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Balla A, Weaver DL. Pathologic Evaluation of Lymph Nodes in Breast Cancer: Contemporary Approaches and Clinical Implications. Surg Pathol Clin 2022; 15:15-27. [PMID: 35236631 DOI: 10.1016/j.path.2021.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The presence of detected metastases in locoregional lymph nodes of women with breast cancer is an important prognostic variable for cancer staging, prognosis, and treatment planning. Systematic and standardized lymph node evaluation with gross and microscopic protocols designed to detect all macrometastases larger than 2.0 mm is the appropriate objective based on clinical outcomes evidence. Pathologists will detect smaller micrometastases and isolated tumor cell clusters (ITCs) by random chance but will also leave similar sized metastases undetected in paraffin blocks. Although these smaller metastases have prognostic significance, they are not predictive of recurrence for chemotherapy naïve patients. Thus, protocols to reliably detect metastases smaller than 2.0 mm are not required or recommended by guidelines. Women with T1-T2 breast cancer with a clinically negative axilla but with 1 or 2 pathologically positive sentinel nodes now have alternative options including observation and axillary irradiation and do not require completion axillary dissection.
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Affiliation(s)
- Agnes Balla
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont and UVM Medical Center, 111 Colchester Avenue, Burlington, VT 05401, USA.
| | - Donald L Weaver
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, UVM Cancer Center, UVM Medical Center, Given Courtyard South, 89 Beaumont Avenue, Burlington, VT 05405-0068, USA
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Less Axillary Lymphadenectomy is More Beneficial: 27-Year Follow-up of Patients with Breast Cancer. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2021. [DOI: 10.5812/ijcm.108538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: One of the most important alterations in breast cancer treatment is the change of view in axillary lymph node management. At the moment, sentinel lymph node biopsy (SLNB) is the standard care in axillary lymph node management. However, in patients with clinically positive lymph nodes or in patients, who have no willingness to receive radioactive drugs, axillary lymph node dissection (ALND) must be done. To the best of our knowledge, there is no overall survival (OS) benefit in ALND, especially at the early stage of breast cancer, during which this procedure is not justified. Objectives: Herein, we have reported the results of 27 years of experiments in limited axillary lymph node dissection (LALND) in comparison to ALND as well as the relationship among the number of removed lymph nodes, OS, and disease-free survival (DFS) at the early stage of breast cancer. Methods: OS and DFS for 588 cases, who were at the early stage of breast cancer and treated by LALND between 1984 and 2019, were compared with 1026 patients, who were treated by ALND during the same interval in this study. Notably, SLNB cases were excluded. Results: The results revealed no significant difference among the groups in terms of DFS (P = 0.268, 0.123, and 0.333). Also, there was no difference in terms of OS between the LALND group (1 - 4 nodes, 5 - 6 nodes, and 7 - 8 nodes) and ALND group (≥ 9 nodes) in patients without lymph node involvement (AHR less than 2). However, in the patients with axillary lymph node metastasis (N1, N2), similar results were obtained. Correspondingly, in this group, the best results were observed in those patients, whose 7 - 8 lymph nodes were removed. Conclusions: Regarding the results of the current study; it can be concluded that performing the LALND in the defined anatomic range and removing 7 - 8 lymph nodes instead of removing 10 lymph nodes are not inferior when it is not possible to do SLNB (there is no access to it) and/or being a contraindication to do it for evaluating the status of axillary lymph nodes in the patients at the early stage of breast cancer.
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Shinde A, Horne ZD, Li R, Glaser S, Massarelli E, Koczywas M, Erhunmwunsee L, Reckamp KL, Weksler B, Salgia R, Beriwal S, Amini A. Optimal adjuvant therapy in clinically N2 non-small cell lung cancer patients undergoing neoadjuvant chemotherapy and surgery: The importance of pathological response and lymph node ratio. Lung Cancer 2019; 133:136-143. [DOI: 10.1016/j.lungcan.2019.05.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 05/16/2019] [Accepted: 05/17/2019] [Indexed: 01/14/2023]
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Tang C, Wang P, Li X, Zhao B, Yang H, Yu H, Li C. Lymph node status have a prognostic impact in breast cancer patients with distant metastasis. PLoS One 2017; 12:e0182953. [PMID: 28806399 PMCID: PMC5555564 DOI: 10.1371/journal.pone.0182953] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 07/27/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The objective of this retrospective study was to determine whether lymph node metastasis has a prognostic impact on patients with stage IV breast cancer. PATIENTS AND METHODS Seven thousand three hundred and seventy-nine patients with de novo stage IV breast cancer diagnosed from 2004 to 2013 were identified. Kaplan-Meier estimate method was fitted to measure overall survival and breast cancer-specific survival (BCSS). Cox proportional hazard analysis was used to evaluate the association between N stage and BCSS after controlling variables such as other patient/tumor characteristics. RESULTS The primary site of M1 tumors was mainly upper-outer quadrant and overlapping lesion of the breast. Patients with N1 disease had better overall survival and BCSS than did those without lymph node metastasis. The overall survival and BCSS of M1 patients with N3 disease were significantly lower than that of those with N0, N1 and N2 disease, whereas patients with N2 and N0/N1 involvement showed no significant difference with survival. Multivariate analysis showed that lymph node metastasis was an important prognostic factor for M1 patients (N1 versus N0, hazard ratio [HR] = 0.902, 95% confidence interval [CI]: 0.825-0.986, p = 0.023; N3 versus N0, HR = 1.161, 95% CI: 1.055-1.276, p = 0.002). For M1 patients, age, race, marital status, primary site, ER, PR and HER2 were the independent prognostic factors. CONCLUSIONS The cohort study provides an insight into de novo stage IV breast cancer with lymph node metastasis. Our results indicated that accurate lymph node evaluation for stage IV patients is still necessary to obtain important prognostic information.
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Affiliation(s)
- Chuangang Tang
- Department of Breast Surgery, Xuzhou Central Hospital, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, China
| | - Pei Wang
- Department of Breast Surgery, Xuzhou Central Hospital, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, China
| | - Xiaoxin Li
- Department of Pathology, Xuzhou Central Hospital, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, China
| | - Bingqing Zhao
- Department of Surgery, Tianjin Second People's Hospital, Tianjin, China
| | - Haochang Yang
- College of Clinical Medicine, Binzhou Medical University, Yantai, China
| | - Haifeng Yu
- Department of General Surgery, Tianjin First Central Hospital, Tianjin, China
| | - Changwen Li
- Department of Breast Surgery, Xuzhou Central Hospital, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, China
- * E-mail:
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Li JL, Lin XY, Zhuang LJ, He JY, Peng QQ, Dong YP, Wu JX. Establishment of a risk scoring system for predicting locoregional recurrence in T1 to T2 node-negative breast cancer patients treated with mastectomy: Implications for postoperative radiotherapy. Medicine (Baltimore) 2017; 96:e7343. [PMID: 28658151 PMCID: PMC5500073 DOI: 10.1097/md.0000000000007343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
To establish a risk scoring system for predicting locoregional recurrence (LRR) and explore the potential value of radiotherapy in T1 to T2 node-negative breast cancer patients treated with mastectomy. From January 2001 to February 2008, a total of 353 node-negative T1 to T2 breast cancer cases treated with mastectomy without adjuvant radiotherapy were retrospectively analyzed. Preliminary screening of the prognostic factors was accomplished by Kaplan-Meier univariate analysis, and survival curves between different groups were compared by log-rank test. Risk factors were determined using Cox proportional hazards model. A categorical risk scoring system was generated according to the Cox model, weighing the relative importance of each risk variable. Median follow-up was 115.7 months (range, 1.2-238.4 months). The overall 5-year locoregional recurrence-free survival (LRFS) was 89.8% (95% confidence interval [CI] = 86.7%-92.9%). Chest wall (53.8%) was found to be the most common site of LRR, followed by supraclavicular nodes (48.7%). Age ≤40 years, primary tumor size ≥4.5 cm and number of nodes resected ≤10 were found to be independent factors for poor prognosis of LRR. Two risk stratifications based on the scoring system were subsequently obtained. The 5-year LRFS was 91.6% (95% CI = 88.5%-94.7%) with low risk (score <2) and 75.7% (95% CI = 61.8%-89.6%) with high risk (score ≥2), respectively (χ = 7.544, P = .006). In addition, significant differences in overall survival (P = .045) and disease-free survival (P = .019) were presented between them. Patients with T1-2N0M0 breast cancer achieved favorable prognosis in general. Those with risk factors, including age ≤40 years, primary tumor size ≥4.5 cm and number of nodes resected ≤10, were at higher risk of LRR. The established scoring system could help to distinguish the subgroups that might potentially benefit from postoperative radiotherapy.
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Affiliation(s)
- Jin-luan Li
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou
| | - Xiao-yi Lin
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou
| | - Li-juan Zhuang
- Department of Gynecology and Obstetrics, Quanzhou Maternity and Child Health Hospital, QuanZhou, China
| | - Jun-yan He
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou
| | - Qing-qin Peng
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou
| | - Ya-ping Dong
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou
| | - Jun-xin Wu
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou
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Wang S, Zhang B, Li C, Cui C, Yue D, Shi B, Zhang Q, Zhang Z, Zhang X, Wang C. Prognostic value of number of negative lymph node in patients with stage II and IIIa non-small cell lung cancer. Oncotarget 2017; 8:79387-79396. [PMID: 29108317 PMCID: PMC5668050 DOI: 10.18632/oncotarget.18154] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 05/06/2017] [Indexed: 12/14/2022] Open
Abstract
Background The definitive validation evidence of the implications of lymph node metastases regarding the survival of Non-Small Cell Lung Cancer (NSCLC) patients is lacking. We aimed to evaluate the prognostic impact of several lymph node metastases-associated risk factors including Number of Negative Lymph Node (NLN) and risk-stratify NSCLC patients into subsets with different prognosis. Method A total of 482 patients with N1 and N2 NSCLC were included in this study. The prognostic importance of a set of risk factors was examined by univariate and multivariate analysis. The cut-off points and 5 years survival rates were calculated to test the best grouping system to stratify the patients with difference outcome. Results Our analysis indicated that both Ratio of the Metastatic Lymph nodes (RML) and Number of Negative Lymph Node (NLN) were associated with overall survival (OS) and disease free survival (DFS). RML percentage 20% and 55%, and NLN counts 10 and 30 were proved as the optimal cut-off points to predict OS by classifying patients into 3 groups, respectively. RML and NLN actually are more powerful in predicting survival outcome for male patients compared to female patients. Stratified survival analyses using combined factors indicated that the 5-year survival rate (5-YSR) is high in RML I + NLN I/III subgroup (5-YSR = 57.1% and 43.3%) and low in RML III + NLN II/III subgroup (5-YSR = 0.0 % each). Conclusions NLN is a strong prognostic factor for OS and DFS of stage II/IIIa NSCLC patients, and provides a useful classification scheme for NSCLC patients when combined with RML.
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Affiliation(s)
- Shengguang Wang
- Department of Lung Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, 300060, China.,Tianjin Lung Cancer Center, Tianjin, 300060, China.,Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin, 300060, China.,National Clinical Research Center for Cancer, Tianjin, 300060, China
| | - Bin Zhang
- Department of Lung Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, 300060, China.,Tianjin Lung Cancer Center, Tianjin, 300060, China.,Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin, 300060, China.,National Clinical Research Center for Cancer, Tianjin, 300060, China
| | - Chenguang Li
- Department of Lung Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, 300060, China.,Tianjin Lung Cancer Center, Tianjin, 300060, China.,Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin, 300060, China.,National Clinical Research Center for Cancer, Tianjin, 300060, China
| | - Chao Cui
- Graduate School, Tianjin Medical University, Tianjin, 300070, China.,Department of Thoracic Surgery, Tianjin Haihe Hospital, Tianjin, 300350, China
| | - Dongsheng Yue
- Department of Lung Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, 300060, China.,Tianjin Lung Cancer Center, Tianjin, 300060, China.,Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin, 300060, China.,National Clinical Research Center for Cancer, Tianjin, 300060, China
| | - Bowen Shi
- Department of Lung Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, 300060, China.,Tianjin Lung Cancer Center, Tianjin, 300060, China.,Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin, 300060, China.,National Clinical Research Center for Cancer, Tianjin, 300060, China
| | - Qiang Zhang
- Department of Lung Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, 300060, China.,Tianjin Lung Cancer Center, Tianjin, 300060, China.,Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin, 300060, China.,National Clinical Research Center for Cancer, Tianjin, 300060, China
| | - Zhenfa Zhang
- Department of Lung Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, 300060, China.,Tianjin Lung Cancer Center, Tianjin, 300060, China.,Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin, 300060, China.,National Clinical Research Center for Cancer, Tianjin, 300060, China
| | - Xi Zhang
- Affiliated Yueqing Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, 325000, China.,School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, 325000, China
| | - Changli Wang
- Department of Lung Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, 300060, China.,Tianjin Lung Cancer Center, Tianjin, 300060, China.,Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin, 300060, China.,National Clinical Research Center for Cancer, Tianjin, 300060, China
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He J, Wang H, Ma F, Feng F, Lin C, Qian H. Prognosis of lymph node-negative breast cancer: Association with clinicopathological factors and tumor associated gene expression. Oncol Lett 2014; 8:1717-1724. [PMID: 25202398 PMCID: PMC4156224 DOI: 10.3892/ol.2014.2339] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 06/24/2014] [Indexed: 12/20/2022] Open
Abstract
The aim of the present study was to investigate the association between the prognosis of lymph node-negative breast cancer patients and clinicopathological factors, as well as the association between tumor-associated gene expression and prognosis. Clinical data and survival information was collected for 341 patients with lymph node-negative breast cancer, admitted to the Cancer Hospital of the Chinese Academy of Medical Sciences (Beijing, China) from 1995 to 1999. Kaplan-Meier survival analysis and Log-rank tests were used to evaluate the association of clinical parameters and prognosis. In addition, the gene expression of HER2, TOP2A and CCND1 in patients with good [disease-free survival (DFS), ≥5 years] and poor (DFS, <5 years) prognoses was analyzed. The clinicopathological factors of the 341 lymph node-negative breast cancer patients were determined. The 5-year DFS and overall survival rate (OS) in patients >35 years old was higher as compared with those of patients under the age of 35. Tumor size significantly affected the 5-year DFS. Patients with smaller tumors (≤2 cm) had a significantly higher DFS rate as compared with patients with larger tumors (>2 cm). Estrogen receptor (ER)-positive patients had a significantly higher 5-year DFS and OS rate as compared with ER-negative patients. By contrast, there were no significant differences in the 5-year DFS and OS rates between progesterone receptor-positive and -negative patients. The 5-year DFS and OS rates were significantly higher in patients treated with adjuvant hormone therapy, as compared with patients without hormone therapy. The expression of HER2 protein was higher in patients with a poor prognosis as compared with those with a good prognosis; however, there were no differences in the protein expression of CCND1 and TOP2A between patients with a good and poor prognosis. The results of quantitative polymerase chain reaction showed that the gene expression of HER2 and CCND1 was higher in patients with a poor prognosis as compared with that in patients with a good prognosis. TOP2A gene expression was not significantly different between patients with a poor and good prognosis. The age at diagnosis, tumor size, ER status and hormone therapy were associated with prognosis in patients with lymph node-negative breast cancer. The molecular biomarker, HER2, but not CCND1 or TOP2A, may be a critical factor for predicting prognosis.
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Affiliation(s)
- Jing He
- Department of Internal Medicine, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing 100021, P.R. China
| | - Haijuan Wang
- State Key Laboratory of Molecular Oncology, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing 100021, P.R. China
| | - Fei Ma
- Department of Internal Medicine, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing 100021, P.R. China
| | - Fengyi Feng
- Department of Internal Medicine, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing 100021, P.R. China
| | - Chen Lin
- State Key Laboratory of Molecular Oncology, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing 100021, P.R. China
| | - Haili Qian
- State Key Laboratory of Molecular Oncology, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing 100021, P.R. China
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Chin SN, Green C, Strachan GG, Wharfe G. Clinicopathologic Characteristics of Breast Cancer in Jamaica. Asian Pac J Cancer Prev 2014; 15:3319-22. [DOI: 10.7314/apjcp.2014.15.7.3319] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Erbes T, Orlowska-Volk M, Zur Hausen A, Rücker G, Mayer S, Voigt M, Farthmann J, Iborra S, Hirschfeld M, Meyer PT, Gitsch G, Stickeler E. Neoadjuvant chemotherapy in breast cancer significantly reduces number of yielded lymph nodes by axillary dissection. BMC Cancer 2014; 14:4. [PMID: 24386929 PMCID: PMC3884010 DOI: 10.1186/1471-2407-14-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 12/30/2013] [Indexed: 11/21/2022] Open
Abstract
Background Neoadjuvant chemotherapy (NC) is an established therapy in breast cancer, able to downstage positive axillary lymph nodes, but might hamper their detectibility. Even if clinical observations suggest lower lymph node yield (LNY) after NC, data are inconclusive and it is unclear whether NC dependent parameters influence detection rates by axillary lymph node dissection (ALND). Methods We analyzed retrospectively the LNY in 182 patients with ALND after NC and 351 patients with primary ALND. Impact of surgery or pathological examination and specific histomorphological alterations were evaluated. Outcome analyses regarding recurrence rates, disease free (DFS) and overall survival (OS) were performed. Results Axillary LNY was significantly lower in the NC in comparison to the primary surgery group (median 13 vs. 16; p < 0.0001). The likelihood of incomplete axillary staging was four times higher in the NC group (14.8% vs. 3.4%, p < 0.0001). Multivariate analyses excluded any influence by surgeon or pathologist. However, the chemotherapy dependent histological feature lymphoid depletion was an independent predictive factor for a lower LNY. Outcome analyses revealed no significant impact of the LNY on local and regional recurrence rates as well as DFS and OS, respectively. Conclusion NC significantly reduces the LNY by ALND and has profound effects on the histomorphological appearance of lymph nodes. The current recommendations for a minimum removal of 10 lymph nodes by ALND are clearly compromised by the clinically already established concept of NC. The LNY of less than 10 by ALND after NC might not be indicative for an insufficient axillary staging.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Elmar Stickeler
- Department of Gynaecology and Obstetrics, University Medical Center Freiburg, Hugstetter Street 55, 79106 Freiburg, Germany.
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Karlsson P, Cole BF, Chua BH, Price KN, Lindtner J, Collins JP, Kovács A, Thürlimann B, Crivellari D, Castiglione-Gertsch M, Forbes JF, Gelber RD, Goldhirsch A, Gruber G. Patterns and risk factors for locoregional failures after mastectomy for breast cancer: an International Breast Cancer Study Group report. Ann Oncol 2012; 23:2852-2858. [PMID: 22776708 PMCID: PMC3477880 DOI: 10.1093/annonc/mds118] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 01/04/2012] [Accepted: 03/20/2012] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Rates and risk factors of local, axillary and supraclavicular recurrences can guide patient selection and target for postmastectomy radiotherapy (PMRT). PATIENTS AND METHODS Local, axillary and supraclavicular recurrences were evaluated in 8106 patients enrolled in 13 randomized trials. Patients received chemotherapy and/or endocrine therapy and mastectomy without radiotherapy. Median follow-up was 15.2 years. RESULTS Ten-year cumulative incidence for chest wall recurrence of >15% was seen in patients aged <40 years (16.1%), with ≥4 positive nodes (16.5%) or 0-7 uninvolved nodes (15.1%); for supraclavicular failures >10%: ≥4 positive nodes (10.2%); for axillary failures of >5%: aged <40 years (5.1%), unknown primary tumor size (5.2%), 0-7 uninvolved nodes (5.2%). In patients with 1-3 positive nodes, 10-year cumulative incidence for chest wall recurrence of >15% were age <40, peritumoral vessel invasion or 0-7 uninvolved nodes. Age, number of positive nodes and number of uninvolved nodes were significant parameters for each locoregional relapse site. CONCLUSION PMRT to the chest wall and supraclavicular fossa is supported in patients with ≥4 positive nodes. With 1-3 positive nodes, chest wall PMRT may be considered in patients aged <40 years, with 0-7 uninvolved nodes or with vascular invasion. The findings do not support PMRT to the dissected axilla.
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Affiliation(s)
- P Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - B F Cole
- Department of Mathematics and Statistics College of Engineering and Mathematical Sciences, University of Vermont, Burlington; IBCSG Statistical Center, Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, USA
| | - B H Chua
- Department of Radiation Oncology, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Australia
| | - K N Price
- IBCSG Statistical Center, Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, USA; Frontier Science and Technology Research Foundation, Boston, USA
| | - J Lindtner
- The Institute of Oncology, Ljubljana, Slovenia
| | - J P Collins
- Department of Surgery, Royal Melbourne Hospital, Victoria, Australia
| | - A Kovács
- Department of Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - B Thürlimann
- The Breast Center, Kantonsspital, St Gallen, Switzerland and Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
| | - D Crivellari
- Department of Medical Oncology, Centro di Riferimento Oncologico, Aviano, Italy
| | | | - J F Forbes
- Australian New Zealand Breast Cancer Trials Group, University of Newcastle, Calvary Mater Newcastle, Newcastle, Australia
| | - R D Gelber
- IBCSG Statistical Center, Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, USA; Frontier Science and Technology Research Foundation, Boston, USA; Harvard School of Public Health and Harvard Medical School, Boston, USA
| | - A Goldhirsch
- European Institute of Oncology, Milan, Italy; Swiss Center for Breast Health, Sant'Anna Clinics, Lugano-Sorengo
| | - G Gruber
- Institut fuer Radiotherapie, Klinik Hirslanden, Zürich, Switzerland
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Liersch R, Hirakawa S, Berdel WE, Mesters RM, Detmar M. Induced lymphatic sinus hyperplasia in sentinel lymph nodes by VEGF-C as the earliest premetastatic indicator. Int J Oncol 2012; 41:2073-8. [PMID: 23076721 PMCID: PMC3583645 DOI: 10.3892/ijo.2012.1665] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 05/17/2012] [Indexed: 12/12/2022] Open
Abstract
Research on tumor-induced lymphangiogenesis has predominantly focused on alterations and abnormal growth of peritumoral and intratumoral lymphatic vessels. However, recent evidence indicates that lymphangiogenesis of sentinel lymph nodes might also contribute to cancer progression. In clinical oncology, the sentinel lymph nodes play an important role in diagnosis, staging and management of disease. The prognostic value that may be placed in the analysis of various parameters in tumor-free lymph nodes is still under debate. We, therefore, chose to investigate genetically fluorescent MDA-MB-435/green fluorescent protein human cancer cells transfected to overexpress VEGF-C in a nude mouse model and investigated metastasis, lymph node lymphangiogenesis, lymph node angiogenesis and size of sentinel lymph nodes. The nature of MDA-MB-435, identified as a breast cancer cell line for several decades, has recently been reidentified as being from melanoma origin. Vascular endothelial growth factor-C overexpression induced early metastasis and significantly increased the lymphatic vessel area in sentinel lymph nodes even before the tumor metastasis. At early time-points, expansion of the lymphatic network was observed even though no difference of blood vessel area and lymph node size was detected. These results suggest that primary tumors -via secretion of VEGF-C- can induce hyperplasia of the sentinel lymph node lymphatic vessel network and thereby promote their further spread. In cases of tumor-free lymph nodes the increased lymphatic network of sentinel lymph nodes is a very early premetastatic sign and may provide a new prognostic indicator and target for aggressive diseases.
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Affiliation(s)
- Ruediger Liersch
- Cutaneous Biology Research Center, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA.
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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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Martinez-Ramos D, Escrig-Sos J, Torrella-Ramos A, Alcalde-Sanchez M, Salvador-Sanchis JL, Ferraris C, Greco M. Prognostic significance of the number of negative axillary lymph nodes in patients with pT1-2 N0 M0 breast cancer: a population-based study. Breast J 2010; 16:437-9. [PMID: 20522102 DOI: 10.1111/j.1524-4741.2010.00944.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Tai P, Yu E, Sadikov E, Joseph K. A long-term study of radiation therapy in t1-2 node-negative breast cancer patients in relation to the number of axillary nodes examined. Int J Radiat Oncol Biol Phys 2009; 74:453-7. [PMID: 18947940 DOI: 10.1016/j.ijrobp.2008.08.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Revised: 08/16/2008] [Accepted: 08/20/2008] [Indexed: 12/01/2022]
Abstract
PURPOSE The optimal number of axillary nodes to be resected is controversial. This large series investigated the effect of surgery with or without adjuvant radiotherapy among node-negative breast cancer patients in relation to the number of nodes examined. METHODS AND MATERIALS Node-negative patients from the Saskatchewan registry of 1981-1995 were studied. Because nodal status may be more reliable with more number of nodes examined, we analyzed T1-2 age < 90 patients with < 10 nodes examined treated with surgery alone (Group A_S, n = 509) vs. surgery and adjuvant radiotherapy (Group A_S+R, n = 342); and T1-2 age < 90 patients with > or = 10 nodes examined treated with surgery alone (Group B_S, n = 902) vs. surgery and adjuvant radiotherapy (Group B_S+R, n = 596). RESULTS For the two radiotherapy groups, patients with < 10 nodes (Group A_S+R) vs. > or = 10 nodes (Group B_S+R), there was no difference in overall survival (p = 0.14). In the two nonradiotherapy groups (A_S and B_S), there is a statistically significant decrease in overall survival for patients with < 10 nodes removed (p < 0.001, log-rank test). The optimal number of axillary nodes examined could be 8 nodes with adjuvant radiotherapy (p = 0.05, logrank test) and 12 nodes without adjuvant radiotherapy (p = 0.02, log-rank test). CONCLUSIONS The poorer prognosis of a lesser number of nodes resected was overcome partly by the use of radiotherapy, raising the possibility of micrometastases in lymph nodes not removed. The optimal number of axillary nodes examined could be 8 nodes with adjuvant radiotherapy and 12 nodes without adjuvant radiotherapy.
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Affiliation(s)
- Patricia Tai
- Department of Oncology, Allan Blair Cancer Center, University of Saskatchewan, Canada.
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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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Fitzal F, Riedl O, Jakesz R. Recent developments in breast-conserving surgery for breast cancer patients. Langenbecks Arch Surg 2008; 394:591-609. [DOI: 10.1007/s00423-008-0412-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Accepted: 08/07/2008] [Indexed: 10/21/2022]
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Bélanger J, Soucy G, Sidéris L, Leblanc G, Drolet P, Mitchell A, Leclerc YE, Beaudet J, Dufresne MP, Dubé P. Neoadjuvant chemotherapy in invasive breast cancer results in a lower axillary lymph node count. J Am Coll Surg 2008; 206:704-8. [PMID: 18387477 DOI: 10.1016/j.jamcollsurg.2007.10.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2007] [Revised: 10/28/2007] [Accepted: 10/31/2007] [Indexed: 11/17/2022]
Abstract
BACKGROUND It is essential to have the highest level of confidence in axillary staging assessment. Many surgeons and pathologists believe that fewer lymph nodes are present in axillary dissection specimens of women treated by neoadjuvant chemotherapy. Consequently, the purpose of this study was to compare the lymph node counts of axillary dissection specimens from patients having received neoadjuvant chemotherapy with those of patients treated with primary operation. STUDY DESIGN A retrospective analysis of a prospective database from our institution identified 283 women with invasive breast cancer who underwent level I and II axillary lymph node dissections. Women from the neoadjuvant chemotherapy group (n=107) were compared with those from the primary surgery group (n=176). The total number of lymph nodes harvested was considered as a continuous variable, but also dichotomized into two categories (< 10 and >or=10). Its correlation with the different variables was analyzed. RESULTS The median number of lymph nodes retrieved in the neoadjuvant chemotherapy group was 10.0 (range 0 to 38) compared with 12.5 (range 0 to 30) in the control group (p=0.002). There were also significantly more patients with fewer than 10 lymph nodes recovered in the neoadjuvant group (45 versus 28%, p=0.007). Logistic regression showed that neoadjuvant chemotherapy was the only factor associated with retrieval of fewer than 10 lymph nodes. CONCLUSIONS This study suggests that administration of neoadjuvant chemotherapy to breast cancer patients results in a reduced number of lymph nodes retrieved in the axillary dissection specimens.
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Affiliation(s)
- Julie Bélanger
- Department of General Surgery, Maisonneuve-Rosemont Hospital, University of Montréal, Montréal, PQ, Canada
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Williams RN, Jones L, Stotter A. Lymph nodes in the tail of the breast can be missed in standard axillary dissection. Eur J Surg Oncol 2008; 35:271-5. [PMID: 18407454 DOI: 10.1016/j.ejso.2008.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2007] [Accepted: 02/26/2008] [Indexed: 10/22/2022] Open
Abstract
AIMS To determine whether excision of the tail of the breast usually by mastectomy or occasionally wide excision together with formal level 1 axillary node dissection (AND) for early breast cancer influences the quantity of harvested lymph nodes and the detection of axillary metastases. METHODS Multiple regression and binary logistic regression analysis were performed on lymph node harvest data for level 1 AND performed prior to the adoption of sentinel node biopsy during a five year period from 1997 to 2001 at the Leicestershire Breast Unit, comparing AND with and without excision of the tail of the breast. RESULTS One thousand six hundred and forty-eight level 1 ANDs were performed with a median node harvest of 14 (3-44). Multiple regression analysis identified that the total node harvest was increased by 1.03 nodes if the tail of the breast was excised (p<0.001) and this was independent of the effect on node count of node positivity. Operating surgeon and reporting pathologist did not influence node count. CONCLUSIONS The results of this study indicate that low axillary nodes may be missed by AND without excision of the tail of the breast and support the use of targeted sentinel node biopsy that should identify an involved node at any site.
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Affiliation(s)
- R N Williams
- Glenfield Hospital, University Hospitals of Leicester, UK.
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Nos C, Lesieur B, Clough KB, Lecuru F. Blue Dye Injection in the Arm in Order to Conserve the Lymphatic Drainage of the Arm in Breast Cancer Patients Requiring an Axillary Dissection. Ann Surg Oncol 2007; 14:2490-6. [PMID: 17549570 DOI: 10.1245/s10434-007-9450-4] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Accepted: 03/16/2007] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite the widespread use of the sentinel lymph node biopsy technique, many patients with invasive breast cancer still undergo an axillary lymph node dissection and are at risk of arm lymphedema. With the new awareness of lymphatic spread in the axillary nodes, it should be possible to define a new surgical approach between sentinel lymph node biopsy and complete axillary dissection, a procedure preserving specifically lymph nodes in relation to the arm. METHODS Twenty-one patients with an operable breast cancer requiring an axillary dissection underwent surgery with an attempt to separate nodes related to the breast from specific nodes related to the arm. After an injection of blue dye in the arm, the surgeon performed the axillary dissection trying to identify blue nodes and ducts in order to preserve lymphatic arm drainage (LAD). If the blue nodes were located in the normal axillary dissection, they were removed separately. RESULTS In 15 of 21 patients (71%), blue nodes in relation with LAD were identified. In 10 (47%) patients, it was possible to dissect the LAD with the preservation lymphatic ducts. In 10 patients, the LAD nodes were removed: none of them contained metastases, despite the fact that the non-LAD axillary nodes contained metastases in 7 of 10 cases. CONCLUSIONS Identifying the LAD with blue dye injection in the arm is possible. A subsequent study can now begin to determine if this procedure is safe for patients and able to prevent lymphedema of the arm.
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Affiliation(s)
- Claude Nos
- Department of Gynecologic and Oncologic Surgery, Hôpital Européen Georges Pompidou, Paris, France.
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Karlsson P, Cole BF, Price KN, Coates AS, Castiglione-Gertsch M, Gusterson BA, Murray E, Lindtner J, Collins JP, Holmberg SB, Fey MF, Thürlimann B, Crivellari D, Forbes JF, Gelber RD, Goldhirsch A, Wallgren A. The role of the number of uninvolved lymph nodes in predicting locoregional recurrence in breast cancer. J Clin Oncol 2007; 25:2019-26. [PMID: 17420511 DOI: 10.1200/jco.2006.09.8152] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To identify groups of early breast cancer patients with substantial risk (10-year risk > 20%) for locoregional failure (LRF) who might benefit from postmastectomy radiotherapy (RT). PATIENTS AND METHODS Prognostic factors for LRF were evaluated among 6,660 patients (2,588 node-negative patients, 4,072 node-positive patients) in International Breast Cancer Study Group Trials I to IX treated with chemotherapy and/or endocrine therapy, and observed for a median of 14 years. In total, 1,251 LRFs were detected. All patients were treated with mastectomy without RT. RESULTS No group with 10-year LRF risk exceeding 20% was found among patients with node-negative disease. Among patients with node-positive breast cancer, increasing numbers of uninvolved nodes were significantly associated with decreased risk of LRF, even after adjustment for other prognostic factors. The highest quartile of uninvolved nodes was compared with the lowest quartile. Among premenopausal patients, LRF risk was decreased by 35% (P = .0010); among postmenopausal patients, LRF risk was decreased by 46% (P < .0001). The 10-year cumulative incidence of LRF was 20% among patients with one to three involved lymph nodes and fewer than 10 uninvolved nodes. Age younger than 40 years and vessel invasion were also associated significantly with increased risk. Among patients with node-positive disease, overall survival was significantly greater in those with higher numbers of uninvolved nodes examined (P < .0001). CONCLUSION Patients with one to three involved nodes and a low number of uninvolved nodes, vessel invasion, or young age have an increased risk of LRF and may be candidates for a similar treatment as those with at least four lymph node metastases.
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Affiliation(s)
- Per Karlsson
- Department of Oncology, University of Göteborg, Sahlgrenska University Hospital, Göteborg, Sweden.
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Blancas I, García-Puche JL, Bermejo B, Hanrahan EO, Monteagudo C, Martínez-Agulló A, Rouzier R, Hennessy BT, Valero V, Lluch A. Low number of examined lymph nodes in node-negative breast cancer patients is an adverse prognostic factor. Ann Oncol 2006; 17:1644-9. [PMID: 16873428 DOI: 10.1093/annonc/mdl169] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The aim of the study was to determine whether the number of lymph nodes removed at axillary dissection is associated with recurrence and survival in node-negative breast cancer (NNBC) patients. PATIENTS AND METHODS We retrospectively reviewed the medical records of 1606 women with pathologically node-negative T1-T3 invasive breast cancer. Median follow-up was 61 months (range 2-251). Potential prognostic factors assessed included: number of axillary lymph nodes examined, age, menopausal status, tumor size, histological type, tumor grade, estrogen receptor(ER), progesterone receptor (PR) and HER2. RESULTS At 5 years, relapse-free survival (RFS) rate was 85% and breast cancer-specific survival (BCSS) rate was 94%. In univariate analysis, factors significantly associated with lower RFS and BCSS were: fewer than six lymph nodes examined (RFS, P = 0.01; BCSS, P = 0.007), tumor size >2 cm, grade III, negative ER or PR. Statistically significant factors for lower RFS and BCSS in multivariate analysis were: fewer than six lymph nodes examined [RFS, hazard ratio (HR) 1.36, P = 0.029; BCSS, HR 1.87, P = 0.005], tumor size >2 cm, tumor grade III and negative PR. CONCLUSIONS Examination of fewer than six lymph nodes is an adverse prognostic factor in NNBC because it could lead to understaging. Six or more nodes need to be examined at axillary dissection to be confident of a node-negative status. This may be useful, in conjunction with other prognostic factors, in the assessment of NNBC patients for adjuvant systemic therapy.
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Affiliation(s)
- I Blancas
- Department of Oncology and Hematology, Clinic Hospital, Valencia, Spain.
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Callcut RA, Breslin TM. Lower nodal counts in axillary dissection following neoadjuvant chemotherapy: are there implications? Am J Surg 2006; 191:830-1. [PMID: 16720160 DOI: 10.1016/j.amjsurg.2006.01.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2006] [Revised: 01/25/2006] [Accepted: 01/31/2006] [Indexed: 11/23/2022]
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