Prediction of axillary lymph node involvement of women with invasive breast carcinoma

Assessment of the axilla in women with early-stage breast cancer undergoing primary surgery: a review

Sentinel node biopsy (SNB) is routinely performed in people with node-negative early breast cancer to assess the axilla. SNB has no proven therapeutic benefit. Nodal status information obtained from SNB helps in prognostication and can influence adjuvant systemic and locoregional treatment choices. However, the redundancy of the nodal status information is becoming increasingly apparent. The accuracy of radiological assessment of the axilla, combined with the strong influence of tumour biology on systemic and locoregional therapy requirements, has prompted many to consider alternative options for SNB. SNB contributes significantly to decreased quality of life in early breast cancer patients. Substantial improvements in workflow and cost could accrue by removing SNB from early breast cancer treatment. We review the current viewpoints and ideas for alternative options for assessing and managing a clinically negative axilla in patients with early breast cancer (EBC). Omitting SNB in selected cases or replacing SNB with a non-invasive predictive model appear to be viable options based on current literature.

Diagnostic accuracy of pre-operative breast magnetic resonance imaging (MRI) in predicting axillary lymph node metastasis: variations in intrinsic subtypes, and strategy to improve negative predictive value-an analysis of 2473 invasive breast cancer patients

BACKGROUND

The value and utility of axillary lymph node (ALN) evaluation with MRI in breast cancer were not clear for various intrinsic subtypes. The aim of the current study is to test the potential of combining breast MRI and clinicopathologic factors to identify low-risk groups of ALN metastasis and improve diagnostic performance.

MATERIAL AND METHODS

Patients with primary operable invasive breast cancer with pre-operative breast MRI and post-operative pathologic reports were retrospectively collected from January 2009 to December 2021 in a single institute. The concordance of MRI and pathology of ALN status were determined, and also analyzed in different intrinsic subtypes. A stepwise strategy was designed to improve MRI-negative predictive value (NPV) on ALN metastasis.

RESULTS

2473 patients were enrolled. The diagnostic performance of MRI in detecting metastatic ALN was significantly different between intrinsic subtypes (p = 0.007). Multivariate analysis identified tumor size and histologic type as independent predictive factors of ALN metastases. Patients with HER-2 (MRI tumor size ≤ 2 cm), or TNBC (MRI tumor size ≤ 2 cm) were found to have MRI-ALN-NPV higher than 90%, and these false cases were limited to low axillary tumor burden.

CONCLUSION

The diagnostic performance of MRI to predict ALN metastasis varied according to the intrinsic subtype. Combined pre-operative clinicopathologic factors and intrinsic subtypes may increase ALN MRI NPV, and further identify some groups of patients with low risks of ALN metastasis, high NPV, and low burdens of axillary disease even in false-negative cases.

Novel model based on ultrasound predict axillary lymph node metastasis in breast cancer

BACKGROUND

Whether there is axillary lymph node metastasis is crucial for formulating the treatment plan for breast cancer. Currently, invasive methods are still used for preoperative evaluation of lymph nodes. If non-invasive preoperative evaluation can be achieved, it will effectively improve the treatment plan.

OBJECTIVE

Constructed a predict model based on ultrasound examination, which forest axillary lymph node metastasis in breast cancer, and validated this model.

METHOD

Patients admitted to Xiamen First Hospital from April 2018 to August 2021 with complete case data were included in this study. Patients who had undergone breast cancer resection and axillary lymph node dissection or sentinel lymph node biopsy were divided into a training and validation cohort in a 7:3 ratio. In the training cohort, patients were divided into metastatic and non-metastatic groups based on whether axillary lymph nodes had metastasis. The parameters of the two groups were compared, and statistically significant parameters were included in multivariate analysis. Then, a Nomogram model was constructed, named Lymph metastasis predict model (LMPM). Calibration curves, receiver operating curve (ROC), and decision curve analysis (DCA) were plotted between the training and validation cohort, calculate the risk score of each patient, identify the optimal cutoff value, and test the predictive efficacy of LMPM.

RESULT

Two hundred seventy-three patients were enrolled in final study, the average age 49.7 ± 8.7, training cohort included 191 patients, the diameter of breast cancer, the lymph node peak systolic flow velocity (LNPS) and the cortex area hilum ratio (CH) of lymph node were exist significant difference in metastatic and non-metastatic group. Multivariate analysis showed cancer diameter, LNPS and CH included in LMPM, the cutoff value was 95, the calibration curve, ROC, DCA in training and validation cohort show satisfactory result.

CONCLUSION

The predict model-LMPM, can predict axillary lymph node metastasis in breast cancer, which is useful for developing personalized treatment plans. However, further validation of the model is required by incorporating a larger number of patients.

Factors Predicting Positive Sentinel Lymph Node Biopsy in Clinically Node-Negative Breast Cancer

Purpose

Sentinel lymph node (SLN) biopsy (SLNB) is the standard tool to stage the axilla of breast cancer patients. This study aimed to identify the predictors of positive SLNB in patients with clinically node-negative breast cancer.

Patients and Methods

A retrospective, single-institution cohort of patients with early-stage breast cancer without clinically identifiable axillary lymphadenopathy was chosen from January 2010 to December 2018. Logistic regression was used to identify possible predictors of positive SLNB.

Results

Four hundred and seventy patients were identified; their mean age was 50±11 years. Most patients had the following characteristics: invasive ductal carcinoma (n=382, 81.3%), unilateral tumor (n=461, 98.1%), unifocal disease (n=351, 74.7%), intermediate grade (n=276, 59.0%), and estrogen and progesterone receptor positivity with human epidermal growth factor receptor 2 negativity (n=305, 64.9%). The mean size of the breast mass was 2.3±1.5 cm. SLNB was positive in 128 (27.2%) cases. The mean number of SLNs was 2±1.2. Axillary lymph node dissection was performed in 109 patients. The mean number of lymph nodes removed was 15±6. In 66 (60.6%) of the 109 patients with metastatic axillary nodes, only the SLNs were found to be positive. The number of SLNs, tumor size, tumor grade, receptor status, prominent axillary lymph nodes, and lymphovascular invasion predicted positive SLNB (P = 0.01, 0.03, 0.03, and 0.04 and <0.001 and <0.001, respectively).

Conclusion

Our results suggest that a number of histopathological and radiological characteristics of breast cancer can predict SLNB positivity in clinically node-negative breast cancer patients.

A Model to Predict the Risk of Lymph Node Metastasis in Breast Cancer Based on Clinicopathological Characteristics

Background

Sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) may cause lymphatic and nervous system side effects in patients with breast cancer. It is imperative to develop a model to evaluate the risk of sentinel lymph node metastasis to avoid unnecessary operation.

Patients and Methods

A total of 2705 cases of female breast cancer patients enrolled in this retrospective study. We divided into the training group (SLNB group) and the validation group (ALND group) to analyze the relathionship between lymph node metastasis and clinical-pathological factors. Logistic regression analysis was performed to verify the variables which involved in ALN metastasis and established a prediction model. ROC curves were employed to evaluate the predictive ability of the model.

Results

In the SLNB group, 9 variables, including pathological type, histological grade, tumor size, hormone receptor, HER-2, Ki-67, multifocality, and molecular subtypes, were related to breast cancer ALN metastasis. Clinically negative lymph nodes, favorable histologic type, tumor size <2 cm, and Ki-67 <15% were at very low risk for lymph node metastasis. The AUC of the validation group was 0.786.

Conclusion

We successfully establish a mathematics model to predict lymph node metastasis of breast cancer. Axillary surgery should be individual with preoperative clinical characteristics, especially for patients with a longer life expectancy.

Clinical implication of subcategorizing T2 category into T2a and T2b in TNM staging of breast cancer

Regarding TNM staging in breast cancer, T2 category is currently not divided into subcategories even though it covers a wider range of tumor sizes than T1 category. Using Korean Breast Cancer Registry database, data of 41 071 women diagnosed as non-metastatic T2 breast cancer between 2001 and 2014 were analyzed. Cutoff value for optimal tumor size was approximated by receiver operating characteristic (ROC) curve to subcategorize T2 tumors. Overall survival (OS) was compared between two subcategories. Median follow-up period was 65 months. Of 41 071 patients, 4504 (11.0%) died. Based on ROC curve analysis, 3.0 cm was selected as the cutoff value. Five-year OS rate was 91% in patients with breast tumors ≤3.0 cm (T2a) and 86% in patients with breast tumors >3.0 cm (T2b) (log-rank P < 0.001). T2b subcategory showed worse OS than T2a subcategory regardless of node status (log-rank P < 0.001 for all node categories). Within every subgroup defined by primary OS analysis covariates, T2b subcategory consistently showed worse outcome compared to T2a subcategory. By multivariate analysis, T2b subcategory was a significant independent prognostic factor of OS (hazard ratio: 1.26, 95% CI = 1.18-1.34). T2 category of breast cancer could be subcategorized into T2a and T2b with a cutoff value of 3 cm. These subcategories definitely showed different OSs even after adjusted for known prognostic factors. Subcategorization of T2 category might be useful for predicting prognosis more accurately and tailoring adjuvant therapy.

The relationship between tumour size, nodal status and distant metastases: on the origins of breast cancer

Background

In patients with breast cancer, increasing tumour size at diagnosis is associated with an increased likelihood of axillary lymph node involvement and increased breast cancer-specific mortality. However, this relation is based on studies which combine all tumours smaller than 1.0 cm in a single category and all tumours larger than 5.0 cm in another category. This coarse classification may obscure a nuanced description of the effects of tumour size across the full range of possible sizes.

Methods

We examined the relationship between primary tumour size, lymph node status and distant metastases in a cohort of 819,647 women diagnosed with first primary invasive breast cancer from 1990 to 2014 in the Surveillance, Epidemiology and End Results (SEER) registries database. All patients in the cohort had a known primary tumour size between 1 and 150 mm in greatest dimension. Primary tumour size was examined as a continuous (1–150 mm) and categorical variable (15 size groups; 10-mm intervals). For each 1- or 10-mm size group, we determined the proportion of patients with positive lymph nodes at diagnosis, the proportion of patients with distant metastases at diagnosis and the actuarial cumulative risk of breast cancer-specific mortality at 15 years from diagnosis.

Results

Among 819,647 patients with invasive breast tumours between 1 and 150 mm in size, there was a non-linear correlation between increasing tumour size and the prevalence of lymph node metastases at diagnosis (% node-positive), the prevalence of distant metastases at diagnosis (% stage IV) and the 15-year rate of breast cancer-specific mortality across the entire size spectrum. For very small tumours (under 10 mm) and for very large tumours (larger than 60–90 mm) there was little correlation between tumour size and metastasis risk.

Conclusions

The relationship between tumour size, lymph node status and distant metastases in patients with invasive breast cancer is not linear. This calls into question the conventional model that the capacity for a primary breast tumour to metastasize increases as the tumour enlarges.

Electronic supplementary material

The online version of this article (10.1007/s10549-018-4796-9) contains supplementary material, which is available to authorized users.

Correlation of Various Biomarkers with Axillary Nodal Metastases: Can a Panel of Such Biomarkers Guide Selective Use of Axillary Surgery in T1 Breast Cancer?

To evaluate the correlation of various clinic-pathological variables with axillary nodal involvement in T1 breast cancer & to identify a sub-group of T1 cancers, on the basis of observed variables, with a low risk of axillary nodal metastases. Clinico-pathological variables observed included tumor size, lymphovascular invasion (LVI), histological grade of tumor, tumor palpability, estrogen/progesterone (ER/PR) & her2/neu receptors, age, family history, histological type of tumor, axillary nodal metastases for 100 patients without clinically palpable nodes who underwent axillary lymph node dissection in Bombay Hospital & Medical Research Center from March, 2009. Data compiled was analyzed by univariate & multivariate analysis. All the variables viz. tumor size, LVI, histological grade, tumor palpability & ER/PR/Her2 receptor profile, which were found to be significantly associated with axillary lymph node involvement (ALNI) on univariate analysis were also found to be independent predictors of ALNI on multivariate analysis. Age of the patient, family history & histological type of tumor were not significantly correlated with ALNI. None of the 12 patients with tumor biomarker profile of T1a-b tumors without LVI & with histological grade I, had ALNI. The risk of ALNI can be predicted by using various tumor biomarker variables. Based on the predicted risk of ALNI, the management strategy for axilla can be individualized. The omission of operative axillary staging may be considered in patients with low predictive risk of ALNI.

Obesity and Breast Cancer: Molecular Interconnections and Potential Clinical Applications

Obesity is an important risk factor for breast cancer (BC) in postmenopausal women; interlinked molecular mechanisms might be involved in the pathogenesis. Increased levels of estrogens due to aromatization of the adipose tissue, inflammatory cytokines such as tumor necrosis factor-α, interleukin-6, and prostaglandin E2, insulin resistance and hyperactivation of insulin-like growth factors pathways, adipokines, and oxidative stress are all abnormally regulated in obese women and contribute to cancerogenesis. These molecular factors interfere with intracellular signaling in the mitogen-activated protein kinase and phosphatydilinositol-3-phosphate/mammalian target of rapamycin (mTOR) pathways, which regulate the progression of the cell cycle, apoptosis, and protein synthesis. In this context, structural defects of typical genes related to both BC and obesity, such as leptin, leptin receptor, serum paraoxonase/arylesterase 1, the fat mass and obesity-associated gene and melanocortin receptor 4, have been associated with a high or low risk of BC development. The early detection of these gene alterations might be useful as risk predictors in obese women, and targeting these pathways involved in the BC pathogenesis in obese women is a potential therapeutic tool. In particular, mTOR pathway deregulation concurs in both obesity and BC, and inhibition of this might disrupt the molecular interlinks in a similar manner to that of metformin, which exerts definite anticancer activity and is currently used as an antidiabetic drug with a weight-reducing property. The identification of both genetic and pharmacological implications on the prevention and management of BC is the ultimate aim of these studies.

IMPLICATIONS FOR PRACTICE

Obese women are at risk of breast cancer, but clinicians lack concrete tools for the prevention or early diagnosis of this risk. The present study, starting from the biology and the molecular defects characterizing both obesity and breast cancer, analyzed the potential molecules and genetic defects whose early identification could delineate a risk profile. Three steps are proposed that are potentially achievable in the clinical assessment of obese women, namely the evaluation of altered levels of serum molecules, the identification of genetic polymorphisms, and the study of the transcriptomic profile of premalignant lesions. Finally, the therapeutic implications of this molecular assessment were evaluated.

Apparent diffusion coefficient value in invasive ductal carcinoma at 3.0 Tesla: is it correlated with prognostic factors?

OBJECTIVE

To investigate the correlation between apparent diffusion coefficient (ADC) values and prognostic factors in patients with invasive ductal carcinoma (IDC).

METHODS

48 lesions belonging to 47 patients with histopathologically proven IDC were examined using conventional MR and diffusion-weighted imaging at a 3.0-T system. All of the patients had modified radical mastectomies or breast-sparing surgery plus axillary lymph node dissection. The ADC values acquired from the ADC maps consisted of six different b-values (0, 50, 100, 500, 1000 and 1500 s mm(-2)) and were compared with the patients' ages, tumour size, histological grade of the lesions, tumour localization, lesions' distance to skin surface and nipples, the existence of axillary lymph node involvement, the number of involved axillary lymph nodes, oestrogen/progesterone receptor status, peritumoral lymphovascular invasion status and the existence of human epidermal growth factor 2 (c-erbB-2) overexpression.

RESULTS

A statistically significant relationship was found regarding axillary lymph node involvement (p = 0.027), and oestrogen/progesterone receptor status (p = 0.013). No significant relationship was detected regarding other prognostic factors (p > 0.05).

CONCLUSION

Among various prognostic factors, ADC values were significantly correlated with only axillary lymph node positivity and oestrogen/progesterone receptor status.

ADVANCES IN KNOWLEDGE

In the present study, the relationship between ADC values of IDC lesions that are acquired at a high magnetic field (3.0 T) system by using multiple b-values and some specific prognostic factors that were not evaluated before in the medical literature was investigated.

Breast cancer subtypes can be determinant in the decision making process to avoid surgical axillary staging: A retrospective cohort study

INTRODUCTION

The need for performing axillary lymph-node dissection in early breast cancer when the sentinel lymph node (SLN) is positive has been questioned in recent years. The purpose of this study was to identify a low-risk subgroup of early breast cancer patients in whom surgical axillary staging could be avoided, and to assess the probability of having a positive lymph-node (LN).

METHODS

We evaluated the cohort of 612 consecutive women affected by early breast cancer. We considered age, tumor size, histological grade, vascular invasion, lymphatic invasion and cancer subtype (Luminal A, Luminal B HER-2+, Luminal B HER-2-, HER-2+, and Triple Negative) as variables for univariate and multivariate analyses to assess probability of there being a positive SLN o nonsentinel lymph node (NSLN). Chi-square, Fisher's Exact test and Student's t tests were used to investigate the relationship between variables; whereas logit models were used to estimate and quantify the strength of the relationship among some covariates and SLN or the number of metastases.

RESULTS

A significant positive effect of vascular invasion and lymphatic invasion (odds ratios are 4 and 6), and a negative effect of TN (odds ratios is 10) were noted. With respect to positive NSLN, size alone has a significant (positive) effect on tumor presence, but focusing on the number of metastases, also age has a (negative) significant effect.

CONCLUSION

This work shows correlation between subtypes and the probability of having positive SLN. Patients not expressing vascular invasion, lymphatic invasion and, moreover, a triple-negative tumor subtype may be good candidates for breast conservative surgery without axillary surgical staging.

Predictive factors for additional non-sentinel lymph node involvement in breast cancer patients with one positive sentinel node

AIM

The aim of this study was to identify a subgroup of breast cancer patients in whom it is possible to avoid axillary lymph node dissection (ALND) when the sentinel lymph node (SLN) is positive.

METHODS

A series of 292 patients treated with breast-conserving surgery or mastectomy underwent ALND after positive SLN detection. To correlate SLN metastasis with the chances of finding additional metastasis in non-SLNs we evaluated the main clinicopathological characteristics. No patients received adjuvant radiotherapy to the axillary region.

RESULTS

Fifty-six patients (35.4%) with positive SLNs for macrometastases (n = 158) had additional metastases upon completion ALND compared with 7 patients (5.2%) with micrometastases in the SLN (n = 132). Cases with a higher number of positive axillary lymph nodes tended to have higher pT stage (p = 0.004). In multivariate analysis, pT was confirmed as an independent predictor of non-SLN metastases (OR = 2.40; 95% CI = 1.16-4.99). No patients with micrometastases in SLN and cancer lt;10 mm had additional positive non-SLNs.

CONCLUSIONS

Our results, in agreement with the major published studies, suggest that ALND can be avoided in selected patients without the need for additional treatment to the axillary region.

Management of the regional lymph nodes following breast-conservation therapy for early-stage breast cancer: an evolving paradigm

Radiation therapy to the breast following breast conservation surgery has been the standard of care since randomized trials demonstrated equivalent survival compared to mastectomy and improved local control and survival compared to breast conservation surgery alone. Recent controversies regarding adjuvant radiation therapy have included the potential role of additional radiation to the regional lymph nodes. This review summarizes the evolution of regional nodal management focusing on 2 topics: first, the changing paradigm with regard to surgical evaluation of the axilla; second, the role for regional lymph node irradiation and optimal design of treatment fields. Contemporary data reaffirm prior studies showing that complete axillary dissection may not provide additional benefit relative to sentinel lymph node biopsy in select patient populations. Preliminary data also suggest that directed nodal radiation therapy to the supraclavicular and internal mammary lymph nodes may prove beneficial; publication of several studies are awaited to confirm these results and to help define subgroups with the greatest likelihood of benefit.

Estrogen receptor, progesterone receptor, and HER2 status predict lymphovascular invasion and lymph node involvement

BACKGROUND

The ACOSOG Z0011 trial demonstrated that axillary dissection (ALND) is not necessary for local control or survival in women with T1/2cN0 cancer undergoing breast-conserving therapy. There is concern about applying these results to triple-negative (TN) cancers secondary to their high local-recurrence (LR) rate. We examined the frequency of lymphovascular invasion (LVI) and nodal metastases in TN cancers to determine whether ALND can be safely avoided in this subtype.

METHODS

Data were obtained from a database of patients with invasive breast cancer treated at Memorial Sloan Kettering Cancer Center from January 1998 to December 2010. A total of 11,596 tumors were classifiable into clinical surrogates for molecular subtype by immunohistochemical analysis: hormone receptor (HR)+/HER2+, HR+/HER2-, HR-/HER2+, and TN (HR-/HER2-). Multivariable logistic regression analysis (MVA) was used to determine associations between clinicopathologic variables and subtype.

RESULTS

There were differences in age, tumor size, LVI, grade, and nodal involvement among groups. On MVA controlling for size, grade, and age, ER, PR, and HER2 status were significantly associated with LVI (p < 0.0001). Relative to TN tumors, HR+/HER2-, HR+/HER2+, and HR-/HER2+ tumors had higher odds of demonstrating LVI of 1.8 (odds ratio 1.8; 95 % confidence interval 1.6-2.1), 2.5 (2.5; 2.0-3.0), and 1.7 (1.7; 1.4-2.1), respectively. On MVA adjusting for size, grade, LVI, and age, TN tumors had the lowest odds of having any or high-volume nodal involvement (≥4 nodes, p < 0.0001).

CONCLUSIONS

LVI and nodal metastases were least frequent in TN cancers compared with other subtypes, despite the uniformly worse prognosis and increased LR rate in TN tumors. This suggests TN cancers spread via lymphatics less frequently than other subtypes and ALND may be avoided in TN patients meeting Z0011 eligibility criteria.

A Cost-Utility Analysis Comparing Standard Axillary Lymph Node Dissection with Sentinel Lymph Node Biopsy in Patients with Early Stage Breast Cancer in Thailand

OBJECTIVES

In Thailand, axillary lymph node dissection (ALND) is the dominant form of treatment for breast cancer, even though the treatment often leaves patients with some degree of arm morbidity. Sentinel lymph node biopsy (SNB) is widely accepted globally as a preferable alternative procedure because of its lower rates of associated morbidity. This study compared the cost-utility of SNB and ALND in patients with early stage breast cancer in Thailand.

METHODS

A decision tree with a 5-year time horizon was developed. Outcomes that were relevant to SNB and ALND were included, along with locoregional recurrence of cancer and lymphedema scenarios. The model parameters were derived from a meta-analysis of international clinical trials and other relevant literature. The resources and cost data were derived from the medical records of tertiary hospitals. Health utilities were measured by using the standard gamble technique. A sensitivity analysis was performed using a set of plausible parameters.

RESULTS

The incremental cost-effectiveness ratio (ICER) in the base-case analysis showed that SNB was more cost-effective than ALND. ICERs were -275,140 and -470,600 Thailand baht/quality-adjusted life-year gained from the provider perspective and the societal perspective, respectively. The most sensitive parameter was the utility score of patients with early stage breast cancer who had received breast-conserving therapy with lymphedema; the sensitivity and specificity of SNB had no impact on the ICER.

CONCLUSIONS

The study confirmed that SNB was an economically viable alternative treatment to ALND. In developing countries, where resources are limited, nationwide implementation of SNB warrants widespread support from relevant stakeholders, including medical personnel and policymakers.

A prediction model for the presence of axillary lymph node involvement in women with invasive breast cancer: a focus on older women

Axillary lymph node (ALN) status at diagnosis is the most powerful prognostic indicator for patients with breast cancer. Our aim is to examine the contribution of variables that lead to ALN metastases in a large dataset with a high proportion of patients greater than 70 years old. Using the data from two multicenter prospective studies, a retrospective review was performed on 2,812 patients diagnosed with clinically node-negative invasive breast cancer from 1996 to 2005 and who underwent ALN sampling. Univariate and multivariate logistic regression were used to identify variables that were strongly associated with axillary metastases, and an equation was developed to estimate risk of ALN metastases. Of the 2,812 patients with invasive breast cancer, 18% had ALN metastases at diagnosis. Based on univariate analysis, tumor size, lymphovascular invasion (LVI), tumor grade, age at diagnosis, menopausal status, race, tumor location, tumor type, and estrogen and progesterone receptor status were statistically significant. The relationship between age and involvement of axillary metastases was nonlinear. In multivariate analysis, LVI, tumor size and menopausal status were the most significant factors associated with ALN metastases. Age, however, was not a significant contributing factor for axillary metastases. Tumor size, LVI, and menopausal status are strongly associated with ALN metastases. We believe that age may have been a strong factor in previous analyses because there was not an adequate representation of women in older age groups and because of the violation of the assumption of linearity in their multivariate analyses.

Level III axillary lymph nodes involvement in node positive breast cancer received neoadjuvant chemotherapy

OBJECTIVE

To investigate the incidence, associated factors and prognosis of level III node involvement for breast cancer with positive axillary lymph nodes after neoadjuvant chemotherapy.

METHODS

A consecutive series of 521 node positive T0-2 invasive breast cancer cases were included in this retrospective study. Axillary node metastases were proved by ultrasound guided needle biopsy (NB) if ultrasonographic abnormal node was detected or by sentinel node biopsy (SNB) if no abnormal node was detected. After 4 to 8 cycles of neoadjuvant chemotherapy (NCT）, axillary lymph nodes dissection included level III lymph nodes were completed for each case.

RESULTS

The pathologic complete response rate of axillary nodes was 31.1% (90/289) in NB positive subgroup. The incidence of residual positive level III lymph nodes were 9.0% (47/521). Multivariate analysis showed that node NB positivity (OR = 2.212, 95% CI: 1.022-4.787, P = 0.044), clinical tumor size >2 cm before NCT (OR = 2.672, 95% CI: 1.170-6.098, P = 0.020), and primary tumor non-response to neoadjuvant chemotherapy (OR = 1.718, 95% CI: 1.232-2.396, P = 0.001) were independent predictors of level III lymph nodes positivity. At median follow-up time of 30 months, the distant disease-free survival (DDFS) rate of level III node positive group was much lower than that of level III negative group (p = 0.011).

CONCLUSIONS

About 9% of node positive T0-2 breast cancer will have residual positive node in level III region after neoadjuvant chemotherapy. Node positivity proved by NB, large tumor size, and primary tumor non-response to neoadjuvant chemotherapy are independent predictors of level III lymph nodes positivity.

Axillary staging by ultrasound-guided fine-needle aspiration cytology in breast cancer patients. Still up to date?

To investigate whether clinicopathological features of breast cancer patients could predict the likelihood of lymph node metastases and the likelihood of false-negative results of ultrasound-guided fine-needle aspiration cytology of suspicious lymph nodes (US+FNAC). Between 2004 and 2009, US+FNAC was performed in 1,150 axillae (18 bilateral breast carcinomas). Based on final histologic diagnosis, the true- and false-negative group of US+FNAC were defined. Subsequently, 11 clinicopathological factors were compared between these two groups. These factors were also compared between patients with and patients without lymph node metastases. Of 1,150 axillae, 429 had lymph node metastases at final histology. US+FNAC indicated metastases in 107 axillae. 1,043 axillae were negative by US+FNAC. Final histology showed metastases in 323 of these 1,043 axillae, resulting in a false-negative group of US+FNAC of 31%. Both age <60 years and a cT2/cT3 breast carcinoma were significantly associated with lymph node metastases and with false-negative results of US+FNAC. Lymph node metastases were found in 59.6% of patients <60 years with a cT2/cT3 breast carcinoma. In these patients, 52.3% of the negative US+FNAC results were falsely negative. In patients <60 years with a cT2/cT3 breast carcinoma, we recommend to omit US+FNAC preoperatively and perform a SNB directly, because lymph node metastases were found in 59.6% of these patients and 52.3% of negative US+FNAC results were falsely negative.

Prediction of axillary lymph node status in male breast carcinoma

BACKGROUND

To evaluate whether predictive factors of axillary lymph node metastasis in female breast cancer (BC) are similar in male BC.

PATIENTS AND METHODS

From January 1994 to May 2011, we recorded 80 non-metastatic male BC treated at Institut Curie (IC). We analysed the calibration and discrimination performance of two nomograms [IC, Memorian Sloan-Kettering Cancer Center (MSKCC)] originally designed to predict axillary lymph node metastases in female BC.

RESULTS

About 55% and 24% of the tumours were pT1 and pT4, respectively. Nearly 46% demonstrated axillary lymph node metastasis. About 99% were oestrogen receptor positive and 94% HER2 negative. Lymph node status was the only significant prognostic factor of overall survival (P = 0.012). The area under curve (AUC) of IC and MSKCC nomograms were 0.66 (95% CI 0.54-0.79) and 0.64 (95% CI 0.52-0.76), respectively. The calibration of these two models was inadequate.

CONCLUSIONS

Multi-variate models designed to predict axillary lymph node metastases for female BC were not effective in our male BC series. Our results may be explained by (i) small sample size (ii) different biological determinants influencing axillary metastasis in male BC compared with female BC.

Predictors of axillary lymph node metastases in early breast cancer and their applicability in clinical practice

PURPOSE

Lymph node involvement is the most important prognostic factor in breast cancer. It is a multifactorial event determined by patient and tumour characteristics. The purpose of this study was to determine clinical and pathological factors predictive for axillary lymph node metastasis (ALNM) in patients with early breast cancer and to build a model to portend lymph node involvement.

METHODS

We evaluated 1300 consecutive patients surgically treated in our institution (2007-2009) for cT1-T2 invasive breast cancer. The patient and tumour characteristics evaluated included: age at diagnosis, number of foci, histologic grade, location, tumour size, histologic subtype, lymphovascular invasion (LVI), estrogen-receptor (ER), progesterone-receptor (PR) and Her-2 status. Univariate and multivariate analyses were performed. Factors significantly associated with ALNM by univariate analysis plus histologic subtype were included in the multivariate analysis.

RESULTS

By univariate analysis, the incidence of ALNM was significantly associated with the presence of LVI (P < 0.0001), larger tumour size (P < 0.0001), higher histologic grade (P < 0.0001), retroareolar or lateral location in the breast (P < 0.0001), multiple foci (P = 0.0002) and in patients who underwent an axillary lymph node dissection. We found no effect of age, ER⁄PR nor HER-2 status. By multivariate analysis, ALNM was significantly associated with the presence of LVI (P < 0.0001), larger tumour size (P < 0.0001), axillary lymph node dissection (P = 0.0003), retroareolar and lateral tumour location in the breast (P = 0.0019) and the presence of multiple foci (P = 0.0155).

CONCLUSIONS

LVI and tumour size emerged as the most powerful independent predictors of ALNM, followed by the location of the tumour in the breast and the presence of multiple foci.

Breast Cancer Close to the Nipple: Does This Increase the Risk of Nodal Metastasis at Diagnosis?

Background

Previous studies of patients with invasive breast cancer examined, with mixed results, tumour location as a predictor of axillary lymph node metastasis. This study assessed whether tumour location in relation to the nipple impacts the presence of axillary lymph node metastasis at the time of diagnosis.

Methods

A retrospective review was undertaken of the medical records and available imaging of 285 patients diagnosed with invasive breast cancer between January 2001 to June 2007 at Boston University Medical Center. The incidence of axillary lymph node metastasis was correlated with tumour location in relation to the posterior nipple line to control for variation in breast size. Bivariate analysis identified significant variables that were applied to a multiple logistic regression model.

Results

Axillary lymph node metastasis was not significantly associated with tumour proximity to the nipple. In the multivariate logistic regression analysis, known prognostic factors for axillary metastasis, such as surgical size, lymphovascular invasion, and age of diagnosis, were significant, whereas breast density, palpability, and histologic grade were no longer significant.

Conclusions

Our study found that there was no evidence that correlates intramammary tumour proximity to the nipple with the presence of axillary lymph node metastasis at diagnosis. However, known prognostic factors, such as lymphovascular invasion, surgical size, and younger age at diagnosis, are strong independent predictors for axillary lymph node involvement.

The molecular subtype classification is a determinant of sentinel node positivity in early breast carcinoma

Introduction

Several authors have underscored a strong relation between the molecular subtypes and the axillary status of breast cancer patients. The aim of our work was to decipher the interaction between this classification and the probability of a positive sentinel node biopsy.

Materials and Methods

Our dataset consisted of a total number of 2654 early-stage breast cancer patients. Patients treated at first by conservative breast surgery plus sentinel node biopsies were selected. A multivariate logistic regression model was trained and validated. Interaction covariate between ER and HER2 markers was a forced input of this model. The performance of the multivariate model in the training and the two validation sets was analyzed in terms of discrimination and calibration. Probability of axillary metastasis was detailed for each molecular subtype.

Results

The interaction covariate between ER and HER2 status was a stronger predictor (p = 0.0031) of positive sentinel node biopsy than the ER status by itself (p = 0.016). A multivariate model to determine the probability of sentinel node positivity was defined with the following variables; tumour size, lympho-vascular invasion, molecular subtypes and age at diagnosis. This model showed similar results in terms of discrimination (AUC = 0.72/0.73/0.72) and calibration (HL p = 0.28/0.05/0.11) in the training and validation sets. The interaction between molecular subtypes, tumour size and sentinel nodes status was approximated.

Discussion

We showed that biologically-driven analyses are able to build new models with higher performance in terms of breast cancer axillary status prediction. The molecular subtype classification strongly interacts with the axillary and distant metastasis process.

Lobular and non-lobular breast cancers differ regarding axillary lymph node metastasis: a cross-sectional study on 4,292 consecutive patients

Invasive lobular carcinoma (ILC) accounts for 8-14% of all breast cancers and carries distinct prognostic and biologic implications. The goal of our study was to investigate the impact of lobular histology on axillary lymph node (ALN) involvement. This is a cross-sectional study of 4,292 consecutive patients surgically treated for breast carcinoma at the University Hospitals Leuven. Logistic regression analysis was used to relate ILC to lymph node involvement while controlling for the following clinicopathologic features: tumor size, multifocal disease, tumor grade, lobular subtype and the combined steroid, and Her-2 status. Odds ratios (ORs) and 95% confidence intervals (CIS) were computed. A subgroup analysis was performed for patients that underwent a sentinel lymph node (SLN) procedure. The observed incidence of ILC was 13%. ILCs were larger, were more often grade II, multifocal, steroid receptor positive and Her-2 negative, and tended to be present in older patients. Incidence of ALN involvement was 42.0% for ILCs versus 38.3% for other tumors (OR 1.17, 95% CI 0.97-1.40). For the SLN subgroup, ILCs were less often ALN positive than non-ILCs (20.5% versus 28.3%, OR 0.66, 95% CI: 0.41-1.00). In the multivariable analysis, the lobular subtype was identified as less likely to have ALN involvement (adjusted OR 0.66, 95% CI 0.53-0.82). The analysis for the SLN subgroup showed comparable results (adjusted OR 0.49, 95% CI 0.30-0.78). This study has demonstrated that the lobular subtype is an independent predictor of lymph node involvement with ILC having a lower incidence of involved lymph nodes. The mildly higher incidence of ALN metastasis in lobular cancers in univariable analysis is not due to the lobular subtype, but due to confounding factors that interact with lymph node involvement.

Does primary breast cancer in older women (≥80 years) have unfavorable histological characteristics?

INTRODUCTION

Although the majority of breast cancer patients are older than 65 years, limited data exist regarding the pathological features in very elderly patients. The aim of this study was to evaluate the histological characteristics of breast cancer in women aged over 80 years.

METHODS

The histological data were reviewed for 137 women aged 80 years and older who were diagnosed with primary breast carcinoma at a university clinic during the period 1990-2005.

RESULTS

Although it is believed that older women have more advanced tumor, the majority of the tumors were assessed as stage I (35%) and II (32.9%). Mucinous, papillary, medullary, tubular, and cribriform histological subtypes have been demonstrated often in this age group (16.8%). In 49.7 and 70.6% of cases, respectively, there were no regional lymph node metastases and no distant metastases. The frequency of ER-positive (72%) and PR-positive (56%) tumors in these patients is high.

CONCLUSIONS

An accurate prognostic evaluation at the time of initial diagnosis is of high importance for older patients, since this could avoid unnecessary and risky therapies. As an increasing number of women ≥80 years old may be diagnosed with breast cancer in the coming years, treatment in this specific age group should be individualized to the patient and tumor factors.

A risk stratification by hormonal receptors (ER, PgR) and HER-2 status in small (< or = 1 cm) invasive breast cancer: who might be possible candidates for adjuvant treatment?

As the use of screening mammography expands, the proportion of invasive breast cancer > or = 1 cm is increasing. The aims of this study were: (1) to identify risk factors for systemic metastases in patients with > or = 1 cm invasive breast cancer and (2) to investigate the patient groups at the greatest risk for metastases with such small tumors. Data were collected retrospectively from the breast cancer registry of our institution for patients with invasive breast cancer from October 1994 to December 2004. Of 4,036 patients who received curative breast cancer surgery, we identified 427 patients who had T1a or T1b breast cancer excluding 39 patients who received neoadjuvant chemotherapy. Ipsilateral axillary lymph node involvement was found in 13% (57/427) of patients at the time of surgery. A multivariate analysis was conducted in 370 (T1aN0, T1bN0) patients without lymph node involvement. In a Cox-regression model, HER-2 positive and triple negative (TN) groups were identified as independent risk factors to predict distant relapse-free survival (DRFS) [Hazard ratio (HR) 8.8, P = 0.003 for HER-2 positive group; HR 5.1, P = 0.026 for TN group] in T1bN0 tumors. Statistical significance was not maintained when the analysis was limited to T1aN0 tumors. Even though T1aN0 and T1bN0 tumors have a relatively low risk of systemic failure, antiHER-2-directed therapy for HER-2 group and new innovative adjuvant systemic treatment for TNBC patients with T1bN0 tumors should be considered. Prospective adjuvant trials are warranted in these subgroups of patients.

Value of frozen section and primary tumor factors in determining sentinel lymph node spread in early breast carcinoma

INTRODUCTION

Sentinel lymph node biopsy (SLNB) is the standard of care to assess the metastasis in breast carcinoma. Accuracy of intraoperative frozen section examination to evaluate SLN in detecting metastasis is important as it determines the further management of axilla. Primary tumor characteristics determining the metastasis to the lymph node will help in predicting the probability of spread and to determine the nature of disease. It also helps in refining selection of patients for SLNB. We evaluated all these criteria on Indian patients for the better management.

MATERIALS AND METHODS

Between January 2005 and April 2009, 114 consecutive patients of all age group of both sex, with cytology or biopsy proven carcinoma breast, clinical stage T1/T2 N0 M0 at Manipal Comprehensive Cancer Center, Manipal Hospital, Bangalore were subjected to SLNB and introperative frozen examination. First 75 cases had complete axillary clearance irrespective of SLNB result and subsequently, positive cases underwent axillary lymph node dissection (ALND). Age of the patient and primary tumor characteristics like size, grade, lymphovascular invasion (LVI), perineural invasion, ER/PR status, Her2-neu status and histological sub-types were evaluated for predicting the SLN metastasis. Feasibility of SLNB in previously treated patient is also evaluated.

RESULTS

The age of the patient ranged from 23 to 87 years and its association with SLN spread is not significant. Frozen section examination had accuracy of 97.37% in determining metastatic sentinel node with sensitivity of 96.15% and specificity of 100% with value P < 0.001. SLN remained significant indicator of the status of rest of axilla with value P < 0.001. Primary tumor characteristics like histological subtypes, grade (P = 0.353), ER/PR status (P = 0.839), Her2-neu status (P =0.296) were not significantly associated with SLN metastasis. Size of the primary tumor (P = 0.002), LVI (P < 0.001), perineural invasion (P = 0.084+) were significant factors determining the SLN metastasis. SLNB evaluation had no false negative values in previously treated breast.

CONCLUSION

SLNB is a valuable method of determining the axillary nodal metastasis. Intraoperative frozen section examination is highly ac-curate in detecting nodal metastasis. Primary tumor characteristics like size, LVI and perineural invasion are significant in predicting SLN metastasis. SLNB remains an important method of predicting axillary metastasis even in previously treated breast carcinomas.

A Comparison of the Proteomic Expression in Pooled Saliva Specimens from Individuals Diagnosed with Ductal Carcinoma of the Breast with and without Lymph Node Involvement

Purpose. The objective was to compare the salivary protein profiles of saliva specimens from individuals diagnosed with invasive ductal carcinoma of the breast (IDC) with and without lymph node involvement. Methods. Three pooled saliva specimens from women were analyzed. One pooled specimen was from healthy women; another was from women diagnosed with Stage IIa IDC and a specimen from women diagnosed with Stage IIb. The pooled samples were trypsinized and the peptide digests labeled with the appropriate iTRAQ reagent. Labeled peptides from each of the digests were combined and analyzed by reverse phase capillary chromatography on an LC-MS/MS mass spectrometer. Results. The results yielded approximately 174 differentially expressed proteins in the saliva specimens. There were 55 proteins that were common to both cancer stages in comparison to each other and healthy controls while there were 20 proteins unique to Stage IIa and 28 proteins that were unique to Stage IIb.

A long-term study of radiation therapy in t1-2 node-negative breast cancer patients in relation to the number of axillary nodes examined

PURPOSE

The optimal number of axillary nodes to be resected is controversial. This large series investigated the effect of surgery with or without adjuvant radiotherapy among node-negative breast cancer patients in relation to the number of nodes examined.

METHODS AND MATERIALS

Node-negative patients from the Saskatchewan registry of 1981-1995 were studied. Because nodal status may be more reliable with more number of nodes examined, we analyzed T1-2 age < 90 patients with < 10 nodes examined treated with surgery alone (Group A_S, n = 509) vs. surgery and adjuvant radiotherapy (Group A_S+R, n = 342); and T1-2 age < 90 patients with > or = 10 nodes examined treated with surgery alone (Group B_S, n = 902) vs. surgery and adjuvant radiotherapy (Group B_S+R, n = 596).

RESULTS

For the two radiotherapy groups, patients with < 10 nodes (Group A_S+R) vs. > or = 10 nodes (Group B_S+R), there was no difference in overall survival (p = 0.14). In the two nonradiotherapy groups (A_S and B_S), there is a statistically significant decrease in overall survival for patients with < 10 nodes removed (p < 0.001, log-rank test). The optimal number of axillary nodes examined could be 8 nodes with adjuvant radiotherapy (p = 0.05, logrank test) and 12 nodes without adjuvant radiotherapy (p = 0.02, log-rank test).

CONCLUSIONS

The poorer prognosis of a lesser number of nodes resected was overcome partly by the use of radiotherapy, raising the possibility of micrometastases in lymph nodes not removed. The optimal number of axillary nodes examined could be 8 nodes with adjuvant radiotherapy and 12 nodes without adjuvant radiotherapy.

The value of level III clearance in patients with axillary and sentinel node positive breast cancer

BACKGROUND

The value of level III axillary clearance is contentious, with great variance worldwide in the extent and levels of clearance performed.

OBJECTIVE

To determine rates of level III positivity in patients undergoing level I-III axillary clearance, and identify which patients are at highest risk of involved level III nodes.

METHODS

From a database of 2850 patients derived from symptomatic and population-based screening service, 1179 patients who underwent level I-III clearance between the years 1999-2007 were identified. The pathology, surgical details, and prior sentinel nodes biopsies of patients were recorded.

RESULTS

Eleven hundred seventy nine patients had level I-III axillary clearance. Of the patients, 63% (n = 747) were node positive. Of patients with node positive disease, 23% (n = 168) were level II positive and 19% (n = 141) were level III positive. Two hundred fifty patients had positive sentinel node biopsies prior to axillary clearance. Of these, 12% (n = 30) and 9% (n = 22) were level II and level III positive, respectively. On multivariate analysis, factors predictive of level III involvement in patients with node positive disease were tumor size (P < 0.001, OR = 1.36; 95% CI: 1.2-1.5), invasive lobular disease (P < 0.001, OR = 3.6; 95% CI: 1.9-6.95), extranodal extension (P < 0.001, OR = 0.27; 95% CI: 0.18-0.4), and lymphovascular invasion (P = 0.04, OR = 0.58; 95% CI: 0.35-1). Lobular invasive disease (P = 0.049, OR = 4.1; 95% CI: 1-16.8), extranodal spread (P = 0.003, OR = 0.18; 95% CI: 0.06-0.57), and having more than one positive sentinel node (P = 0.009, OR = 4.9; 95% CI: 1.5-16.1) were predictive of level III involvement in patients with sentinel node positive disease.

CONCLUSION

Level III clearance has a selective but definite role to play in patients who have node positive breast carcinoma. Pathological characteristics of the primary tumor are of particular use in identifying those who are at various risk of level III nodal involvement.

Detection of circulating tumor cells in early-stage breast cancer metastasis to axillary lymph nodes

PURPOSE

Clinical and pathologic prognostic factors do not always accurately predict disease outcome. Patients with early-stage breast cancer may harbor clinically significant but undetected systemic disease. We hypothesized that a multimarker quantitative real-time reverse transcription-PCR (qRT) assay could detect circulating tumor cells (CTC) in patients with early-stage breast cancer and correlate with sentinel lymph node (SLN) and non-SLN metastasis status.

EXPERIMENTAL DESIGN

Blood samples from 90 women with the American Joint Committee on Cancer stages I to III breast cancer and 39 age-matched normal healthy volunteers were assessed by qRT for mRNA expression of three markers: stanniocalcin-1 (STC-1), N-acetylgalactosaminyltransferase (GalNacT), and melanoma antigen gene family-A3 (MAGE-A3). CTC biomarker detection was correlated with overall axillary LN (ALN), SLN, and non-SLN histopathology status.

RESULTS

CTCs were detected in 39 of 90 (43%) patients, but not in normal volunteers. At least one CTC biomarker was detected in 10 of 35 (29%) stage I patients, 19 of 42 (45%) stage II patients, and 10 of 13 (77%) stage III patients. In multivariate analysis, only lymphovascular invasion and >or=2 CTC biomarkers detected significantly correlated with ALN metastasis [odds ratio (OR), 12.42; 95% confidence interval (95% CI), 3.52-43.77, P<0.0001; and OR, 3.88; 95% CI, 1.69-8.89, P=0.001, respectively]. The number of CTC biomarkers detected similarly correlated with SLN and non-SLN metastasis status (P=0.0004). At least one CTC biomarker was detected in 10 of 11 (91%) patients with non-SLN metastases.

CONCLUSION

The detection of CTCs offers a novel means to assess the presence of systemic disease spreading relative to SLN and ALN histopathology status.

Doctor, what are my chances of having a positive sentinel node? A validated nomogram for risk estimation

PURPOSE

Lymph node metastasis is a multifactorial event. Several variables have been described as predictors of lymph node metastasis in breast cancer. However, it is difficult to apply these data-usually expressed as odds ratios-to calculate the probability of sentinel lymph node (SLN) metastasis for a specific patient. We developed a user-friendly prediction model (nomogram) based on a large data set to assist in predicting the presence of SLN metastasis.

PATIENTS AND METHODS

Clinical and pathologic features of 3,786 sequential SLN biopsy procedures were assessed with multivariable logistic regression to predict the presence of SLN metastasis in breast cancer. The model was subsequently applied to 1,545 sequential SLN biopsies. A nomogram was created from the logistic regression model. A computerized version of the nomogram was developed and is available on the Memorial Sloan-Kettering Cancer Center (New York, NY) Web site.

RESULTS

Age, tumor size, tumor type, lymphovascular invasion, tumor location, multifocality, and estrogen and progesterone receptors were associated with SLN metastasis in multivariate analysis. The nomogram was accurate and discriminating, with an area under the receiver operating characteristic curve of 0.754 when applied to the validation group.

CONCLUSION

Newly diagnosed breast cancer patients are increasingly interested in information about their disease. This nomogram is a useful tool that helps physicians and patients to accurately predict the likelihood of SLN metastasis.

Preoperative selection of symptomatic breast cancer patients appropriate for lymphatic mapping and sentinel node biopsy

BACKGROUND

This study examines whether preoperative ultrasound-assessed tumour diameter and diagnostic core biopsy-determined grade can be used to select those most likely to benefit from SLNB (i.e. those that are "node negative") before their definitive operation.

METHODS

Breast ultrasound (US) and a simultaneous core biopsy was performed in all patients at their initial presentation, and their estimates of tumor size and grade compared with the final pathological specimen (FPS).

RESULTS

Of the T1 group 47% had lymphatic metastases as did 49% of those with grade I or II cancers. By combining these measures, however, subgroups of patients with lower rates of nodal metastases were identified (32% of patients with T1, non-grade III disease had lymphatic disease while only 15% of those with T < 1.5 cm, non-grade III cancers had such metastases).

CONCLUSION

Combination of the US and ultrasound guided core biopsy (UGCB) may however identify subgroups unlikely to have axillary disease that are therefore suitable for SLNB.

Predictors of axillary lymph node metastasis in breast cancer: A systematic review

AIMS

To review the established and emerging techniques in axillary lymph node prediction and explore their potential impact on clinical practice. To reliably identify patients in whom axillary lymph node surgery, including SLNB, can be safely omitted.

METHODS

Searches of PubMed were made using the search terms "axilla" (or "axillary"), "lymph", "node" and "predictor" (or "prediction"). Articles from abstracts and reports from meetings were included only when they related directly to previously published work.

FINDINGS

There are numerous studies in which the predictive utility of biomarkers as determinants of axillary lymph node status have been investigated. Few of these have specifically addressed the attributes of the primary tumour which could offer much potential for the prediction of tumour metastasis to the axillary lymph nodes.

CONCLUSIONS

Currently, no single marker is sufficiently accurate to obviate the need for formal axillary staging using SLNB or axillary clearance.

Proteomic Profiling of Primary Breast Cancer Predicts Axillary Lymph Node Metastasis

To determine if protein expression in primary breast cancers can predict axillary lymph node (ALN) metastasis, we assessed differences in protein expression between primary breast cancers with and without ALN metastasis using surface-enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF-MS). Laser capture microdissection was performed on invasive breast cancer frozen sections from 65 patients undergoing resection with sentinel lymph node (SLN) or level I and II ALN dissection. Isolated proteins from these tumors were applied to immobilized metal affinity capture (IMAC-3) ProteinChip arrays and analyzed by SELDI-TOF-MS to generate unique protein profiles. Correlations between unique protein peaks and histologically confirmed ALN status and other known clinicopathologic factors were examined using ANOVA and multivariate logistic regression. Two metal-binding polypeptides at 4,871 and 8,596 Da were identified as significant risk factors for nodal metastasis (P = 0.034 and 0.015, respectively) in a multivariate analysis. Lymphovascular invasion (LVI) was the only clinicopathologic factor predictive of ALN metastasis (P = 0.0038). In a logistic regression model combining the 4,871 and 8,596 Da peaks with LVI, the area under the receiver operating characteristic curve was 0.87. Compared with patients with negative ALN, those with > or =2 positive ALN or non-SLN metastases were significantly more likely to have an increased peak at 4,871 Da (P = 0.016 and 0.0083, respectively). ProteinChip array analysis identified differential protein peaks in primary breast cancers that predict the presence and number of ALN metastases and non-SLN status.

Allometric Scaling Law Questions the Traditional Mechanical Model for Axillary Lymph Node Involvement in Breast Cancer

Purpose

To find a quantitative relationship between tumor size and frequency of axillary lymph node involvement.

Patients and Methods

The frequency of axillary node involvement versus primary tumor volume was analyzed in 10 selected series of patients incorporating a total of 57,244 women with resectable breast cancer. The average number of events per unit volume resulting in tumor spread to axillary lymph nodes before tumor surgical removal Θ(V)/V, was estimated under simple probabilistic assumptions.

Results

The allometric scaling law Θ(V)/V = 0.0586V−0.7457 was estimated on the data, fitting the proportion of lymph node involvement on tumor volume V (in microliters). The estimate 0.7457 (95% CI, 0.7200 to 0.7713) suggests that the true scaling exponent, under the assumed model, may be the fractional value, which characterizes scaling relationships for a wide variety of biologic variables at both the whole organism level and organ level.

Conclusion

Results suggest that the phenomenon should be related to some internal structural trait of the tumor. The vascular network seems to be the best candidate. This result does not support a mere mechanical model of lymphatic tumor spread. A more complex biology-based model of lymphohematogenous spread is suggested, in which the axillary nodes draining the lymph from the primary tumor may become activated by factors produced by both tumor cells and tumor stroma, thus favoring cell-selective homing of otherwise circulating tumor cells. The success of fractal features related to the internal architecture brings additional support to the consideration of primary breast cancer as an organ-like structure.

Breast cancer sagittal/horizontal plane location influences axillary lymph node involvement

AIM

To assess the influence of tumour location on axillary lymph node involvement (ALNI) and prognosis in breast cancer by evaluating the significance of the sagittal/horizontal alignment.

METHODS

We compared 57 patients with superficially located breast carcinomas up to 3.0 cm with patients having lesions in posterior planes of the breast. Both groups were matched according to age, time of diagnosis, tumour size, grade, hormonal receptor status and tumour site within the frontal plane. Histologic evidence of skin involvement, excluding tumours fulfilling the criteria for pT4b, was defined as inclusion criteria and reference plane for superficial tumour location.

RESULTS

Tumours situated in the superficial region of the breast, compared to those located in deeper planes, have an increased risk of ALNI (p=0.023), whereas no difference was observed with reference to disease-specific survival (p=0.203).

CONCLUSION

This study shows that ALNI is dependent on sagittal/horizontal as well as frontal tumour location. Clinicians should be aware that tumours lying posteriorly may be at increased risk of occult spread outside axillary lymph nodes.

Clinical and pathological factors predictive of lymph node status in women with screen-detected breast cancer

Two thousand one hundred and thirty five asymptomatic invasive breast cancers detected through screening mammography were analysed to identify predictors of lymph node involvement. Multivariable analysis indicated that predictors included larger tumour diameter, an infiltrating ductal or lobular histological type, multifocal disease, a palpable lesion, and a younger age at diagnosis. An association also was found between nodal involvement and the presence of an extensive in situ component (EIC). Grade was associated with nodal involvement as a univariate predictor. It would be more accurate for screening assessment clinics to use models for predicting nodal status that were customised to their own experience rather than generic models developed in other settings that related predominantly to symptomatic cancer. These models could assist clinical decision-making on axillary node dissection and give guidance to pathologists on numbers of tissue sections to examine.

The Prognostic Effect of the Number of Histologically Examined Axillary Lymph Nodes in Breast Cancer: Stage Migration or Age Association?

BACKGROUND

The number of pathologically examined axillary nodes has been associated with breast cancer survival, and examination of >or=10 nodes has been advocated for reliable axillary staging. The considerable variation observed in axillary staging prompted this population-based study, which evaluated the prognostic effect of a variable number of pathologically examined nodes.

METHODS

In total, 5314 consecutive breast cancer patients who underwent mastectomy or breast-conserving surgery and axillary dissection between 1994 and 1999 were included. The prognostic effect of the examined number of nodes was assessed with crude and relative survival analysis.

RESULTS

A median number of 12 (range, 1-43) nodes were histologically examined, and 59% of the patients had no nodal tumor involvement. The number of examined nodes decreased with age (P<.001) and increased with tumor size (P<.001). Stratified for the number of tumor-positive nodes, overall survival seemed to be worse for patients with <10 compared with patients with >or=10 examined nodes (P<.001), whereas the relative survival did not differ. After adjusting for age, tumor size, number of positive nodes, and detection by screening in a multivariate analysis, the number of examined nodes was not associated with relative survival.

CONCLUSIONS

This study shows that the association between the number of pathologically examined axillary nodes and overall survival in node-negative and node-positive patients results from stage migration. The absence of an association between the number of examined nodes and relative survival further indicates that the association between the number of examined nodes and crude survival is confounded by age.