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Li Z, Li X, Guan S, Zhu G, Lin H, Wu H, Jia J, Guo Z, Cai Z, Zheng Q, Zhang H, Ruan F, Zheng X, Yang C, Xu Y, Ye J. Correlation Analysis Between Tumor Deposit and Clinicopathologic Characteristics and Prognosis of Gastric Cancer: A Multicenter Retrospective Study. Ann Surg Oncol 2024; 31:5984-5996. [PMID: 38814549 DOI: 10.1245/s10434-024-15508-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 05/09/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND The mechanism underlying the formation of gastric tumor deposits (TDs) is unclear. We aimed to explore the risk factors for the formation and prognostic value of TDs. METHODS This retrospective analysis included 781 locally advanced gastric cancer (LAGC) patients from four medical institutions in China, from June 2014 to June 2018. The risk factors for TD formation and prognostic value were determined through univariate and multivariate analyses. RESULTS Univariate analysis revealed that TD positivity was closely related to tumor diameter, Borrmann classification, differentiation degree, pT stage, pN stage, pTNM stage, and nerve and vascular invasion (p < 0.05). Multivariate logistic regression revealed that tumor diameter ≥ 5 cm (odds ratio [OR] 1.836, 95% confidence interval [CI] 1.165-2.894, p = 0.009) and vascular invasion (OR 2.152, 95% CI 1.349-3.433, p = 0.001) were independent risk factors for TD positivity. Multivariate Cox analysis revealed that TD positivity (OR 1.533, 95% CI 1.101-2.134, p = 0.011), tumor diameter ≥ 5 cm (OR 1.831, 95% CI 1.319-2.541, p < 0.001), pT4a stage (OR 1.652, 95% CI 1.144-2.386, p = 0.007), and vascular invasion (OR 1.458, 95% CI 1.059-2.008, p = 0.021) were independent risk factors for GC prognosis. The 5-year overall and disease-free survival of the TD-positive group showed significant effects among patients in the pT4a and pN3b stages (p < 0.05). CONCLUSIONS TDs are closely related to tumor diameter and vascular invasion in LAGC patients, and TD positivity is an independent prognostic factor for LAGC patients, especially those at pT4a and pN3b stages.
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Affiliation(s)
- Zhixiong Li
- Gastrointestinal Surgery Unit 1, The First Hospital of Putian City, Putian, 351100, Fujian, China
- Gastrointestinal Surgery Unit 2, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350004, Fujian, China
| | - Xinyu Li
- Department of Gastrointestinal Surgery, The First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, 362002, Fujian, China
| | - Shen Guan
- Department of Gastrointestinal Surgery, Clinical Oncology School of Fujian Medical University Fujian Cancer Hospital, Fuzhou, 350004, Fujian, China
| | - Guangwei Zhu
- Gastrointestinal Surgery Unit 2, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350004, Fujian, China
| | - Huimei Lin
- Department of Anorectal Surgery, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, 361021, Fujian, China
| | - Haiyan Wu
- Department of Pathology, The First Hospital of Putian City, Putian, 351100, Fujian, China
| | - Jing Jia
- Department of Gastrointestinal Surgery, The First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, 362002, Fujian, China
| | - Zipei Guo
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, 350122, Fujian, China
| | - Zhiming Cai
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, 350122, Fujian, China
| | - Qiajun Zheng
- Gastrointestinal Surgery Unit 2, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350004, Fujian, China
| | - Haoxiang Zhang
- Gastrointestinal Surgery Unit 2, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350004, Fujian, China
| | - Fangqiu Ruan
- Gastrointestinal Surgery Unit 2, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350004, Fujian, China
| | - Xu Zheng
- Gastrointestinal Surgery Unit 2, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350004, Fujian, China
| | - Chunkang Yang
- Department of Gastrointestinal Surgery, Clinical Oncology School of Fujian Medical University Fujian Cancer Hospital, Fuzhou, 350004, Fujian, China
| | - Yanchang Xu
- Gastrointestinal Surgery Unit 1, The First Hospital of Putian City, Putian, 351100, Fujian, China.
| | - Jianxin Ye
- Gastrointestinal Surgery Unit 2, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350004, Fujian, China.
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Fujikawa K, Omori T, Shinno N, Hara H, Yamamoto M, Yasui M, Matsuda C, Wada H, Nishimura J, Haraguchi N, Akita H, Ohue M, Miyata H. Tumor Deposit Is an Independent Factor Predicting Early Recurrence and Poor Prognosis in Gastric Cancer. J Gastrointest Surg 2023; 27:1336-1344. [PMID: 37014588 DOI: 10.1007/s11605-023-05668-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/11/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Accurate prognostic estimation is crucial; however, the prognostic value of tumor deposits in gastric cancer remains controversial. This study aimed to investigate their prognostic significance. METHODS Clinicopathological and prognostic data of 1012 gastric cancer patients who underwent R0 or R1 surgery from 2010 to 2017 at the Osaka International Cancer Institute were retrospectively reviewed. RESULTS Overall, 6.3% patients had tumor deposits, which were associated with Borrmann type, surgical procedure, type of gastrectomy, extent of lymphadenectomy, tumor size, histology, pT, pN, pM, pStage, lymphatic invasion, vascular invasion, preoperative chemotherapy, and postoperative chemotherapy. Tumor deposit-positive patients had worse 5-year disease-free survival (32.60% vs. 92.45%) and overall survival (41.22% vs. 89.37%) than tumor deposit-negative patients. Subgroup analysis regarding pStage II-III also showed significant differences between patients with and without tumor deposits for 5-year disease-free survival (34.15% vs. 80.98%) and overall survival (43.17% vs. 75.78%). Multivariable analysis showed that older age, undifferentiated histology, deeper tumor invasion, lymph node metastasis, distant metastasis, and presence of tumor deposits were significantly correlated with early tumor recurrence and shorter survival time; these factors were identified as independent prognostic factors. The 5-year disease-free survival of tumor deposit-positive patients was significantly worse than that of patients in the pStage III group and comparable to that of patients in the pT4, pN3, and pM1 groups. The 5-year overall survival of tumor deposit-positive patients was comparable to that of the pT4, pN3, pM1, and pStage III groups. CONCLUSIONS Tumor deposits are strong and independent predictors of tumor recurrence and poor survival.
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Affiliation(s)
- Kaoru Fujikawa
- Osaka International Cancer Institute, 3-1-69 Otemae, Tyuo-Ward, Osaka City, Osaka-Prefecture, Japan
| | - Takeshi Omori
- Osaka International Cancer Institute, 3-1-69 Otemae, Tyuo-Ward, Osaka City, Osaka-Prefecture, Japan.
| | - Naoki Shinno
- Osaka International Cancer Institute, 3-1-69 Otemae, Tyuo-Ward, Osaka City, Osaka-Prefecture, Japan
| | - Hisashi Hara
- Osaka International Cancer Institute, 3-1-69 Otemae, Tyuo-Ward, Osaka City, Osaka-Prefecture, Japan
| | - Masaaki Yamamoto
- Osaka International Cancer Institute, 3-1-69 Otemae, Tyuo-Ward, Osaka City, Osaka-Prefecture, Japan
| | - Masayoshi Yasui
- Osaka International Cancer Institute, 3-1-69 Otemae, Tyuo-Ward, Osaka City, Osaka-Prefecture, Japan
| | - Chu Matsuda
- Osaka International Cancer Institute, 3-1-69 Otemae, Tyuo-Ward, Osaka City, Osaka-Prefecture, Japan
| | - Hiroshi Wada
- Osaka International Cancer Institute, 3-1-69 Otemae, Tyuo-Ward, Osaka City, Osaka-Prefecture, Japan
| | - Junichi Nishimura
- Osaka International Cancer Institute, 3-1-69 Otemae, Tyuo-Ward, Osaka City, Osaka-Prefecture, Japan
| | - Naotsugu Haraguchi
- Osaka International Cancer Institute, 3-1-69 Otemae, Tyuo-Ward, Osaka City, Osaka-Prefecture, Japan
| | - Hirofumi Akita
- Osaka International Cancer Institute, 3-1-69 Otemae, Tyuo-Ward, Osaka City, Osaka-Prefecture, Japan
| | - Masayuki Ohue
- Osaka International Cancer Institute, 3-1-69 Otemae, Tyuo-Ward, Osaka City, Osaka-Prefecture, Japan
| | - Hiroshi Miyata
- Osaka International Cancer Institute, 3-1-69 Otemae, Tyuo-Ward, Osaka City, Osaka-Prefecture, Japan
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Zhou M, Yang W, Zou W, Yang J, Zhou C, Zhang Z, Wang Y, Zhang J, Wang Y, Li G, Zhang Z, Xia F. Prognostic significance of tumor deposits in radically resected gastric cancer: a retrospective study of a cohort of 1915 Chinese individuals. World J Surg Oncol 2022; 20:304. [PMID: 36138439 PMCID: PMC9502614 DOI: 10.1186/s12957-022-02773-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 08/09/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Tumor deposits (TDs) have been identified as an independent prognostic factor in gastric cancer (GC). However, the associated clinicopathological factors and how to simply and reasonably incorporate TD into the TNM staging system remain undetermined. The aim of the current study was therefore to assess the significance of TD among radically resected GC patients. METHODS We retrospectively reviewed 1915 patients undergoing radical resection between 2007 and 2012. The patients were classified into two groups according to TD status (absent vs. present), and the clinicopathologic characteristics, DFS, and OS were compared. Associations of TD presence with other clinicopathologic factors were evaluated by logistic regression analysis. Univariate and multivariate Cox regression analyses were performed to determine the prognostic factors for DFS and OS in the primary cohort. Propensity score matching (PSM) was performed to reduce the possibility of selection bias according to the presence of TD. External validation of previously proposed modified staging systems incorporating TD was conducted. RESULTS The detection rate of TD was 10.5% (201/1915). The presence of TD was significantly related to unfavorable clinicopathologic variables, including advanced T and N categories. According to the multivariate Cox regression analysis, the presence of TD was identified as an independent prognostic factor for DFS and OS in the primary cohort (both P < 0.001). In the after-PSM cohort, TD presence also significantly shortened DFS and OS. In the external validation, one system that incorporated TD into the pTNM stage had the best performance. CONCLUSIONS The presence of TD was significantly associated with poor survival in radically resected GC patients. The incorporation of TD into the TNM staging system can further improve the predictive capability. A multicenter cohort with a large sample size is needed to determine the appropriate method of incorporation.
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Affiliation(s)
- Menglong Zhou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong’an Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 People’s Republic of China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032 People’s Republic of China
| | - Wang Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong’an Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 People’s Republic of China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032 People’s Republic of China
| | - Wei Zou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong’an Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 People’s Republic of China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032 People’s Republic of China
| | - Jianing Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong’an Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 People’s Republic of China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032 People’s Republic of China
| | - Changming Zhou
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 People’s Republic of China
- Department of Cancer Prevention, Fudan University Shanghai Cancer Center, Shanghai, 200032 People’s Republic of China
| | - Zhiyuan Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong’an Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 People’s Republic of China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032 People’s Republic of China
| | - Yaqi Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong’an Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 People’s Republic of China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032 People’s Republic of China
| | - Jing Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong’an Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 People’s Republic of China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032 People’s Republic of China
| | - Yan Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong’an Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 People’s Republic of China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032 People’s Republic of China
| | - Guichao Li
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong’an Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 People’s Republic of China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032 People’s Republic of China
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong’an Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 People’s Republic of China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032 People’s Republic of China
| | - Fan Xia
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong’an Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 People’s Republic of China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032 People’s Republic of China
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Asian Society of Mastology (ASOMA)–Proposed Standards for Care of Breast Cancer Patients. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02223-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Liang Y, Wu L, Liu L, Ding X, Wang X, Liu H, Meng J, Xu R, He D, Liang H. Impact of extranodal tumor deposits on prognosis and N stage in gastric cancer. Surgery 2019; 166:305-313. [PMID: 31221435 DOI: 10.1016/j.surg.2019.04.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/14/2019] [Accepted: 04/23/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Extranodal tumor deposits have been reported to be associated with a poor prognosis in many malignancies and are also included in the tumor, node, and metastasis staging system for colorectal cancer. METHODS We reviewed retrospectively a total of 2,344 gastric cancer patients who underwent gastrectomy with curative intent at the Tianjin Medical University Cancer Institute and Hospital (Hexi District, Tianjin, China) and the First Affiliated Hospital of Hainan Medical University (Longhua District, Haikou, China). Patients were categorized into 2 groups based on extranodal tumor deposit status: a positive group, including those with extranodal tumor deposits, and a negative group composed of those with no extranodal tumor deposits. Clinicopathologic factors were correlated with extranodal tumor deposits, and their individual prognoses were analyzed. In addition, a pathologically modified node classification system was proposed by incorporating the extranodal tumor deposit status into the 8th ed of the N staging system. The superiority of prognostic prediction between the modified node classification and node stage was compared. RESULTS A total of 645 (27.5%) patients had extranodal tumor deposits. The presence of extranodal tumor deposits was associated with a larger tumor size, Borrmann type III and IV, a deeper depth of invasion, and an advanced node stage. In the multivariate analysis, extranodal tumor deposits were an independent prognostic factor for gastric cancer patients after curative resection. Gastric cancer patients with extranodal tumor deposits demonstrated a lesser 5-year overall survival than those with no extranodal tumor deposits (31.9% vs 61.4%, P < .001). With the strata analysis, statistically significant prognostic differences between the two groups were only observed in patients at the N0-N2 stage. The modified node classification was found to be more appropriate for predicting the overall survival of gastric cancer patients after curative resection than node stage, and the -2 log likelihood of the modified node classification (16,042.890) was smaller than the value of node stage (16,150.811). CONCLUSION Extranodal tumor deposits in gastric cancer patients indicate aggressive characteristics and a poorer prognosis of gastric cancer. We maintain that extranodal tumor deposits should be incorporated into the N staging system to enhance the accuracy of the prognostic prediction of patients with gastric cancer.
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Affiliation(s)
- Yuexiang Liang
- Department of Gastrointestinal Oncology, The First Affiliated Hospital of Hainan Medical University, Longhua District, Haikou, China
| | - Liangliang Wu
- Department of Gastric Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center For Cancer, Hexi District, Tianjin, China
| | - Lijie Liu
- Department of Gastrointestinal Oncology, The First Affiliated Hospital of Hainan Medical University, Longhua District, Haikou, China
| | - Xuewei Ding
- Department of Gastric Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center For Cancer, Hexi District, Tianjin, China
| | - Xiaona Wang
- Department of Gastric Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center For Cancer, Hexi District, Tianjin, China
| | - Hongmin Liu
- Department of Gastric Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center For Cancer, Hexi District, Tianjin, China
| | - Jin Meng
- Department of Gastrointestinal Oncology, The First Affiliated Hospital of Hainan Medical University, Longhua District, Haikou, China
| | - Ronghua Xu
- Department of Gastrointestinal Oncology, The First Affiliated Hospital of Hainan Medical University, Longhua District, Haikou, China
| | - Donglei He
- Department of Gastrointestinal Oncology, The First Affiliated Hospital of Hainan Medical University, Longhua District, Haikou, China
| | - Han Liang
- Department of Gastric Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center For Cancer, Hexi District, Tianjin, China.
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Ilknur GB, Hilmi A, Tülay C, Oguz C, Selma S, Serdar S, Uğur Y, Pinar B, Omer H, Münir K. The Importance of Extracapsular Extension of Axillary Lymph Node Metastases in Breast Cancer. TUMORI JOURNAL 2018; 90:107-11. [PMID: 15143982 DOI: 10.1177/030089160409000122] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose To evaluate the prognostic value of extracapsular extension (ECE) of axillary lymph node metastases in 221 patients with axillary lymph node-positive, T1-T2 breast cancer treated at Dokuz Eylul University Hospital, Department of Radiation Oncology. Patients and methods The clinical records of patients with axillary node-positive, pathological stage II—III breast cancer examined at Dokuz Eylul University Hospital, Department of Radiation Oncology, between 1991–1999 were reviewed. All patients underwent modified radical mastectomy (MRM) or wide excision with axillary node dissection. Axillary surgery consisted of level l-ll dissection. The number of lymph nodes dissected from the axilla was equal to or more than 10 in 92% of the patients. All 221 patients had pathological T1–T2 tumors. The number of involved lymph nodes was four or more in 112 51% patients and less than four in the remaining 109 (49%). In 127 (57.5%) patients, extracapsular extension was detected in axillary lymph nodes. Tangential radiotherapy fields were used to treat the breast or chest wall. Lymphatic irradiation was performed in 215 (97%) patients with fields covering both the supraclavicular and axillary regions. Median radiotherapy dose for lymph nodes was 5000 cGy in 25 fractions. The following factors were evaluated: age, menopausal status, histological tumor type, pathological stage, number of involved axillary lymph nodes, and extracapsular extension. The chisquare test was used to compare proportions of categorical covariates between groups of patients with and without ECE. Survival analyses were estimated with the Kaplan-Meier method. The Cox regression model was used for the analysis of prognostic factors. Results The median follow-up for the survivors was 55 months (range, 19–23). The median age was 52 years (range, 28–75). In patients with extracapsular extension the percentages of pathological stage III (22% vs 4.3%, P <0.0001 and involvement of four or more axillary nodes (25.5% vs 69.3%, p<0.0000) were higher. Multivariate analysis revealed a significant correlation between the presence of ECE and disease-free survival (DFS) (P = 0.04) as well as distant metastases-free survival (DMFS) (P = 0.002), but there was no significant correlation between ECE and overall survival (OS). Only an elevated number of involved axillary lymph nodes significantly reduced the overall survival (P = 0.001). Conclusion The rate of extracapsular extension was found to be directly proportional to the number of axillary lymph nodes involved and the stage of disease. Extracapsular extension had significant prognostic value in both univariate and multivariate analysis for DFS and DMFS but not OS. The reason for ECE not affecting OS might be related to the much more dominant prognostic effect of the involvement of four or more axillary nodes on OS. Studies with more patients are needed to demonstrate that ECE is a likely independent prognostic factor for OS.
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Affiliation(s)
- Görken Bilkay Ilknur
- Department of Radiation Oncology, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey.
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Zhang Y, Hui ZG, Zhang JH, Yu ZH, Liu XF, Jin J, Wang WH, Wang SL, Song YW, Liu YP, Ren H, Fang H, Li YX. Survey on the Use of Radiotherapy to Treat Early Breast Cancer following Breast-conserving Surgery in China. TUMORI JOURNAL 2018. [DOI: 10.1177/1660.18166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ye Zhang
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhou-guang Hui
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiang-hu Zhang
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zi-hao Yu
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin-fan Liu
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Jin
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei-hu Wang
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-lian Wang
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong-wen Song
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-ping Liu
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hua Ren
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Fang
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ye-xiong Li
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Lee IS, Park YS, Ryu MH, Song MJ, Yook JH, Oh ST, Kim BS. Impact of extranodal extension on prognosis in lymph node-positive gastric cancer. Br J Surg 2014; 101:1576-84. [PMID: 25223244 DOI: 10.1002/bjs.9640] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 06/14/2014] [Accepted: 07/31/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND The TNM classification system is used widely for tumour staging, and directs the treatment and prognosis of patients with cancer. The aim of this study was to assess the prognostic value of extranodal extension (ENE) in patients with early gastric cancer. METHODS All patients who underwent gastrectomy with lymphadenectomy for primary gastric cancer with lymph node metastases between January 2003 and June 2006 were reviewed. Histological slides of metastatic nodes were reviewed by two gastrointestinal pathologists. The association of ENE with clinicopathological characteristics was assessed. The disease-specific survival rate was calculated by the Kaplan-Meier method, and a multivariable Cox regression model was used to identify independent prognostic factors. RESULTS Some 1143 patients were included. ENE was associated with advanced pT and pN category, larger tumour size and lymphovascular/perineural invasion. In multivariable analysis, pT category, pN category, ENE, lymphovascular invasion and perineural invasion were found to be independent prognostic factors in node-positive gastric carcinoma. The 5-year survival rate of patients with ENE was 48·1 per cent, compared with 78·2 per cent for patients without ENE (P < 0·001). In the subgroup of patients with early gastric cancer, ENE was associated with a worse 5-year survival rate in patients with early (T1) gastric cancer: 75 per cent in patients with ENE versus 96·9 per cent in those without (P < 0·001). CONCLUSION ENE is an independent prognostic factor in patients with early and advanced gastric cancer.
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Affiliation(s)
- I-S Lee
- Departments of Surgery, Ulsan University College of Medicine and Asan Medical Centre, Seoul, Korea
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Kaygusuz EI, Cetiner H, Yavuz H. Clinico-pathological significance of extra-nodal spread in special types of breast cancer. Cancer Biol Med 2014; 11:116-22. [PMID: 25009753 PMCID: PMC4069798 DOI: 10.7497/j.issn.2095-3941.2014.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 05/16/2014] [Indexed: 12/02/2022] Open
Abstract
Objective To investigate the significance of extra-nodal spread in special histological sub-types of breast cancer and the relationship of such spread with prognostic parameters. Methods A total of 303 breast cancer cases were classified according to tumor type, and each tumor group was subdivided according to age, tumor diameter, lymph node metastasis, extra-nodal spread, vein invasion in the adjacent soft tissue, distant metastasis, and immunohistochemical characteristics [estrogen receptor (ER), progesterone receptor (PR) existence, p53, c-erbB-2, and proliferative rate (Ki-67)]. The 122 cases with extra-nodal spread were clinically followed up. Results An extra-nodal spread was observed in 40% (122 cases) of the 303 breast cancer cases. The spread most frequently presented in micro papillary carcinoma histological sub-type (40 cases, 75%), but least frequently presents in mucinous carcinoma (2 cases, 8%). Patients with extra-nodal spread had a high average number of metastatic lymph nodes (8.3) and a high distant metastasis rate (38 cases, 31%) compared with patients without extra-nodal spread. Conclusion The existence of extra-nodal spread in the examined breast cancer sub-types has predictive value in forecasting the number of metastatic lymph nodes and the disease prognosis.
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Affiliation(s)
- Ecmel Isik Kaygusuz
- Department of Pathology, Zeynep Kamil Maternity and Children's Training and Research Hospital, Istanbul 34668, Turkey
| | - Handan Cetiner
- Department of Pathology, Zeynep Kamil Maternity and Children's Training and Research Hospital, Istanbul 34668, Turkey
| | - Hulya Yavuz
- Department of Pathology, Zeynep Kamil Maternity and Children's Training and Research Hospital, Istanbul 34668, Turkey
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Primary Retroperitoneal Lymph Node Dissection in Low-stage Testicular Germ Cell Tumors: A Detailed Pathologic Study With Clinical Outcome Analysis With Special Emphasis on Patients Who Did Not Receive Adjuvant Therapy. Urology 2013; 82:1341-6. [DOI: 10.1016/j.urology.2013.04.082] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 04/07/2013] [Accepted: 04/27/2013] [Indexed: 11/20/2022]
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Abstract
Place of axillary radiotherapy in the management of patients with breast cancer remains debated. While the prognostic value of axillary lymph node extension has been largely demonstrated, the benefit of axillary treatment is more uncertain. Large clinical trials having demonstrated the benefit of adjuvant radiotherapy in advanced breast cancer comprised large nodal irradiation, including axillary area. Analyzing the true benefit of axillary radiotherapy is rendered difficult by heterogeneity of series, particularly when focusing on the extent of lymph node dissection. Although adjuvant axillary radiotherapy is usually recommended in patients with insufficient lymph node dissection or with bulky axillary involvement, the prognosis in these patients remains poor by metastatic evolution and such strategy exposes to increased toxicity and functional sequels. Further assessments should better define the optimal indications and the true benefit of axillary radiotherapy.
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Hasebe T, Iwasaki M, Akashi-Tanaka S, Hojo T, Shibata T, Sasajima Y, Kinoshita T, Tsuda H. Prognostic significance of mitotic figures in metastatic mammary ductal carcinoma to the lymph nodes. Hum Pathol 2011; 42:1823-32. [DOI: 10.1016/j.humpath.2011.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 02/12/2011] [Accepted: 02/16/2011] [Indexed: 10/18/2022]
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Seiler R, von Gunten M, Thalmann GN, Fleischmann A. Extracapsular extension but not the tumour burden of lymph node metastases is an independent adverse risk factor in lymph node-positive bladder cancer. Histopathology 2011; 58:571-8. [DOI: 10.1111/j.1365-2559.2011.03778.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Fujii T, Yanagita Y, Fujisawa T, Hirakata T, Iijima M, Kuwano H. Implication of extracapsular invasion of sentinel lymph nodes in breast cancer: prediction of nonsentinel lymph node metastasis. World J Surg 2011; 34:544-8. [PMID: 20066412 DOI: 10.1007/s00268-009-0389-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Accurate intraoperative diagnosis of sentinel lymph node (SLN) metastases enables the selection of patients who require axillary lymph node dissection (ALND). However, many patients with positive SLN do not show metastasis to other axillary lymph nodes. In this study, we investigated the factors that may determine the likelihood of additional positive nodes in the axilla when metastasis is found in the SLN. METHODS SLN biopsy was performed on 276 patients with breast cancer with clinically negative nodes, of which 46 (16.6%) had positive SLNs and underwent ALND. Eleven (23.9%) of these 46 cases had additional metastasis in nonsentinel lymph nodes (NSLN). The clinical and pathological features of these cases were reviewed and statistical analysis was performed. RESULTS All cases of positive nodes in NSLN in our series had extracapsular invasion (ECI) at the metastatic SLNs. Furthermore, the absence of ECI of SLN was significantly associated with the absence of metastasis in the NSLN (P < 0.001). As contributing factors, the absence of lymphatic invasion at the primary tumor, primary tumor size (<2 cm) and foci size in the metastatic SLN fell short of reaching statistical significance. Other factors, including histological type, pathological grade, estrogen receptor status, HER2 status, and age, were not significantly associated with metastatic involvement of NSLN. CONCLUSIONS Our results suggest that the presence of ECI at metastatic SLNs is a strong predictor for residual disease in the axilla. These findings imply the possibility that ALND might be foregone in the treatment of patients with breast cancer without ECI at metastatic SLNs.
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Affiliation(s)
- Takaaki Fujii
- Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showa-machi, Maebashi Gunma, 371-8511, Japan.
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The value of level III clearance in patients with axillary and sentinel node positive breast cancer. Ann Surg 2009; 249:834-9. [PMID: 19387317 DOI: 10.1097/sla.0b013e3181a40821] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Nagatomo A, Abe N, Takeuchi H, Yanagida O, Masaki T, Mori T, Sugiyama M, Ohkura Y, Fujioka Y, Atomi Y. Microscopic cancer cell spread in gastric cancer: whole-section analysis of mesogastrium. Langenbecks Arch Surg 2008; 394:655-60. [DOI: 10.1007/s00423-008-0427-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Accepted: 08/11/2008] [Indexed: 11/28/2022]
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18
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Gruber G, Cole BF, Castiglione-Gertsch M, Holmberg SB, Lindtner J, Golouh R, Collins J, Crivellari D, Thürlimann B, Simoncini E, Fey MF, Gelber RD, Coates AS, Price KN, Goldhirsch A, Viale G, Gusterson BA. Extracapsular tumor spread and the risk of local, axillary and supraclavicular recurrence in node-positive, premenopausal patients with breast cancer. Ann Oncol 2008; 19:1393-1401. [PMID: 18385202 DOI: 10.1093/annonc/mdn123] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Extracapsular tumor spread (ECS) has been identified as a possible risk factor for breast cancer recurrence, but controversy exists regarding its role in decision making for regional radiotherapy. This study evaluates ECS as a predictor of local, axillary, and supraclavicular recurrence. PATIENTS AND METHODS International Breast Cancer Study Group Trial VI accrued 1475 eligible pre- and perimenopausal women with node-positive breast cancer who were randomly assigned to receive three to nine courses of classical combination chemotherapy with cyclophosphamide, methotrexate, and fluorouracil. ECS status was determined retrospectively in 933 patients based on review of pathology reports. Cumulative incidence and hazard ratios (HRs) were estimated using methods for competing risks analysis. Adjustment factors included treatment group and baseline patient and tumor characteristics. The median follow-up was 14 years. RESULTS In univariable analysis, ECS was significantly associated with supraclavicular recurrence (HR = 1.96; 95% confidence interval 1.23-3.13; P = 0.005). HRs for local and axillary recurrence were 1.38 (P = 0.06) and 1.81 (P = 0.11), respectively. Following adjustment for number of lymph node metastases and other baseline prognostic factors, ECS was not significantly associated with any of the three recurrence types studied. CONCLUSIONS Our results indicate that the decision for additional regional radiotherapy should not be based solely on the presence of ECS.
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Affiliation(s)
- G Gruber
- Institut für Radiotherapie, Klinik Hirslanden and Swiss Group for Clinical Cancer Research (SAKK), Zurich, Switzerland.
| | - B F Cole
- International Breast Cancer Study Group Statistical Center, Boston, MA and Department of Mathematics and Statistics, University of Vermont, Burlington, USA
| | - M Castiglione-Gertsch
- International Breast Cancer Study Group (IBCSG) Coordinating Center, Bern, Switzerland
| | - S B Holmberg
- Department of Surgery, Sahlgrenska University Hospital, Göteborg, Sweden
| | - J Lindtner
- The Institute of Oncology, Ljubljana, Slovenia
| | - R Golouh
- The Institute of Oncology, Ljubljana, Slovenia
| | - J Collins
- Department of Surgery, The Royal Melbourne Hospital, Melbourne, Australia
| | | | - B Thürlimann
- Senology Center of Eastern Switzerland, Kantonsspital and SAKK, St Gallen, Switzerland
| | - E Simoncini
- Oncologia Medica-Spedali Civili, Brescia, Italy
| | - M F Fey
- Department of Medical Oncology, Inselspital and SAKK, Bern, Switzerland
| | - R D Gelber
- IBCSG Statistical Center, Dana-Farber Cancer Institute, Frontier Science and Technology Research Foundation, Harvard School of Public Health, Boston, MA, USA
| | - A S Coates
- International Breast Cancer Study Group, Bern, Switzerland and University of Sydney, Sydney, Australia
| | - K N Price
- IBCSG Statistical Center, Frontier Science and Technology Research Foundation, Boston, MA, USA
| | - A Goldhirsch
- Oncology Institute of Southern Switzerland, Lugano, Switzerland and European Institute of Oncology, Milan, Italy
| | - G Viale
- Division of Pathology and Laboratory Medicine, European Institute of Oncology and University of Milan, Milan, Italy
| | - B A Gusterson
- Division of Cancer Sciences and Molecular Pathology, Faculty of Medicine, Glasgow University, Glasgow, UK
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Gorgulu S, Can MF, Yagci G, Sahin M, Tufan T. Extracapsular extension is associated with increased ratio of metastatic to examined lymph nodes in axillary node-positive breast cancer. Clin Breast Cancer 2007; 7:796-800. [PMID: 18021482 DOI: 10.3816/cbc.2007.n.042] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Extracapsular extension of nodal tumor cells, although it is not a parameter of staging, has recently been shown to be correlated with the high number of metastatic lymph nodes in patients with axillary-positive breast cancer. It is suggested that the use of involved/examined lymph node ratio instead of the number of metastatic lymph nodes in axillary evaluation would obtain standardized prognostic data for patient management. This study investigated the association of the extracapsular extension with the lymph node ratio in a node-positive group of patients. PATIENTS AND METHODS Medical records of 170 patients with positive axillary status were retrospectively reviewed. Of these, 54 were extracapsular extension positive, and the remaining were extracapsular extension negative. A comparison was made between extracapsular extension-positive and extracapsular extension-negative groups with respect to some potential prognostic indicators. RESULTS Number of metastatic lymph nodes, number of examined lymph nodes, and involved/examined lymph node ratio were found to be significantly higher in patients with a presence of extracapsular extension. CONCLUSION The results suggest that the presence of extracapsular extension might force physicians to perform more aggressive adjuvant therapies and that the extracapsular extension could be a valuable parameter in the management of breast cancer because it has a strong relationship with the proven prognostic factors.
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Affiliation(s)
- Semih Gorgulu
- Department of General Surgery, Gulhane School of Medicine, Ankara, Turkey
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Hui Z, Li Y, Yu Z, Liao Z. Survey on use of postmastectomy radiotherapy for breast cancer in China. Int J Radiat Oncol Biol Phys 2006; 66:1135-42. [PMID: 16979834 DOI: 10.1016/j.ijrobp.2006.06.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2006] [Revised: 05/01/2006] [Accepted: 06/22/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE To comprehensively assess the current use of postmastectomy radiotherapy (PMRT) throughout China. METHODS AND MATERIALS A questionnaire on the indications and techniques for PMRT for breast cancer was mailed to all 715 radiotherapy centers in mainland China. RESULTS Of the 715 questionnaires sent out, 210 were answered (29.4%). The median interval between surgery and PMRT was 6 weeks. "Sandwich" sequencing of chemotherapy and PMRT was the most common combination, performed in 75.7% of the responding clinics. Of the respondents, 11.9% used PMRT for T1-T2N0 breast cancer, 63.8% for T1-T2N0 with tumors located in the center or inner quadrant, 87.6% for Stage T1-T2 and one to three positive lymph nodes (LN+), and 97.1% for T3 or Stage III tumors and/or four or more LN+. The supraclavicular region was the most common radiation target used by the respondents (96.2%), followed by the internal mammary chain (85.2%), chest wall (79.0%), and axilla (74.8%). Photon-based tangential fields were the most common technique used for chest wall irradiation (45.8%). The median total dose to each target was 50 Gy, with 2-Gy fractions. CONCLUSION A consensus has been reached in China that PMRT is needed for patients with T3 or Stage III disease and/or four or more LN+ and that irradiation to the chest wall and supraclavicular region is necessary in such patients. However, most Chinese radiation centers are also likely to apply PMRT to patients with one to three LN+ and to irradiate the internal mammary chain and the axilla.
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Affiliation(s)
- Zhouguang Hui
- Department of Radiation Oncology, Cancer Institute (Hospital), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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21
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Etoh T, Sasako M, Ishikawa K, Katai H, Sano T, Shimoda T. Extranodal metastasis is an indicator of poor prognosis in patients with gastric carcinoma. Br J Surg 2006; 93:369-73. [PMID: 16392106 DOI: 10.1002/bjs.5240] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The aim of this study was to determine the clinical significance and prognostic impact of extranodal metastasis (EM) in gastric carcinoma. METHODS The study included 1023 patients who underwent gastrectomy with lymphadenectomy for primary gastric carcinoma between January 1993 and December 1996. EM was defined as the presence of tumour cells in extramural soft tissue that was discontinuous with either the primary lesion or locoregional lymph nodes. RESULTS EM was detected in 146 (14.3 per cent) of the 1023 patients and in 1060 (3.0 per cent) of the 35 811 nodules that were retrieved as 'lymph nodes' from adipose connective tissues. The incidence of EM was significantly higher in patients with tumours that were large (diameter 10 cm or more), infiltrative, deeply invading or undifferentiated and in those with lymph node, peritoneal or liver metastases, or lymphatic or vascular involvement. After curative operation overall survival was significantly worse for patients with EM than those without (P < 0.001). Multivariate analysis identified EM as an independent prognostic factor (hazard ratio 1.82 (95 per cent confidence interval 1.23 to 2.71); P = 0.003). CONCLUSION EM is an independent prognostic factor and should therefore be included in the tumour node metastasis (TNM) staging system.
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Affiliation(s)
- T Etoh
- Gastric Surgery Division, National Cancer Centre Hospital, 5-1-1 Tsukiji-Chuoku, 104-0045, Tokyo, Japan
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Kuijt GP, van de Poll-Franse LV, Roumen RMH, van Beek MWPM, Voogd AC. The significance of one positive axillary node. Eur J Surg Oncol 2006; 32:139-42. [PMID: 16412602 DOI: 10.1016/j.ejso.2005.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2005] [Accepted: 11/28/2005] [Indexed: 11/24/2022] Open
Abstract
AIMS The aim of this study was to identify a subgroup of patients with breast cancer that can safely avoid axillary dissection. METHODS Using data collected by the Eindhoven Cancer Registry, we compared the clinico-pathological features of 489 patients with only one positive lymph node to those of 817 patients with more than one positive lymph node in the axilla. All patients underwent complete axillary dissection, not preceded by a sentinel node biopsy. RESULTS Tumour size greater than 1cm, harvesting more than 15 axillary lymph nodes at histopathological examination, metastasis size larger than 2mm, extranodal extension, and nodal involvement of the axillary apex are independently associated with the occurrence of more than one metastatic axillary lymph node. CONCLUSION No subgroup could be identified in which axillary dissection can always be omitted. However, tumour size<1cm, finding a micrometastasis rather than a macrometastasis, and especially not finding extranodal extension were independently associated with finding only one positive axillary lymph node.
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Affiliation(s)
- G P Kuijt
- Department of Surgery, Maxima Medical Centre, P.O. Box 7777, 5500 MB Veldhoven, The Netherlands.
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Gruber G, Bonetti M, Nasi ML, Price KN, Castiglione-Gertsch M, Rudenstam CM, Holmberg SB, Lindtner J, Golouh R, Collins J, Crivellari D, Carbone A, Thürlimann B, Simoncini E, Fey MF, Gelber RD, Coates AS, Goldhirsch A. Prognostic value of extracapsular tumor spread for locoregional control in premenopausal patients with node-positive breast cancer treated with classical cyclophosphamide, methotrexate, and fluorouracil: long-term observations from International Breast Cancer Study Group Trial VI. J Clin Oncol 2005; 23:7089-97. [PMID: 16192592 DOI: 10.1200/jco.2005.08.123] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We sought to determine retrospectively whether extracapsular spread (ECS) might identify a subgroup that could benefit from radiotherapy after mastectomy, especially patients with 1 to 3 positive lymph nodes (LN1-3+). PATIENTS AND METHODS We randomized 1,475 premenopausal women with node-positive breast cancer to three, six, or nine courses of "classical" CMF (cyclophosphamide, methotrexate, and fluorouracil). After a review of all pathology forms, 933 patients (63%) had information on the presence or absence of ECS. ECS was present in 49.5%. The median follow-up was 10 years. RESULTS In univariate analyses, ECS was associated with worse disease-free survival (DFS) and overall survival (OS). In multivariate analyses adjusting for tumor size, vessel invasion, surgery type, and age group, ECS remained significant (DFS: hazard ratio, 1.61; 95% CI, 1.34 to 1.93; P < .0001; OS: 1.67; 95% CI, 1.34 to 2.08; P < .0001). However, ECS was not significant when the number of positive nodes was added. The locoregional failure rate +/- distant failure (LRF +/- distant failure) within 10 years was estimated at 19% (+/- 2%) without ECS, versus 27% (+/- 2%) with ECS. The difference was statistically significant in univariate analyses, but not after adjusting for the number of positive nodes. No independent effect of ECS on DFS, OS, or LRF could be confirmed within the subgroup of 382 patients with LN1-3+ treated with mastectomy without radiotherapy. CONCLUSION Our results do not support an independent prognostic value of ECS, nor its use as an indication for irradiation in premenopausal patients with LN1-3+ treated with classical CMF. However, we could not examine whether extensive ECS is of prognostic importance.
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Affiliation(s)
- Günther Gruber
- Department of Radiation Oncology, and the Institute of Medical Oncology, Inselspital, Switzerland.
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Affiliation(s)
- Lori J Pierce
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, MI, USA.
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Neri A, Marrelli D, Roviello F, De Stefano A, Guarnieri A, Pallucca E, Pinto E. Prognostic Value of Extracapsular Extension of Axillary Lymph Node Metastases in T1 to T3 Breast Cancer. Ann Surg Oncol 2005; 12:246-53. [PMID: 15827817 DOI: 10.1245/aso.2005.02.029] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2004] [Accepted: 10/21/2004] [Indexed: 11/18/2022]
Abstract
BACKGROUND The importance of extracapsular extension (ECE) of axillary metastases as a risk factor for either local or distant recurrence and poorer survival in breast cancer has been suggested, but its prognostic value has not been uniformly confirmed. METHODS From a prospective database including 1142 breast cancer patients operated on at the Department of General Surgery and Surgical Oncology of the University of Siena, we selected 376 cases with pT1 to pT3 node-positive breast cancer. The prognostic significance of ECE of axillary metastases was evaluated with respect to disease-free survival, overall survival, and the patterns of disease recurrence. Such prognostic significance was then compared with that of other clinical and pathologic factors. RESULTS With a median follow-up of 103 months, factors with independent prognostic value for disease-free survival by multivariate analysis included absence of estrogen receptors (P < .0005), pN category (P < .01), presence of lymphovascular invasion (LVI; P < .005), and ECE (P < .0001). An independent negative prognostic effect on overall survival was observed for absence of estrogen and progesterone receptors (P < .05), pN category (P < .05), and presence of LVI (P < .005) and ECE (P < .0001). The presence of ECE was significantly related to an increased risk of regional (13.4% vs. 6.6%; P = .037) and distant (43% vs. 16.2%; P < .001) recurrences. CONCLUSIONS ECE demonstrated a stronger statistical significance in predicting prognosis than the pN category and was also related to an increased risk of distant recurrences. We suggest that the decision on adjuvant therapy should consider the presence of ECE of axillary metastases and peritumoral LVI as indicators of high biological aggressiveness.
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Affiliation(s)
- Alessandro Neri
- Department of General Surgery and Surgical Oncology, Surgical Oncology Unit, University of Siena, Policlinico Le Scotte, V. le Bracci, 53100 Siena, Italy.
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Ragaz J, Olivotto IA, Spinelli JJ, Phillips N, Jackson SM, Wilson KS, Knowling MA, Coppin CML, Weir L, Gelmon K, Le N, Durand R, Coldman AJ, Manji M. Locoregional radiation therapy in patients with high-risk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized trial. J Natl Cancer Inst 2005; 97:116-26. [PMID: 15657341 DOI: 10.1093/jnci/djh297] [Citation(s) in RCA: 707] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The British Columbia randomized radiation trial was designed to determine the survival impact of locoregional radiation therapy in premenopausal patients with lymph node-positive breast cancer treated by modified radical mastectomy and adjuvant chemotherapy. Three hundred eighteen patients were assigned to receive no further therapy or radiation therapy (37.5 Gy in 16 fractions). Previous analysis at the 15-year follow-up showed that radiation therapy was associated with a statistically significant improvement in breast cancer survival but that improvement in overall survival was of only borderline statistical significance. We report the analysis of data from the 20-year follow-up. METHODS Survival was analyzed by the Kaplan-Meier method. Relative risk estimates were calculated by the Wald test from the proportional hazards regression model. All statistical tests were two-sided. RESULTS At the 20 year follow up (median follow up for live patients: 249 months) chemotherapy and radiation therapy, compared with chemotherapy alone, were associated with a statistically significant improvement in all end points analyzed, including survival free of isolated locoregional recurrences (74% versus 90%, respectively; relative risk [RR] = 0.36, 95% confidence interval [CI] = 0.18 to 0.71; P = .002), systemic relapse-free survival (31% versus 48%; RR = 0.66, 95% CI = 0.49 to 0.88; P = .004), breast cancer-free survival (48% versus 30%; RR = 0.63, 95% CI = 0.47 to 0.83; P = .001), event-free survival (35% versus 25%; RR = 0.70, 95% CI = 0.54 to 0.92; P = .009), breast cancer-specific survival (53% versus 38%; RR = 0.67, 95% CI = 0.49 to 0.90; P = .008), and, in contrast to the 15-year follow-up results, overall survival (47% versus 37%; RR = 0.73, 95% CI = 0.55 to 0.98; P = .03). Long-term toxicities, including cardiac deaths (1.8% versus 0.6%), were minimal for both arms. CONCLUSION For patients with high-risk breast cancer treated with modified radical mastectomy, treatment with radiation therapy (schedule of 16 fractions) and adjuvant chemotherapy leads to better survival outcomes than chemotherapy alone, and it is well tolerated, with acceptable long-term toxicity.
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Affiliation(s)
- Joseph Ragaz
- McGill University Health Center, Royal Victoria Hospital, 687 Pine Ave., Montreal, PQ, Canada H3A 1A1.
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Zekioglu O, Erhan Y, Ciris M, Bayramoglu H, Ozdemir N. Invasive micropapillary carcinoma of the breast: high incidence of lymph node metastasis with extranodal extension and its immunohistochemical profile compared with invasive ductal carcinoma. Histopathology 2004; 44:18-23. [PMID: 14717664 DOI: 10.1111/j.1365-2559.2004.01757.x] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
AIMS Invasive micropapillary carcinoma of the breast is an aggressive and distinctive variant of breast cancer. These tumours have a characteristic histological appearance and have been associated with a high incidence of axillary lymph node metastases and a poor clinical outcome. The aims of this study were to investigate the immunohistochemical profile of invasive micropapillary carcinoma of the breast, to compare it with invasive ductal carcinoma, and to identify the morphological parameters which predict its poor outcome. METHODS AND RESULTS Fifty-three (2.6%) invasive micropapillary carcinomas of the breast from 2022 cases of infiltrating breast carcinomas were identified by retrospective review. The patient age at presentation ranged from 33 to 78 years (mean 52.5 years). The tumour size ranged from 5 to 70 mm (mean 27 mm). Eighty-two percent (43 of 53) were of high histological grade; 69% (33 of 48) of cases with axillary lymph node dissections had positive lymph nodes; and 75.5% (40 of 53) had lymphatic invasion: 46% (22 of 48) of cases had extranodal extension. Of lymph node-positive cases, 61% had four or more metastatic lymph nodes. Of tumours with tumour size >10 mm, 77% had positive lymph nodes. The percentages of cases positive for oestrogen receptor (ER) and progesterone receptor (PR) were 68% and 61%, respectively. These values were significantly higher than the values for invasive ductal carcinomas. p53 and c-erbB-2 were detected in 48% and 54% of cases, respectively. The mean value of Ki67 was 26%. Follow-up was available in 36 patients. Eight patients had local recurrences, nine patients had distant metastases, and 10 patients died of disease within a follow-up period of 9 years. CONCLUSION Lymphotropism and an unfavourable prognosis are the hallmarks of this distinct entity. Prognostic markers such as ER, PR, p53, and c-erbB-2 failed to provide new criteria to allow discrimination of these tumours from other breast cancers.
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MESH Headings
- Aged
- Biomarkers, Tumor/analysis
- Breast Neoplasms/chemistry
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/chemistry
- Carcinoma, Ductal, Breast/secondary
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Papillary/chemistry
- Carcinoma, Papillary/secondary
- Carcinoma, Papillary/surgery
- Female
- Humans
- Immunoenzyme Techniques
- Lymph Nodes/pathology
- Lymphatic Metastasis
- Middle Aged
- Neoplasm Recurrence, Local/pathology
- Receptors, Estrogen/analysis
- Receptors, Progesterone/analysis
- Retrospective Studies
- Treatment Outcome
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Affiliation(s)
- O Zekioglu
- Department of Pathology, Ege University Medical Faculty, Izmir, Turkey.
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28
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Hasebe T, Sasaki S, Imoto S, Ochiai A. Histological characteristics of tumor in vessels and lymph nodes are significant predictors of progression of invasive ductal carcinoma of the breast: a prospective study. Hum Pathol 2004; 35:298-308. [PMID: 15017585 DOI: 10.1016/j.humpath.2003.05.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Invasive ductal carcinomas (IDCs) of the breast are composed of primary invasive tumors as well as tumor cells in blood vessels and lymph nodes. The purpose of this study was to determine whether the histological characteristics of tumor in the vessels and nodes are significantly associated with outcome. In a series of 393 patients, multivariate analyses showed that in IDCs without nodal metastasis and with fibrotic focus dimension, lymph vessel tumor emboli with >6 apoptotic figures and those invading >3 mm from the tumor margin had significantly higher hazard rates (HRs) for recurrence (P<0.05). In IDCs with 1 to 3 nodal metastases, >2 apoptotic figures in tumor emboli in blood vessels and >5 invaded lymph vessels were associated with significantly higher HRs for tumor recurrence and death (P<0.005). In IDCs with 4 or more nodal metastases, nodal tumors with >5 mitotic figures and >5 nodes with extranodal extension were associated with significantly higher HRs for tumor recurrence or death (P<0.05). We conclude that several histological characteristics of tumors in vessels and nodes have significant implications for the progression of IDCs.
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Affiliation(s)
- Takahiro Hasebe
- Pathology Division, National Cancer Center Research Institute East, Kashiwa, Chiba, Japan
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29
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Truong PT, Olivotto IA, Whelan TJ, Levine M. Clinical practice guidelines for the care and treatment of breast cancer: 16. Locoregional post-mastectomy radiotherapy. CMAJ 2004; 170:1263-73. [PMID: 15078851 PMCID: PMC385392 DOI: 10.1503/cmaj.1031000] [Citation(s) in RCA: 140] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE To provide information and recommendations to assist women with breast cancer and their physicians in making decisions regarding the use of locoregional post-mastectomy radiotherapy (PMRT). OUTCOMES Locoregional control, disease-free survival, overall survival and treatment-related toxicities. EVIDENCE This guideline is based on a review of all meta-analyses, consensus statements and other guidelines published between 1966 and November 2002. Searches of MEDLINE and CANCERLIT for English-language randomized controlled trials published between 1995 and November 2002 were also conducted to supplement the literature previously reviewed by the American Society of Clinical Oncology (ASCO) Health Services Research Committee panel in its published guideline. A nonsystematic review of the literature was continued through June 2003. RECOMMENDATIONS Locoregional PMRT is recommended for women with an advanced primary tumour (tumour size 5 cm or greater, or tumour invasion of the skin, pectoral muscle or chest wall). Locoregional PMRT is recommended for women with 4 or more positive axillary lymph nodes. The role of PMRT in women with 1 to 3 positive axillary lymph nodes is unclear. These women should be offered the opportunity to participate in clinical trials of PMRT. Locoregional PMRT is generally not recommended for women who have tumours that are less than 5 cm in diameter and who have negative axillary nodes. Other patient, tumour and treatment characteristics, including age, histologic grade, lymphovascular invasion, hormone receptor status, number of axillary nodes removed, axillary extracapsular extension and surgical margin status, may affect locoregional control, but their use in specifying additional indications for PMRT is currently unclear. PMRT should encompass the chest wall and the supraclavicular, infraclavicular and axillary apical lymph node areas. To reduce the risk of lymphedema, radiation of the entire axilla should not be used routinely after complete axillary dissection of level I and II lymph nodes. A definite recommendation regarding the inclusion of the internal mammary lymph nodes in PMRT cannot be made because of limited and inconsistent data. The use of modern techniques in radiotherapy planning is recommended to minimize excessive normal tissue exposure, particularly to the cardiac and pulmonary structures. Common short-term side effects of PMRT, including fatigue and skin erythema, are generally tolerable and not dose-limiting. Severe long-term side effects, including lymphedema, cardiac and pulmonary toxicities, brachial plexopathy, rib fractures and secondary neoplasms, are relatively rare. The optimal sequencing of PMRT and systemic therapy is currently unclear. Regimens containing anthracyclines or taxanes should not be administered concurrently with radiotherapy because of the potential for increased toxicity. VALIDATION The authors' original text was submitted for review, revision and approval by the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Subsequently, feedback was provided by 11 oncologists from across Canada. The final document was approved by the steering committee. SPONSOR The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer was convened by Health Canada. COMPLETION DATE: November 2003.
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30
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Stitzenberg KB, Meyer AA, Stern SL, Cance WG, Calvo BF, Klauber-DeMore N, Kim HJ, Sansbury L, Ollila DW. Extracapsular extension of the sentinel lymph node metastasis: a predictor of nonsentinel node tumor burden. Ann Surg 2003; 237:607-12; discussion 612-3. [PMID: 12724626 PMCID: PMC1514520 DOI: 10.1097/01.sla.0000064361.12265.9a] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify predictors of nonsentinel node (NSN) tumor involvement in patients with a tumor-involved sentinel node (SN). SUMMARY BACKGROUND DATA For many breast cancer patients who undergo intraoperative lymphatic mapping and sentinel lymphadenectomy (LM/SL), the SN is the only tumor-involved axillary node. Associations between NSN tumor involvement and several clinical and histopathologic factors have been identified. The authors hypothesize that extracapsular extension (ECE) of the SN metastasis is highly predictive of NSN tumor involvement. METHODS Between May 1998 and December 2001, 260 patients (263 cases) with clinical T1 or T2 (<5.0 cm) breast cancer underwent LM/SL at the University of North Carolina, using a combined blue dye and technetium sulfur colloid technique. In all cases with a tumor-involved SN, axillary lymph node dissection (ALND) was recommended. Statistical analysis, with Pearson chi-square tests, Fisher exact test, and multiple logistic regression, was performed. RESULTS The SN contained tumor in 74 (28.1%) cases. ALND was performed in 70 of the 74 cases. ECE of the SN metastasis was present in 18 (25.7%) of the 70 cases. Patients with ECE of the SN metastasis were more likely to have NSN tumor involvement and had a greater total number of tumor-involved nodes than patients without ECE of the SN metastasis. Increasing size of the SN metastasis and increasing size of the primary tumor, examined as continuous variables, were associated with an increased likelihood of NSN tumor involvement on univariate analysis. However, only ECE of the SN metastasis was associated with NSN tumor involvement on multivariate analysis. CONCLUSIONS ECE of the SN metastasis is a strong predictor of NSN tumor involvement. All patients with ECE of the SN metastasis should undergo mandatory completion ALND.
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Affiliation(s)
- Karyn B Stitzenberg
- Department of Surgery, University of North Carolina, 3010 Old Clinic Building, Chapel Hill, NC 27599, USA
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31
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Hasebe T, Sasaki S, Imoto S, Ochiai A. Significance of nodal metastatic tumor characteristics in nodal metastasis and prognosis of patients with invasive ductal carcinoma of the breast. Cancer Sci 2003; 94:181-7. [PMID: 12708494 PMCID: PMC11160216 DOI: 10.1111/j.1349-7006.2003.tb01416.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2002] [Revised: 12/02/2002] [Accepted: 12/13/2002] [Indexed: 01/05/2023] Open
Abstract
There is no study evaluating the significance of nodal metastatic tumor characteristics in tumor progression of invasive ductal carcinomas (IDCs) of the breast. The purpose of this study was to investigate whether nodal metastatic tumor characteristics play an important role in the tumor progression of IDCs. The subjects of this study were 205 IDC patients with nodal metastases. Significant associations with increased numbers of nodal metastases, and patient outcomes were evaluated by multivariate analyses, in comparison with well-known histological parameters. The numbers of lymph nodes with extra-nodal invasion and with extranodal blood vessel tumor emboli, the distance of extra-nodal blood vessel tumor emboli from the nodes, and the nodal tumor dimensions significantly increased the number of nodal metastases in the multivariate analysis (P<0.001). Cox multivariate analyses showed that the parameters which significantly increased hazard rates (HRs) of disease-free survival (DFS), distant organ metastasis (DOM) and overall survival were 6 or more mitotic figures of nodal metastatic tumors (P<0.05). Six or more lymph nodes with extra-nodal invasion, and an extra-nodal blood vessel tumor emboli dimension of >0.6 mm significantly increased the HRs of DFS and DOM in multivariate analyses (P<0.05). The present study demonstrated the important roles of nodal metastatic tumors in the tumor progression of IDCs.
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Affiliation(s)
- Takahiro Hasebe
- Pathology Division, National Cancer Center Research Institute East, Chiba, 6-5-1 Kashiwanoha, Kashiwa, Chiba 277-8577
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32
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Arnould L. [Basic anatomopathological features of tumors and their extensions. Prognostic and therapeutic implications]. Cancer Radiother 2002; 6 Suppl 1:61s-69s. [PMID: 12587384 DOI: 10.1016/s1278-3218(02)00232-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Surgical pathology analysis of biopsies or surgical specimens directly determines the diagnosis of the disease. It gives also the different characteristics that are useful for the establishment of the prognosis and for the treatment of each tumor. We report here a synthesis of the different characteristics of neoplastic lesions, necessary or useful for the establishment of the care program of the patients. These macroscopic and microscopic analyses should result in the most precise possible diagnosis and should take into account a list of other factors that allow the development of an optimal strategy for therapy, and the establishment of prognosis of the tumor. These characteristics include properties of the tumor like the size, shape, exact location, and the grade of the lesion, etc. They also concern the relationship of the tumor with certain structures like the basal membranes, the extracapsular extensions, the stroma reaction, the lymphatic vessels, the nerves, etc. The description of local and loco-regional spreading, as well as the analysis of the surgical margins gives also essential information. Sometimes, the description of modifications induced by neoadjuvant therapy, as chemo or radiotherapy, allows the evaluation of the efficiency of these treatments.
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Affiliation(s)
- L Arnould
- Service d'anatomie et de cytologie pathologiques, centre G. F. Leclerc, 1, rue Professeur-Marion, BP 7798, 21080 Dijon, France.
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33
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Pierce LJ. Treatment guidelines and techniques in delivery of postmastectomy radiotherapy in management of operable breast cancer. J Natl Cancer Inst Monogr 2002:117-24. [PMID: 11773304 DOI: 10.1093/oxfordjournals.jncimonographs.a003448] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Radiation therapy has been shown to statistically significantly reduce the risk of locoregional recurrence in high-risk patients with operable breast cancer following mastectomy and systemic therapy. Recent trials have also demonstrated a significant survival benefit following radiotherapy in high-risk patients. Therefore, it is important to identify the patients who could potentially derive that survival benefit and to not offer treatment to those patients who are not at increased risk for failure. Established risk factors that predict for increased rates of locoregional recurrence include axillary lymph node involvement and T3 (or T4) disease. While treatment-related factors, such as the extent of the axillary dissection and extent of lymph nodal positivity, also undoubtedly affect locoregional recurrence, additional studies are needed to define the magnitude of their risk. Locoregional patterns of failure have identified the chest wall and supraclavicular/infraclavicular regions to be the most common sites of locoregional failure following mastectomy, which justifies treatment to these regions. While long-term complications are uncommon following locoregional radiotherapy, careful treatment planning is critical to minimize cardiac (and pulmonary) toxicity.
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Affiliation(s)
- L J Pierce
- Department of Radiation Oncology, University of Michigan School of Medicine UHB2C490, Box 0010, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA.
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34
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Cheng JCH, Chen CM, Liu MC, Tsou MH, Yang PS, Jian JJM, Cheng SH, Tsai SY, Leu SY, Huang AT. Locoregional failure of postmastectomy patients with 1-3 positive axillary lymph nodes without adjuvant radiotherapy. Int J Radiat Oncol Biol Phys 2002; 52:980-8. [PMID: 11958892 DOI: 10.1016/s0360-3016(01)02724-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To analyze the incidence and risk factors for locoregional recurrence (LRR) in patients with breast cancer who had T1 or T2 primary tumor and 1-3 histologically involved axillary lymph nodes treated with modified radical mastectomy without adjuvant radiotherapy (RT). MATERIALS AND METHODS Between April 1991 and December 1998, 125 patients with invasive breast cancer were treated with modified radical mastectomy and were found to have 1-3 positive axillary nodes. The median number of nodes examined was 17 (range 7-33). Of the 125 patients, 110, who had no adjuvant RT and had a minimum follow-up of 25 months, were included in this study. Sixty-nine patients received adjuvant chemotherapy and 84 received adjuvant hormonal therapy with tamoxifen. Patient-related characteristics (age, menopausal status, medial/lateral quadrant of tumor location, T stage, tumor size, estrogen/progesterone receptor protein status, nuclear grade, extracapsular extension, lymphovascular invasion, and number of involved axillary nodes) and treatment-related factors (chemotherapy and hormonal therapy) were analyzed for their impact on LRR. The median follow-up was 54 months. RESULTS Of 110 patients without RT, 17 had LRR during follow-up. The 4-year LRR rate was 16.1% (95% confidence interval [CI] 9.1-23.1%). All but one LRR were isolated LRR without preceding or simultaneous distant metastasis. According to univariate analysis, age <40 years (p = 0.006), T2 classification (p = 0.04), tumor size >==3 cm (p = 0.002), negative estrogen receptor protein status (p = 0.02), presence of lymphovascular invasion (p = 0.02), and no tamoxifen therapy (p = 0.0006) were associated with a significantly higher rate of LRR. Tumor size (p = 0.006) was the only risk factor for LRR with statistical significance in the multivariate analysis. On the basis of the 4 patient-related factors (age <40 years, tumor >==3 cm, negative estrogen receptor protein, and lymphovascular invasion), the high-risk group (with 3 or 4 factors) had a 4-year LRR rate of 66.7% (95% CI 42.8-90.5%) compared with 7.8% (95% CI 2.2-13.3%) for the low-risk group (with 0-2 factors; p = 0.0001). For the 110 patients who received no adjuvant RT, LRR was associated with a 4-year distant metastasis rate of 49.0% (9 of 17, 95% CI 24.6-73.4%). For patients without LRR, it was 13.3% (15 of 93, 95% CI 6.3-20.3%; p = 0.0001). The 4-year survival rate for patients with and without LRR was 75.1% (95% CI 53.8-96.4%) and 88.7% (95% CI 82.1-95.4%; p = 0.049), respectively. LRR was independently associated with a higher risk of distant metastasis and worse survival in multivariate analysis. CONCLUSION LRR after mastectomy is not only a substantial clinical problem, but has a significant impact on the outcome of patients with T1 or T2 primary tumor and 1-3 positive axillary nodes. Patients with risk factors for LRR may need adjuvant RT. Randomized trials are warranted to determine the potential benefit of postmastectomy RT on the survival of patients with a T1 or T2 primary tumor and 1-3 positive nodes.
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Affiliation(s)
- Jason Chia-Hsien Cheng
- Department of Radiation Oncology, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.
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35
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Ollila DB, Stitzenberg KB. Breast cancer sentinel node metastases: histopathologic detection and clinical significance. Cancer Control 2001; 8:407-14. [PMID: 11579336 DOI: 10.1177/107327480100800503] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Lymphatic mapping with sentinel lymphadenectomy (LM/SL) is an accurate and less morbid means of determining the tumor status of the axilla in breast cancer patients than standard level I and II axillary lymph node dissection (ALND). This review addresses the handling and pathologic examination of the sentinel node (SN), the clinical significance of tumor within the SN, and the risk factors for non-SN tumor involvement. METHODS The seminal works that have addressed pathologic examination of ALND specimens and SN specimens are summarized, and the important studies attempting to identify predictors of non-SN metastases in patients with a tumor-involved SN are reviewed. RESULTS Standard single-section hematoxylin-eosin (H&E) examination is inadequate for reliable detection of axillary or SN metastases. Large studies appropriately powered to detect a survival difference for patients with micrometastatic disease are reviewed. The current data on the clinical significance of micrometastatic nodal disease is inconclusive. While several strong predictors of non-SN tumor involvement have been identified, none is reliable enough to allow omission of ALND in patients with a tumor-involved SN. CONCLUSIONS Routine examination of the SN specimen should include serial sections with H&E stain. Ongoing prospective clinical trials should help to define the clinical significance of SN micrometastases. Furthermore, these trials could help identify predictors of non-SN metastasis that would allow a subset of patients with a tumor-involved SN to avoid the morbidity of ALND.
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Affiliation(s)
- D B Ollila
- Department of Surgery, University of North Carolina at Chapel Hill, NC 27599-7210, USA.
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36
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Affiliation(s)
- I Gage
- Division of Radiation Oncology, Department of Oncology, The Johns Hopkins Hospital, Baltimore, Maryland
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37
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Ragaz J, Jackson SM. Significance of axillary lymph node extranodal soft tissue extension and indications for postmastectomy irradiation. Cancer 2000. [DOI: 10.1002/1097-0142(20000701)89:1<223::aid-cncr34>3.0.co;2-d] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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