Role of ultrasound-guided fine needle cytology of axillary lymph nodes in breast carcinoma staging.

PURPOSE: To evaluate the efficacy of cytology on axillary lymph node ultrasound-guided aspiration biopsy in the reduction of inappropriate surgery, such as the sentinel node (SN) procedure if positive, or axillary dissection if negative. MATERIALS AND METHODS: Cytology was performed on 159 consecutive cases, on the ultrasonographically most suspicious lymph node. Lymph node histology was used as a reference standard to determine accuracy. Four different scenarios were simulated: routine axillary ultrasonography with cytology of the lymph nodes visible at ultrasonography (A), or of only the lymph nodes suspicious at ultrasonography (B), with ultrasonography limited to clinically negative axillae and cytology of the lymph nodes visible at ultrasonography (C), or only of the lymph nodes suspicious at ultrasonography only (D). RESULTS: Cytologic sensitivity was 58.6%, specificity 100%. Immediate axillary dissection only in the case of positive cytology would have avoided 6/6 inappropriate axillary dissections and 5/34 (14.7%) inappropriate SN, compared to routine practice (immediate dissection for palpable adenopathy, SN in the remaining cases). Each of the simulated scenarios saved inappropriate surgical procedures (A: 6 dissections, 5 SNs; B: 6 dissections, 3 SNs; C: 13 SNs; D: 11 SNs) at no expense (A and B) or limited expense (C: Euro 348, D: Euro 232 for each inappropriate surgical procedure saved). CONCLUSIONS: Axillary lymph node cytology can save axillary dissections or sentinel node procedures and is recommended as routine practice. Routine axillary ultrasonography, with cytology of sonographically visible lymph nodes, followed by immediate axillary dissection only in case of positive cytology proved to be the best approach in terms of cost-benefit ratio.

Comparison of standard reading and computer aided diagnosis (CAD) on a proficiency test of screening mammography.

PURPOSE: To evaluate the role of computer aided diagnosis (CAD) to improve screening mammograms interpretation. MATERIALS AND METHODS: Six radiologists underwent a screening mammography proficiency test first by conventional, then by CAD assisted reading. Sensitivity and recall rate at conventional and CAD reading were compared. Independent conventional double reading was simulated (15 pair combinations) and compared to single CAD reading. RESULTS: CAD marked 31 of 32 cancers (case-based sensitivity=96.8%). On a film and lesion basis, CAD identified 31 of 32 (96.8%) malignant calcifications and 29 of 42 (69.0%) malignant opacities, the only cancer not identified by CAD being depicted as an isolated opacity. CAD marked 348 areas (153 microcalcifications and 195 opacities) in 88 of 108 non cancer cases, with a case-based specificity of 18.5% (20/108). Considering all six readings, cancer was identified in 164 or 174 of 192 readings (85.4 vs 90.6%, c2 2.03, df=1, p=0.15) and recalls of non-cancer cases were 108 or 159 of 648 readings (16.6 vs 24.5%, c2 11.7, df=1, p<0.001) at conventional or CAD reading, respectively. CAD reading (average of 6 readings, 192 cancer, 648 non-cancer readings) was slightly, non significantly less sensitive (sensitivity 90.6 vs 92.9%, c2 0.73, df=1, p=0.39) and slightly, but not significantly more specific (recall rate 24.5 vs 26.1%, c2 0.56, df=1, p=0.45) as compared to simulated independent double reading (average of 15 combinations, 480 cancer, 1620 non-cancer readings). CONCLUSION: CAD seems to allow for a limited absolute increase (+5.2%) in sensitivity and for a limited absolute increase (+7.9%) in recall rate, the latter difference only reaching statistical significance. CAD reading showed no significant difference in diagnostic accuracy as compared to conventional (simulated) double reading, although further studies are needed to confirm it as possible alternative to double reading in the current screening practice.