Immunohistochemically detected lymph node metastases from breast carcinoma

Cure frailty models for survival data: Application to recurrences for breast cancer and to hospital readmissions for colorectal cancer

Owing to the natural evolution of a disease, several events often arise after a first treatment for the same subject. For example, patients with a primary invasive breast cancer and treated with breast conserving surgery may experience breast cancer recurrences, metastases or death. A certain proportion of subjects in the population who are not expected to experience the events of interest are considered to be ‘cured’ or non-susceptible. To model correlated failure time data incorporating a surviving fraction, we compare several forms of cure rate frailty models. In the first model already proposed non-susceptible patients are those who are not expected to experience the event of interest over a sufficiently long period of time. The other proposed models account for the possibility of cure after each event. We illustrate the cure frailty models with two data sets. First to analyse time-dependent prognostic factors associated with breast cancer recurrences, metastases, new primary malignancy and death. Second to analyse successive rehospitalizations of patients diagnosed with colorectal cancer. Estimates were obtained by maximization of likelihood using SAS proc NLMIXED for a piecewise constant hazards model. As opposed to the simple frailty model, the proposed methods demonstrate great potential in modelling multivariate survival data with long-term survivors (‘cured’ individuals).

Separate and combined analysis of successive dependent outcomes after breast-conservation surgery: recurrence, metastases, second cancer and death

BACKGROUND

In the setting of recurrent events, research studies commonly count only the first occurrence of an outcome in a subject. However this approach does not correctly reflect the natural history of the disease. The objective is to jointly identify prognostic factors associated with locoregional recurrences (LRR), contralateral breast cancer, distant metastases (DM), other primary cancer than breast and breast cancer death and to evaluate the correlation between these events.

METHODS

Patients (n = 919) with a primary invasive breast cancer and treated in a cancer center in South-Western France with breast-conserving surgery from 1990 to 1994 and followed up to January 2006 were included. Several types of non-independent events could be observed for the same patient: a LRR, a contralateral breast cancer, DM, other primary cancer than breast and breast cancer death. Data were analyzed separately and together using a random-effects survival model.

RESULTS

LRR represent the most frequent type of first failure (14.6%). The risk of any event is higher for young women (less than 40 years old) and in the first 10 years of follow-up after the surgery. In the combined analysis histological tumor size, grade, number of positive nodes, progesterone receptor status and treatment combination are prognostic factors of any event. The results show a significant dependence between these events with a successively increasing risk of a new event after the first and second event. The risk of developing a new failure is greatly increased (RR = 4.25; 95%CI: 2.51-7.21) after developing a LRR, but also after developing DM (RR = 3.94; 95%CI: 2.23-6.96) as compared to patients who did not develop a first event.

CONCLUSION

We illustrated that the random effects survival model is a more satisfactory method to evaluate the natural history of a disease with multiple type of events.

VEGF-D in association with VEGFR-3 promotes nodal metastasis in human invasive lobular breast cancer

We assessed the expression of vascular endothelial growth factors (VEGF-C and VEGF-D) in breast cancer cells and the density of lymph vessels and VEGF receptor-3 (VEGFR-3)-positive vessels in and around the tumor in invasive lobular breast cancer. We found significant correlation between peritumoral lymph vessel density and presence of lymph node metastases (P=.001) and the number of metastatic lymph nodes (P<.001). A significant correlation was detected between tumor cell VEGF-D expression and lymph node status (P=.001) and density of lymphatic vessel endothelial receptor (LYVE)-1-positive vessels (P=.035). VEGFR-3+/VEGF-D+ and VEGFR-3+/VEGF-C+ tumors had a significantly higher number of metastatic lymph nodes than tumors with other staining patterns (P<.001). Tumors positive for neither VEGF-D nor VEGFR-3 had a lower density of LYVE-1+ vessels than tumors with other staining patterns (P=.033). Our results indicate that peritumoral lymph vessel density is associated with lymph node metastases in invasive lobular breast cancer and that invasive lobular cancer producing VEGF-D, surrounded by VEGFR-3+ vessels, has a significantly higher peritumoral lymph vessel density and a higher number of metastatic lymph nodes.

Ductal carcinoma in situ: Value of sentinel lymph node biopsy

BACKGROUND

Ductal carcinoma in situ (DCIS) represents about 20% of newly diagnosed breast carcinomas. Axillary metastasis is often related to undiagnosed DCIS with microinvasion (DCISM). The aim of this study was to confirm the interest of sentinel lymph node (SLN) biopsy in extensive DCIS.

METHODS

Patients with a diagnosis of DCIS or DCISM and axillary lymph node evaluation were selected. Surgical treatment included SLN biopsy and/or axillary lymph node dissection (ALND). Serial sections were stained with hematoxylin and eosin (H&E) and with an immunohistochemical (IHC) method. When a micrometastasis was found, the breast specimen was revised searching for occult microinvasion.

RESULTS

Hundred and forty patients with initial DCIS were enrolled in the study. Node metastasis was identified in 9 patients (7%) of the 128 patients with DCIS and DCISM. At final histology, 4 (10%) of the 39 patients with pure DCIS and SLN biopsy and 1 (7%) of the 14 patients with DCISM and SLN biopsy had axillary micrometastasis. Four of the 12 patients upstaged to invasive carcinoma had metastatic SLNs.

CONCLUSIONS

Sentinel lymph node biopsy is valuable in patients with diffuse DCIS or DCISM who are scheduled for mastectomy in order to search for axillary micrometastases and occult breast microinvasion.