Extra-axillary nodal metastases in breast cancer: comparison of ultrasound, MRI, PET/CT, and CT

To evaluate how ultrasound (US), MRI, PET/CT, and CT predict extra-axillary nodal metastases. This IRB approved, retrospective study consisted of 124 suspicious supraclavicular and 88 internal mammary (IM) nodal cases with US and at least one additional cross-sectional examination (MRI, PET/CT or CT) from a total of 1472 invasive cancers with staging nodal US between January 2016–January 2019. Imaging findings were compared with the true node status, determined by fine needle aspirate (FNA) biopsy or evidence of response to chemotherapy on follow up imaging. In the supraclavicular region, US had accuracy 98.2%, consisting of 97 true positives (TP), 27 false positives (FP), and 1348 true negative (TN). 93.5% of suspicious supraclavicular nodes had FNA for a PPV 78.2%. PET/CT had accuracy 88.6% (26 TP, 5 TN and 4 false negatives (FN)). CT exams had accuracy 61.7% (42 TP, 16 TN, 7 FP, and 29 FN). In the IM region, US had accuracy 93.2% (82 TP, 1 FP, 5 FN, and 1384 TN) but only 43.2% of suspicious IM nodes had FNA for a PPV 98.8%. MRI had accuracy 100.0% (all 47 TP). PET/CT exams had accuracy 96.8% (30 TP and 1FN). CT exams had accuracy 62.7% (36 TP, 1 TN, and 22 FN). US/FNA has accuracy 98.2% and 93.2% in the supraclavicular and IM regions, however only 43.2% of suspicious IM nodes are directly sampled. In these cases, MRI or PET/CT can be used to problem solve and guide treatment decisions. •US/FNA has accuracy of 98.2% in the supraclavicular and 93.2% in the IM region.•FNA 93.5% of supraclavicular and 43.2% of IM suspicious nodes underwent direct FNA biopsy.•In the IM region, MRI and PET/CT are accurate, and can guide treatment decisions when biopsy may not be available.