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Ultrasound and Elastographic Features predicting Axillary Nodal Metastasis in Breast Cancer
This article was originally published by Thieme Medical and Scientific Publishers Private Ltd. and was migrated to Scientific Scholar after the change of Publisher.
How to cite this article: Phatak SV, Shinde RK, Gupta NA, Pawar G, Phatak PS. Ultrasound and Elastographic Features predicting Axillary Nodal Metastasis in Breast Cancer. Int J Recent Surg Med Sci 2017;3(2):127-129.
Abstract
Lymph node metastasis is an important prognostic factor in cases of carcinoma breast. In this pictorial essay, various sonographic and elastographic signs of lymph node metastasis are described with classical images.
Keywords
Axilla
Breast
Elastography
Metastasis
Ultrasound
INTRODUCTION
Axillary lymph node metastasis is an important prognostic factor in early-stage breast cancer and remains crucial on which individual treatment decisions are made.1 Mammography has its limitations in detecting metastatic lymph nodes because the entire axillary region cannot be adequately evaluated with this method. Positron emission tomography combined with computed tomography and magnetic resonance imaging do not have a place in routine staging because of higher costs and possibility of side effects.2 Ultrasonography (USG) is the most widely used imaging method for detection of axillary lymph node metastasis and for their characterization.3
Ultrasonography Appearance of Normal Axillary Lymph Node (Fig. 1)
- Normal axillary node is seen as elongated morphology, with an elliptical shape, containing a high proportion of central echogenic tissue, due to fat, network of blood and lymphatic vessels in the hilum. The cortex is hypoechoic, with its echogenicity similar to that of the hypoechoic subcutaneous fat
Ultrasonography Features of Malignant Axillary Lymph Node
Cortical Thickening (Fig. 2)
- Eccentric cortical thickening is seen here, which is caused by metastasis arrested in periphery of node. This usually happens before generalized cortical enlargement
Marked Hypoechogenicity and Loss of Fatty Hilum (Fig. 3)
- Marked hypoechogenicity and a fatty hilum loss attributable to metastatic deposits in lymph node
Calcification (Fig. 4)
- Hypoechoic axillary node containing calcification similar to primary tumor in breast is hallmark of metastasis
Capsular Breach (Fig. 5)
- Capsular breach in a lymph node is a salient feature of metastatic lymph node
Longitudinal–transverse Axis Ratio (Fig. 6)
- Enlargement of the short plane of the lymph node causing low longitudinal–transverse axis ratio (1.1; longitudinal short-axis ratio less than 2 is significant), due to the neoplastic involvement enlarging the short plane of the lymph node causing round shape of node, which is seen in malignant nodes
Cortex to Hilum Ratio (Figs 7 and 8)
- Metastatic lymph node showing cortex to hilum of 2.6 taken by trace method. A value more than 2 is an important feature of metastatic lymph node. Hilum is displaced at the periphery of node
- Color Doppler showing peripheral blood flow in subcapsular region due to tumor angiogenesis is also a characteristic of metastatic lymph node
Sonoelastographic Findings in Metastatic Lymph Node (Figs 9 and 10)
- Although elliptical, this lymph node is showing eccentric cortical thickening, and on elastography stiff color is noted in cortex (blue), indicating metastatic deposit confirmed on fine needle aspiration cytology. Strain ratio of lymph node in this case was 61.67
- Reactive lymph node in this case of carcinoma breast showing soft colors (score 1) with a strain ratio of 1.59, indicating benign nature of disease
Elastography Scoring System for Metastatic Lymph Node (Fig. 11)4-9
- Metastatic lymph node showing score of 4 on elastography score system (blue area more than 45% with or without green rim)
SUMMARY
Metastasis to axillary lymph node is an important factor in the prognosis of early-stage breast cancer and crucial for decision-making in management. There are many classical gray-scale and elastographic features that predict metastasis to axillary lymph node. These features are discussed in brief and classical images are illustrated in patients of breast cancer. These features help in early detection of lymph node metastasis.
Source of support:
Nil
Conflict of interest:
None.
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