Predictors of Axillary Lymph Node Metastases in Breast Cancer: Is There a Role for Minimal Axillary Surgery?

Nomogram based on multiparametric analysis of early-stage breast cancer: Prediction of high burden metastatic axillary lymph nodes

BACKGROUND

The Z0011 and AMAROS trials found that axillary lymph node dissection (ALND) was no longer mandatory for early-stage breast cancer patients who had one or two metastatic axillary lymph nodes (mALNs). The aim of our study was to establish a nomogram which could be used to quantitatively predict the individual likelihood of high burden mALN (≥3 mALN).

METHODS

We retrospectively analyzed 564 women with early breast cancer who had all undergone both ultrasound (US) and magnetic resonance imaging (MRI) to examine axillary lymph nodes before radical surgery. All the patients were divided into training (n = 452) and validation (n = 112) cohorts by computer-generated random numbers. Their clinicopathological features and preoperative imaging associated with high burden mALNs were evaluated by logistic regression analysis to develop a nomogram for predicting the probability of high burden mALNs.

RESULTS

Multivariate analysis showed that high burden mALNs were significantly associated with replaced hilum and the shortest diameter >10 mm on MRI, with cortex thickness >3 mm on US (p < 0.05 each). These imaging criteria plus higher grade (grades II and III) and quadrant of breast tumor were used to develop a nomogram calculating the probability of high burden mALNs. The AUC of the nomogram was 0.853 (95% CI: 0.790-0.908) for the training set and 0.783 (95% CI: 0.638-0.929) for the validation set. Both internal and external validation evaluated the accuracy of nomogram to be good.

CONCLUSION

A well-discriminated nomogram was developed to predict the high burden mALN in early-stage breast patients, which may assist the breast surgeon in choosing the appropriate surgical approach.

The ratio of lymphocyte/red blood cells and platelets/lymphocytes are predictive biomarkers for lymph node metastasis in patients with breast cancer

BACKGROUND

Axillary lymph node metastasis (LNM) affects the progression of breast cancer. However, it is difficult to preoperatively diagnose axillary lymph node status with high sensitivity. Therefore, we hypothesized that platelets/lymphocytes ratio (PLR) and lymphocytes/ red blood cells ratio (LRR) might help in the prognosis of lymph node metastasis in T1-T2 breast cancer.

METHODS

166 patients (Chang Ning Maternity & Infant Health Institute) were included in our study, and the associations of PLR and LPR with lymph node metastasis were investigated. Peripheral blood was collected one week before the surgery, and the patients were divided into different categories based on their PLR and LRR.

RESULTS

The incidence of LNM was significantly increased in the high PLR group (p= 0.002) compared with the low PLR group; LNM was also significantly increased in the low LRR group (p= 0.036) compared with the high LPR group. Further, our study revealed that high PLR (p< 0.001, OR = 4.397, 95% CI = 2.005-9.645), low LRR (p= 0.017, OR = 0.336, 95%CI = 0.136-0.825) and high clinical T stage (p< 0.001, OR = 3.929, 95%CI = 1.913-8.071) are independent predictors of LNM.

CONCLUSIONS

PLR and LRR could be identified as predictors of LNM in patients with T1/T2 breast cancer.

A meta-analysis of the diagnostic performance of machine learning-based MRI in the prediction of axillary lymph node metastasis in breast cancer patients

Background

Despite that machine learning (ML)-based MRI has been evaluated for diagnosis of axillary lymph node metastasis (ALNM) in breast cancer patients, diagnostic values they showed have been variable. In this study, we aimed to assess the use of ML to classify ALNM on MRI and to identify potential covariates that might influence the diagnostic performance of ML.

Methods

A systematic research of PubMed, Embase, Web of Science, and the Cochrane Library was conducted until 27 December 2020 to collect the included articles. Subgroup analysis was also performed.

Findings

Fourteen studies assessing a total of 2247 breast cancer patients were included in the analysis. The overall AUC for ML in the validation set was 0.80 (95% confidence interval [CI] 0.76–0.83) with a negative predictive value of 0.83. The pooled sensitivity and specificity were 0.79 (95% CI 0.74–0.84) and 0.77 (95% CI 0.73–0.81), respectively. In the subgroup analysis of the validation set, T1-weighted contrast-enhanced (T1CE) imaging with ML yielded a higher sensitivity (0.80 vs. 0.67 vs. 0.76) than the T2-weighted fat-suppressed (T2-FS) imaging and diffusion-weighted imaging (DWI). Support vector machines (SVMs) had a higher specificity than linear regression (LR) and linear discriminant analysis (LDA) (0.79 vs. 0.78 vs. 0.75), whereas LDA showed a higher sensitivity than LR and SVM (0.83 vs. 0.70 vs. 0.77).

Interpretation

MRI sequences and algorithms were the main factors that affect the diagnostic performance of ML. Although its results were encouraging with the pooled sensitivity of around 0.80, it meant that 1 in 5 women that would go with undetected metastases, which may have a detrimental effect on the overall survival for 20% of patients with positive SLN status. Despite that a high NPV of 0.83 meant that ML could potentially benefit those with negative SLN, it might also translate to 1 in 5 tests being false negative. We would like to suggest that ML may not be yet usable in clinical routine especially when patient survival is used as a primary measurement of its outcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13244-021-01034-1.

Accuracy of CEUS-guided sentinel lymph node biopsy in early-stage breast cancer: a study review and meta-analysis

Objective

To investigate whether preoperative localization of sentinel lymph node (SLN) by contrast-enhanced ultrasound (CEUS) can further improve the accuracy of sentinel lymph node biopsy (SLNB).

Method

Collect published literatures or conference reports by searching electronic databases. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) evaluation method is used to evaluate the quality of the screened literatures. The pooled risk ratio of cancer metastasis of SLN identified by CEUS (CE-SLN) compared with SLN not identified by CEUS (nonCE-SLN) is calculated, and the pooled diagnostic accuracy of CE-SLN for pathological status of all SLNs is also evaluated.

Result

Through search and screening, a total of 16 studies were included, of which five and seven studies, respectively, entered the meta-analysis of metastatic risk ratio and diagnostic accuracy. The localization rate of preoperative CEUS for sentinel lymph nodes was 70 to 100%. The meta-analysis shows that the risk of metastasis of SLN identified by CEUS is significantly higher than that not identified by CEUS, 26.0% vs 4.6%, and risk ratio (RR) is 6.08 (95% CI 4.17–8.85). In early-stage breast cancer, the pathological status of CE-SLN is a good representative of all SLNs, with a pooled sensitivity of 98% (95% CI 0.94–1.00), pooled specificity of 100% (95% CI 0.99–1.00), diagnostic odds ratio (DOR) of 2153.18 (95% CI 476.53–9729.06), and area under the subject receiver operating characteristic (SROC) curve of 0.9968.

Conclusion

In early-stage breast cancer, preoperative localization of SLN by CEUS is expected to further improve the accuracy of sentinel lymph node biopsy (SLNB).

Are breast conservation treatment rates optimized for Asian women with symptomatic malignancies?

BACKGROUND

Published data indicate that 20-40% of patients undergo breast conservation treatment (BCT) in Asia, which is below an indicative benchmark of 50%. With an increasing body of evidence suggesting that BCT might be associated with improved survival outcomes, it is exigent to increase BCT utilization. This study was therefore undertaken to evaluate BCT rates for women presenting with symptomatic breast cancer and potential for de-escalation of surgical treatment.

METHODS

All patients who presented with symptomatic tumours and underwent surgical treatment at the authors' healthcare facility between January 2009 and December 2011 were included in this retrospective study. Standard wide excision was performed to achieve clear margins and reasonable cosmetic outcomes for BCT-eligible patients. Oncoplastic techniques such as therapeutic mammoplasty or volume replacement with flaps were not employed.

RESULTS

A total of 116 women presented with symptomatic breast cancer. The majority (92.2%) were Asian. Mean age at diagnosis was 48.3 years and mean tumour size was 23.4 mm. Ninety-five patients (81.9%) underwent BCT. Of the 22 patients, 13 (59%) who underwent neoadjuvant chemotherapy had sufficient tumour size downstaging to successfully undergo BCT instead of mastectomy.

CONCLUSION

It is possible for more than 80% of Asian women with symptomatic breast malignancies to undergo BCT, with the appropriate use of neoadjuvant medical therapy and surgical techniques. As increasing data indicate improved survival with BCT, this should be offered as the treatment of choice.

Predicting metastasis in clinically negative axillary lymph nodes with minimum apparent diffusion coefficient value in luminal A-like breast cancer

BACKGROUND

We investigated the usefulness of the minimum ADC value of primary breast lesions for predicting axillary lymph node (LN) status in luminal A-like breast cancers with clinically negative nodes in comparison with the mean ADC.

METHODS

Forty-four luminal A-like breast cancers without axillary LN metastasis at preoperative clinical evaluation, surgically resected with sentinel LN biopsy, were retrospectively studied. Mean and minimum ADC values of each lesion were measured and statistically compared between LN positive (n = 12) and LN negative (n = 32) groups. An ROC curve was drawn to determine the best cutoff value to differentiate LN status. Correlations between mean and minimum ADC values and the number of metastatic axillary LNs were investigated.

RESULTS

Mean and minimum ADC values of breast lesions with positive LN were significantly lower than those with negative LN (mean 839.9 ± 110.9 vs. 1022.2 ± 250.0 × 10^- 6 mm²/s, p = 0.027, minimum 696.7 ± 128.0 vs. 925.0 ± 257.6 × 10^- 6 mm²/s, p = 0.004). The sensitivity and NPV using the best cutoff value from ROC using both mean and minimum ADC were 100%. AUC of the minimum ADC (0.784) was higher than that of the mean ADC (0.719). Statistically significant negative correlations were observed between both mean and minimum ADCs and number of positive LNs, with stronger correlation to minimum ADC than mean ADC.

CONCLUSIONS

The minimum ADC value of primary breast lesions predicts axillary LN metastasis in luminal A-like breast cancer with clinically negative nodes, with high sensitivity and high NPV.

Lymph node positivity in different early breast carcinoma phenotypes: a predictive model

Background

A strong correlation between breast cancer (BC) molecular subtypes and axillary status has been shown. It would be useful to predict the probability of lymph node (LN) positivity. Objective: To develop the performance of multivariable models to predict LN metastases, including nomograms derived from logistic regression with clinical, pathologic variables provided by tumor surgical results or only by biopsy.

Methods

A retrospective cohort was randomly divided into two separate patient sets: a training set and a validation set. In the training set, we used multivariable logistic regression techniques to build different predictive nomograms for the risk of developing LN metastases. The discrimination ability and calibration accuracy of the resulting nomograms were evaluated on the training and validation set.

Results

Consecutive sample of 12,572 early BC patients with sentinel node biopsies and no neoadjuvant therapy. In our predictive macro metastases LN model, the areas under curve (AUC) values were 0.780 and 0.717 respectively for pathologic and pre-operative model, with a good calibration, and results with validation data set were similar: AUC respectively of 0.796 and 0.725.

Among the list of candidate’s regression variables, on the training set we identified age, tumor size, LVI, and molecular subtype as statistically significant factors for predicting the risk of LN metastases.

Conclusions

Several nomograms were reported to predict risk of SLN involvement and NSN involvement. We propose a new calculation model to assess this risk of positive LN with similar performance which could be useful to choose management strategies, to avoid axillary LN staging or to propose ALND for patients with high level probability of major axillary LN involvement but also to propose immediate breast reconstruction when post mastectomy radiotherapy is not required for patients without LN macro metastasis.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5227-3) contains supplementary material, which is available to authorized users.

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.

Identification of genes and pathways related to lymphovascular invasion in breast cancer patients: A bioinformatics analysis of gene expression profiles

Surgery is the most effective treatment for breast cancer patients. However, some patients developed recurrence and distant metastasis after surgery. Adjuvant therapy is considered for high-risk patients depending on several prognostic markers, and lymphovascular invasion has become one of such prognostic markers that help physicians to identify the risk for distant metastasis and recurrence. However, the mechanism of lymphovascular invasion in breast cancer remains unknown. This study aims to unveil the genes and pathways that may involve in lymphovascular invasion in breast cancer. In total, 108 breast cancer samples were collected during surgery and microarray analysis was performed. Significance analysis of the microarrays and limma package for R were used to examine differentially expressed genes between lymphovascular invasion-positive and lymphovascular invasion-negative cases. Network and pathway analyses were mapped using the Ingenuity Pathway Analysis and the Database for Annotation, Visualization and Integrated Discovery. In total, 86 differentially expressed genes, including 37 downregulated genes and 49 upregulated genes were identified in lymphovascular invasion-positive patients. Among these genes, TNFSF11, IL6ST, and EPAS1 play important roles in cytokine-receptor interaction, which is the most enriched pathway related to lymphovascular invasion. Moreover, the results also suggested that an imbalance between extracellular matrix components and tumor micro-environment could induce lymphovascular invasion. Our study evaluated the underlying mechanisms of lymphovascular invasion, which may further help to assess the risk of breast cancer progression and identify potential targets of adjuvant treatment.

The Relevance of Ultrasound Imaging of Suspicious Axillary Lymph Nodes and Fine-needle Aspiration Biopsy in the Post-ACOSOG Z11 Era in Early Breast Cancer

RATIONALE AND OBJECTIVES

Evaluation of nodal involvement in early-stage breast cancers (T1 or T2) changed following the Z11 trial; however, not all patients meet the Z11 inclusion criteria. Hence, the relevance of ultrasound imaging of the axilla and fine-needle aspiration biopsy (FNA) in early-stage breast cancers was investigated.

MATERIALS AND METHODS

In this single-center, retrospective study, 758 subjects had pathology-verified breast cancer diagnosis over a 3-year period, of which 128 subjects with T1 or T2 breast tumors had abnormal axillary lymph nodes on ultrasound, had FNA, and proceeded to axillary surgery. Ultrasound images were reviewed and analyzed using multivariable logistic regression to identify the features predictive of positive FNA. Accuracy of FNA was quantified as the area under the receiver operating characteristic curve with axillary surgery as reference standard.

RESULTS

Of 128 subjects, 61 were positive on FNA and 65 were positive on axillary surgery. Sensitivity, specificity, positive predictive value, and negative predictive value of FNA were 52 of 65 (80%), 54 of 63 (85.7%), 52 of 61(85.2%), and 54 of 67 (80.5%), respectively. After adjusting for neoadjuvant chemotherapy between FNA and surgery, a positive FNA was associated with higher likelihood for positive axillary surgery (odds ratio: 22.7; 95% confidence interval [CI]: 7.2-71.3, P < .0001), and the accuracy of FNA was 0.801 (95% CI: 0.727-0.876). Among ultrasound imaging features, cortical thickness and abnormal hilum were predictive (P < .017) of positive FNA with accuracy of 0.817 (95% CI: 0.741-0.893).

CONCLUSIONS

Ultrasound imaging and FNA can play an important role in the management of early breast cancers even in the post-Z11 era. Higher weightage can be accorded to cortical thickness and hilum during ultrasound evaluation.

Correlation of Various Biomarkers with Axillary Nodal Metastases: Can a Panel of Such Biomarkers Guide Selective Use of Axillary Surgery in T1 Breast Cancer?

To evaluate the correlation of various clinic-pathological variables with axillary nodal involvement in T1 breast cancer & to identify a sub-group of T1 cancers, on the basis of observed variables, with a low risk of axillary nodal metastases. Clinico-pathological variables observed included tumor size, lymphovascular invasion (LVI), histological grade of tumor, tumor palpability, estrogen/progesterone (ER/PR) & her2/neu receptors, age, family history, histological type of tumor, axillary nodal metastases for 100 patients without clinically palpable nodes who underwent axillary lymph node dissection in Bombay Hospital & Medical Research Center from March, 2009. Data compiled was analyzed by univariate & multivariate analysis. All the variables viz. tumor size, LVI, histological grade, tumor palpability & ER/PR/Her2 receptor profile, which were found to be significantly associated with axillary lymph node involvement (ALNI) on univariate analysis were also found to be independent predictors of ALNI on multivariate analysis. Age of the patient, family history & histological type of tumor were not significantly correlated with ALNI. None of the 12 patients with tumor biomarker profile of T1a-b tumors without LVI & with histological grade I, had ALNI. The risk of ALNI can be predicted by using various tumor biomarker variables. Based on the predicted risk of ALNI, the management strategy for axilla can be individualized. The omission of operative axillary staging may be considered in patients with low predictive risk of ALNI.

Patterns of axillary lymph node metastases and recurrent disease in grade 1 breast cancer in a New Zealand cohort: Does ethnicity matter?

BACKGROUND

In New Zealand, Māori and Pacific women are more likely than New Zealand/European women to present at a younger age with larger tumours and metastatic disease. Survival rates are also differential by ethnicity. Many factors are believed to be responsible for this including differences in comorbidities, delays to presentation and delays in treatment. It is unclear whether these differences exist amongst women with grade 1 cancer in New Zealand. Therefore, we examined patterns of axillary nodal involvement, recurrent disease and mortality in grade 1 breast cancer in New Zealand women, and whether ethnicity was an important predictor for any of these outcomes.

METHOD

Data was retrieved from the Auckland Breast Cancer Registry (ABCR) and the Waikato Breast Cancer Registry (WBCR) which are prospective, population-based databases. All women newly diagnosed with grade 1 primary invasive breast cancer between 1 June 2000 and 31 May 2013 were identified from the two registries.

RESULTS

There were 2857 grade 1 breast cancers diagnosed over this time period. Axillary lymph nodes were involved in 19.0% of women, and 5.1% developed recurrent disease (locoregional or distant). Pacific and Māori women were more likely than NZ European women to have larger tumours and lymphovascular invasion (LVI). Predictors for axillary node involvement were tumour size greater than 10mm, LVI and non-screen detected cancers. Tumour size greater than 10mm, lobular carcinoma and BCS without radiotherapy were predictive of recurrent and or metastatic disease. Ethnicity was not observed to be an independent predictor for axillary nodal involvement, recurrent and/or metastatic disease, or breast cancer specific mortality amongst New Zealand women with grade 1 breast cancer.

CONCLUSION

Ethnicity was not a predictor of axillary node involvement, recurrent disease or mortality in grade 1 breast cancer in our population.

Minimising unnecessary mastectomies in a predominantly Chinese community

Background. Recent data shows that the use of breast conservation treatment (BCT) for breast cancer may result in superior outcomes when compared with mastectomy. However, reported rates of BCT in predominantly Chinese populations are significantly lower than those reported in Western countries. Low BCT rates may now be a concern as they may translate into suboptimal outcomes. A study was undertaken to evaluate BCT rates in a cohort of predominantly Chinese women. Methods. All patients who underwent surgery on the breast at the authors' healthcare facility between October 2008 and December 2011 were included in the study and outcomes of treatment were evaluated. Results. A total of 171 patients were analysed. Two-thirds of the patients were of Chinese ethnicity. One hundred and fifty-six (85.9%) underwent BCT. Ninety-eight of 114 Chinese women (86%) underwent BCT. There was no difference in the proportion of women undergoing BCT based on ethnicity. After a median of 49 months of follow-up, three patients (1.8%) had local recurrence and 5 patients (2.9%) suffered distant metastasis. Four patients (2.3%) have died from their disease. Conclusion. BCT rates exceeding 80% in a predominantly Chinese population are possible with acceptable local and distant control rates, thereby minimising unnecessary mastectomies.

T-cadherin association with clinicopathological features and prognosis in axillary lymph node-positive breast cancer

The purpose of this study was to investigate the correlation of T-cadherin expression with clinicopathological features and prognosis in patients with axillary lymph node-positive breast cancer. Based on the immunohistochemistry results, all 142 patients with operable axillary lymph node-positive breast cancer were divided into the T-cadherin-negative and T-cadherin-positive groups. Clinical data including the association of T-cadherin expression with clinicopathological features and prognosis were analyzed using the Chi square test and Fisher's exact test using SPSS 13.0 software. The impact of T-cadherin expression on the 5-year disease-free survival (DFS) and the 5-year overall survival (OS) of these patients was measured using the log-rank test. DFS and OS were analyzed using both Kaplan-Meier function and Cox regression analyses. Compared with the T-cadherin-positive group (55.07, 28.99, and 13.4 %, respectively; P = 0.030, P = 0.0132, and P = 0.009), tumor size >2 cm, lymph-vascular invasion, and pathological stage III disease were seen more frequently in the T-cadherin-negative group (72.60, 49.32, and 31.51 %, respectively). Both 5-year DFS and 5-year OS were poorer in the T-cadherin-negative group than in the T-cadherin-positive group (log-rank test = 9.295, P = 0.002; log-rank test = 5.718, P = 0.017). On multivariate analysis, T-cadherin-negative expression remained an independent prognostic factor for DFS (P = 0.002) but not for OS (P = 0.067). Our results suggested that negative T-cadherin expression has a worse prognosis in patients with axillary lymph node-positive breast cancer.

Evaluation of eligibility and utilization of breast conservation treatment in an Asian context

BACKGROUND

Breast conservation treatment (BCT) has long been recognised to provide survival outcomes equivalent to mastectomy for the treatment of breast cancer. However, published reports of BCT rates in Asian communities are lower than those from Western countries. This study sought to investigate the eligibility and utilisation of BCT in a predominantly Asian population.

MATERIALS AND METHODS

All patients treated surgically by a single surgeon at a private medical facility between 2009 and 2011 were included in the study. Patients were deemed to have successful BCT if they underwent breast conserving surgery with pathologic clear margins and completed all recommended adjuvant treatment. Those who did not complete adjuvant treatment were excluded from the analysis.

RESULTS

Data from a total of 161 patients who underwent treatment during the study period were analysed. The mean age was 48.8 years. One hundred and six patients (65.8%) were of Chinese ethnicity, 12 were Indian (7.5%), 11 were Malay (6.8%), 18 were Caucasian (11.2%) and 14 (8.7%) were of other Asian ethnicity. One hundred and thirty-eight women (85.7%) underwent BCT. Of the 23 (14.3%) who underwent mastectomy, 8 (5.4%) elected to undergo a mastectomy despite being eligible for BCT. In total, it was assessed that 146 of 161 patients (90.7%) were eligible for BCT and utilisation was 94.5%.

CONCLUSIONS

In this study, eligibility, utilisation of BCT and eventual successful breast conservation rates are similar to published rates in Western communities. Additional research is needed to investigate the reasons for the lower published BCT rates in Asian countries and determine ways to improve them.

Detectability and clinicohistological characteristics of small (≤1 cm) invasive breast cancer

PURPOSE

To investigate the detectability and imaging characteristics of primary tumors according to imaging modalities and to identify clinical features and histological prognostic factors for axillary metastases in patients with small (≤1cm, T1a and T1b) invasive breast cancer.

MATERIALS AND METHODS

A total of 221 patients with histologically confirmed small invasive cancers were included for the statistical analysis. At mammography, ultrasonography and MRI, the detectability, and imaging characteristics of primary tumors were compared in patients with or without axillary metastases. Clinical features and histological prognostic factors for axillary metastases were investigated.

RESULTS

Of 221 patients examined, axillary metastasis was found in 42 (19%) at the time of surgery. There was no significant difference in detectability of small tumors using ultrasonography and MRI between patients with and without axillary metastasis. However, mammography had a higher positive rate of primary tumors in patients with axillary metastasis than without metastasis (92.9% vs. 77.1%, p=0.023). Patients with axillary metastasis in small cancers showed more common architectural distortion than negative (p=0.0147) or mass (p=0.0356) on mammography. Clinical features were not different in the two groups. Only lymphovascular invasion was independently associated with axillary metastasis (p=0.0051, 95% CI, 1.527-11.597).

CONCLUSION

The detectability of small invasive breast cancers among patients with and without axillary metastasis is different with mammography, but not with US and MRI. Lymphovascular invasion is only a predictor for axillary metastasis in small invasive cancers.

Prediction of axillary lymph node status in male breast carcinoma

BACKGROUND

To evaluate whether predictive factors of axillary lymph node metastasis in female breast cancer (BC) are similar in male BC.

PATIENTS AND METHODS

From January 1994 to May 2011, we recorded 80 non-metastatic male BC treated at Institut Curie (IC). We analysed the calibration and discrimination performance of two nomograms [IC, Memorian Sloan-Kettering Cancer Center (MSKCC)] originally designed to predict axillary lymph node metastases in female BC.

RESULTS

About 55% and 24% of the tumours were pT1 and pT4, respectively. Nearly 46% demonstrated axillary lymph node metastasis. About 99% were oestrogen receptor positive and 94% HER2 negative. Lymph node status was the only significant prognostic factor of overall survival (P = 0.012). The area under curve (AUC) of IC and MSKCC nomograms were 0.66 (95% CI 0.54-0.79) and 0.64 (95% CI 0.52-0.76), respectively. The calibration of these two models was inadequate.

CONCLUSIONS

Multi-variate models designed to predict axillary lymph node metastases for female BC were not effective in our male BC series. Our results may be explained by (i) small sample size (ii) different biological determinants influencing axillary metastasis in male BC compared with female BC.

Real-time ultrasound elastography in 180 axillary lymph nodes: elasticity distribution in healthy lymph nodes and prediction of breast cancer metastases

BACKGROUND

To determine the general appearance of normal axillary lymph nodes (LNs) in real-time tissue sonoelastography and to explore the method's potential value in the prediction of LN metastases.

METHODS

Axillary LNs in healthy probands (n=165) and metastatic LNs in breast cancer patients (n=15) were examined with palpation, B-mode ultrasound, Doppler and sonoelastography (assessment of the elasticity of the cortex and the medulla). The elasticity distributions were compared and sensitivity (SE) and specificity (SP) were calculated. In an exploratory analysis, positive and negative predictive values (PPV, NPV) were calculated based upon the estimated prevalence of LN metastases in different risk groups.

RESULTS

In the elastogram, the LN cortex was significantly harder than the medulla in both healthy (p=0.004) and metastatic LNs (p=0.005). Comparing healthy and metastatic LNs, there was no difference in the elasticity distribution of the medulla (p=0.281), but we found a significantly harder cortex in metastatic LNs (p=0.006). The SE of clinical examination, B-mode ultrasound, Doppler ultrasound and sonoelastography was revealed to be 13.3%, 40.0%, 14.3% and 60.0%, respectively, and SP was 88.4%, 96.8%, 95.6% and 79.6%, respectively. The highest SE was achieved by the disjunctive combination of B-mode and elastographic features (cortex >3mm in B-mode or blue cortex in the elastogram, SE=73.3%). The highest SP was achieved by the conjunctive combination of B-mode ultrasound and elastography (cortex >3mm in B-mode and blue cortex in the elastogram, SP=99.3%).

CONCLUSIONS

Sonoelastography is a feasible method to visualize the elasticity distribution of LNs. Moreover, sonoelastography is capable of detecting elasticity differences between the cortex and medulla, and between metastatic and healthy LNs. Therefore, sonoelastography yields additional information about axillary LN status and can improve the PPV, although this method is still experimental.

Assessment of the Memorial Sloan-Kettering Cancer Center nomogram to predict sentinel lymph node metastases in a Dutch breast cancer population

AIM

Sentinel lymph node (SLN) biopsy is an accepted alternative to axillary lymph node dissection to assess the axillary tumour status in breast cancer patients. Memorial Sloan-Kettering Cancer Center (MSKCC) developed a nomogram to predict the likelihood of SLN metastases in breast cancer patients. Nomogram performance was tested on a Dutch population.

METHODS

Data of 770 breast cancer patients who underwent successful SLN biopsy were collected. SLN metastases were present in 222 patients. A receiver operating characteristic (ROC) curve was drawn and the area under the curve was calculated to assess the discriminative ability of the MSKCC nomogram. A calibration plot was drawn to compare actual versus nomogram-predicted probabilities.

RESULTS

The area under the ROC curve for the predictive nomogram was 0.67 (95% confidence interval 0.63-0.72) as compared to 0.75 in the original population. The nomogram was well-calibrated in the Dutch population.

CONCLUSIONS

In a Dutch population, the MSKCC nomogram estimated risk of sentinel node metastases in breast cancer patients well (i.e. calibration) with reasonable discrimination (area under ROC curve). Nomogram performance on core needle biopsy data has to be evaluated prospectively.

The association between the preoperative serum levels of lipocalin-2 and matrix metalloproteinase-9 (MMP-9) and prognosis of breast cancer

Background

Although a number of experimental studies have suggested the role of lipocalin-2 (LCN2) and matrix metalloproteinase-9 (MMP-9) in breast cancer progression, limited numbers of epidemiological studies have examined the relationship between the levels of lipocalin-2 and MMP-9 and breast cancer survival.

Methods

Preoperative serum levels of lipocalin-2 and MMP-9 were measured in 303 breast cancer patients and 74 healthy controls recruited between 2004 and 2007. We examined the association between lipocalin-2 and MMP-9 levels and disease-free survival (DFS) using Cox proportional hazard regression model.

Results

The serum levels of lipocalin-2 and MMP-9 were not significantly different between patients and controls (P > 0.05). Elevated lipocalin-2 and MMP-9 levels were associated with reduced DFS of breast cancer ( P_trend = 0.029 and P_trend = 0.063, respectively). When lipocalin-2 and MMP-9 levels were categorized based on the combined risk score, patients with higher levels of both lipocalin-2 and MMP-9 exhibited poor DFS compared to patients with lower levels (P_trend = 0.004). Furthermore, these effects were profound in patients with BMI less than 25 kg/m² (adjusted hazard ratio (aHR), 3.17; 95% confidence intervals (CI), 1.66-6.06, P_trend < 0.001) or lymph-node negative breast cancer (aHR, 5.36; 95% CI, 2.18-13.2, P_trend < 0.001).

Conclusions

Our study suggests that the elevated levels of lipocalin-2 and MMP-9 are associated with reduced breast cancer survival, particularly in patients with lower BMI and lymph-node negative breast cancers.

The molecular subtype classification is a determinant of sentinel node positivity in early breast carcinoma

Introduction

Several authors have underscored a strong relation between the molecular subtypes and the axillary status of breast cancer patients. The aim of our work was to decipher the interaction between this classification and the probability of a positive sentinel node biopsy.

Materials and Methods

Our dataset consisted of a total number of 2654 early-stage breast cancer patients. Patients treated at first by conservative breast surgery plus sentinel node biopsies were selected. A multivariate logistic regression model was trained and validated. Interaction covariate between ER and HER2 markers was a forced input of this model. The performance of the multivariate model in the training and the two validation sets was analyzed in terms of discrimination and calibration. Probability of axillary metastasis was detailed for each molecular subtype.

Results

The interaction covariate between ER and HER2 status was a stronger predictor (p = 0.0031) of positive sentinel node biopsy than the ER status by itself (p = 0.016). A multivariate model to determine the probability of sentinel node positivity was defined with the following variables; tumour size, lympho-vascular invasion, molecular subtypes and age at diagnosis. This model showed similar results in terms of discrimination (AUC = 0.72/0.73/0.72) and calibration (HL p = 0.28/0.05/0.11) in the training and validation sets. The interaction between molecular subtypes, tumour size and sentinel nodes status was approximated.

Discussion

We showed that biologically-driven analyses are able to build new models with higher performance in terms of breast cancer axillary status prediction. The molecular subtype classification strongly interacts with the axillary and distant metastasis process.

Factors predicting the axillary lymph node metastasis in breast cancer: is axillary node clearance indicated in every breast cancer patient?: factors predicting the axillary lymphnode metastases in breast cancer

The study was carried out to find out predictors of axillary lymph node metastasis in breast cancer and to evaluate its significance in selecting the group of patients in whom axillary dissection could be avoided. Ninety-five breast cancer patients who underwent mastectomy and axillary dissection were included in the study. Factors like patient's age, tumor size, histopathological type, histological grade and estrogen and progesterone receptor status were correlated with the axillary metastases. Out of 95 cases axillary metastasis was found in 47 (49.47%) cases. There was no correlation between patient's age and tumor size with axillary metastasis (p > 0.05). Based on histopathological typing tumors like ductal carcinoma in situ, tubular carcinoma and mucinous carcinoma showed less tendency for axillary metastasis (p < 0.046). Association was found between histological grade and estrogen receptor and progesterone receptor positivity with presence of axillary metastasis (p < 0.001 and 0.002 respectively). The findings in this study indicate that breast cancer patients having favorable histological type, grade I tumors and estrogen and progesterone receptor negative tumor are good candidates to avoid axillary dissection.

Prediction of lymph node involvement in breast cancer from primary tumor tissue using gene expression profiling and miRNAs

The aim of this study was to investigate whether lymph node involvement in breast cancer is influenced by gene or miRNA expression of the primary tumor. For this purpose, we selected a very homogeneous patient population to minimize heterogeneity in other tumor and patient characteristics. First, we compared gene expression profiles of primary tumor tissue from a group of 96 breast cancer patients balanced for lymph node involvement using Affymetrix Human U133 Plus 2.0 microarray chip. A model was built by weighted Least-Squares Support Vector Machines and validated on an internal and external dataset. Next, miRNA profiling was performed on a subset of 82 tumors using Human MiRNA-microarray chips (Illumina). Finally, for each miRNA the number of significant inverse correlated targets was determined and compared with 1000 sets of randomly chosen targets. A model based on 241 genes was built (AUC 0.66). The AUC for the internal dataset was 0.646 and 0. 651 for the external datasets. The model includes multiple kinases, apoptosis-related, and zinc ion-binding genes. Integration of the microarray and miRNA data reveals ten miRNAs suppressing lymph node invasion and one miRNA promoting lymph node invasion. Our results provide evidence that measurable differences in gene and miRNA expression exist between node negative and node positive patients and thus that lymph node involvement is not a genetically random process. Moreover, our data suggest a general deregulation of the miRNA machinery that is potentially responsible for lymph node invasion.

Axillary nodal metastases from carcinoma of unknown primary (CUPAx): a systematic review of published evidence

Axillary lymph node metastases from adeno carcinoma or poorly differentiated carcinoma of unknown primary (CUPAx) represent a rare clinical entity without consensus on its biology, management and outcome. We systematically reviewed published CUPAx series and identified 24 retrospective studies enrolling 689 patients from 1975 till 2006. CUPAx affected women at a mean age of 52 years, 66% of whom post-menopausal harbouring low-volume (N1, 48%) or high-volume (52%) nodal disease from ductal adenocarcinoma (83%). Among a total of 446 patients managed with mastectomy, a small breast primary was identified histologically in 321 (72% of cases). Hormone receptor protein expression was observed in 40-50% of cases, while HER2 overexpression in 31%. CUPAx patients were managed with axillary lymph node dissection coupled to mastectomy (59%), primary breast irradiation (26%) or observation (15%). Observation was associated with high locoregional relapse rates (42%) and risk of metastatic spread. Mastectomy or radiotherapy provided locoregional disease control in 75-85% of cases, while adjuvant systemic therapy was associated with a nonsignificant trend for improved survival in few series. Five-year survival ranged from 59.4 to 88% at a median follow-up of 62 months (mean 5-year survival 72%), with axillary tumour burden being the pivotal prognostic factor. CUPAx is associated with similar presentation, biology and outcome to resected node-positive overt breast cancer and should be treated accordingly.