Histopathological Predictors of Axillary Lymph Node Metastases in Patients with Breast Cancer

A Study Correlating the Tumor Site and Size with the Level of Axillary Lymph Node Involvement in Breast Cancer

Background

Breast cancer is the leading cancer in women. The most common histologic type of breast cancer is infiltrating ductal carcinoma. The mainstay of the treatment of breast cancer is surgery when the tumor is localized, followed by chemotherapy as well as radiotherapy (when indicated) and in estrogen receptor and progesterone receptor positive tumors, adjuvant hormonal therapy.

Aims and Objectives

The aim of this study is to correlate tumor site and size with the level of axillary lymph node involvement (ALNI) in early and locally advanced breast cancer.

Materials and Methods

This prospective and observational study was conducted on fifty female patients of carcinoma breast with early and locally advanced breast cancer.

Results

The age distribution showed two peaks at 41-50 years and 51-60 years with 42 and 24 patients, respectively, in both the age groups. Preoperative lymph node positivity by ultrasonography matched with postoperative histopathological examination (HPE) report. Preoperative ultrasonographically determined tumor size was similar to the final histopathological T stage.

Conclusion

As size of tumor increases, there is an increase in ALNI which suggests that nodal metastasis is indicative of tumor chronology. Ultrasonography is a good tool to objectively measure tumor size and lymph node involvement preoperatively. Quadrant of involvement can emerge as a clinically useful prognostic cancer in breast cancer as there is a higher incidence of lymph node positivity with increasing size of the breast tumor and for tumors located at the upper outer quadrant of the breast.

[Axillary lymph node irradiation in breast cancer: state of the art]

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.

Estrogen receptor and breast MR imaging features: a correlation study

PURPOSE

To compare the MRI features between estrogen receptor (ER) positive and negative breast cancers.

MATERIALS AND METHODS

Breast MRI of 90 consecutive patients confirmed with invasive ductal carcinoma (IDC), 51 ER positive and 39 ER negative, were analyzed. The tumor morphology and dynamic contrast-enhanced (DCE) kinetics were evaluated based on the American College of Radiology (ACR) Breast Imaging Reporting and Data System (BI-RADS) MRI lexicon and compared. Enlarged axillary lymph nodes on MRI and choline (Cho) detection using MR spectroscopy (MRS) were also analyzed and compared. For patients receiving axillary node dissection the pathological nodal status was also compared.

RESULTS

ER negative breast cancer had bigger tumors compared to ER positive cancer (3.6 +/- 2.0 cm vs. 1.8 +/- 1.3 cm, P < 0.00005). ER negative cancer was more likely to exhibit nonmass type enhancements compared to ER positive cancer (P < 0.005). Enlarged axillary lymph nodes were more frequently identified on MRI in ER negative compared to ER positive patients (P < 0.05). After excluding patients undergoing neoadjuvant chemotherapy, auxiliary lymph node status did not show significant difference between ER positive and ER negative cancer on MRI and pathology. ER negative cancer was more likely to show the malignant type enhancement kinetics (P = 0.15), rim enhancement (P = 0.15), and Cho detection on MRS (P = 0.23) compared to ER positive cancer, but it did not reach a level of statistical significance.

CONCLUSION

ER negative breast cancer was more aggressive, with larger tumor size, more non-mass-type enhancement lesions, and a higher percentage showing enlarged axillary nodes on MRI. These features might be related to its poorer cellular differentiation and/or a higher angiogenesis.

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

AIMS

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

Correlation between breast tumour size and level of axillary lymph node involvement

OBJECTIVE

Axillary lymph node dissection (ALND) is important for prognosis but does carry certain morbidities, particularly arm lymphoedema. Our aim was to determine whether tumour size correlates with level of axillary lymph node involvement in order to minimize ALND for small tumours.

METHODS

Data were collected prospectively. Patients undergoing breast cancer surgery between May and December 2002 underwent preoperative breast ultrasound to measure the size of the primary tumour. Standard ALND was performed for all patients and levels of lymph nodes were sent separately to determine extent of involvement.

RESULTS

Of the 203 cases studied, 91 (44.8%) had T1 tumours (<2 cm). The incidence of level II lymph nodes in T1 tumours was 4.4% (4/91 patients). The greater the T stage, the higher the incidence of level I and II involvement (4.4% in T1, 7.1% in T2 and 36.5% in T3 tumours). No node-positive patients had isolated level II lymph node involvement. Ultrasound-determined tumour size correlated well with final histological size (p<0.0005).

CONCLUSION

Based on size, 95.6% (87/91) of patients with T1 tumours did not have level II lymph node metastases, so for these patients, level I axillary dissection is adequate.

Clinical and pathologic factors predicting axillary lymph node involvement in breast cancer

The diagnosis of axillary disease remains a challenge in the management of breast cancer and is a subject of controversy. In 1998, the Japanese Breast Cancer Society conducted a study assessing axillary lymph node involvement in breast cancer. The study included (a) clinical assessment by pre-operative imaging modalities, (b) histologic assessment for peritumoral lymphatic invasion, (c) biologic assessment by gelatinolytic activity using film in situ zymography, and (d) sentinel lymph node (SLN) biopsy. Clinical assessments by CT, PET, and US as well as biologic assessment were limited in their ability to detect axillary lymph node disease, although these imaging techniques may be useful to exclude node-positive patients from the need for SLN biopsy. Histologic assessment for peritumoral lymphatic invasion was useful, particularly for detecting false-negative cases by SLN biopsy. Nevertheless, the utility of SLN biopsy in assessing axillary nodal status was confirmed. Axillary lymph node dissection (ALND) can be avoided in patients with a small tumor and a negative SLN. However, further studies will be required to investigate the value of SLN biopsy for predicting regional control and survival before it can replace routine ALND as the optimal staging procedure for operable breast cancer.