An Intraoperative Ultrasound Evaluation of Axillary Lymph Nodes: Cassandra Predictive Models in Patients with Breast Cancer—A Multicentric Study
<i>Background and Objectives:</i> Axillary lymph node (ALN) staging is crucial for the management of invasive breast cancer (BC). Although various radiological investigations are available, ultrasound (US) is the preferred tool for evaluating ALNs. Despite its immediacy, widespread use,...
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2024-11-01
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| author | Simona Parisi Francesco Saverio Lucido Federico Maria Mongardini Roberto Ruggiero Francesca Fisone Salvatore Tolone Antonio Santoriello Francesco Iovino Domenico Parmeggiani David Vagni Loredana Cerbara Ludovico Docimo Claudio Gambardella |
| author_facet | Simona Parisi Francesco Saverio Lucido Federico Maria Mongardini Roberto Ruggiero Francesca Fisone Salvatore Tolone Antonio Santoriello Francesco Iovino Domenico Parmeggiani David Vagni Loredana Cerbara Ludovico Docimo Claudio Gambardella |
| author_sort | Simona Parisi |
| collection | DOAJ |
| description | <i>Background and Objectives:</i> Axillary lymph node (ALN) staging is crucial for the management of invasive breast cancer (BC). Although various radiological investigations are available, ultrasound (US) is the preferred tool for evaluating ALNs. Despite its immediacy, widespread use, and good predictive value, US is limited by intra- and inter-operator variability. This study aims to evaluate US and Elastosonography Shear Wave (SW-ES) parameters for ALN staging to develop a predictive model, named the Cassandra score (CS), to improve the interpretation of findings and standardize staging. <i>Materials and Methods:</i> Sixty-three women diagnosed with BC and treated at two Italian hospitals were enrolled in the study. A total of 529 lymph nodes were surgically removed, underwent intraoperative US examination, and were individually sent for a final histological analysis. The study aimed to establish a direct correlation between eight US-SWES features (margins, vascularity, roundness index (RI), loss of hilum fat, cortical thickness, shear-wave elastography hardness (SWEH), peripheral infiltration (PI), and hypoechoic appearance) and the histological outcome (benign vs. malignant). <i>Results:</i> Several statistical models were compared. PI was strongly correlated with malignant ALNs. An ROC analysis for Model A revealed an impressive AUC of 0.978 (S.E. = 0.007, <i>p</i> < 0.001), while in Model B, the cut-offs of SWEH and RI were modified to minimize the risk of false negatives (AUC of 0.973, S.E. = 0.009, <i>p</i> < 0.001). Model C used the same cut-offs as Model B, but excluded SWEH from the formula, to make the Cassandra model usable even if the US machine does not have SW-ES capability (AUC of 0.940, S.E. = 0.015, <i>p</i> < 0.001). A two-tiered model was finally set up, leveraging the strong predictive capabilities of SWEH and RI. In the first tier, only SWES and RI were evaluated: a positive result was predicted if both hardness and roundness were present (SWES > 137 kPa and RI < 1.55), and conversely, a negative result was predicted if both were absent (SWES < 137 kPa and RI > 1.55). In the second tier, if there was a mix of the results (SWES > 137 kPa and RI > 1.55 or SWES < 137 kPa and RI < 1.55), the algorithm in Model B was applied. The model demonstrated an overall prediction accuracy of 90.2% in the training set, 87.5% in the validation set, and 88.9% across the entire dataset. The NPV was notably high at 99.2% in the validation set. This model was named the Cassandra score (CS) and is proposed for the clinical management of BC patients. <i>Conclusion:</i> CS is a simple, non-invasive, fast, and reliable method that showed a PPV of 99.1% in the malignancy prediction of ALNs, potentially being also well suited for young sonographers. |
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| language | English |
| publishDate | 2024-11-01 |
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| series | Medicina |
| spelling | doaj-art-73672bfff19e4263b0dee633479ad3a62025-08-20T02:04:54ZengMDPI AGMedicina1010-660X1648-91442024-11-016011180610.3390/medicina60111806An Intraoperative Ultrasound Evaluation of Axillary Lymph Nodes: Cassandra Predictive Models in Patients with Breast Cancer—A Multicentric StudySimona Parisi0Francesco Saverio Lucido1Federico Maria Mongardini2Roberto Ruggiero3Francesca Fisone4Salvatore Tolone5Antonio Santoriello6Francesco Iovino7Domenico Parmeggiani8David Vagni9Loredana Cerbara10Ludovico Docimo11Claudio Gambardella12Department of Advanced Medical and Surgical Sciences, Division of General, Oncological, Mini-Invasive and Obesity Surgery—University of Study of Campania “Luigi Vanvitelli”, 80136 Naples, ItalyDepartment of Advanced Medical and Surgical Sciences, Division of General, Oncological, Mini-Invasive and Obesity Surgery—University of Study of Campania “Luigi Vanvitelli”, 80136 Naples, ItalyDepartment of Advanced Medical and Surgical Sciences, Division of General, Oncological, Mini-Invasive and Obesity Surgery—University of Study of Campania “Luigi Vanvitelli”, 80136 Naples, ItalyDepartment of Advanced Medical and Surgical Sciences, Division of General, Oncological, Mini-Invasive and Obesity Surgery—University of Study of Campania “Luigi Vanvitelli”, 80136 Naples, ItalyDepartment of Advanced Medical and Surgical Sciences, Division of General, Oncological, Mini-Invasive and Obesity Surgery—University of Study of Campania “Luigi Vanvitelli”, 80136 Naples, ItalyDepartment of Advanced Medical and Surgical Sciences, Division of General, Oncological, Mini-Invasive and Obesity Surgery—University of Study of Campania “Luigi Vanvitelli”, 80136 Naples, ItalyBreast Unit, Division of Surgery, Cobelli’s Hospital, Vallo della Lucania, 84078 Salerno, ItalyDepartment of Traslational Sciences, Division of General, Oncological, Mini-Invasive and Obesity Surgery—University of Study of Campania “Luigi Vanvitelli”, 80136 Naples, ItalyDepartment of Advanced Medical and Surgical Sciences, Division of General, Oncological, Mini-Invasive and Obesity Surgery—University of Study of Campania “Luigi Vanvitelli”, 80136 Naples, ItalyNational Research Council, Institute for Research and Biomedical Innovation, 98164 Messina, ItalyNational Research Council, Institute for Research on Population and Social Policies (CNR-IRPPS), 00185 Rome, ItalyDepartment of Advanced Medical and Surgical Sciences, Division of General, Oncological, Mini-Invasive and Obesity Surgery—University of Study of Campania “Luigi Vanvitelli”, 80136 Naples, ItalyDepartment of Advanced Medical and Surgical Sciences, Division of General, Oncological, Mini-Invasive and Obesity Surgery—University of Study of Campania “Luigi Vanvitelli”, 80136 Naples, Italy<i>Background and Objectives:</i> Axillary lymph node (ALN) staging is crucial for the management of invasive breast cancer (BC). Although various radiological investigations are available, ultrasound (US) is the preferred tool for evaluating ALNs. Despite its immediacy, widespread use, and good predictive value, US is limited by intra- and inter-operator variability. This study aims to evaluate US and Elastosonography Shear Wave (SW-ES) parameters for ALN staging to develop a predictive model, named the Cassandra score (CS), to improve the interpretation of findings and standardize staging. <i>Materials and Methods:</i> Sixty-three women diagnosed with BC and treated at two Italian hospitals were enrolled in the study. A total of 529 lymph nodes were surgically removed, underwent intraoperative US examination, and were individually sent for a final histological analysis. The study aimed to establish a direct correlation between eight US-SWES features (margins, vascularity, roundness index (RI), loss of hilum fat, cortical thickness, shear-wave elastography hardness (SWEH), peripheral infiltration (PI), and hypoechoic appearance) and the histological outcome (benign vs. malignant). <i>Results:</i> Several statistical models were compared. PI was strongly correlated with malignant ALNs. An ROC analysis for Model A revealed an impressive AUC of 0.978 (S.E. = 0.007, <i>p</i> < 0.001), while in Model B, the cut-offs of SWEH and RI were modified to minimize the risk of false negatives (AUC of 0.973, S.E. = 0.009, <i>p</i> < 0.001). Model C used the same cut-offs as Model B, but excluded SWEH from the formula, to make the Cassandra model usable even if the US machine does not have SW-ES capability (AUC of 0.940, S.E. = 0.015, <i>p</i> < 0.001). A two-tiered model was finally set up, leveraging the strong predictive capabilities of SWEH and RI. In the first tier, only SWES and RI were evaluated: a positive result was predicted if both hardness and roundness were present (SWES > 137 kPa and RI < 1.55), and conversely, a negative result was predicted if both were absent (SWES < 137 kPa and RI > 1.55). In the second tier, if there was a mix of the results (SWES > 137 kPa and RI > 1.55 or SWES < 137 kPa and RI < 1.55), the algorithm in Model B was applied. The model demonstrated an overall prediction accuracy of 90.2% in the training set, 87.5% in the validation set, and 88.9% across the entire dataset. The NPV was notably high at 99.2% in the validation set. This model was named the Cassandra score (CS) and is proposed for the clinical management of BC patients. <i>Conclusion:</i> CS is a simple, non-invasive, fast, and reliable method that showed a PPV of 99.1% in the malignancy prediction of ALNs, potentially being also well suited for young sonographers.https://www.mdpi.com/1648-9144/60/11/1806axillary stagingbreast canceraxillary ultrasoundaxillary surgeryultrasound score |
| spellingShingle | Simona Parisi Francesco Saverio Lucido Federico Maria Mongardini Roberto Ruggiero Francesca Fisone Salvatore Tolone Antonio Santoriello Francesco Iovino Domenico Parmeggiani David Vagni Loredana Cerbara Ludovico Docimo Claudio Gambardella An Intraoperative Ultrasound Evaluation of Axillary Lymph Nodes: Cassandra Predictive Models in Patients with Breast Cancer—A Multicentric Study Medicina axillary staging breast cancer axillary ultrasound axillary surgery ultrasound score |
| title | An Intraoperative Ultrasound Evaluation of Axillary Lymph Nodes: Cassandra Predictive Models in Patients with Breast Cancer—A Multicentric Study |
| title_full | An Intraoperative Ultrasound Evaluation of Axillary Lymph Nodes: Cassandra Predictive Models in Patients with Breast Cancer—A Multicentric Study |
| title_fullStr | An Intraoperative Ultrasound Evaluation of Axillary Lymph Nodes: Cassandra Predictive Models in Patients with Breast Cancer—A Multicentric Study |
| title_full_unstemmed | An Intraoperative Ultrasound Evaluation of Axillary Lymph Nodes: Cassandra Predictive Models in Patients with Breast Cancer—A Multicentric Study |
| title_short | An Intraoperative Ultrasound Evaluation of Axillary Lymph Nodes: Cassandra Predictive Models in Patients with Breast Cancer—A Multicentric Study |
| title_sort | intraoperative ultrasound evaluation of axillary lymph nodes cassandra predictive models in patients with breast cancer a multicentric study |
| topic | axillary staging breast cancer axillary ultrasound axillary surgery ultrasound score |
| url | https://www.mdpi.com/1648-9144/60/11/1806 |
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