The promise of axillary imaging in individualized surgical management of breast cancer patients: another step forward.

Breast surgical oncologists are to be commended for moving forward rapidly to embrace selective and individualized therapy for their patients. Eleven years after publication of the first report and 3 years after reporting results from the largest randomized controlled clinical trial of sentinel lymph node resection (SLNR) versus axillary lymph node dissection (ALND) for clinically node-negative breast cancer patients, SLNR is widely accepted as standard in this setting and endorsed by national and international guidelines. Moving forward, there is considerable interest in further refining and individualizing management of the axilla for newly diagnosed breast cancer patients, especially for those patients with nodepositive disease. We have become champions of further minimizing patient morbidity. Enhanced axillary imaging as an approach toward more accurate preoperative nodal staging is an area of active investigation. At one end of the spectrum, there are patients without nodal disease who might be spared axillary surgery altogether, and at the other, there is growing interest in distinguishing nodepositive patients who might be managed appropriately with SLNR alone from those who will benefit from ALND, with or without adjuvant radiation. In this issue of Annals of Surgical Oncology, Caudle and coauthors address the use of preoperative axillary ultrasound (AUS) for nodal staging of breast cancer patients in the era of American College of Surgeons Oncology Group (ACOSOG) Z0011 and International Breast Cancer Study Group (IBCSG) 23-01 trials. These well-publicized studies and others suggest the noninferiority of SLNR alone to ALND for many early stage breast cancer patients with one or two metastatic sentinel nodes undergoing (for the most part) breast-conserving surgery, planned whole-breast radiation, and adjuvant systemic therapy. Publication of these reports has caused many to question the value of preoperative AUS. Some centers have abandoned preoperative AUS for early stage breast cancer in tandem with adoption of Z0011. However, as demonstrated by the data presented by Caudle et al., this may not be the most appropriate reaction. Caudle and coauthors challenge us to move forward yet again from a one-size-fits-all approach and thoughtfully examine how we best might use enhanced imaging technology to further stratify patients and improve oncologic outcome for our breast cancer patients. The authors report on a group of 708 node-positive T1 and T2 invasive breast cancer patients evaluated between 2002 and 2012 who were operated on directly after diagnosis and did not undergo neoadjuvant chemotherapy. Patients were stratified by whether their node-positive disease was identified by preoperative AUS and fine needle aspiration (FNA) (190 patients) or at the time of SLNR (518 patients). They found that patients with a suspicious axillary lymph node who were documented node-positive by a preoperative ultrasound-guided FNA were substantially more likely than those with a negative AUS or suspicious AUS but negative FNA to have 3 or more metastatic axillary nodes, larger nodal metastases, and extranodal extension of disease. They also identified significant axillary disease burden in patients who had 1 or 2 sonographically suspicious axillary nodes and a positive preoperative lymph node FNA (45 % with C3 positive nodes). The authors additionally noted that infiltrating lobular histology, but no other clinicopathologic feature, was associated with C3 positive nodes at operation. Further, a finding of C3 sonographically suspicious nodes among the FNA-positive patient group was associated with pathologic stage N2 or higher disease in 60 %. They Society of Surgical Oncology 2014