European Journal o1" Surgical Ontology 1996: 22:140-143 Role of ultrasonography to detect axillary node involvement in operable breast cancer Jayant S. Vaidya, Jitendra J. Vyas, Meenakshi H. Thakur*, Kamlesh C. Khandelwal* and Indraneel Mittra Breast Service 'A', Department of Surgery, *Department of Radiology, Tata Memorial Hospital, Dr Ernest Borges Road, Bombay, 400 012, India Prompted by the concern about unnecessary axillary dissections, we prospectively studied the accuracy of clinical examination (CE) and conventional ultrasonography (USG, 7.5 MHz), to diagnose pre-operatively metastatic axillary lymph nodes in 200 operable breast cancer patients. USG had higher specificity (90% vs 77%, P= 0.025) and higher positive predictive value (ppv = 90% vs 76"/0, P=0.02) than CE. Together, CE + USG had higher sensitivity (82% vs 58%, P=0.00005) and higher negative predictive value (npv = 76'¼, vs 58°/,,, P=0.008) than CE alone, in women <45 years, CE + USG had higher sensitivity (91'¼, vs 76%, P = 0.037) and npv (89'¼, vs 67%, P = 0.018) than in older women. The sensitivity and npv of CE + USG to detect >I positive node were 97% (for both) in women <45 years compared to 81% and 79% in older women. The high sensitivity of CE+USG (82°/,, for the whole group) is probably due to the higher proportion of young women (median age=45) in our population. It suggests that using CE+USG to avoid axillary dissection in some patients is feasible. Key words: ultrasonography; breast cancer; axillary nodes. Introduction It is estimated that if I00 patients with TI lesions underwent axillary dissection, about 80% would have uninvolved nodes ~'2 and would therefore have had an unnecessary procedure. With T2 lesions the gain is larger but 65% of axillary dissections are still unnecessary.'- The proportion of TI and T2 patients is increasing and a test which can pre- operatively predict axillary lymph node involvement and help in selecting patients for axillary dissection would be welcome. Hence the search for better imaging modalities for the axillary nodal status. Ultrasonographic (USG) examination of the axilla has been under evaluation for some time. Although better technology has resulted in higher specificity, the sensitivity of USG has not significantly improved. The specificity is 89°/° with a 3.5 MHz probe 3 and 97.9% with a 7.5 mHz linear-array transduceP but their sensitivity is only 68o/,,. 3.4 Although the specificity ofcolour doppler has been reported to be 98% 5 and 100%,6 its sensitivity is still low viz., 70%~ and 75%. 6The high specificity may not be relevant in clinical practice in the absence of high sensitivity. Although CT scan has been found to be more sensitive than USG (82% vs 72'¼,), 6 it still missed 18'/o of node-positive patients. We prospectively analysed the accuracy of clinical Correspondence to: Dr Jayant S. Vaidya Ms DNB,Tara Memorial Hospital, Dr Ernest Borges Road, Bombay 400 012, India. examination and ultrasonography in the detection axillary nodal metastases. Patients and methods Two hundred consecutive adult female patients diagnosed as operable breast cancer (clinical stages Tx, T1, T2 and T3 and NO or N I) who were scheduled to undergo modified radical mastectomy or lumpectomy and axillary clearance at the Tata Memorial Hospital, were entered in a prospective study. There was a gap of 5 months after 121 patients were entered, due to the long absence of a radiologist. Each patient underwent clinical examination (CE) of tile axilla which recorded the number of palpable nodes, followed by axillary ultrasonography (USG) with a 7.5 MHz linear array probe which reported the number and the largest size, of axillary lymph nodes. CE was considered positive if any node was palpated and USG was considered positive if any node above 0.5cm was detected. The examinations were carried out by the authors, CE by the surgeons and USG by the radiologists. Each patient underwent complete axillary dissection of all three levels, accompanied by a total mastectomy or a lumpectomy according to the merits of the case. The histopathology was noted and correlated with the clinical and ultrasonographic assessment of the axilla. Adjuvant treatment was routinely administered to the patients with 0748-7983/96/020140+04$12.00/0 © 1996W.B.SaundersCompanyLimited