Positive predictive value of axillary lymph node cortical thickness and nodal, clinical, and tumor characteristics in newly diagnosed breast cancer patients

Abstract Purpose Axillary lymph nodes (LNs) with cortical thickness > 3 mm have a higher likelihood of malignancy. Examination of the positive predictive value (PPV) of axillary LN cortical thickness in newly diagnosed breast cancer patients, and nodal, clinical, and tumor characteristics associated with axillary LN metastasis. Methods Retrospective review of axillary LN fine needle aspirations (FNAs) performed 1/1/2018-12/31/2019 included 135 axillary FNAs in 134 patients who underwent axillary surgery. Patient demographics, clinical characteristics, histopathology and imaging features were obtained from medical records. Hypothesis testing was performed to identify predictors of axillary LN metastasis. Results Cytology was positive in 72/135 (53.3%), negative in 61/135 (45.2%), and nondiagnostic in 2/135 (1.5%). At surgery, histopathology was positive in 84 (62.2%) and negative in 51 (37.8%). LN cortices were thicker in metastatic compared to negative nodes (p < 0.0001). PPV of axillary LNs with cortical thickness ≥3 mm, ≥3.5 mm, ≥4 mm and ≥4.25 mm was 0.62 [95% CI 0.53, 0.70], 0.63 [0.54, 0.72], 0.67 [0.57, 0.76] and 0.74 [0.64, 0.83], respectively. At multivariable analysis, abnormal hilum was associated with nodal metastasis (OR = 3.44, p = 0.016), while focal/eccentric cortical thickening was inversely associated with metastasis (OR = 0.35, p = 0.038). Conclusion In newly diagnosed breast cancer patients, increasing axillary LN cortical thickness, abnormal fatty hilum, and diffuse cortical thickening are associated with nodal metastasis. PPV of axillary LN cortical thickness ≥3 mm and ≥3.5 mm is similar but increases for cortical thickness ≥4 mm. FNA of axillary LNs with cortex < 4 mm may be unnecessary for some patients undergoing sentinel LN biopsy.