Is risk of axillary lymph node metastasis associated with proximity of breast cancer to the skin?

Investigating the role of tumour-to-skin proximity in predicting nodal metastasis in breast cancer

BACKGROUND

Understanding the factors influencing nodal status in breast cancer is vital for axillary staging, therapy, and patient survival. The nodal stage remains a crucial factor in prognostication indices. This study investigates the relationship between tumour-to-skin distance (in T1-T3 tumours where the skin is not clinically involved) and the risk of nodal metastasis.

METHODS

We retrospectively reviewed data from 100 patients who underwent neoadjuvant chemotherapy (NACT). Besides patient demographics and tumour variables, a radiologist retrospectively reviewed pre-operative MRI to measure tumour-to-skin distance. R core packages were used for univariate (χ2 and T-Wilcoxon tests) and bivariate logistic regression statistical analysis.

RESULTS

Of 95 analysable datasets, patients' median age was 51 years (IQR: 42-61), 97% were symptomatic (rest screen detected), and the median tumour size was 43 mm (IQR, 26-52). On multivariate analysis, increasing invasive tumour size (p = 0.02), ER positivity (p = 0.007) and shorter tumour-to-skin distance (p = 0.05) correlated with nodal metastasis.  HER2 was not included in multivariate analysis as there was no association with nodal status on univariate analysis. In node-positive tumours, as tumour size increased, the tumour-to-skin distance decreased (r = - 0.34, p = 0.026). In node-negative tumours, there was no correlation (r = + 0.18, p = 0.23).

CONCLUSION

This study shows that non-locally advanced cancers closer to the skin (and consequent proximity to subdermal lymphatics) are associated with a greater risk of nodal metastasis. Pre-operative identification of those more likely to be node positive may suggest the need for a second-look USS since a higher nodal stage may lead to a change in therapeutic strategies, such as upfront systemic therapy, node marking, and axillary clearance without the need to return to theatre following sentinel node biopsy.

Biophysical control of plasticity and patterning in regeneration and cancer

Cells and tissues display a remarkable range of plasticity and tissue-patterning activities that are emergent of complex signaling dynamics within their microenvironments. These properties, which when operating normally guide embryogenesis and regeneration, become highly disordered in diseases such as cancer. While morphogens and other molecular factors help determine the shapes of tissues and their patterned cellular organization, the parallel contributions of biophysical control mechanisms must be considered to accurately predict and model important processes such as growth, maturation, injury, repair, and senescence. We now know that mechanical, optical, electric, and electromagnetic signals are integral to cellular plasticity and tissue patterning. Because biophysical modalities underly interactions between cells and their extracellular matrices, including cell cycle, metabolism, migration, and differentiation, their applications as tuning dials for regenerative and anti-cancer therapies are being rapidly exploited. Despite this, the importance of cellular communication through biophysical signaling remains disproportionately underrepresented in the literature. Here, we provide a review of biophysical signaling modalities and known mechanisms that initiate, modulate, or inhibit plasticity and tissue patterning in models of regeneration and cancer. We also discuss current approaches in biomedical engineering that harness biophysical control mechanisms to model, characterize, diagnose, and treat disease states.

The effect of the tumor-to-skin distance on axillary lymph node metastasis in breast cancer

OBJECTIVE

Tumor-to-skin distance is known to have an effect on axillary lymph node metastasis but has no clinical use with nomograms. This study aimed to investigate the effect of tumor-to-skin distance on axillary lymph node metastasis alone and in combination with nomogram for clinical use.

METHODS

A total of 145 patients who underwent surgery for breast cancer (T1-T2 stage) and whose axillary lymph nodes were evaluated (axillary dissection or sentinel lymph node biopsy) between January 2010 and December 2020 were included in the study. Tumor-to-skin distance and other pathological data of the patients were evaluated.

RESULTS

Of the 145 patients, 83 (57.2%) had metastatic lymph nodes in the axilla. Tumor-to-skin distance was different in terms of lymph node metastasis (p=0.045). In the receiver operating characteristic curve for tumor-to-skin distance, area under curve was 0.597 (95%CI 0.513-0.678, p=0.046), area under curve of the nomogram was 0.740 (95%CI 0.660-0.809), p<0.001) and nomogram+tumor-to-skin distance was 0.753 (95%CI 0.674-0.820), p<0.001). No statistical difference was found for axillary lymph node metastasis between the nomogram+tumor-to-skin distance and the nomogram alone (p=0.433).

CONCLUSION

Although tumor-to-skin distance demonstrated a significant difference in axillary lymph node metastasis, it had a poor association with an area under curve value of 0.597 and did not produce a significant improvement in predicting lymph node metastasis when combined with the nomogram. The tumor-to-skin distance may be unlikely to enter clinical practice.

Distance Between the Tumour and Nipple as a Predictor of Axillary Lymph Node Involvement in Breast Cancer

Purpose

The possibility of axillary node metastasis via the lymphatics might be related to a cancer’s location within the breast. Previous studies of this topic had small sample sizes, inaccuracies because of subjective differences, and the inability to depict the entire three-dimensional structure of the breast. Here, we aimed to improve upon these existing drawbacks by retrospectively analysing whether tumour location (quadrants) and tumour–nipple distance can predict axillary node positivity.

Patients and Methods

We identified 961 patients with invasive breast cancer between January 2000 and April 2016. The tumour–nipple distance was objectively measured intraoperatively and clinicopathological information was extracted from hospital database. The distance was measured radially from the nipple to the epicentre rather than the edge of tumour to obviate confounders resulting from tumour size variations.

Results

A total of 847 breast cancers (839 patients) met the eligibility criteria and were included in the statistical analysis. The tumour–nipple distance was smaller in node-positive patients (n = 307; 2.76 ± 2.07 cm) than in node-negative patients (n = 297; 3.41 ± 2.18 cm) (p < 0.001). Tumour–nipple distance was an independent predictor of axillary involvement on logistic regression analysis. However, no statistically significant relationship was detected between node positivity and breast quadrant tumour location.

Conclusion

Tumour–nipple distance can be used to predict axillary lymph node metastasis and assist in surgical decision-making and therapy planning. However, exploratory studies are required to increase our understanding of the mechanism.

Distance between tumor and nipple as a prognostic factor in breast cancers: Opposite effects in young and old patients

The present study aimed to investigate the prognostic implication of distance from tumor to nipple according to clinicopathological factors with known prognostic value.We retrospectively identified 961 patients of invasive breast cancer from January 2000 to April 2016. Clinicopathological information was extracted from hospital database and distance from tumor to nipple was objectively measured during surgeries. Overall survival (OS) and disease-free survival (DFS) were compared among patients with tumor-nipple distance ≤2, 2 to 5, and >5 cm. Subgroup analyses were performed according to age at diagnosis (≤35 vs >35), tumor size, histological features, treatment, axillary nodal metastasis and lymphovascular invasion.A total of 627 cases were included in statistical analysis. There was no difference detected in OS or DFS among patients with different tumor-nipple distance. Better OS was associated with greater tumor-nipple distance in old patients (HR = 0.582, 95%CI: 0.345-0.982, P = 0.042), while the association between OS and tumor-nipple distance was not observed in young patients. DFS was influenced by tumor-nipple distance in both young (HR = 5.321, 95%CI: 1.151-24.595, P = 0.032) and old (HR = 0.593, 95%CI: 0.385-0.913, P = 0.018) patients with opposite effects.Tumor-nipple distance can be adopted as a prognostic factor of breast cancer and it functions oppositely in young and old patients. Multicenter prospective studies with larger sample size are needed to validate the result.

Effect of Primary Breast Tumor Location on Axillary Nodal Positivity

BACKGROUND

Variables such as tumor size, histology, and grade, tumor biology, presence of lymphovascular invasion, and patient age have been shown to impact likelihood of nodal positivity. The aim of this study is to determine whether primary location of invasive disease within the breast is associated with nodal positivity.

PATIENTS AND METHODS

Patients with invasive breast cancer undergoing axillary staging from 2010 to 2014 were identified from the National Cancer Data Base. Rates of axillary nodal positivity by primary tumor locations were compared, and multivariable analysis performed using logistic regression to control for factors known to impact nodal positivity.

RESULTS

A total of 599,722 patients met inclusion criteria. Likelihood of nodal positivity was greatest with primary tumors located in the nipple (43.8%), followed by multicentric disease (40.8%), central breast lesions (39.4%), and axillary tail lesions (38.4%). Tumor location remained independently associated with nodal positivity on multivariable analysis adjusting for variables known to affect nodal positivity with odds ratio 2.8 for tumors in the nipple [95% confidence interval (CI) 2.5-3.1], 2.2 for central breast (95% CI: 2.2-2.3), and 2.7 for axillary tail (95% CI: 2.4-2.9). When restricted to patients with clinically negative nodes (n = 430,949), a similar association was seen.

CONCLUSION

Patients with invasive breast cancer located in the nipple, central breast, and axillary tail have the highest risk of positive axillary lymph nodes independent of patient age, tumor grade, biologic subtype, histology, and size. This should be considered along with other factors in preoperative counseling and decision-making regarding plans for axillary lymph node staging.

Distance of Tumor to Skin as a Predictive Marker for Axillary Lymph Node Metastasis in Cases of Breast Carcinoma - A Retrospective Study

Background: Breast cancer is arising as the most common cancer among women. Axillary lymph node status is considered as one of the most important predictors of survival in breast cancer and a very important component to the staging system. The tumors under the skin have abundant access to the dermal lymphatic and have an increased chance of metastasizing to draining lymph nodes. Aim of the Study: To evaluate whether distance of tumor to skin can be considered as a predictor for lymph node metastasis. Materials and Methods: This was a retrospective study on all operated cases of infiltrating mammary carcinoma from January 2013 to December 2016. Both lumpectomy and mastectomy specimens with invasive carcinoma component were included in the study. The distance of the tumor was measured from the base of the epidermis of the skin to the anterior margin of the tumor on gross examination or microscopically the closest invasive carcinoma component. The distance was measured, tabulated, and correlated with the nodal status on axillary node dissection. Also, compared are the other parameters such as size, site, and grade of the tumor. Results:: Out of 200 patients enrolled, positive nodes were seen in 67.5% (135) of cases, of which tumor with distance from skin <0.3 cm show maximum nodal positivity (64.4%) and maximum cases with N2 and N3 disease (48.8%). Most important and significant finding was that 100% cases with tumor size corresponding in T2 size with skin invasion either grossly or microscopically and T3 size tumor with microscopically involving epidermis was positive for metastatic deposits in axillary nodes and 10/11 cases (90%) in T4 stage were positive. Conclusion: The distance of tumor from skin is an important predictor for Axillary lymph nodal metastasis in invasive breast cancers. Closer the tumor, the incidence of axillary nodal metastasis increases. Hence, distance of tumor from skin should be considered while evaluating a breast cancer patient.

Dependence of gold nanoparticle radiosensitization on cell geometry

The radiosensitization effect of gold nanoparticles (GNPs) has been demonstrated both in vitro and in vivo in radiation therapy. The purpose of this study was to systematically assess the biological effectiveness of GNPs distributed in the extracellular media for realistic cell geometries. TOPAS-nBio simulations were used to determine the nanometre-scale radial dose distributions around the GNPs, which were subsequently used to predict the radiation dose response of cells surrounded by GNPs. MDA-MB-231 human breast cancer cells and F-98 rat glioma cells were used as models to assess different cell geometries by changing (1) the cell shape, (2) the nucleus location within the cell, (3) the size of GNPs, and (4) the photon energy. The results show that the sensitivity enhancement ratio (SER) was increased up to a factor of 1.2 when the location of the nucleus is close to the cell membrane for elliptical-shaped cells. Heat-maps of damage-likelihoods show that most of the lethal events occur in the regions of the nuclei closest to the membrane, potentially causing highly clustered damage patterns. The effect of the GNP size on radiosensitization was limited when the GNPs were located outside the cell. The improved modelling of the cell geometry was shown to be crucial because the dose enhancement caused by GNPs falls off rapidly with distance from the GNPs. We conclude that radiosensitization can be achieved for kV photons even without cellular uptake of GNPs when the nucleus is shifted towards the cell membrane. Furthermore, damage was found to concentrate in a small region of the nucleus in close proximity to the extracellular, GNP-laden region.

Monte Carlo simulations shed light on Bathsheba's suspect breast

In 1654, Rembrandt van Rijn painted his famous painting Bathsheba at her Bath. Over the years, the depiction of Bathsheba's left breast and especially the presence of local discoloration, has generated debate on whether Rembrandt's Bathsheba suffered from breast cancer. Historical, medical and artistic arguments appeared to be not sufficient to prove if Bathsheba's model truly suffered from breast cancer. However, the bluish discoloration of the breast is an intriguing aspect from a biomedical optics point of view that might help us ending the old debate. By using Monte Carlo simulations in combination with the retinex theory of color vision, we showed that is highly unlikely that breast cancer results in a local bluish discoloration of the skin as is present on Bathsheba's breast.

Tumor location and nature of lymphatic vessels are key determinants of cancer metastasis

Tumor metastasis to lymph nodes is a key indicator of patient survival, and is enhanced by the neo-lymphatics induced by tumor-secreted VEGF-C or VEGF-D, acting via VEGFR-3 signalling. These targets constitute important avenues for anti-metastatic treatment. Despite this new understanding, clinical observations linking metastasis with tumor depth or location suggest that lymphangiogenic growth factors are not the sole determinants of metastasis. Here we explored the influence of tumor proximity to lymphatics capable of responding to growth factors on nodal metastasis in a murine VEGF-D over-expression tumor model. We found that primary tumor location profoundly influenced VEGF-D-mediated lymph node metastasis: 89 % of tumors associated with the flank skin metastasised, in contrast with only 19 % of tumors located more deeply on the body wall (p < 0.01). Lymphatics in metastatic tumors arose from small lymphatics, and displayed distinct molecular and morphological profiles compared with those found in normal lymphatics. Smaller lymphatic subtypes were more abundant in skin (2.5-fold, p < 0.01) than in body wall, providing a richer source of lymphatics for VEGF-D(+) skin tumors, a phenomenon also confirmed in human samples. This study shows that the proximity of a VEGF-D(+) primary tumor to small lymphatics is an important determinant of metastasis. These observations may explain why tumor location relative to the lymphatic network is prognostically important for some human cancers.

Breast Cancer Close to the Nipple: Does This Increase the Risk of Nodal Metastasis at Diagnosis?

Background

Previous studies of patients with invasive breast cancer examined, with mixed results, tumour location as a predictor of axillary lymph node metastasis. This study assessed whether tumour location in relation to the nipple impacts the presence of axillary lymph node metastasis at the time of diagnosis.

Methods

A retrospective review was undertaken of the medical records and available imaging of 285 patients diagnosed with invasive breast cancer between January 2001 to June 2007 at Boston University Medical Center. The incidence of axillary lymph node metastasis was correlated with tumour location in relation to the posterior nipple line to control for variation in breast size. Bivariate analysis identified significant variables that were applied to a multiple logistic regression model.

Results

Axillary lymph node metastasis was not significantly associated with tumour proximity to the nipple. In the multivariate logistic regression analysis, known prognostic factors for axillary metastasis, such as surgical size, lymphovascular invasion, and age of diagnosis, were significant, whereas breast density, palpability, and histologic grade were no longer significant.

Conclusions

Our study found that there was no evidence that correlates intramammary tumour proximity to the nipple with the presence of axillary lymph node metastasis at diagnosis. However, known prognostic factors, such as lymphovascular invasion, surgical size, and younger age at diagnosis, are strong independent predictors for axillary lymph node involvement.