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 EdM 1, Welela Tereffe MD MPH 1, Kenneth R. Hess PhD 2, Ana M. Gonzalez-Angulo MD MSc 3, Basak E. Dogan MD 4, Michael C. Stauder MD 1, Vicente Valero MD 3, Savitri Krishnamurthy MD 4, Eric A. Strom MD 1, Kelly K. Hunt MD 5, Thomas A. Buchholz MD 1, Gary J. Whitman MD 4 1 Department 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, 4 Department of Diagnostic Radiology, MD Anderson Cancer Center, 5 Department 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 ReceivedUpstaged by Ultrasound Not Upstagedp-value Axillary Lymph Node Dissection99% (110/111)35% (159/461)<.0001 Neoadjuvant Chemotherapy92% (102/111)51 % (236/461)<.0001 Adjuvant Chemotherapy15% (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 Ultrasound Upstaging Total Patients with Nodal Upstaging19% (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) cN2  cN3 cN2  cN3a cN2  cN3b cN2  cN3c 2% (12/572) 0% (1/572) 1% (6/572) 1% (5/572) cN3a  cN3b cN3a  cN3c 0% (1/572) Clinical Nodal Stage Physical Examination Ultrasound Alone Overall Clinical Nodal Stage (P.E., Imaging & Biopsy) Nx N0 N1 N2 N3a N3b N3c 0% 58% 37% 4% 1% 0% 1% 0% 34% 45% 0% 8% 3% 10% 0% 62% 24% 0% 5% 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) Postmenopausal61% (349/572) Invasive Ductal Histology95% (541/572) Nuclear Grade 392% (524/572) Lymphovascular Space Invasion20% (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 Dissection46% (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) Results Table 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