Use of primary breast carcinoma characteristics to predict lymph node metastases?reply

Predicting axillary lymph node metastases in patients with T1infiltrating ductal carcinoma of the breast

Factors which can predict an increased risk of axillary metastases in cases of T1 breast cancer could help to identify those patients most likely to benefit from axillary surgery. This pragmatic study aimed to examine the ability of commonly reported tumour pathological features to predict axillary metastases. All cases of T1 infiltrating ductal carcinoma excised with ipsilateral axillary nodes over a 7 year period were reviewed retrospectively. Of the 639 cases, 197 (30.8%) had positive nodes. Axillary metastases were found with 66.3% of tumours showing vascular invasion but only 16.0% of those without vascular invasion. Following multivariate analysis, vascular invasion and tumour size were found to be independent predictors of positive nodes but tumour grade was not. The decision to perform axillary dissection in T1 breast cancer could be based on the presence of vascular invasion and the size of the primary tumour.

Assessment of axillary lymph node involvement in small breast cancer: analysis of 893 cases

Axillary nodal involvement (ANI) remains an essential prognostic factor for breast cancer patients, as it implies the necessity of systemic adjuvant treatment and locoregional irradiation. Axillary dissection (AD) contributes to improved local disease control and may increase survival. However, AD results in a 10%-25% incidence of long-term side effects, particularly lymphedema. Moreover, many small primary lesions with low risk of ANI are now discovered by screening, and it is not clear whether AD should be used routinely in all such patients. Sentinel lymph node biopsy (SLNB) is a selective procedure that allows selective staging of the axilla with few side effects. However, indications for SLNB are not precisely defined yet, so some patients may be understaged and the axillary relapse rate may increase. This study was conducted to help clinicians assess the risk of ANI and analyzed six clinical and histological parameters to optimally recognize patients who might benefit from SLNB, with a minimal risk of false-negative rate. We retrospectively analyzed the ANI risk among 893 women treated by conservative surgery and radiation for T0, T1, or T2 invasive tumours < 3 cm in size. All patients underwent AD with sampling of a minimum of seven lymph nodes. In each case, we assessed the clinical and pathological tumor size, histological subtype (including grading), tumor location, age at diagnosis, and breast size. The global ANI rate in the entire cohort was 25.3%. In multivariate analysis, three variables were significantly predictive of the ANI risk: tumor size (P < 0.0001), histological subtype (P = 0.0005), and breast size (P = 0.004). By combining these parameters, we were able to define three categories of women with low (< 20%), intermediate (21%-25%), and high (> 25%) ANI risk. We suggest that women with nonpalpable (T0), T1 grade 1/2, and T2 < 3 cm tumors of medullary, mucinous, tubular, or papillary histological subtype are the best candidates for SLNB. For other patients with a higher ANI risk tumor, AD may still remain the best procedure to obtain accurate staging and definitive local control.

Sentinel lymph node biopsy for breast cancer: a suitable alternative to routine axillary dissection in multi-institutional practice when optimal technique is used

PURPOSE

Previous studies have demonstrated the feasibility of sentinel lymph node (SLN) biopsy for nodal staging of patients with breast cancer. However, unacceptably high false-negative rates have been reported in several studies, raising doubt about the applicability of this technique in widespread surgical practice. Controversy persists regarding the optimal technique for correctly identifying the SLN. Some investigators advocate SLN biopsy using injection of a vital blue dye, others recommend radioactive colloid, and still others recommend the use of both agents together.

PATIENTS AND METHODS

A total of 806 patients were enrolled by 99 surgeons. SLN biopsy was performed by single-agent (blue dye alone or radioactive colloid alone) or dual-agent injection at the discretion of the operating surgeon. All patients underwent attempted SLN biopsy followed by completion level I/II axillary lymph node dissection to determine the false-negative rate.

RESULTS

There was no significant difference (86% v 90%) in the SLN identification rate among patients who underwent single- versus dual-agent injection. The false-negative rates were 11.8% and 5.8% for single- versus dual-agent injection, respectively (P <.05). Dual-agent injection resulted in a greater mean number of SLNs identified per patient (2. 1 v 1.5; P <.0001). The SLN identification rate was significantly less for patients older than 50 years as compared with that of younger patients (87.6% v 92.6%; P =.03). Upper-outer quadrant tumor location was associated with an increased likelihood of a false-negative result compared with all other locations (11.2% v 3. 9%; P <.05).

CONCLUSION

In multi-institutional practice, SLN biopsy using dual-agent injection provides optimal sensitivity for detection of nodal metastases. The acceptable SLN identification and false-negative rates associated with the dual-agent injection technique indicate that this procedure is a suitable alternative to routine axillary dissection across a wide spectrum of surgical practice and hospital environments.

Lymphatic invasion, tumor size, and age are independent predictors of axillary lymph node metastases in women with T1 breast cancers

OBJECTIVE

To identify characteristics of the primary tumor highly associated with lymph node metastases.

SUMMARY BACKGROUND DATA

Recent enthusiasm for limiting axillary lymph node dissection (ALND) in women with breast cancer may increase the likelihood that nodal metastases will be missed. Identification of characteristics of primary tumors predictive of lymph node metastases may prompt a more extensive surgical and pathologic search for metastases in patients with negative sentinel lymph nodes or limited ALND.

METHODS

The authors studied 850 consecutive patients who underwent ALND for T1 breast cancer. Age, tumor size, histopathologic diagnosis, tumor differentiation, presence of lymphatic invasion, and estrogen and progesterone receptor results were studied prospectively. Stepwise logistic regression was used to identify variables independently associated with axillary lymph node metastases.

RESULTS

Lymphatic invasion, tumor size, and age were independently associated with lymph node metastases. Fifty-one percent of the 181 patients with lymphatic invasion had axillary lymph node metastases, compared with 19% of the 669 patients without lymphatic invasion. Thirty-five percent of the 470 patients with tumors >1 cm had nodal involvement compared with 13% of the 380 patients with smaller cancers. Thirty-seven percent of the 63 women younger than age 40 had lymph node involvement compared with 25% of the 787 women older than age 40. Significant correlations were noted between lymphatic invasion and patient age and between lymphatic invasion and tumor size. The proportion of tumors with lymphatic invasion decreased progressively with increasing age and increased with increasing tumor size.

CONCLUSIONS

Axillary lymph node metastases are most significantly related to lymphatic invasion in the primary tumor, followed, in order of significance, by tumor size and patient age. Axillary nodal metastases should be suspected in the presence of lymphatic invasion of large tumors in young patients.

[Identification of axillary sentinel node by lymphotropic dye in breast cancer. Feasibility study apropos of 128 cases]

AIM OF THE STUDY

The goal of this study was to evaluate the technical feasibility of sentinel node biopsy in breast cancer and its predictivity of axillary node status.

PATIENTS AND METHODS

Between January 1996 and June 1997, 128 patients with invasive breast carcinomas, referred to the Cancer Center of Strasbourg and Lyon (France), underwent lymphatic mapping (Patent Blue dye) and sentinel node biopsy followed by axillary clearance (Berg's level I to II).

RESULTS

Sentinel node was identified in 76.5% of cases and was predictive of axillary status in 94.9% of cases. The false negative rate of the procedure was 5.1%. Sentinel lymph node was involved in 43.9% of cases and it was the only one involved in 30.2% of cases. The sensitivity of the procedure was 94% (CI: 95% = [88%-98%]) and its specificity 100%.

CONCLUSION

Actually considered as new attractive procedure under ongoing evaluation in prospective controlled trials, this study confirms the feasibility and reproductibility of lymphatic mapping and sentinel node biopsy, first stage before entering a new era of minimally invasive axillary surgery in breast cancer.