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The Role of Ultrasound of the Regional Nodal Basins in Staging Patients with Triple
Negative Breast Cancer: Implications for Local-Regional Treatment
Simona F. Shaitelman MD EdM1, Welela Tereffe MD MPH1, Kenneth R. Hess PhD2, Ana M. Gonzalez-Angulo MD MSc3, Basak E. Dogan MD4, Michael C.
Stauder MD1, Vicente Valero MD3, Savitri Krishnamurthy MD4, Eric A. Strom MD1, Kelly K. Hunt MD5, Thomas A. Buchholz MD1, Gary J. Whitman MD4
1Department
of Radiation Oncology, MD Anderson Cancer Center, 2 Department of Biostatistics, MD Anderson Cancer Center, 3 Department of Breast Medical Oncology, MD Anderson Cancer Center, 4Department of Diagnostic Radiology, MD Anderson
Cancer Center, 5Department of Surgical Oncology, MD Anderson Cancer Center
Introduction
 Patients with triple negative receptor breast cancer (TNBC)
are commonly treated with neoadjuvant chemotherapy, for
which accurate clinical staging is especially important.
 Patients with TNBC attain pathologic complete response
(pCR) rates of 30-40% (Liedtke et al, JCO, 2008).
 Determination of accurate clinical staging is critical for
patients with TNBC to ensure they are treated with optimal
local-regional management
Aims
 To understand the role of regional nodal ultrasound in
the clinical staging of patients with TNBC and if this
staging evaluation influences treatment delivered.
Patients & Methods
 Women evaluated sequentially at the University of Texas
MD Anderson Cancer Center between 2004 and 2011
with stage I-III TNBC were reviewed retrospectively.
 The population of patients with TNBC who had a physical
examination, mammography, and breast and regional
nodal basin ultrasound +/- biopsy of suspicious lymph
node(s) and definitive local-regional treatment at our
institution was identified for the purpose of this study.
 Clinical stage of patients prior to and after ultrasound of
the regional nodal basins was compared, as was the
definitive treatment given to these patients.
 Clinical characteristics of the 572 breast cancer patients
studied are shown in Table 1.
Figure 1. Sample Patient Case
Table 1. Baseline Patient Characteristics
Patient Characteristics
Race
White
Hispanic
Black
Age at Diagnosis
<40yo
40-49yo
50-59yo
60-69yo
≥ 70yo
Postmenopausal
Invasive Ductal Histology
Nuclear Grade 3
Lymphovascular Space Invasion
Clinical (Imaging/P.E.) T Stage
Tx-T0
T1
T2
T3
T4
Axillary Lymph Node Dissection
Chemotherapy
Neoadjuvant Chemotherapy
Adjuvant Chemotherapy
Radiotherapy (RT)
Breast/Chestwall
Breast/Chestwall + RNI
% (ratio)
59% (335/572)
15% (84/572)
20% (115/572)
17% (97/572)
27% (155/572)
30% (174/572)
19% (108/572)
7% (38/572)
61% (349/572)
95% (541/572)
92% (524/572)
20% (113/572)
10% (55/572)
21% (121/572)
45% (255/572)
17% (99/572)
7% (42/572)
46% (261/572)
59% (338/572)
38% (218/572)
30% (169/572)
41% (232/572)
Results
Table 2. Clinical Nodal Stage based on Physical
Examination, Ultrasound, and Biopsy
Clinical Nodal
Physical Ultrasound
Stage
Examination Alone
Nx
N0
N1
N2
N3a
N3b
N3c
0%
58%
37%
4%
1%
0%
1%
0%
34%
45%
0%
8%
3%
10%
Overall Clinical
Nodal Stage
(P.E., Imaging & Biopsy)
0%
62%
24%
0%
5%
4%
4%
Table 3. Clinical Upstaging with Ultrasound & Biopsy
Ultrasound Upstaging
Total Patients with Nodal Upstaging
cN0  cN+
cN0  cN1
cN0  cN3a
cN0  cN3b
cN0  cN3c
cN1  cN3
cN1  cN3a
cN1  cN3b
cN1  cN3c
cN2  cN3
cN2  cN3a
cN2  cN3b
cN2  cN3c
cN3a  cN3b
cN3a  cN3c
19% (111/572)
9% (50/572)
6% (36/572)
1% (5/572)
1% (4/572)
1% (5/572)
8% (47/572)
4% (23/572)
2% (12/572)
2% (12/572)
2% (12/572)
0% (1/572)
1% (6/572)
1% (5/572)
0% (1/572)
0% (1/572)
Table 4. Treatment Delivered Based on Ultrasound Upstaging
Treatment Received
Axillary Lymph Node Dissection
Upstaged by
Ultrasound
99% (110/111)
Not Upstaged p-value
35% (159/461) <.0001
Neoadjuvant Chemotherapy
92% (102/111)
51 % (236/461) <.0001
Adjuvant Chemotherapy
15% (17/111)
44% (201/461) <.0001
Radiation Therapy
RNI as a part of RT
Boost Dose to Nodal Basin as a
part of RNI
94% (104/111)
94% (98/104)
69% (68/98)
64% (297/461) <.0001
45% (134/297) <.0001
8% (10/134) <.0001
Conclusions
 Ipsilateral regional nodal ultrasound with ultrasound-guided biopsy is
important for accurately determining the extent of regional nodal
involvement in patients with TNBC.
 Regional nodal ultrasound frequently changes the clinical stage of TNBC and
should play an important role in multidisciplinary treatment decisions,
including local-regional management.