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E1654. A Multidisciplinary Approach to Axillary Lymph Node Imaging Evaluation in the Setting of a Highly Suggestive or Suspicious Breast Mass
Authors
  1. Alyssa Cubbison; Prentice Women's Hospital
  2. Lillian Wang; Prentice Women's Hospital
  3. Tyler Litton; Prentice Women's Hospital
  4. Sarah Friedewald; Prentice Women's Hospital
  5. David Schacht; Prentice Women's Hospital
  6. Dipti Gupta; Prentice Women's Hospital
  7. Sonya Bhole; Prentice Women's Hospital
Background
The purpose of our project was to generate a standardized algorithm to guide utilization of diagnostic axillary ultrasound in the setting of a highly suggestive or highly suspicious breast mass (Breast Imaging Reporting and Data System (BI-RADS) 4C or 5) without a known cancer diagnosis. We evaluated the breast imaging radiologist’s role of diagnosing axillary metastasis in light of the Z0011 trial, which demonstrated that proving pre-operative axillary metastasis may not affect the surgical plan. The algorithm was created with Z0011 practices in mind while reflecting the clinical preferences of our radiology and surgical teams.

Educational Goals / Teaching Points
The educational goals of this project include: 1. A review of the appropriate use of axillary ultrasound with or without lymph node biopsy in the setting of a suspicious breast mass and assess its utility in this setting. 2. A review of imaging features of normal appearing and suspicious axillary lymph nodes. 3. A review of the current radiologic and surgical literature of axillary imaging with or without biopsy in the setting of a suspicious breast mass including the major implications of the Z0011 trial to the radiologist. 4. An assessment of best radiologic practices of axillary imaging in the setting of a suspicious breast mass as a quality improvement measure through standardization of our approach.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
There was agreement that the presence of suspicious axillary lymph node(s) on ultrasound could be used for treatment planning and patient discussion but would not be used for surgical planning in most cases. The surgical group agreed that an ultrasound-guided core needle biopsy of a suspicious axillary lymph node should be deferred until after surgical consultation. Discussion among the breast radiologists resulted in the consensus that axillary ultrasound at the time of initial diagnostic evaluation would be warranted if there was any of the following: a) palpable axillary lymphadenopathy b) suspicious axillary lymph nodes on mammography, or c) if tumor burden is high enough that the patient may be excluded from the Z0011 management. i.e. having breast mass size over 5 cm or if mass(s) spanned over 1 quadrant.

Conclusion
The standardization of our imaging approach to the axilla was an opportunity to incorporate the change in surgical best practices after the Z0011 trial into the imaging algorithm in a time and cost-efficient manner. The performance of axillary ultrasound in the setting of a BI-RADS 4C or 5 mass is now deferred at our institution until after surgical consultation unless there is palpable axillary lymphadenopathy, a suspicious lymph node on mammography, or a tumor that is at least stage T3. We do not routinely perform biopsies of suspicious axillary lymph nodes without a prior surgical consultation with the surgeon in order to avoid a potentially unnecessary procedure. The standardization of our imaging algorithm can hopefully act as guidance for other institutions to tailor imaging and biopsy of axillary lymph nodes in a multi-disciplinary approach.