The Role of Ultrasound of the Regional Nodal Basins in Staging Patients with Triple Negative Breast Cancer: Implications for Local-Regional TreatmentSimona 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 MD41Department 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

Patients & Methods

Figure 1. Sample Patient Case

Conclusions

To understand the role of regional nodal ultrasound in the clinical staging of patients with TNBC and if this staging evaluation influences treatment delivered.

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.

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.

Treatment Received Upstaged by Ultrasound

Not Upstaged p-value

Axillary Lymph Node Dissection 99% (110/111) 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)45% (134/297)

8% (10/134)

<.0001<.0001<.0001

Ultrasound UpstagingTotal Patients with Nodal Upstaging 19% (111/572)

cN0 cN+ cN0 cN1 cN0 cN3a cN0 cN3b cN0 cN3c

9% (50/572)6% (36/572)1% (5/572)1% (4/572)1% (5/572)

cN1 cN3 cN1 cN3a cN1 cN3b cN1 cN3c

8% (47/572)4% (23/572)2% (12/572)2% (12/572)

cN2 cN3 cN2 cN3a cN2 cN3b cN2 cN3c

2% (12/572)0% (1/572)1% (6/572)1% (5/572)

cN3a cN3bcN3a cN3c

0% (1/572)0% (1/572)

Clinical Nodal Stage

Physical Examination

Ultrasound Alone

Overall Clinical Nodal Stage

(P.E., Imaging & Biopsy)NxN0N1N2

N3aN3bN3c

0%58%37%4%1%0%1%

0%34%45%0%8%3%

10%

0%62%24%0%5%4%4%

Patient Characteristics % (ratio)Race White Hispanic Black

59% (335/572)15% (84/572)

20% (115/572)Age at Diagnosis <40yo 40-49yo 50-59yo 60-69yo ≥ 70yo

17% (97/572)27% (155/572)30% (174/572)19% (108/572)

7% (38/572)Postmenopausal 61% (349/572)Invasive Ductal Histology 95% (541/572)Nuclear Grade 3 92% (524/572)Lymphovascular Space Invasion 20% (113/572)Clinical (Imaging/P.E.) T Stage Tx-T0 T1 T2 T3 T4

10% (55/572)21% (121/572)45% (255/572)17% (99/572)7% (42/572)

Axillary Lymph Node Dissection 46% (261/572)Chemotherapy Neoadjuvant Chemotherapy Adjuvant Chemotherapy

59% (338/572)38% (218/572)

Radiotherapy (RT) Breast/Chestwall Breast/Chestwall + RNI

30% (169/572)41% (232/572)

ResultsTable 2. Clinical Nodal Stage based on Physical Examination, Ultrasound, and Biopsy

Table 3. Clinical Upstaging with Ultrasound & Biopsy

Table 4. Treatment Delivered Based on Ultrasound Upstaging

Table 1. Baseline Patient Characteristics