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 role of diffusion-weighted MR imaging in discrimination between benign and malignant axillary lymph nodes in breast cancer patients

Background

Noninvasive preoperative evaluation of axillary lymph nodes proved to have a significant role not only on the protocol of treatment of breast cancer but also impact the whole life of the patient. Complications of lymph node biopsy or axillary clearance increase the need for noninvasive reliable diagnostic tool. We aimed in the current study to evaluate the role of diffusion-weighted magnetic resonance imaging (DW-MRI) and apparent diffusion coefficient (ADC) in discrimination between benign and malignant axillary lymph nodes. We included 44 suspicious lymph nodes from 29 patients. Qualitative DW-MRI was analyzed into restricted or not; ADC maps and cut-off value were calculated, and they were correlated with histopathological results, which were the gold standard tool of the current study.

Results

The cut-off value of ADC-differentiated between malignant and benign lymph nodes was 0.89 × 10−3 mm2/s. The statistical indices including the sensitivity, specificity, PPV, NPV and accuracy were 89.66%, 86.67%, 93.9, 81.2% and 87.8%, respectively, with P value < 0.001, while DW-MRI results were classified into restricted or not restricted with qualitative statistical indices of 96.6%, 80%, 90.3%, 92.3% and 90.9% for sensitivity, specificity, PPV, NPV and accuracy, respectively, with P value < 0.001.

Conclusion

DW-MRI and ADC both have significant role in discrimination between benign and malignant axillary lymph nodes increasing the accuracy of MRI examination in breast cancer patients.

The additive role of diffusion-weighted magnetic resonance imaging to axillary nodal status evaluation in cases of newly diagnosed breast cancer

Background

Axillary nodal status is crucial for the management of cases with recently diagnosed breast cancer; usually addressed via axillary ultrasonography (US) along with tissue sampling in case of suspicion. Axillary nodal dissection and sentinel biopsy may be done, but are rather invasive, carrying a potential complication risk, which raises the need for non-invasive, reliable, pre-operative axillary imaging. We aimed at evaluating the performance of diffusion-weighted imaging (DWI) regarding preoperative axillary evaluation, using functional information derived from diffusion capacity differences between benign and malignant tissue. We included 77 axillary nodes from 77 patients (age range 20–78 years, mean 50 ± 12.6 SD) in our prospective study, presenting with variable clinical breast complaints, all scoring BIRADS 4/5 on sonomammography (SM). They underwent axillary evaluation by both US and DW-MRI where US classified nodes into benign, indeterminate, or malignant by evaluating nodal size, shape, cortical thickness, and hilar fat. Qualitative DWI classified them into either restricted or not and a cut-off apparent diffusion coefficient (ADC) value was calculated to differentiate benign and malignant nodal involvement. Results for each modality were correlated to those of final histopathology, which served as the standard of reference.

Results

The calculated sensitivity, specificity, accuracy, PPV, and NPV for US was 100%, 36.6%, 75.3%, 71.2%, and 100%, respectively. Statistical indices for qualitative DWI were 76.6%, 63.3%, 76.6%, 63.3%, and 71.4%, respectively (P value < 0.001). The calculated cut off value for ADC between infiltrated and non-infiltrated nodes was 0.95 × 10−3 mm2/s concluding statistical indices of 76.6%, 63.3%, 76.6%, 63.3%, and 71.4%, respectively (P value < 0.001).

Conclusion

Combining DW-MRI to conventional US improves diagnostic specificity and overall accuracy of preoperative axillary evaluation of patients with recently discovered breast cancer.

Feasibility and surgical impact of Z0011 trial criteria in a single-Institution practice

The purpose of this study is the evaluation of clinical and surgical impact of the Z0011 trial criteria on the management of breast cancer (BC) patients undergoing breast conservative surgery (BCS) at the European Institute of Oncology (IEO). We studied 1386 patients who underwent BCS and sentinel lymph node biopsy (SLNB) from July 2016 to July 2018. Clinical evaluation, breast ultrasound, mammogram, and cyto/histological examination were performed for all patients at the time of diagnosis. Frozen sections of the sentinel lymph node (SLN) were not performed for any patient. Patients who underwent neo-adjuvant therapy were excluded. To evaluate the results before and after the introduction of Z0011 criteria, a group of 1425 patients with the same characteristics who underwent BCS and SLNB from July 2013 to July 2015 were analyzed. We studied the characteristics of the patients by nodal status, and we observed that T stage, tumor grade, and lymphovascular invasion were statistically related with the highest rate of positive SLN. Of the 1386 patients who underwent surgery after the introduction of the Z011 trial, 1156 patients (83.4%) had negative SLN, 230 patients (16.6%) had positive SLN. Subsequent axillary lymph node dissection (ALND) was performed in only 7 cases (3.0%). Of the 1425 patients operated before the introduction of the Z0011 trial, 216 patients had subsequent ALND (15%). The reduction in the number of ALND performed after the introduction of Z0011 is statistically significant, and this could result in a remarkable reduction of the comorbidities of our patients.

Characteristics of Invasive Breast Cancer Detected by Digital Breast Tomosynthesis on Screening and Diagnostic Mammograms

OBJECTIVE

To determine whether there is added benefit for 3D mammography in the context of screening and diagnostic imaging, particularly relating to known prognostic characteristics, including histopathology, receptor status, and axillary lymph node involvement.

METHODS

An institutional review board-approved retrospective review was performed of our mammography and pathology databases from October 2012 to May 2015 to identify biopsy-proven invasive breast carcinoma detected on screening and diagnostic mammograms by 2D plus 3D (2D + 3D) imaging. Percentages of cancer detection by 2D and 3D were compared. Correlation with histopathology and lymph node status was analyzed.

RESULTS

Of 53 cancers diagnosed on 12 543 screening mammograms, 36 (67.9%) were better visualized on 3D (not visualized, equivocal, or only seen in retrospect on 2D). Of the 62 cancers diagnosed on 4090 diagnostic mammograms, 24 (38.7%) cancers were better detected on 3D. A statistically significant greater number of cancers were better detected on 3D in the screening compared to the diagnostic mammograms (67.9% vs 38.7%, P < .05). A significantly higher frequency of less aggressive tumors (grade I and grade II, positive estrogen/progesterone receptor, Her2 negative) was detected by 3D, with higher significance in the screening population. Additionally, there was a higher frequency of positive axillary lymph nodes in cancers detected by 3D in the screening group.

CONCLUSION

Three-dimension increases invasive breast cancer detection, particularly pathologically less aggressive tumors, in both screening and diagnostic mammograms with more benefit for the screening population. Three-dimensional mammography detected more breast cancer associated with metastatic axillary lymph nodes in the screening population.

Comparison of [99mTc]3PRGD2 Imaging and [18F]FDG PET/CT in Breast Cancer and Expression of Integrin αvβ3 in Breast Cancer Vascular Endothelial Cells

PURPOSE

This study aimed to investigate the value of ^99mtechnetium-three polyethylene glycol spacers-arginine-glycine-aspartic acid ([^99mTc]3PRGD₂) imaging in diagnosis and staging of breast cancer compared with 2-deoxy-2-[¹⁸F]fluoro-D-glucose ([¹⁸F]FDG) imaging, and to explore the expression of integrin α_vβ₃ in tumor vascular endothelial cells.

PROCEDURES

Forty-two women with suspected breast cancer underwent both [^99mTc]3PRGD₂ imaging and [¹⁸F]FDG imaging. Visual analysis was used to assess primary breast lesion, axillary lymph node, and distant metastasis. The tumor-blood (T/B) ratios from [^99mTc]3PRGD₂ imaging and the maximum standardized uptake value (SUVmax) from [¹⁸F]FDG imaging were analyzed for breast lesions. Integrin α_vβ₃ was analyzed through immunohistochemistry.

RESULTS

Forty-five breast lesions were found (malignant, n = 38; benign, n = 7). The sensitivity, specificity, and accuracy of [^99mTc]3PRGD₂ and [¹⁸F]FDG imaging in visual analysis for the breast lesion were 97.4, 87.5, and 95.6 % and 97.4, 71.4, and 93.3 %, respectively (P > 0.05). For semi-quantitative analysis, no significant difference of the area under the curves (AUC) was found in the imaging using the two radiopharmaceuticals (0.880 and 0.955; Z = 0.88, P > 0.05). The sensitivity, specificity, and accuracy for axillary lymph node metastasis with [^99mTc]3PRGD₂ and [¹⁸F]FDG were 78.05, 99.36, and 94.92 % and 85.37, 98.72, and 95.64 %, respectively (P > 0.05). Nine patients with distant metastases were all detected with the two radiopharmaceuticals. The expression of integrin α_vβ₃ was correlated with [^99mTc]3PRGD₂ uptake (r = 0.582, P = 0.001), which were significantly higher in the HER2-positive and stage III-IV patients (P < 0.05).

CONCLUSIONS

The prospective study demonstrated that [^99mTc]3PRGD₂ imaging seems to be valuable for diagnosis of breast cancer and its staging. It may be less sensitive for detecting small lymph node metastatic lesions when compared with [¹⁸F]FDG imaging. Integrin α_vβ₃ in tumor microvessels was associated with the breast cancer subtype and its staging.

Frequency and Predictors of Axillary Lymph Node Metastases in Iranian Women with Early Breast Cancer

Background:

Axillary lymph node metastasis is the most important predictive factor for recurrence risk and survival in patients with invasive breast carcinoma. The aim of this study was to determine factors associated with metastatic involvement of axillary lymph nodes in Iranian women with early breast cancer.

Methods:

This article reports a retrospective study of 774 patients with T1-T2 breast cancer who underwent resection of the primary tumor and axillary staging by SLNB and/or ALND between 2005 and 2015 at our institution.

Results:

Of the 774 patients included in this study, 35.5% (275 cases) had axillary lymph node involvement at the time of diagnosis. Factors associated with nodal involvement in univariate analyses were tumor size, lymphovascular invasion (LVI), tumor grade, ER/PR status and HER2 expression. All factors identified with univariate analyses were entered into a multivariate logistic regression model and tumor size (OR= 3.01, CI 2.01–4.49, P <0.001), ER/PR positivity (OR = 1.74, CI 1.1.16–2.62, P = 0.007) and presence of LVI (OR = 3.3.8, CI 2.31–4.95, P <0.001) remained as independent predictors of axillary lymph node involvement.

Conclusions:

In conclusion, the results of this study suggests that positive hormonal receptor status, LVI and tumor size are predictive factors for ALNM in Iranian women with early breast cancer.

Impact of Size of the Tumour, Persistence of Estrogen Receptors, Progesterone Receptors, HER2Neu Receptors and Ki67 Values on Positivity of Axillary Lymph Nodes in Patients with Early Breast Cancer with Clinically Negative Axillary Examination

AIM:

The study aimed to identify factors that influence the positivity of axillary lymph nodes in patients with early breast cancer and clinically negative axillary lymph nodes, who were subjected for modified radical mastectomy and axillary lymphadenectomy.

MATERIAL AND METHODS:

This study included 81 surgically treated, early breast cancer patients during the period from 08-2015 to 05-2017. All the cases have been analysed by standard histological analysis including macroscopic and microscopic examination by routine H&E staining. For determination of molecular receptors, immunostaining by PT LINK immunoperoxidase has been done for HER2neu, ER, PR, p53 and Ki67.

RESULTS:

Patients age ranged between 31-73 years, an average of 56.86 years. The mean size of a primary tumour in the surgically treated patient was 20.33 ± 6.0 mm. Axillary dissection revealed from 5 to 32 lymph nodes, with an average of 14. Metastases have been found in 1 to 7 lymph nodes, with an average 0.7. Only 26 (32.1%) of the patients showed metastases in the axillary lymph nodes. The univariant regression analysis showed that the size of a tumour and presence of HER2neu receptors on cancer cells influence the positivity of the axillary lymph nodes. The presence of the estrogen receptors, progesterone receptors have no influence on the positivity for metastatic deposits of lymph nodes. Multivariant model and logistic regression analysis as significant independent factors or predictors of positivity of the axillary lymph nodes are influenced by the tumour size only.

CONCLUSION:

Our study showed that the metastatic involvement of the axillary lymph nodes is mainly influenced by the size of a tumour and presence of HER2neu receptors in the univariant analysis. This point to the important influence of positivity of the axillary lymph nodes but, in multi-variant regressive analysis the lymph node status correlates with the tumour size only.

Prognostic Factors on the Positivity for Metastases of the Axillary Lymph Nodes from Primary Breast Cancer

AIM

The aim of the study was to identify the impact of T stage, the presence of estrogen, progesterone, HER2neu receptors and the values of the Ki67 on the positivity for metastases of the axillary lymph nodes, from primary breast cancer.

MATERIAL AND METHODS

290 surgically treated patients for breast cancer were included in the study. All cases have been analyzed by standard histological analysis including microscopic analysis on standard H&E staining. For determining the molecular receptors - HER2neu, ER, PR, p53 and Ki67, immunostaining by PT LINK immunoperoxidase has been done.

RESULTS

Patients age was ranged between 18-90 years, average of 57.6+11.9. The mean size of the primary tumor in the surgically treated patient was 30.27 + 18.3 mm. On dissection from the axillary pits 8 to 39 lymph nodes were taken out, an average of 13.81+5.56. Metastases have been found in 1 to 23 lymph nodes, an average 3.14+4.71. In 59% of the patients there have been found metastases in the axillary lymph nodes. The univariate regression analysis showed that the location, size of tumor, differentiation of the tumor, stage, the value of the Ki67 and presence of lymphovascular invasion influence on the positivity of the axillary lymph nodes. The presence of the estrogen receptors, progesterone receptors and HER2neu receptors showed that they do not have influence on the positivity for metastatic deposits in axillary lymph nodes. The multivariate model and the logistic regression analysis as independent significant factors or predictors of positivity of the axillary lymph nodes are influenced by the tumor size and the positive lymphovascular invasion.

CONCLUSION

Our study showed that the involving of the axillary lymph nodes is mainly influenced by the size of the tumor and the presence of lymphovascular invasion in the tumor. Ki67 determined proliferative index in the univariate analysis points the important influence of positivity in the axillary lymph nodes, but not in the multivariate regressive analysis.