is really an expanded area of cortex, and the hilum is displaced off to the side.

So oftentimes in the malignant lymph node, we may not see the echogenic hilum.

And as the lymph node goes to malignant, it will go from more of an oval to more of a rounded shape.

And here's just an example.

The hilum is compressed and flattened as we see here.

And this is the expanded cortex of we are biopsying, we biopsy in this area right here, and here we see that the hilum is displaced and flattened.

And if we were to do a biopsy, again, we would biopsy in this expanded cortical region, as you note here.

So ultrasound can really help us to determine if the lymph node is likely benign or if it's likely malignant.

And furthermore, ultrasound has a great value in guiding biopsy, either FNA or core biopsy.

Again, FNA should be performed when you have good cytology support.

If that is lacking or not present, then one would suggest doing core biopsy.

And if we were to biopsy this lymph node, we would go for the area where the cortex is expanded, where there's the outward bump.

That's where we would biopsy in that area to prove evidence of metastatic disease.

When we think of patients with palpable breast cancers, about half of those will have excellent lymph node involvement.

In general, nodal involvement correlates with tumor size.

However, there are some limitations on the use of sonography.

And also when we do biopsies, we're not perfect.

So there are some limitations.

For example, in this case, we see an abnormal lymph node.

It's hypo coic.

I don't see a hilum.

We did the FNA here and we found no evidence of malignancy.

The patient even went on to x-ray lymph node dissection, and there was no evidence of metastatic disease.

So lymph node sonography is more sensitive than palpation.

It can identify suspicious non palpable lymph nodes, and it can be used to guide biopsy FNA or core biopsy.

Again, FNA, if there is cytology support, or if not, then one would use core biopsy.

The axillary lymph node status is associated with relapse-free survival and overall survival.

Furthermore, the nodal status is very helpful in determining what should be the local therapy, especially systemic therapy such as chemotherapy.

For example, at our institution, if we document that there's evidence of nodal involvement, then that patient will undergo chemotherapy and it usually is neoadjuvant chemotherapy.

Again, just to show you that this is a very expanded cortex, somewhat lobulated, and the hilum is displaced off to the side here.

So in general, the prior gold standard was the axial lymph node dissection where there would be control of axillary disease and accurate assessment of metastatic involvement of aary lymph nodes.

And it really provided quite a lot of prognostic information.

Now, in the current era, we try to avoid axial lymph node dissection as much as possible, so we can avoid the sequelae of lymphedema and nerve damage hematoma.

And in current practice, we try to do sentinel lymph node biopsy as much as possible.

Ultrasound plays an important role there for a negative ultrasound.

Then the patient can undergo sentinel lymph node biopsy.

If the ultrasound is positive and we prove evidence of metastatic disease by biopsy, then the patient will undergo axial lymph node dissection.

Conclusion

So we hope that in this session, we've given you a sense of the use of ultrasound with known or suspected cancers, specifically to stage the main lesion and determine how many lesions there are.

Is there evidence of multifocal or multicentric disease?

Is there ipsilateral as well as contralateral disease?

And also to keep in mind that sonography can be a very valuable tool in evaluating the lymph nodes.

When we think of the axillary, the intra and squi, if those are positive, those would both be N three.

The internal mammary, we're paying more attention to those and we know that they have significance as well, as well as the intra mammary lymph nodes, lymph nodes within the breast.

For example, if there's an intra mammary lymph node, we would biopsy it.

If it was proven to be malignant, then we would put a clip marker in that lymph node.

So we think that staging with ultrasound is valuable at the time of the initial evaluation.

Also to monitor assessment of response to therapy or even after therapy, for example, to determine if the appropriate surgery or therapy was performed.

So this would, for example, could be used to assess for evidence of disease prior to re-excision.

Thank you very much.