Impact on regional recurrence and survival of axillary surgery in women with node-negative primary breast cancer

A Nomogram Combined Radiomics and Kinetic Curve Pattern as Imaging Biomarker for Detecting Metastatic Axillary Lymph Node in Invasive Breast Cancer

Objective: To construct and validate a nomogram model integrating the magnetic resonance imaging (MRI) radiomic features and the kinetic curve pattern for detecting metastatic axillary lymph node (ALN) in invasive breast cancer preoperatively. Materials and Methods: A total of 145 ALNs from two institutions were classified into negative and positive groups according to the pathologic or surgical results. One hundred one ALNs from institution I were taken as the training cohort, and the other 44 ALNs from institution II were taken as the external validation cohort. The kinetic curve was computed using dynamic contrast-enhanced MRI software. The preprocessed images were used for radiomic feature extraction. The LASSO regression was applied to identify optimal radiomic features and construct the Radscore. A nomogram model was constructed combining the Radscore and the kinetic curve pattern. The discriminative performance was evaluated by receiver operating characteristic analysis and calibration curve.

Results: Five optimal features were ultimately selected and contributed to the Radscore construction. The kinetic curve pattern was significantly different between negative and positive lymph nodes. The nomogram model showed a better performance in both training cohort [area under the curve (AUC) = 0.91, 95% CI = 0.83–0.96] and external validation cohort (AUC = 0.86, 95% CI = 0.72–0.94); the calibration curve indicated a better accuracy of the nomogram model for detecting metastatic ALN than either Radscore or kinetic curve pattern alone.

Conclusion: A nomogram model integrated the Radscore and the kinetic curve pattern could serve as a biomarker for detecting metastatic ALN in patients with invasive breast cancer.

Prognostic implication of the primary tumor location in early-stage breast cancer: focus on lower inner zone

BACKGROUND

The aim of this study was to investigate the prognostic significance of tumor location of lower inner zone (LIZ) on the survival of patients with early-stage breast cancer.

METHODS

We retrospectively identified 961 breast cancer patients from Jan 2000 to Apr 2016 from hospital database. We evaluated overall survival (OS) and disease-free survival (DFS) in patients with tumors in and outside LIZ. Subgroup analyses were performed according to clinicopathological characteristics and treatment strategies.

RESULTS

A total of 838 cases were finally included. Patients with tumor location of LIZ showed significantly lower survival rates than tumors in other sites in terms of DFS (p = 0.028) but not OS (p = 0.106). When stratified into subgroups, tumors in LIZ retained a significant worse prognosis in DFS in patients with HER-2-negative, high ki-67 expression breast cancers, those who received neoadjuvant chemotherapy, axillary nodal negative patients, and patients with lymphovascular invasion. Univariate and multivariate analyses suggested that tumor location of LIZ was an independent prognostic factor for DFS (p = 0.022).

CONCLUSIONS

Our results suggested that tumor location of LIZ was an independent adverse prognostic factor for DFS in patients with early-stage breast cancer. Multicenter studies with larger sample size are needed to confirm the conclusion and anatomical experiments are desired to elaborate the mechanism.

Dual-modal computer-assisted evaluation of axillary lymph node metastasis in breast cancer patients on both real-time elastography and B-mode ultrasound

PURPOSE

To propose a computer-assisted method for quantifying the hardness of an axillary lymph node on real-time elastography (RTE) and its morphology on B-mode ultrasound; and to combine the dual-modal features for differentiation of metastatic and benign axillary lymph nodes in breast cancer patients.

MATERIALS AND METHODS

A total of 161 axillary lymph nodes (benign, n=69; metastatic, n=92) from 158 patients with breast cancer were examined with both B-mode ultrasound and RTE. With computer assistance, five morphological features describing the hilum, size, shape, and echogenic uniformity of a lymph node were extracted from B-mode, and three hardness features were extracted from RTE. Single-modal and dual-modal features were used to classify benign and metastatic nodes with two computerized classification approaches, i.e., a scoring approach and a support vector machine (SVM) approach. The computerized approaches were also compared with a visual evaluation approach.

RESULTS

All features exhibited significant differences between benign and metastatic nodes (p<0.001), with the highest area under the receiver operating characteristic curve (AUC) of 0.803 and the highest accuracy (ACC) of 75.2% for a single feature. The SVM on dual-modal features achieved the largest AUC (0.895) and ACC (85.7%) among all methods, exceeding the scoring (AUC=0.881; ACC=83.6%) and the visual evaluation methods (AUC=0.830; ACC=84.5%). With the leave-one-out cross validation, the SVM on dual-modal features still obtained an ACC as high as 84.5%.

CONCLUSION

Dual-modal features can be extracted from RTE and B-mode ultrasound with computer assistance, which are valuable for discrimination between benign and metastatic lymph nodes. The SVM on dual-modal features outperforms the scoring and visual evaluation methods, as well as all methods using single-modal features. The computer-assisted dual-modal evaluation of lymph nodes could be potentially used in daily clinical practice for assessing axillary metastasis in breast cancer patients.

Tumor location is a prognostic factor for survival of Chinese women with T1-2N0M0 breast cancer

OBJECTIVE

The purpose of this study was to investigate the effects of primary tumor location on the survival of Chinese women with T1-2N0M0 breast cancer.

METHODS

The clinical data of 1044 patients with stage T1-2N0M0 breast cancer who were treated from 1999 to 2007 were retrospectively analyzed. Patients were divided according to the primary tumor location: upper-outer quadrant (UOQ), upper-inner quadrant (UIQ), lower-outer quadrant (LOQ), lower-inner quadrant (LIQ), and nipple and central breast (central). The effect of primary tumor location on recurrence-free survival (RFS) and overall survival (OS) were determined.

RESULTS

The median age at diagnosis was 47 years. The tumor was located in the UOQ in 524 patients (50.2%), the LOQ in 124 (11.9%), the UIQ in 229 (21.9%), the LIQ in 59 (5.7%), and centrally in 108 patients (10.3%). The 5- and 10-year RFS and OS of the LIQ group were significantly poorer than that of patients in the other groups (RFS: 72.1% vs. 82.2-86.7%, P = 0.041; OS: 73.6% vs. 85.3-89.1%, P = 0.024). Multivariate Cox analysis showed that primary tumor location in the LIQ was an independent prognostic factor for RFS (hazard ratio [HR] = 2.977; 95% confidence interval [CI] 1.219-7.273; P = 0.017) and OS (HR = 2.949; 95% CI 1.207-7.208; P = 0.018).

CONCLUSION

Primary tumor location is an important prognostic factor for survival of Chinese women with T1-2N0M0 breast cancer.

Intercostobrachial nerves as a novel anatomic landmark for dividing the axillary space in lymph node dissection

Purpose. Our aim was to assess the feasibility of using the intercostobrachial nerves (ICBNs) as a possible new anatomic landmark for axillaries lymph node dissection in breast cancer patients. Background Data Summary. The preservation of ICBN is now an accepted procedure in this type of dissection; however, it could be improved further to reduce the number of postoperative complications. The axillary space is divided into lower and upper parts by the ICBN-a thorough investigation of the metastasis patterns in lymph nodes found in this area could supply new information leading to such improvements. Methods. Seventy-two breast cancer patients, all about to undergo lymph node dissection and with sentinel lymph nodes identified, were included in this trial. The lymph nodes were collected in two groups, from lower and upper axillary spaces, relative to the intercostobrachial nerves. The first group was further subdivided into sentinel (SLN) and nonsentinel (non-SLN) nodes. All lymph nodes were tested to detect macro- and micrometastasis. Results. All the sentinel lymph nodes were found under the intercostobrachial nerves; more than 10 lymph nodes were located in that space. Moreover, when lymph nodes macrometastasize or micrometastasize above the intercostobrachial nerves, we also observe metastasis-positive nodes under the nerves; when the lower group nodes show no metastasis, the upper group is also metastasis free. Conclusions. Our results show that the intercostobrachial nerves are good candidates for a new anatomic landmark to be used in lymph node dissection procedure.

Favorable outcome of secondary axillary dissection in breast cancer patients with axillary nodal relapse

PURPOSE

Little evidence can be found about the long-term outcome of breast cancer patients after axillary lymph node recurrence (ALNR) and its survival benefit after different kinds of management. The present study intends to evaluate the risk factors associated with axillary recurrence after definite surgery for primary breast cancer. The prognosis after ALNR and particularly outcome of different management methods also were studied.

METHODS

We retrospectively reviewed data from 4,473 patients who were diagnosed with primary breast cancer and received surgical intervention in a single institute from January 1990 to December 2002. Medical files were reviewed and data on survival were updated annually. Risk factors and prognosis of patients with axillary recurrence were analyzed. Breast-cancer-specific survival of patients with ALNR and outcomes after different management methods also were studied.

RESULTS

After a median follow-up of 70.2 months, axillary recurrence developed in 0.8% of patients. Factors associated with ALNR included: age younger than 40 years, medial tumor location, no initial standard level I & II axillary dissection, and not receiving hormonal therapy. The 5-year breast-cancer-specific survival after ALNR was 57.9%. For patients who received further axillary dissection, the 5-year survival rate was 82.5% compared with 44.9% for patients who did not receive further dissection.

CONCLUSIONS

ALNR is a rare event in treating breast cancer. Young age at diagnosis and medially located tumor are associated with higher risk, but standardized initial axillary dissection to level II and adjuvant hormonal therapy is protective against ALNR. In patients with ALNR, the outcome is not dismal and survival may be improved if further axillary dissection is given.

Phase III randomized equivalence trial of early breast cancer treatments with or without axillary clearance in post-menopausal patients results after 5 years of follow-up

BACKGROUND

Axillary lymph node clearance (ALNC) improves locoregional control and provides prognostic information for early breast cancer treatment, but effects on survival are controversial. This multicentre, randomized pragmatic equivalence trial compares outcomes for post-menopausal early invasive breast cancer patients after locoregional treatment with ALNC and adjuvant therapies to outcomes after locoregional treatment without ALNC and adjuvant therapies.

METHODS

From 1995-2005, women aged ≥ 50 years with early breast cancer (tumor ≤ 10 mm) and clinically-negative axillary nodes were randomized to receive treatment with ALNC (Ax) or without (no-Ax). Adjuvant therapies were prescribed according to hormonal receptor status and individual histological results. The primary endpoint was overall survival (OS); secondary endpoints were event-free survival (EFS) and functional outcomes. The trial was terminated due to lack of equivalence and low accrual after first interim analyses.

TRIAL REGISTRATION

NCT00210236.

RESULTS

Of 625 patients, 297 no-Ax and 310 Ax patients were maintained for final per-protocol analyses. OS and EFS at five years were not equivalent (Ax vs. no-Ax: 98% vs. 94% and 96% vs. 90% respectively). Recurrence was higher for no-Ax, particularly in the first five years after surgery. Axillary nodes were positive for 14% Ax patients but only 2% no-Ax patients experienced axillary node recurrence. Functional impairments were greater after ALNC.

CONCLUSION

Our results fail to demonstrate equivalence of outcomes when ALNC is omitted from post-menopausal early breast cancer patient treatment. However the low locoregional recurrence rates warrant further examination over a longer duration, in particular to consider whether these would impact on survival.

Sentinel lymph node surgery after neoadjuvant chemotherapy is accurate and reduces the need for axillary dissection in breast cancer patients

OBJECTIVE

Sentinel lymph node (SLN) surgery is widely used for nodal staging in early-stage breast cancer. This study was performed to evaluate the accuracy of SLN surgery for patients undergoing neoadjuvant chemotherapy versus patients undergoing surgery first.

SUMMARY BACKGROUND DATA

Controversy exists regarding the timing of SLN surgery in patients planned for neoadjuvant chemotherapy. Proponents of SLN surgery after chemotherapy prefer a single surgical procedure with potential for fewer axillary dissections. Opponents cite early studies with low identification rates and high false-negative rates after chemotherapy.

METHODS

A total of 3746 patients with clinically node negative T1-T3 breast cancer underwent SLN surgery from 1994 to 2007. Clinicopathologic data were reviewed and comparisons made between patients receiving neoadjuvant chemotherapy and those undergoing surgery first.

RESULTS

Of the patients, 575 (15.3%) underwent SLN surgery after chemotherapy and 3171 (84.7%) underwent surgery first. Neoadjuvant patients were younger (51 vs. 57 years, P < 0.0001) and had more clinical T2-T3 tumors (87.3% vs. 18.8%, P < 0.0001) at diagnosis. SLN identification rates were 97.4% in the neoadjuvant group and 98.7% in the surgery first group (P = 0.017). False-negative rates were similar between groups (5/84 [5.9%] in neoadjuvant vs. 22/542 [4.1%] in the surgery first group, P = 0.39). Analyzed by presenting T stage, there were fewer positive SLNs in the neoadjuvant group (T1: 12.7% vs. 19.0%, P = 0.2; T2: 20.5% vs. 36.5%, P < 0.0001; T3: 30.4% vs. 51.4%, P = 0.04). Adjusting for clinical stage revealed no differences in local-regional recurrences, disease-free or overall survival between groups.

CONCLUSIONS

SLN surgery after chemotherapy is as accurate for axillary staging as SLN surgery prior to chemotherapy. SLN surgery after chemotherapy results in fewer positive SLNs and decreases unnecessary axillary dissections.

Comparable Survival Between pN0 Breast Cancer Patients Undergoing Sentinel Node Biopsy and Extensive Axillary Dissection: A Report From the Korean Breast Cancer Society

Purpose

Recent studies showing survival benefit of extensive axillary lymph node dissection (ALND) in pN0 breast cancer have challenged the concept of sentinel node biopsy (SNB). In this study, the survival and recurrence after SNB alone and ALND in pN0 Korean breast cancer patients were investigated.

Patients and Methods

Using information from two large databases, including a Korean nationwide registry, we assessed survival relative to the extent of ALND in pN0 breast cancer patients. We also compared the survival of pN0 patients who underwent SNB alone with survival in those who underwent varying degrees of ALND.

Results

In an analysis of 1,607 pN0 patients from a single institution, less extensive ALND significantly increased the risks of breast cancer death and systemic recurrence but not of locoregional recurrence. These findings were validated by an analysis of nationwide registry data on 17,672 pN0 patients; patients with > 20 dissected lymph nodes had significantly better overall survival (OS) and breast cancer–specific survival (BCSS) than those with 10 to 20 or < 10 dissected lymph nodes. Patients who underwent SNB alone showed OS (hazard ratio [HR], 1.03; 9% CI, 0.08 to 1.56) and BCSS (HR, 1.15; 95% CI, 0.75 to 1.78) similar to those of patients who underwent extensive ALND (> 20 dissected lymph nodes), despite the small number of lymph nodes removed.

Conclusion

Extensive ALND is associated with better survival and less systemic recurrence than less extensive ALND in patients with pN0 breast cancer. However, SNB alone showed excellent survival results, similar to those of extensive ALND, supporting the long-term oncologic safety of SNB.

Adjuvant regional irradiation after breast-conserving therapy for early stage breast cancer: a survey of canadian radiation oncologists

AIMS

To document the use of adjuvant regional irradiation after breast-conserving therapy for early stage breast cancer by Canadian radiation oncologists and to identify the factors influencing their clinical decisions.

MATERIALS AND METHODS

We conducted a survey to assess the above aims. In April 2008, a questionnaire was sent to 167 members of the Canadian and Quebec Associations of Radiation Oncologists with interest in breast cancer management. The answers were obtained through a dedicated website, which collected the raw data collected for analysis.

RESULTS

In total, 67 radiation oncologists completed the survey, corresponding to a 40% response rate. Most respondents were experienced and high-volume providers. We identified several areas of variation in the decision-making regarding regional lymph node irradiation after breast-conserving therapy. Regarding the decision to combine regional nodal irradiation with irradiation of the breast, the number of positive nodes after axillary dissection (1-3 vs > or =4) was a crucial determinant. For patients with between one and three positive nodes and a nodal ratio of 50%, most respondents added regional irradiation. Similarly, the same nodal ratio of 50% was the main factor for inclusion of the axillary nodal region in the radiation field. However, few radiation oncologists have chosen to include the internal mammary chain in their treatment plan. The number of positive lymph nodes, the nodal ratio, the number of lymph nodes removed and the presence of extracapsular extension were the primary self-reported factors that directed the decision to offer regional radiotherapy.

CONCLUSIONS

This survey showed that there is a wide variation of practices among radiation oncologists in Canada. These results support the need for treatment guidelines and provide guidance on which factors should be included in a decision-making algorithm.