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Impact of Preoperative Ultrasonography and Fine-Needle Aspiration of Axillary Lymph Nodes on Surgical Management of Primary Breast Cancer
smaller than 1.4 cm. The relative cumulative survival of patients with adenoid cystic breast carcinoma was 95.6% at 5 years and 94.9% at 10 years. ACC of the breast is a rare disease with an overall good prognosis. Knowing that this cancer usually presents as localized disease, with lymph node involvement seen only with larger tumors, can help clinicians plan the operative management of these tumors. Mammary ACC is a rare and unusual form of invasive breast cancer that behaves exceedingly favorably. In their study, Thompson and colleagues suggest that routine sentinel node biopsy in patients with ACC may not be necessary, given the low (<5%) overall rate of metastatic involvement of axillary lymph nodes. In fact, a similar individualized approach has also been recommended by Mendez and colleagues for conventional breast cancer of favorable histologic types because of their equally low rates of axillary nodal metastasis.1
Impact of Preoperative Ultrasonography and Fine-Needle Aspiration of Axillary Lymph Nodes on Surgical Management of Primary Breast Cancer Park SH, Kim MJ, Park B-W, et al (Yonsei Univ College of Medicine, Seoul, Korea) Ann Surg Oncol 18:738-744, 2011
Purpose.dTo evaluate the accuracy of preoperative ultrasonography (US) and US-guided fine-needle aspiration (US-FNA) for detecting axillary lymph node (ALN) metastasis. Patients and Methods.dWe retrospectively reviewed 382 breast cancer patients with clinically negative ALN
It is important to remember that ACC is morphologically heterogeneous. Several growth patterns of ACC have been described, with cribriform being by far the most common, and the others being tubular, trabecular, and solid. These patterns most commonly occur in combination. However, a solid ACC with basaloid features has been well illustrated by Shin and Rosen.2 In their study of 9 such tumors, the axillary nodal metastatic rate was about 33% (2/6 axillary dissections), underscoring its aggressive behavior. Although in both cases the primary tumors were fairly large (5 and 15 cm), there are reports of smaller tumors of this type behaving aggressively.3 Based on our experience at Memorial SloanKettering Cancer Center, the solid variant of ACC, although fairly rare, seems to be more prone to lymph node spread (20% rate, unpublished data). It is, therefore, important to be aware of the histologic type of ACC, in addition to the size, when considering whether to perform a sentinel node
who underwent US and/or US-FNA for ALN. US-FNA of ALN was performed in 121 patients with suspicious findings on US. The diagnostic performance of US alone or with the addition of US-FNA for detecting ALN metastasis was calculated on the basis of final pathologic reports of ALN surgery. Results.dAmong a total of 382 patients, 129 had metastatic ALNs while 253 exhibited no signs of axillary metastasis on final pathology. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of axillary US alone were 56.6% (73/129), 81.0% (205/253), 60.3% (73/121), and 78.5% (205/261), respectively. Addition of US-FNA re-
biopsy. Given that the study by Thompson and colleagues is epidemiologic in nature, details of morphology are understandably not available. Centralized pathologic review of the cases (not an easy task) could have potentially addressed this issue. E. A. Slodkowska, MD D. Giri, MD
References 1. Mendez JE, Fey JV, Cody H, Borgen PI, Sclafani LM. Can sentinel lymph node biopsy be omitted in patients with favorable breast cancer histology? Ann Surg Oncol. 2005;12:24-28. 2. Shin SJ, Rosen PP. Solid variant of mammary adenoid cystic carcinoma with basaloid features: a study of nine cases. Am J Surg Pathol. 2002;26: 413-420. 3. Fukuoka K, Hirokawa M, Shimizu M, et al. Basaloid type adenoid cystic carcinoma of the breast. APMIS. 1999;107:762-766.
sulted in sensitivity, specificity, PPV, and NPV of 39.5% (51/129), 95.7% (242/253), 82.3% (51/62), and 75.6% (242/320), respectively. Excluding complete responders to neoadjuvant chemotherapy, specificity and PPVafter adding US-FNA were increased to 99.6% (242/243) and 98.1% (51/52), respectively. The sensitivity and specificity of ALN metastasis were similar between the palpable and nonpalpable breast cancer groups; however, after adding US-FNA, NPV was increased in the nonpalpable breast cancer group compared with the palpable breast cancer group (p ¼ 0.0398). By including preoperative axillary US and US-FNA, 16.2% (62/382) of all breast cancer patients
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 1 2012
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TABLE 1.dPreoperative Ultrasound-Guided Needle Biopsy (UNB) as a Triage Test in Staging the Axilla in Women with Invasive Breast Cancer e Summary Findings From Meta-Analysis Test Accuracy or Utility in Staging the Axilla [Number of Subjects in Series; Number who had UNB]* Ultrasound-only accuracy [4313; not applicable] UNB positive predictive value (PPV) [6166; 2874] UNB modeled pooled accuracy [5981; 2805], excluding insufficient UNB results UNB modeled pooled accuracy [4830; 2397], including insufficient UNB results as test negatives Insufficient (inadequate) UNB results [4830; 2397] Subjects with insufficient UNB found to have node metastases on excision histology [2862; 1741] Women triaged (or potentially triaged) directly to axillary dissection/treatment based on UNB result [5115; 2329] Women triaged (or potentially triaged) to axillary dissection based on UNB result, in studies including only women with clinically node-negative axillae [3733; 1348] Estimated proportion of women with metastatic axillary nodes potentially triaged to axillary dissection/treatment if UNB is used preoperatively in all new breast cancer cases [6166 (2678)†; 2874]
Measure (95% CI or IQR)§
Summary Estimate
Median sensitivity (IQR) Median specificity (IQR) Median PPV (IQR; absolute range) Pooled sensitivity (CI) Pooled specificity (CI) Pooled sensitivity (CI) Pooled specificity (CI) Median proportion (IQR) Median proportion (IQR)
61.4% (51.2% to 79.4%) 82.0% (76.9% to 89.0%) 100% (100% to 100%; 92.5% to 100%) 79.6% (74.1%, 84.2%) 98.3% (97.2%, 99.0%) 75.0% (67.6%, 81.1%) 98.5% (97.3%, 99.1%) 4.1% (0% to 10.9%) 43.1% (36.4% to 60.0%)
Median proportion (IQR)
19.8% (11.6% to 28.1%)
Median proportion (IQR)
17.7% (11.6% to 27.1%)
Median proportion (IQR)
55.2% (41.8% to 68.2%)
Adapted from Houssami N, Ciatto S, Turner RM, Cody HS 3rd, Macaskill P. Preoperative ultrasound-guided needle biopsy of axillary nodes in invasive breast cancer: meta-analysis of its accuracy and utility in staging the axilla. Ann Surg. 2011;254:243-251. *Number of studies contributing data to each summary estimate varies between 16 and 31 studies; therefore, the number of subjects included in each analysis is shown (UNB-specific estimates based on subjects who had UNB). § 95% confidence interval (CI) shown for modeled estimate or interquartile range (IQR) for median proportion of summarized evidence. † Number in parentheses is the number of subjects (of 6166) with metastatic nodes ascertained on excision (surgical) histology.
were able to avoid unnecessary sentinel lymph node biopsy (SLNB). Conclusions.dThe combination of axillary US and US-FNA is useful in preoperative work-up of breast cancer patients and provides valuable information for planning proper breast cancer management. The use of ultrasound-guided needle biopsy (UNB), either FNA or core-needle biopsy, to identify ALN metastases prior to surgical intervention in women with invasive breast cancer is not a new concept.1-5 Many studies, all nonrandomized in design, have examined the accuracy of US and UNB for identifying ALNs; the evidence from the majority of these studies was recently summarized in a metaanalysis.6 Hence, this study from Park and colleagues does not add novel information and does not represent
58
higher quality evidence than similar retrospective studies from the past decade. Rather, it further confirms that preoperative US and UNB effectively triage, directly to axillary dissection, a proportion of women with ALN metastases who can thus avoid unnecessary SLNB. The estimated accuracy and clinical effects of axillary UNB in the Park and colleagues study are best considered in the context of all the available data on this topic, as reported in the meta-analysis by Houssami and colleagues6 and summarized in Table 1, including measures of test utility defined in terms of the proportion of women triaged to axillary surgery or treatment. Critical to the application of UNB in this setting is that adequate US and UNB sensitivity (see estimates in Table 1) will effectively triage 17% to 20% of all women with invasive breast cancer or 50% or more of women
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 1 2012
subsequently found to have ALN metastases.6 In that respect, this study from Park and colleagues reports results generally within the range of the existing evidence,1-6 with the exception of a lower-than-expected sensitivity for UNB. The authors attribute this lower UNB sensitivity (at least in part) to 6 of the 7 cytology results being inadequate in women identified as having ALN metastases on pathology; in the previous metaanalysis, a median of 43% of the cytology results were inadequate in women with ALN metastases on final pathology.6 UNB gives consistently high (and homogeneous) specificity across a large number of studies; however, the sensitivity of UNB appears to be much more variable and is associated with US sensitivity.6 It should be emphasized that a triage test requires
good (but not necessarily very high) sensitivity, and specificity in this staging context is likely to be more important than sensitivity.6 This is because a false-positive UNB result leads to unnecessarily excessive surgery to the axilla, whereas a falsenegative UNB result means that the woman proceeds to standard staging with initial SLNB. Meta-analysis also showed that the odds ratio for the proportion of women with metastatic ALNs potentially triaged to axillary dissection in studies with a median tumor size greater than or equal to 21 mm was 2.57 (95% confidence interval, 1.29-5.09) relative to studies with a median tumor size less than 21 mm, indicating that UNB utility is significantly higher in women with larger tumors. So while systematic use of UNB in all newly diagnosed invasive breast cancers has not been widely adopted, it is likely that, as
a staging test, UNB will provide excellent clinical utility in women with a higher-than-average underlying risk of having ALN metastases based on tumor characteristics.
Intraoperative Assessment of Breast Cancer Specimens Decreases Cost and Number of Reoperations
costs and need for reoperation. One hundred and seven cases met criteria for inclusion in the study (UMCB ¼ 45, SNW ¼ 62). Intraoperative margin assessment was used in zero cases at SNW (0%) and in 17 at UMCB (38%). Intraoperative assessment was used in 16 per cent of total cases. Sixty per cent of cases at SNW required subsequent return to the operating room. Twenty-four per cent of cases at UMCB required subsequent reoperation (P < 0.05). The average number of surgical interventions required was 1 ± 0.3 with intraoperative assessment, 2 ± 0.6 without, (P < 0.05). Total surgical costs were $15,341 ± $4,328 with intraoperative assessment and $22,013 ± $13,821 without (P < 0.05). Use of intraoperative margin assessment for breast cancer operations
Uecker JM, Bui EH, Foulkrod KH, et al (Univ of Texas SouthwesterndAustin) Am Surg 77:342-344, 2011
It is the aim of our study to determine if the assessment of intraoperative breast cancer margins leads to decreased incidence of repeat operations and decreased cost. We collected data prospectively from two hospitals in Austin, TX, University Medical Center at Brackenridge (UMCB) and Seton Northwest Hospital (SNW), over a 2-year period. Comparison was made to see if intraoperative margin assessment affected total surgical
N. Houssami, MBBS, PhD S. Ciatto, PhD
References 1. Ciatto S, Brancato B, Risso G, et al. Accuracy of fine needle aspiration cytology (FNAC) of axillary lymph nodes as a triage test in breast cancer staging. Breast Cancer Res Treat. 2007;103:85-91. 2. de Kanter AY, van Eijck CH, 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. 3. Britton PD, Goud A, Godward S, et al. Use of ultrasound-guided
axillary node core biopsy in staging of early breast cancer. Eur Radiol. 2009;19:561-569. 4. Kuenen-Boumeester V, MenkePluymers M, de Kanter AY, Obdeijn IM, Urich D, Van Der Kwast TH. Ultrasound-guided fine needle aspiration cytology of axillary lymph nodes in breast cancer patients. A preoperative staging procedure. Eur J Cancer. 2003;39:170-174. 5. 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. 6. Houssami N, Ciatto S, Turner RM, Cody HS 3rd, Macaskill P. Preoperative ultrasound-guided needle biopsy of axillary nodes in invasive breast cancer: meta-analysis of its accuracy and utility in staging the axilla. Ann Surg. 2011;254: 243-251.
leads to both a decrease in reoperations as well as a decrease in total operative costs. This study by Uecker and colleagues showed that intraoperative assessment of breast cancer specimens may reduce the total cost as well as the number of reoperations. Their assessment method during the operation was mainly gross specimen evaluation. This assessment method costs less than other methods, such as touch imprint cytology, frozen section analysis, or specimen radiography. As indicated by Camp and colleagues,1 the cost of frozen section analysis during breastconserving surgery was equivalent to the cost of the second surgery needed to achieve a clear resection margin when intraoperative assessment was not
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 1 2012
59
Impact of Preoperative Ultrasonography and Fine-Needle Aspiration of Axillary Lymph Nodes on Surgical Management of Primary Breast Cancer Park SH, Kim MJ, Park B-W, et al (Yonsei Univ College of Medicine, Seoul, Korea) Ann Surg Oncol 18:738-744, 2011
Purpose.dTo evaluate the accuracy of preoperative ultrasonography (US) and US-guided fine-needle aspiration (US-FNA) for detecting axillary lymph node (ALN) metastasis. Patients and Methods.dWe retrospectively reviewed 382 breast cancer patients with clinically negative ALN
It is important to remember that ACC is morphologically heterogeneous. Several growth patterns of ACC have been described, with cribriform being by far the most common, and the others being tubular, trabecular, and solid. These patterns most commonly occur in combination. However, a solid ACC with basaloid features has been well illustrated by Shin and Rosen.2 In their study of 9 such tumors, the axillary nodal metastatic rate was about 33% (2/6 axillary dissections), underscoring its aggressive behavior. Although in both cases the primary tumors were fairly large (5 and 15 cm), there are reports of smaller tumors of this type behaving aggressively.3 Based on our experience at Memorial SloanKettering Cancer Center, the solid variant of ACC, although fairly rare, seems to be more prone to lymph node spread (20% rate, unpublished data). It is, therefore, important to be aware of the histologic type of ACC, in addition to the size, when considering whether to perform a sentinel node
who underwent US and/or US-FNA for ALN. US-FNA of ALN was performed in 121 patients with suspicious findings on US. The diagnostic performance of US alone or with the addition of US-FNA for detecting ALN metastasis was calculated on the basis of final pathologic reports of ALN surgery. Results.dAmong a total of 382 patients, 129 had metastatic ALNs while 253 exhibited no signs of axillary metastasis on final pathology. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of axillary US alone were 56.6% (73/129), 81.0% (205/253), 60.3% (73/121), and 78.5% (205/261), respectively. Addition of US-FNA re-
biopsy. Given that the study by Thompson and colleagues is epidemiologic in nature, details of morphology are understandably not available. Centralized pathologic review of the cases (not an easy task) could have potentially addressed this issue. E. A. Slodkowska, MD D. Giri, MD
References 1. Mendez JE, Fey JV, Cody H, Borgen PI, Sclafani LM. Can sentinel lymph node biopsy be omitted in patients with favorable breast cancer histology? Ann Surg Oncol. 2005;12:24-28. 2. Shin SJ, Rosen PP. Solid variant of mammary adenoid cystic carcinoma with basaloid features: a study of nine cases. Am J Surg Pathol. 2002;26: 413-420. 3. Fukuoka K, Hirokawa M, Shimizu M, et al. Basaloid type adenoid cystic carcinoma of the breast. APMIS. 1999;107:762-766.
sulted in sensitivity, specificity, PPV, and NPV of 39.5% (51/129), 95.7% (242/253), 82.3% (51/62), and 75.6% (242/320), respectively. Excluding complete responders to neoadjuvant chemotherapy, specificity and PPVafter adding US-FNA were increased to 99.6% (242/243) and 98.1% (51/52), respectively. The sensitivity and specificity of ALN metastasis were similar between the palpable and nonpalpable breast cancer groups; however, after adding US-FNA, NPV was increased in the nonpalpable breast cancer group compared with the palpable breast cancer group (p ¼ 0.0398). By including preoperative axillary US and US-FNA, 16.2% (62/382) of all breast cancer patients
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 1 2012
57
TABLE 1.dPreoperative Ultrasound-Guided Needle Biopsy (UNB) as a Triage Test in Staging the Axilla in Women with Invasive Breast Cancer e Summary Findings From Meta-Analysis Test Accuracy or Utility in Staging the Axilla [Number of Subjects in Series; Number who had UNB]* Ultrasound-only accuracy [4313; not applicable] UNB positive predictive value (PPV) [6166; 2874] UNB modeled pooled accuracy [5981; 2805], excluding insufficient UNB results UNB modeled pooled accuracy [4830; 2397], including insufficient UNB results as test negatives Insufficient (inadequate) UNB results [4830; 2397] Subjects with insufficient UNB found to have node metastases on excision histology [2862; 1741] Women triaged (or potentially triaged) directly to axillary dissection/treatment based on UNB result [5115; 2329] Women triaged (or potentially triaged) to axillary dissection based on UNB result, in studies including only women with clinically node-negative axillae [3733; 1348] Estimated proportion of women with metastatic axillary nodes potentially triaged to axillary dissection/treatment if UNB is used preoperatively in all new breast cancer cases [6166 (2678)†; 2874]
Measure (95% CI or IQR)§
Summary Estimate
Median sensitivity (IQR) Median specificity (IQR) Median PPV (IQR; absolute range) Pooled sensitivity (CI) Pooled specificity (CI) Pooled sensitivity (CI) Pooled specificity (CI) Median proportion (IQR) Median proportion (IQR)
61.4% (51.2% to 79.4%) 82.0% (76.9% to 89.0%) 100% (100% to 100%; 92.5% to 100%) 79.6% (74.1%, 84.2%) 98.3% (97.2%, 99.0%) 75.0% (67.6%, 81.1%) 98.5% (97.3%, 99.1%) 4.1% (0% to 10.9%) 43.1% (36.4% to 60.0%)
Median proportion (IQR)
19.8% (11.6% to 28.1%)
Median proportion (IQR)
17.7% (11.6% to 27.1%)
Median proportion (IQR)
55.2% (41.8% to 68.2%)
Adapted from Houssami N, Ciatto S, Turner RM, Cody HS 3rd, Macaskill P. Preoperative ultrasound-guided needle biopsy of axillary nodes in invasive breast cancer: meta-analysis of its accuracy and utility in staging the axilla. Ann Surg. 2011;254:243-251. *Number of studies contributing data to each summary estimate varies between 16 and 31 studies; therefore, the number of subjects included in each analysis is shown (UNB-specific estimates based on subjects who had UNB). § 95% confidence interval (CI) shown for modeled estimate or interquartile range (IQR) for median proportion of summarized evidence. † Number in parentheses is the number of subjects (of 6166) with metastatic nodes ascertained on excision (surgical) histology.
were able to avoid unnecessary sentinel lymph node biopsy (SLNB). Conclusions.dThe combination of axillary US and US-FNA is useful in preoperative work-up of breast cancer patients and provides valuable information for planning proper breast cancer management. The use of ultrasound-guided needle biopsy (UNB), either FNA or core-needle biopsy, to identify ALN metastases prior to surgical intervention in women with invasive breast cancer is not a new concept.1-5 Many studies, all nonrandomized in design, have examined the accuracy of US and UNB for identifying ALNs; the evidence from the majority of these studies was recently summarized in a metaanalysis.6 Hence, this study from Park and colleagues does not add novel information and does not represent
58
higher quality evidence than similar retrospective studies from the past decade. Rather, it further confirms that preoperative US and UNB effectively triage, directly to axillary dissection, a proportion of women with ALN metastases who can thus avoid unnecessary SLNB. The estimated accuracy and clinical effects of axillary UNB in the Park and colleagues study are best considered in the context of all the available data on this topic, as reported in the meta-analysis by Houssami and colleagues6 and summarized in Table 1, including measures of test utility defined in terms of the proportion of women triaged to axillary surgery or treatment. Critical to the application of UNB in this setting is that adequate US and UNB sensitivity (see estimates in Table 1) will effectively triage 17% to 20% of all women with invasive breast cancer or 50% or more of women
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 1 2012
subsequently found to have ALN metastases.6 In that respect, this study from Park and colleagues reports results generally within the range of the existing evidence,1-6 with the exception of a lower-than-expected sensitivity for UNB. The authors attribute this lower UNB sensitivity (at least in part) to 6 of the 7 cytology results being inadequate in women identified as having ALN metastases on pathology; in the previous metaanalysis, a median of 43% of the cytology results were inadequate in women with ALN metastases on final pathology.6 UNB gives consistently high (and homogeneous) specificity across a large number of studies; however, the sensitivity of UNB appears to be much more variable and is associated with US sensitivity.6 It should be emphasized that a triage test requires
good (but not necessarily very high) sensitivity, and specificity in this staging context is likely to be more important than sensitivity.6 This is because a false-positive UNB result leads to unnecessarily excessive surgery to the axilla, whereas a falsenegative UNB result means that the woman proceeds to standard staging with initial SLNB. Meta-analysis also showed that the odds ratio for the proportion of women with metastatic ALNs potentially triaged to axillary dissection in studies with a median tumor size greater than or equal to 21 mm was 2.57 (95% confidence interval, 1.29-5.09) relative to studies with a median tumor size less than 21 mm, indicating that UNB utility is significantly higher in women with larger tumors. So while systematic use of UNB in all newly diagnosed invasive breast cancers has not been widely adopted, it is likely that, as
a staging test, UNB will provide excellent clinical utility in women with a higher-than-average underlying risk of having ALN metastases based on tumor characteristics.
Intraoperative Assessment of Breast Cancer Specimens Decreases Cost and Number of Reoperations
costs and need for reoperation. One hundred and seven cases met criteria for inclusion in the study (UMCB ¼ 45, SNW ¼ 62). Intraoperative margin assessment was used in zero cases at SNW (0%) and in 17 at UMCB (38%). Intraoperative assessment was used in 16 per cent of total cases. Sixty per cent of cases at SNW required subsequent return to the operating room. Twenty-four per cent of cases at UMCB required subsequent reoperation (P < 0.05). The average number of surgical interventions required was 1 ± 0.3 with intraoperative assessment, 2 ± 0.6 without, (P < 0.05). Total surgical costs were $15,341 ± $4,328 with intraoperative assessment and $22,013 ± $13,821 without (P < 0.05). Use of intraoperative margin assessment for breast cancer operations
Uecker JM, Bui EH, Foulkrod KH, et al (Univ of Texas SouthwesterndAustin) Am Surg 77:342-344, 2011
It is the aim of our study to determine if the assessment of intraoperative breast cancer margins leads to decreased incidence of repeat operations and decreased cost. We collected data prospectively from two hospitals in Austin, TX, University Medical Center at Brackenridge (UMCB) and Seton Northwest Hospital (SNW), over a 2-year period. Comparison was made to see if intraoperative margin assessment affected total surgical
N. Houssami, MBBS, PhD S. Ciatto, PhD
References 1. Ciatto S, Brancato B, Risso G, et al. Accuracy of fine needle aspiration cytology (FNAC) of axillary lymph nodes as a triage test in breast cancer staging. Breast Cancer Res Treat. 2007;103:85-91. 2. de Kanter AY, van Eijck CH, 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. 3. Britton PD, Goud A, Godward S, et al. Use of ultrasound-guided
axillary node core biopsy in staging of early breast cancer. Eur Radiol. 2009;19:561-569. 4. Kuenen-Boumeester V, MenkePluymers M, de Kanter AY, Obdeijn IM, Urich D, Van Der Kwast TH. Ultrasound-guided fine needle aspiration cytology of axillary lymph nodes in breast cancer patients. A preoperative staging procedure. Eur J Cancer. 2003;39:170-174. 5. 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. 6. Houssami N, Ciatto S, Turner RM, Cody HS 3rd, Macaskill P. Preoperative ultrasound-guided needle biopsy of axillary nodes in invasive breast cancer: meta-analysis of its accuracy and utility in staging the axilla. Ann Surg. 2011;254: 243-251.
leads to both a decrease in reoperations as well as a decrease in total operative costs. This study by Uecker and colleagues showed that intraoperative assessment of breast cancer specimens may reduce the total cost as well as the number of reoperations. Their assessment method during the operation was mainly gross specimen evaluation. This assessment method costs less than other methods, such as touch imprint cytology, frozen section analysis, or specimen radiography. As indicated by Camp and colleagues,1 the cost of frozen section analysis during breastconserving surgery was equivalent to the cost of the second surgery needed to achieve a clear resection margin when intraoperative assessment was not
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 1 2012
59