Enhancing Specificity in Predicting Axillary Lymph Node Metastasis in Breast Cancer through an Interpretable Machine Learning Model with CEM and Ultrasound Integration

Abstract

IntroductionThe study aims to evaluate the performance of an interpretable machine learning model in predicting preoperative axillary lymph node metastasis using primary breast cancer and lymph node features derived from contrast-enhanced mammography (CEM) and ultrasound (US) breast imaging reporting and data systems (BI-RADS).MethodsThis retrospective study included patients diagnosed with primary breast cancer. Two experienced radiologists extracted the BI-RADS features from the largest cross-section of the lesions and axillary lymph nodes based on CEM and US images, creating three datasets. Each dataset will train six base models to predict axillary lymph nodes, with pathological results serving as the gold standard. The top three models were used to train the five ensemble models. Additionally, SHapley Additive exPlanations (SHAP) was used to interpret the optimal model. The receiver-operating characteristic curve (ROC) and AUC were used to evaluate model performance.ResultsThis study involved 292 female patients, of whom 99 had axillary lymph node metastasis and 193 did not. The combination of CEM and ultrasound BI-RADS demonstrated the best performance in predicting axillary lymph node metastasis. Among these, the LightGBM achieved the highest AUC (0.762) and specificity (86.67%, while the ensemble model using RF as the meta-model had an AUC (0.754) and specificity (83.33%. The most important variables identified by SHAP were the long diameters of the lymph nodes in the CEM recombined image, along with their complete morphology in the low-energy image.ConclusionThe machine learning model using CEM and US BI-RADS features accurately predicted axillary lymph node metastasis before surgery, thereby serving as a valuable tool for clinical decision-making in patients with breast cancer.

Keywords: CEM; axillary lymph node metastasis; breast cancer; machine learning; ultrasound.

Figure 1.

A-B The Long Diameter(A) and Short dDiameter (B) of the Suspicious and Enhanced Lymph Node on the Recombined CEM Image.

Figure 2.

A-B The Vertical Diameter(A) and Transverse Diameter (B) Diameter of the Suspicious Lymph Node on the Ultrasound Image.

Figure 3.

Main CEM Recombination Image Features of the Axillary Lymph Nodes in the Different Groups.

Figure 4.

(A-C) Ultrasound and CEM Images of the Metastatic Axillary Lymph Node. (A) Ultrasound Image. The Left Axillary Lymph Node Cortex is Uiformly Thickened, and the Lymphatic Hilum Disappears, with a Size of 3.7 cm × 2.5 cm and Abundant Blood Flow Signals in and Around it. (B) CEM Low Energy Image. The Left Axillary Lymph Nodes with Full Shape, High Density, and Uniform Thickness are Abnormal. (C) CEM Recombination Image. The Left Axillary Lymph Nodes with Mild-to-Moderate Enhancement are Abnormal.

Figure 5.

SHAP Value of the LightGBM (A) Model and RF-Stacking Classifier (B) for Predicting the Axillary Lymph-Node Status in Breast Cancer Using CEM and Ultrasound Features in the Testing set. CEM, Contrast-Enhanced Mammography; RF, Random Forest Classifier.