Tumoral load quantification of positive sentinel lymph nodes in breast cancer to predict more than two involved nodes

Can axillary lymphadenectomy be avoided in breast cancer with positive sentinel lymph node biopsy? Predictors of non-sentinel lymph node metastasis

PURPOSE

Completion axillary lymph node dissection (cALND) can currently be avoided in those patients with a low tumor load (LTL) and/or a low-risk profile that tested with positive sentinel lymph node biopsy (SLNB). Our objective is to identify prognostic factors that significantly influence axillary lymph node involvement to identify patients who could benefit from surgery without axillary lymphadenectomy.

METHODS

This is an observational retrospective study of consecutive patients diagnosed and operated of breast cancer between 2000 and 2014 at University Hospital La Ribera (UHR).

RESULTS

The size of the sample was 1641 patients, from which 1174 underwent SLNB. In the multivariate analysis, we objectify a raise of risk of positive sentinel lymph node (SLN) up to 5.2% for every millimeter of increase. The risk of positive SLNB when showing lymphovascular invasion seems to be 2.80 times greater but becomes lower when SLN involvement appears in luminal A, luminal B and triple-negative types, regarding HER2. In case of triple negatives, the difference is statistically significant. 16.7% present affected additional lymph nodes. The proportion of patients with affected additional lymph nodes increase dramatically above OSNA values of 12,000 copies/μl of CK19 mRNA and it depends on tumor size and lymphovascular infiltration.

CONCLUSIONS

Tumors smaller than 5 cm whose OSNA SLNB analysis is less than 12,000 copies/μl of CK19 mRNA have a low chance to develop additional affected lymph nodes, thus cALND can be avoided.

Molecular type and maximal metastasis diameter influence risk of axillary recurrence in breast cancer patients after positive sentinel lymph node biopsy

Background

Breast cancer patients with positive sentinel lymph node biopsy (SLNB) may be spared axillary lymph node dissection (ALND) in favour of irradiation. The aim of the study was to estimate local control probability in the axilla (axLCP).

Materials and methods

We identified 1832 invasive breast cancer patients who had undergone SLNB at our centre. We measured maximal metastasis diameter (SLDmax) in the sentinel lymph nodes and lymph node metastasis volume (VALN) from ALND in 246 patients with one or two positive SLNs. We calculated axLCP after irradiation and systemic treatment for different molecular types.

Results

VALN values are higher for high grade tumours and larger metastases in SLNs (> 5 mm). It is smaller in luminal A tumours. axLCP is high, nearly 100%, in all molecular types in radiation sensitive tumours (SF2 Gy = 0.45), except luminal B. Expected axLCP is relatively low (67%) in luminal B radiation sensitive tumours with no chemotherapy and nearly 100% with chemotherapy.

Conclusion

VALN values differ among molecular tumour types. They depend on SLNDmax and tumour grade. New prognostic factors are needed for selected luminal B breast cancer patients (i.e. high grade tumours, large metastases in SLNs) after positive SLNB intended to be spared ALND and chemotherapy.

Nomogram-based estimate of axillary nodal involvement in ACOSOG Z0011 (Alliance): validation and association with radiation protocol variations

PURPOSE

A substantial proportion of patients enrolled on ACOSOG Z0011 received protocol-deviant radiation treatment. It is currently unknown whether these deviations involved the use of more extensive fields in patients at higher nomogram-predicted risk.

METHODS

We used the M.D. Anderson (MDA) and Memorial Sloan-Kettering (MSK) nomograms to estimate risk of additional positive axillary nodes using surgical pathology information. In the control arm, we compared axillary dissection (AD) findings to nomogram-predicted estimates for validation. We used logistic regression to evaluate whether nomogram-estimated higher risk of nodal involvement was associated with high tangent (HT) or supraclavicular (SCV) radiation fields for patients with known radiation field design.

RESULTS

552/856 (64.5%) had complete details for the MDA nomogram. Mean MDA risk estimate in both treatment arms was 23.8%. Estimated risk for patients on the AD arm with positive nodes was 25.9%. Higher risk estimate was associated with additional positive nodes in the AD arm (OR 1.04, 95% CI 1.02-1.06, p < 0.0001). We observed significant association with higher MDA nomogram-estimated risk and SCV radiation (OR 1.07, 95% CI 1.04-1.10, p < 0.0001) but not HT (OR 0.99, 95% CI 0.96-1.02, p = 0.52) The MSK nomogram had similar associations.

CONCLUSION

MDA and MSK nomogram risk estimates were associated with lymph node risk in ACOSOG Z0011. Radiation oncologists' use of differing radiation fields were associated with treating higher risk patients. ClinicalTrials.gov id: NCT00003854.

Sentinel node total tumour load as a predictive factor for non-sentinel node status in early breast cancer patients - The porttle study

OSNA is a molecular assay for the detection of sentinel node metastasis. TTL emerged as a concept that seems to accurately predict the status of the NSN. Authors tried to confirm this motion. This is a retrospective and multicentric study that analyzed 2164 patients, 579 of whom had positive SN and completion AD. Logistic regression models were performed in order to identify a suitable cutoff to identify patients who benefit from AD. Univariate and multivariate regression analysis showed a relationship between TTL>30000 and the presence of NSN metastasis (OR 2.84, CI 1.99-4.08, p < 0.001). Logistic regression indicated that the cutoff of 30000 copies/μL better discriminates patients with NSN positivity and allows wide use of these criteria. This cutoff value may safely assist clinicians and patients to decide to proceed or not with an AD.

The diameter of metastasis in positive sentinel lymph node biopsy affects axillary tumor load in early breast cancer

INTRODUCTION

Omission of axillary lymph node dissection (ALND) after positive sentinel lymph biopsy (SLNB) has become a standard procedure for breast cancer patients with one or two metastatic lymph nodes. Here the aim was model development for selection for ALND.

MATERIAL AND METHODS

We analyzed 323 positive SLNB breast cancer patients, who afterwards underwent ALND. In 126 (39%), there were positive additional axillary lymph nodes. Specimens of resected lymph nodes were scanned and the volumes of tumors (expressed as diameter in mm) were calculated. The maximal diameter of metastasis in the sentinel lymph nodes (SLN_Dmax ) and axillary lymph nodes (ALN_Dsum ) indicated tumor load in the resected lymph nodes. ALN_Dsum higher or equal to 5 mm was defined as high and present in 62 patients (21%).

RESULTS

Risk factors for high ALN_Dsum were primary tumor diameter (P = 0.0092), histopathological type (P = 0.0173), number of positive SLNs (P = 0.0012), type of metastasis (P = 0.0025), molecular type (P = 0.0037), SLN_Dmax (P = 0.0001), and Her-2 status (P = 0.0093). Independent variables for high ALN_Dsum were SLN_Dmax (P < 0.0001), number of positive SLNs (P = 0.0237) and primary tumor diameter (P = 0.0296).

CONCLUSIONS

Twenty-one percent patients with positive SLNB are at risk of high ALN_Dsum . SLN_Dmax is the strong predictive factor for high ALN_Dsum after positive ALND.

Intraoperative prediction of the two axillary lymph node macrometastases threshold in patients with breast cancer using a one-step nucleic acid cytokeratin-19 amplification assay

The aim of the present study was to assess the sensitivity, specificity and practicality of using a one-step nucleic acid amplification (OSNA) assay during breast cancer staging surgery to predict and discriminate between at least 2 involved nodes and more than 2 involved nodes and facilitate the decision to provide axillary conservation in the presence of a low total axillary node tumour burden. A total of 700 consecutive patients, not treated with neo-adjuvant chemotherapy, received intraoperative sentinel lymph node (SLN) analysis using OSNA for cT1-T3 cN0 invasive breast cancer. Patients with at least one macrometastasis on whole-node SLN analysis underwent axillary lymph node dissection (ALND). The total tumour load (TTL) of the macrometastatic SLN sample was compared with the non-sentinel lymph node (NSLN) status of the ALND specimen using routine histological assessment. In total, 122/683 patients (17.9%) were found to have an OSNA TTL indicative of macrometastasis. In addition, 45/122 (37%) patients had NSLN metastases on ALND with a total positive lymph node burden exceeding the American College of Surgeons Oncology Group Z0011 trial threshold of two macrometastatic nodes. The TTL negative predictive value was 0.975 [95% confidence interval (CI), 0.962-0.988]. The area under the curve for the receiver operating characteristic curve was 0.86 (95% CI, 0.81-0.91), indicating that SLN TTL was associated with the prediction (and partitioning) of total axillary disease burden. OSNA identifies a TTL threshold value where, in the presence of involved SLNs, ALND may be avoided. This technique offers objective confidence in adopting conservative management of the axilla in patients with SLN macrometastases.

Lymph node pooling: a feasible and efficient method of lymph node molecular staging in colorectal carcinoma

Background

Pathologic lymph node staging is becoming a deficient method in the demanding molecular era. Nevertheless, the use of more sensitive molecular analysis for nodal staging is hampered by its high costs and extensive time requirements. Our aim is to take a step forward in colon cancer (CC) lymph node (LN) pathology diagnosis by proposing a feasible and efficient molecular method in routine practice using reverse transcription loop-mediated isothermal amplification (RT-LAMP).

Results

Molecular detection of tumor cytokeratin 19 (CK19) mRNA with RT-LAMP was performed in 3206 LNs from 188 CC patients using two methods: individual analysis of 1449 LNs from 102 patients (individual cohort), and pooled LN analysis of 1757 LNs from 86 patients (pooling cohort). A median of 13 LNs (IQR 10–18) per patient were harvested in the individual cohort, and 18 LNs (IQR 13–25) per patient in the pooling cohort (p ≤ 0.001). The median of molecular assays performed in the pooling cohort was 2 per patient (IQR 1–3), saving a median of 16 assays/patient. The number of molecular assays performed in the individual cohort was 13 (IQR 10–18), corresponding to the number of LNs to be analyzed. The sensitivity and specificity of the pooling method for LN involvement (assessed by hematoxylin and eosin) were 88.9% (95% CI 56.5–98.0) and 79.2% (95% CI 68.9–86.8), respectively; concordance, 80.2%; PPV, 33.3%; NPV, 98.4%. The individual method had 100% sensitivity (95% CI 72.2–100), 44.6% specificity (95% CI 34.8–54.7), 50% concordance, 16.4% PPV, and 100% NPV. The amount of tumor burden detected in all LNs of a case, or total tumor load (TTL) was similar in both cohorts (p = 0.228).

Conclusions

LN pooling makes it possible to analyze a high number of LNs from surgical colectomies with few molecular tests per patient. This approach enables a feasible means to integrate LN molecular analysis from CC specimens into pathology diagnosis and provides a more accurate LN pathological staging with potential prognostic implications.