Predictors of tumour involvement in remaining axillary lymph nodes of breast cancer patients with positive sentinel lymph node

Her-2/neu gene amplification and its correlation with other prognostic factors in Iranian breast cancer patients

BACKGROUND

Breast cancer is one of the most common diseases in females, arising from overexpression of a variety of oncogenes like HER2/neu. The amplification rate of this gene is variable in different breast cancer patients. In this study, the amplification of the HER2/neu oncogene was distinguished in breast cancer patients and its correlation with prognostic factors. Also, the simultaneous effect of prognostic factors on the occurrence of a specific prognostic factor was investigated.

MATERIALS AND METHODS

The multiplex PCR technique was used to assay the amplification of the HER2/neu oncogene in breast cancer patients. After extracting DNA from 100 tumor tissue and 8 normal breast tissue samples, the amplification of the HER2/neu gene was distinguished by the co-amplification of a single-copy reference gene, γ-IFN, and the target gene HER2/neu in the PCR reaction and using the Gel analyzer software. SPSS 23 and STATA 9.1 software were used for statistical analysis.

RESULTS

The HER2/neu gene was amplification in 30% of the tumor samples. The statistical analysis showed a statistically significant relationship between HER2/neu gene amplification and progesterone receptors. Amplification of the HER2/neu gene significantly increases the chance of lymph node involvement. Also, the amplification of this gene in tumors with histological grade II tissue is more than grade I.

CONCLUSION

The amplification of the HER2/neu gene can be used as an independent prognostic factor in predicting lymph node involvement and histological grade in breast cancer patients.

Nomogram for predicting preoperative regional lymph nodes metastasis in patients with metaplastic breast cancer: a SEER population-based study

Background

Metaplastic breast cancer (MBC) is a rare subtype of breast cancer, and generally associated with poor outcomes. Lymph nodes metastasis (LNM) is confirmed as a critical independent prognostic factor and determine the optimal treatment strategies in MBC patients. We aimed to develop and validate a nomogram to predict the possibility of preoperative regional LNM in MBC patients.

Methods

MBC patients diagnosed between 1990 and 2016 in the Surveillance, Epidemiology, and End Results (SEER) database were included and stochastically divided into a training set and validation set at a ratio of 7:3. The risk variables of regional LNM in the training set were determined by univariate and multivariate logistic regression analyses. And then we integrated those risk factors to construct the nomogram. The prediction nomogram was further verified in the verification set. The discrimination, calibration and clinical utility of the nomogram were evaluated by the area under the receiver operating characteristic (ROC) curve (AUC), calibration plots and decision curve analysis (DCA), respectively.

Results

A total of 2205 female MBC patients were included in the study. Among the 2205 patients, 24.8% (546/2205) had positive regional lymph nodes. The nomogram for predicting the risk of regional LNM contained predictors of grade, estrogen receptor (ER) status and tumor size, with AUC of 0.683 (95% confidence interval (CI): 0.653–0.713) and 0.667 (95% CI: 0.621–0.712) in the training and validation sets, respectively. Calibration plots showed perfect agreement between actual and predicted regional LNM risks. At the same time, DCA of the nomogram demonstrated good clinical utilities.

Conclusions

The nomogram established in this study showed excellent prediction ability, and could be used to preoperatively estimate the regional LNM risk in MBC.

A Model to Predict the Risk of Lymph Node Metastasis in Breast Cancer Based on Clinicopathological Characteristics

Background

Sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) may cause lymphatic and nervous system side effects in patients with breast cancer. It is imperative to develop a model to evaluate the risk of sentinel lymph node metastasis to avoid unnecessary operation.

Patients and Methods

A total of 2705 cases of female breast cancer patients enrolled in this retrospective study. We divided into the training group (SLNB group) and the validation group (ALND group) to analyze the relathionship between lymph node metastasis and clinical-pathological factors. Logistic regression analysis was performed to verify the variables which involved in ALN metastasis and established a prediction model. ROC curves were employed to evaluate the predictive ability of the model.

Results

In the SLNB group, 9 variables, including pathological type, histological grade, tumor size, hormone receptor, HER-2, Ki-67, multifocality, and molecular subtypes, were related to breast cancer ALN metastasis. Clinically negative lymph nodes, favorable histologic type, tumor size <2 cm, and Ki-67 <15% were at very low risk for lymph node metastasis. The AUC of the validation group was 0.786.

Conclusion

We successfully establish a mathematics model to predict lymph node metastasis of breast cancer. Axillary surgery should be individual with preoperative clinical characteristics, especially for patients with a longer life expectancy.

The prognostic value of lymph node ratio in survival of non-metastatic breast carcinoma patients

PURPOSE

This study was conducted to assess the correlation between lymph node ratio (LNR) and prognosis of non-metastatic invasive breast carcinoma.

METHOD

This retrospective study examined 455 patients who were diagnosed with non-metastatic, unilateral invasive breast carcinoma and underwent either breast conservative surgery (BCS) or modified radical mastectomy (MRM) with axillary lymph node dissection (ALND) with at least one lymph node identified in the ALND specimen. Receiver operating characteristics (ROC) curve analysis was used to find out predictive cut-off values of the LNR and negative lymph nodes (NLN).

RESULTS

The median follow-up duration was 38 months. The median DFS and OS were 68 months and 72 months, respectively. 25.1% of patients had reported recurrence. The optimal cut-off value of LNR was 0.40. LNR was found to correlate significantly with pathological T (p < 0.001), pathological N (p < 0.001), and NLN (p < 0.001). Univariate analysis of the patients showed that the age group ≤ 35 years, menstrual status, pathological T, nodal status, lymphovascular invasion (LVI), perineural invasion (PNI), tumor grade, estrogen receptor (ER), progesterone receptor (PR), molecular subtypes, LNR, and NLN can affect disease-free survival (DFS) (p < 0.05) and OS (p < 0.05). Multivariate analysis showed that the pathological T (p < 0.001), menstrual status (p = 0.030), and LNR (p < 0.001) were the independent prognostic factors for DFS. Pathological T (p < 0.001) and LNR (p < 0.001) were the independent prognostic factors affecting OS.

CONCLUSION

LNR is the independent prognostic factor of DFS and OS for non-metastatic breast carcinoma.

Associated Features with Non-Sentinel Lymph Node Involvement in Early Stage Breast Cancer Patients who Have Positive Macrometastatic Sentinel Lymph Node

Objective

The main goal of this study is to determine the clinico-pathological factors that correlate non-sentinel lymph nodes (LNs) involvement in clinically node negative breast cancer (BC) patients with positive macrometastatic sentinel lymph node (SLN) in order to derive future evidence to define a subgroup where completion axillary lymph node dissection (cALND) might not be recommended.

Materials and Methods

Total 289 SLN biopsies were performed in clinically node negative BC patients between March 2014 and April 2017. Seventy patients who performed cALND due to positive macrometastatic SLN were retrospectively selected and classified into two groups, according to non-SLN involvement (NSLNI). Clinico-pathological features of patients were examined computerized and documentary archives.

Results

Extracapsular extension (ECE) of SLN, number of harvested SLNs, metastatic rate of SLNs, absence of ductal carcinoma in situ (DCIS) and presence of multilocalization were significantly associated with the likelihood of non-SLN involvement after univariate analysis (p<0,05). Absence of DCIS and presence of multilocalization were found to be significant after multivariate analysis.

Conclusion

Careful examination of clinico-pathological features can help to decide avoiding cALND if enough LNs are removed and the rate of SLN metastases is low, particularly in case DCIS accompanying invasive cancer in patients without multi localized tumour.

Correlation of Conventional Ultrasound Characteristics of Breast Tumors With Axillary Lymph Node Metastasis and Ki-67 Expression in Patients With Breast Cancer

OBJECTIVES

To explore the association between the ultrasound (US) characteristics of breast tumors with axillary lymph node metastasis (ALNM) and Ki-67 expression in patients with breast cancer.

METHODS

In total, 527 consecutive patients with breast cancer who had undergone US examinations and curative surgery with axillary lymph node evaluations were included. The size, shape, aspect ratio, margin, internal echo, internal calcification, posterior echo attenuation, lymphatic hilar structure, cortical thickness, and blood flow of the axillary lymph nodes or primary breast lesions were observed with conventional US. Pathologic prognostic factors, including the histologic type of the tumor, histologic grade, estrogen and progesterone receptor status, lymph node status, and Ki-67 expression were determined. A logistic regression model was used to evaluate whether the US characteristics of primary breast lesions were associated with ALNM and Ki-67 expression.

RESULTS

The maximum tumor diameter (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.05-2.27; P = .028), tumor margin (OR, 2.89; 95% CI, 1.69-4.94; P < .001), internal echo (OR, 2.17; 95% CI, 1.47-3.20; P < .001), and Ki-67 status (OR, 3.57; 95% CI, 2.29-5.58; P < .001) had significant value as independent predictors of ALNM. Only the internal echo (OR, 1.95; 95% CI, 1.28-2.95; P = .002) of breast cancer was an independent predictor of the Ki-67 status. The heterogeneity in the internal echo indicated faster cancer cell proliferation and was associated with a worse prognosis in patients with breast carcinoma.

CONCLUSIONS

Certain conventional US characteristics may be useful predictors of ALNM and the Ki-67 status in patients with breast cancer.

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.

Clinicopathologic features predicting involvement of non- sentinel axillary lymph nodes in Iranian women with breast cancer

BACKGROUND

Almost half of the breast cancer patients with positive sentinel lymph nodes have no additional disease in the remaining axillary lymph nodes. This group of patients do not benefit from complete axillary lymph node dissection. This study was designed to assess the clinicopathologic factors that predict non-sentinel lymph node metastasis in Iranian breast cancer patients with positive sentinel lymph nodes.

MATERIALS AND METHODS

The records of patients who underwent sentinel lymph node biopsy, between 2003 and 2012, were reviewed. Patients with at least one positive sentinel lymph node who underwent completion axillary lymph node dissection were enrolled in the present study. Demographic and clinicopathologic characteristics including age, primary tumor size, histological and nuclear grade, lymphovascular invasion, perineural invasion, extracapsular invasion, and number of harvested lymph nodes, were evaluated.

RESULTS

The data of 167 patients were analyzed. A total of 92 (55.1%) had non-sentinel lymph node metastasis. Univariate analysis of data revealed that age, primary tumor size, histological grade, lymphovascular invasion, perineural invasion, extracapsular invasion, and the number of positive sentinel lymph nodes to the total number of harvested sentinel lymph nodes ratio, were associated with non-sentinel lymph node metastasis. After logistic regression analysis, age (OR=0.13; 95% CI, 0.02-0.8), primary tumor size (OR=7.7; 95% CI, 1.4-42.2), lymphovascular invasion (OR=19.4; 95% CI, 1.4- 268.6), extracapsular invasion (OR=13.3; 95% CI, 2.3-76), and the number of positive sentinel lymph nodes to the total number of harvested sentinel lymph nodes ratio (OR=20.2; 95% CI, 3.4-121.9), were significantly associated with non-sentinel lymph node metastasis.

CONCLUSIONS

According to this study, age, primary tumor size, lymphovascular invasion, extracapsular invasion, and the ratio of positive sentinel lymph nodes to the total number of harvested sentinel lymph nodes, were found to be independent predictors of non-sentinel lymph node metastasis.

Sentinel lymph node biopsy in breast cancer: predictors of axillary and non-sentinel lymph node involvement

BACKGROUND

Sentinel lymph node biopsy is a standard method for the evaluation of axillary status in patients with T1-2N0M0 breast cancers.

AIMS

To determine the prognostic significance of primary tumour-related clinico-histopathological factors on axillary and non-sentinel lymph node involvement of patients who underwent sentinel lymph node biopsy.

STUDY DESIGN

Retrospective clinical study.

METHODS

In the present study, 157 sentinel lymph node biopsies were performed in 151 consecutive patients with early stage breast cancer between June 2008 and December 2011.

RESULTS

Successful lymphatic mapping was obtained in 157 of 158 procedures (99.4%). The incidence of larger tumour size (2.543±1.21 vs. 1.974±1.04), lymphatic vessel invasion (70.6% vs. 29.4%), blood vessel invasion (84.2% vs. 15.8%), and invasive lobular carcinoma subtype (72.7% vs. 27.3%) were statistically significantly higher in patients with positive SLNs. Logistic stepwise regression analysis disclosed tumour size (odds ratio: 1.51, p=0.0021) and lymphatic vessel invasion (odds ratio: 4.68, p=0.001) as significant primary tumour-related prognostic determinants of SLN metastasis.

CONCLUSION

A close relationship was identified between tumour size and lymphatic vessel invasion of the primary tumour and axillary lymph node involvement. However, the positive predictive value of these two independent variables is low and there is no compelling evidence to recommend their use in routine clinical practice.

A logistic regression model for predicting axillary lymph node metastases in early breast carcinoma patients

Nodal staging in breast cancer is a key predictor of prognosis. This paper presents the results of potential clinicopathological predictors of axillary lymph node involvement and develops an efficient prediction model to assist in predicting axillary lymph node metastases. Seventy patients with primary early breast cancer who underwent axillary dissection were evaluated. Univariate and multivariate logistic regression were performed to evaluate the association between clinicopathological factors and lymph node metastatic status. A logistic regression predictive model was built from 50 randomly selected patients; the model was also applied to the remaining 20 patients to assess its validity. Univariate analysis showed a significant relationship between lymph node involvement and absence of nm-23 (p = 0.010) and Kiss-1 (p = 0.001) expression. Absence of Kiss-1 remained significantly associated with positive axillary node status in the multivariate analysis (p = 0.018). Seven clinicopathological factors were involved in the multivariate logistic regression model: menopausal status, tumor size, ER, PR, HER2, nm-23 and Kiss-1. The model was accurate and discriminating, with an area under the receiver operating characteristic curve of 0.702 when applied to the validation group. Moreover, there is a need discover more specific candidate proteins and molecular biology tools to select more variables which should improve predictive accuracy.

Factors predicting the non-sentinel lymph node involvement in breast cancer patients with sentinel lymph node metastases

OBJECTIVE

In a significant proportion of patients, the sentinel lymph node (SLN) is the only involved axillary node. The goal of the present study was to identify predictive factors associated with a positive SLN and with a positive non-SLN in patients in whom axillary lymph node dissection (ALND) was performed.

METHODS

Data was reviewed for patients with T1-2 invasive breast cancer who underwent SLN biopsy with or without axillary dissection in a single institution between July 2000 and May 2010. The SLNs were examined by serial sectioning and H&E staining, and by cytokeratin immunostaining in suspicious cases.

RESULTS

Of 332 patients with SLNB, 134 had SLN positivity, and 116 of them further underwent completion axillary dissection. Patients with T2 tumors (OR=3.2; 95% CI, 1.74-5.58), or tumors with lymphovascular invasion (OR=8.0; 95% CI, 4.44-14.27), or invasive ductal cancer (OR=2.92; 95% CI, 1.1-8.0) were more likely to have a positive SLN. In patients with ALND, the non-SLN involvement rates were 10%, 11.5% and 50% in patients with isolated tumor cells (ITC), micrometastasis and macrometastasis, respectively. Finding of ITC or micrometastasis in SLNs (OR=0.28; 95% CI, 0.08-0.99) or presence of extracapsular invasion (ECI) in SLN (OR=0.24; 95% CI, 0.09-0.67) were the predictive factors of not having a non-SLN metastasis in logistic regression analysis.

CONCLUSIONS

These findings suggest further axillary surgery can be best omitted in patients with micrometastasis while validation of nomograms including factors such as ECI are still needed to be studied in patients with macrometastasis.

Incorporation of sentinel lymph node metastasis size into a nomogram predicting nonsentinel lymph node involvement in breast cancer patients with a positive sentinel lymph node

BACKGROUND AND OBJECTIVE

Sentinel lymph node (SLN) metastasis size is an important predictor of non-SLN involvement. The goal of this study was to construct a nomogram incorporating SLN metastasis size to accurately predict non-SLN involvement in patients with SLN-positive disease.

METHODS

We identified 509 patients with invasive breast cancer with a positive SLN who underwent completion axillary lymph node dissection (ALND). Clinicopathologic data including age, tumor size, histology, grade, presence of multifocal disease, estrogen and progesterone receptor status, HER2/neu status, presence of lymphovascular invasion (LVI), number of SLN(s) identified, number of positive SLN(s), maximum SLN metastasis size and the presence of extranodal extension were recorded. Univariate and multivariate logistic regression analyses identified factors predictive of positive non-SLNs. Using these variables, a nomogram was constructed and subsequently validated using an external cohort of 464 patients.

RESULTS

On univariate analysis, the following factors were predictive of positive non-SLNs: number of SLN identified (P < 0.001), number of positive SLN (P < 0.001), SLN metastasis size (P < 0.001), extranodal extension (P < 0.001), tumor size (P = 0.001), LVI (P = 0.019), and histology (P = 0.034). On multivariate analysis, all factors remained significant except LVI. A nomogram was created using these variables (AUC = 0.80; 95% CI, 0.75-0.84). When applied to an external cohort, the nomogram was accurate and discriminating with an AUC = 0.74 (95% CI, 0.68-0.77).

CONCLUSION

SLN metastasis size is an important predictor for identifying non-SLN disease. In this study, we incorporated SLN metastasis size into a nomogram that accurately predicts the likelihood of having additional axillary metastasis and can assist in personalizing surgical management of breast cancer.

Meta-analysis of predictive factors for non-sentinel lymph node metastases in breast cancer patients with a positive SLN

AIMS

A meta-analysis was performed to identify the clinicopathological variables most predictive of non-sentinel node (NSN) metastases when the sentinel node is positive.

METHODS

A Medline search was conducted that ultimately identified 56 candidate studies. Original data were abstracted from each study and used to calculate odds ratios. The random-effects model was used to combine odds ratios to determine the strength of the associations.

FINDINGS

The 8 individual characteristics found to be significantly associated with the highest likelihood (odds ratio >2) of NSN metastases are SLN metastases >2mm in size, extracapsular extension in the SLN, >1 positive SLN, ≤1 negative SLN, tumour size >2cm, ratio of positive sentinel nodes >50% and lymphovascular invasion in the primary tumour. The histological method of detection, which is associated with the size of metastases, had a correspondingly high odds ratio.

CONCLUSIONS

We identified 8 factors predictive of NSN metastases that should be recorded and evaluated routinely in SLN databases. These factors should be included in a predictive model that is generally applicable among different populations.

Implication of extracapsular invasion of sentinel lymph nodes in breast cancer: prediction of nonsentinel lymph node metastasis

BACKGROUND

Accurate intraoperative diagnosis of sentinel lymph node (SLN) metastases enables the selection of patients who require axillary lymph node dissection (ALND). However, many patients with positive SLN do not show metastasis to other axillary lymph nodes. In this study, we investigated the factors that may determine the likelihood of additional positive nodes in the axilla when metastasis is found in the SLN.

METHODS

SLN biopsy was performed on 276 patients with breast cancer with clinically negative nodes, of which 46 (16.6%) had positive SLNs and underwent ALND. Eleven (23.9%) of these 46 cases had additional metastasis in nonsentinel lymph nodes (NSLN). The clinical and pathological features of these cases were reviewed and statistical analysis was performed.

RESULTS

All cases of positive nodes in NSLN in our series had extracapsular invasion (ECI) at the metastatic SLNs. Furthermore, the absence of ECI of SLN was significantly associated with the absence of metastasis in the NSLN (P < 0.001). As contributing factors, the absence of lymphatic invasion at the primary tumor, primary tumor size (<2 cm) and foci size in the metastatic SLN fell short of reaching statistical significance. Other factors, including histological type, pathological grade, estrogen receptor status, HER2 status, and age, were not significantly associated with metastatic involvement of NSLN.

CONCLUSIONS

Our results suggest that the presence of ECI at metastatic SLNs is a strong predictor for residual disease in the axilla. These findings imply the possibility that ALND might be foregone in the treatment of patients with breast cancer without ECI at metastatic SLNs.

Clinical importance of micrometastasis in sentinel lymph nodes

INTRODUCTION

We evaluated the incidence of micrometastasis and nonsentinel lymph node metastasis as well as local and axillary recurrence rates after level I-II axillary lymph node dissection.

MATERIALS AND METHODS

Patients (n=760) with early-stage breast cancer underwent sentinel lymph node biopsy, and 45 patients (6.0%) with micrometastasis (0.2-2.0mm) were included in this study. Data concerning tumor, patients' characteristics and adjuvant treatments were recorded.

RESULTS

The median age was 46 (26-67) years, median breast tumor size was 20 (1-50) mm, and median number of excised sentinel lymph nodes were 2 (1-5). All patients with micrometastasis underwent further level I-II axillary lymph node dissection. Eleven of 45 (24.4%) patients with micrometastasis in their sentinel lymph node biopsy had nonsentinel lymph node metastasis after an axillary lymph node dissection. There was no factor related to nonsentinel lymph node metastasis. Stage migration occurred in 4 of 45 patients (8.8%) due to the detection of micrometastases or macrometastases in nonsentinel lymph nodes.

DISCUSSION

The classical treatment after detection of micrometastasis in sentinel lymph nodes is further axillary dissection. However, nonrandomized, nonprospective studies with 4-5 years follow up showed 0.6% axillary recurrence without further axillary lymph node dissection, although we still need the results of randomized controlled studies.

Assessment of the performance of the Stanford Online Calculator for the prediction of nonsentinel lymph node metastasis in sentinel lymph node-positive breast cancer patients

BACKGROUND

Several models for the prediction of nonsentinel lymph node (NSLN) metastasis in sentinel lymph node (SLN)-positive breast cancer patients have been proposed. In this study, the authors evaluate the Stanford Online Calculator (SOC), which was designed to predict the likelihood of NSLN metastasis using only 3 variables: primary tumor size, SLN metastasis size, and angiolymphatic invasion status. They compared it with the Mayo and Memorial Sloan-Kettering Cancer Center (MSKCC) nomograms.

METHODS

The SOC was used to calculate the probability of NSLN metastasis in 464 breast cancer patients with SLN metastasis who underwent completion axillary lymph node dissection at the Mayo Clinic. The area under the receiver operating characteristic curve (AUC) was calculated for each model. Mean probabilities of patients with and without NSLN metastasis were compared. Patients with <or=5%, <or=10%, and 100% NSLN metastasis probabilities were examined.

RESULTS

The AUCs of the Stanford, MSKCC, and Mayo models were 0.72, 0.74, and 0.77, respectively (P=.13). The mean Stanford probabilities for patients with and without NSLN metastasis were 0.75 (range, 0.06-1.0) and 0.50 (range, 0.05-1.0), respectively (P<.0001). The false-negative rates for patients with a Stanford probability of <or=5% and <or=10% were 0% and 13%, respectively. Of the patients with a Stanford probability of 100%, 26% did not have NSLN metastasis.

CONCLUSIONS

Despite using only 3 variables, the Stanford nomogram appears to perform on a par with, but not better than, the MSKCC and Mayo nomograms. Further validation in other patient populations is needed.

Intraoperative consultation for axillary sentinel lymph node biopsy: an 8-year audit

To summarize the authors' 8-year institutional experience with intraoperative consultation via frozen section (FS) on sentinel lymph node biopsy (SLNB) in breast cancer patients we recorded the, complete operative procedure including additional surgery on the ipsilateral axilla and intraoperative consultation and permanent histopathologic processing for all cases with inoperative consultation on SLNB in breast cancer patients between the groups, chi(2) and Fisher's exact tests were used. Intraoperative consultation was positive in 116/706 cases (16.4%) and final pathology in 158/706 cases (22.4%); the false-negative rate was 26.6%, the false-positive rate was 0%, and the overall accuracy was 94%. False-negative rate was significantly associated with the size of metastasis (micro vs macrometastasis; P < .002) but not significantly associated with the histologic type (P = 0.76) or pathologist expertise (P = 0.08). The rate of spared second procedures was 92% when calculated exclusively for patients who ultimately underwent ALND. Intraoperative consultation via FS for SLNB is a safe practice that can reliably save clinically node-negative patients a second surgery.

Lymph node ratio as an alternative to pN staging in node-positive breast cancer

PURPOSE

In the current pTNM classification system, nodal status of breast cancer is based on the number of involved lymph nodes and does not account for the total number of lymph nodes removed. In this study, we assessed the prognostic value of the lymph node ratio (LNR; ie, ratio of positive over excised lymph nodes) as compared with pN staging and determined its optimal cutoff points.

PATIENTS AND METHODS

From the Geneva Cancer Registry, we identified all women diagnosed with node-positive breast cancer between 1980 and 2004 (n = 1,829). The prognostic value of LNRs was calculated for values ranging from 0.05 to 0.95 by Cox regression analysis and validated by bootstrapping. Based on maximum likelihood, we identified cutoff points classifying women into low-, intermediate-, and high-risk LNR groups.

RESULTS

Optimal cutoff points classified patients into low- (< or = 0.20), intermediate- (> 0.20 and < or = 0.65), and high-risk (> 0.65) LNR groups, corresponding to 10-year disease-specific survival rates of 75%, 63%, and 40%, and adjusted mortality risks of 1 (reference), 1.78 (95% CI, 1.46 to 2.18), and 3.21 (95% CI, 2.54 to 4.06), respectively. In contrast to LNR risk categories, survival curves of pN2 and pN3 crossed after 15 years, and their adjusted mortality risks showed overlapping CIs: 2.07 (95% CI, 1.69 to 2.53) and 2.84 (95% CI, 2.23 to 3.61), respectively.

CONCLUSION

LNR predicts survival after breast cancer more accurately than pN classification and should be considered as an alternative to pN staging.

New models and online calculator for predicting non-sentinel lymph node status in sentinel lymph node positive breast cancer patients

Background

Current practice is to perform a completion axillary lymph node dissection (ALND) for breast cancer patients with tumor-involved sentinel lymph nodes (SLNs), although fewer than half will have non-sentinel node (NSLN) metastasis. Our goal was to develop new models to quantify the risk of NSLN metastasis in SLN-positive patients and to compare predictive capabilities to another widely used model.

Methods

We constructed three models to predict NSLN status: recursive partitioning with receiver operating characteristic curves (RP-ROC), boosted Classification and Regression Trees (CART), and multivariate logistic regression (MLR) informed by CART. Data were compiled from a multicenter Northern California and Oregon database of 784 patients who prospectively underwent SLN biopsy and completion ALND. We compared the predictive abilities of our best model and the Memorial Sloan-Kettering Breast Cancer Nomogram (Nomogram) in our dataset and an independent dataset from Northwestern University.

Results

285 patients had positive SLNs, of which 213 had known angiolymphatic invasion status and 171 had complete pathologic data including hormone receptor status. 264 (93%) patients had limited SLN disease (micrometastasis, 70%, or isolated tumor cells, 23%). 101 (35%) of all SLN-positive patients had tumor-involved NSLNs. Three variables (tumor size, angiolymphatic invasion, and SLN metastasis size) predicted risk in all our models. RP-ROC and boosted CART stratified patients into four risk levels. MLR informed by CART was most accurate. Using two composite predictors calculated from three variables, MLR informed by CART was more accurate than the Nomogram computed using eight predictors. In our dataset, area under ROC curve (AUC) was 0.83/0.85 for MLR (n = 213/n = 171) and 0.77 for Nomogram (n = 171). When applied to an independent dataset (n = 77), AUC was 0.74 for our model and 0.62 for Nomogram. The composite predictors in our model were the product of angiolymphatic invasion and size of SLN metastasis, and the product of tumor size and square of SLN metastasis size.

Conclusion

We present a new model developed from a community-based SLN database that uses only three rather than eight variables to achieve higher accuracy than the Nomogram for predicting NSLN status in two different datasets.

Increased Sentinel Lymph Node Lymphangiogenesis is Associated with Nonsentinel Axillary Lymph Node Involvement in Breast Cancer Patients with a Positive Sentinel Node

PURPOSE

Lymph node (LN) lymphangiogenesis has recently been shown to be important in the premetastatic niche of sentinel LNs. To study its role in the further metastatic spread of human breast cancer, we investigated the association of angiogenesis and lymphangiogenesis in sentinel LN metastases with the presence of nonsentinel LN metastases in breast cancer patients with a positive sentinel LN.

EXPERIMENTAL DESIGN

Angiogenesis and lymphangiogenesis--quantified as endothelial cell proliferation fraction (ECP%) and lymphatic ECP fraction (LECP%)--were assessed in sentinel LN metastases of 65 T(1)/T(2) patients with breast cancer using CD34/Ki67 and D2-40/Ki67 immunohistochemical double stains. Correlations were analyzed between nonsentinel LN status, LECP%, and other clinicopathologic variables (number of involved sentinel LNs, size of the primary tumor and LN metastasis, presence of lymphovascular invasion in the primary tumor, and of extracapsular growth in the sentinel LN metastasis).

RESULTS

Thirty seven out of 65 patients (56.9%) had at least one involved nonsentinel LN. Size of the sentinel LN metastasis (P = 0.001), lymphovascular invasion (P = 0.02), extracapsular growth (P = 0.02), and LECP% (P = 0.01) were correlated with a positive nonsentinel LN status. The multivariate logistic regression model retained high LECP% (odds ratios = 4.2, P = 0.01) and the presence of extracapsular growth (odds ratios = 3.38, P = 0.04) as independently associated with the presence of nonsentinel LN metastases.

CONCLUSIONS

Increased sentinel LN metastasis lymphangiogenesis is associated with metastatic involvement of nonsentinel axillary LNs. These are the first data sustaining the hypothesis that sentinel LN lymphangiogenesis is involved in further metastatic spread of human breast cancer.

Size of Sentinel Node Tumor Deposits and Extent of Axillary Lymph Node Involvement: Which Breast Cancer Patients May Benefit From Less Aggressive Axillary Dissections?

BACKGROUND

In most breast cancer series, nearly 30% to 40% of all patients are sentinel node positive; however, in a large proportion of these, the disease is limited to three or fewer positive nodes. On the basis of these observations, the object of this study is to identify a subset of patients who might benefit from a less aggressive axillary dissection, without compromising staging or local disease control. We reviewed known clinicopathologic variables associated with a higher risk for axillary metastasis in 467 patients who underwent sentinel node mapping at our institution. We then compared the incidence of these variables in patients with N1a versus N2-3 stage disease.

RESULTS

Although the presence of lymphvascular invasion in the primary tumor and extracapsular extension of tumor in the sentinel node were statistically significantly different between N1a and N2-3 patients (P < .025 and P < .01, respectively), the variable that most reliably separated N1a from N2-3 patients was the size of the tumor deposits in the sentinel node (P < .001). All patients with sentinel node tumor deposits <or=5 mm had three or fewer positive nodes; 95% were sentinel node-positive only, and 91% had single-node involvement.

CONCLUSIONS

Patients at low risk for extensive axillary nonsentinel node involvement may benefit from a more conservative surgical approach to their axillae, perhaps limited to sentinel node biopsy only or to axillary procedures restricted to the group of axillary nodes in close proximity to those designated as sentinel nodes.

Positive and negative aspects of sentinel lymph node biopsy in breast cancer

The sentinel lymph node (SLN) is the first lymph node to receive lymphatic drainage from a tumor. SLN biopsy has become a mainstay of breast cancer management and is used when the axilla is clinically clear of disease. Staging of the axilla in breast cancer is used to predict prognosis and in planning adjuvant treatment. SLN biopsy is not used where there has been previous axillary or breast radiotherapy or surgery, locally advanced or inflammatory disease and stage IV disease. Controversies remain in several specific clinical situations, including management of the axilla following detection of a positive SLN. There are no sufficiently robust predictive tumor features to prevent completion axillary dissection in these cases. However, there is evidence that immediate axillary surgery for operable, clinically node-negative breast cancer provides no survival benefit and may be unnecessary for many women. SLN biopsy may have a role after neoadjuvant chemotherapy, sparing some women from axillary node dissection. Further work is required to ascertain SLN biopsy sensitivity prior to its routine use in the clinic for multicentric and multifocal disease.

The competent sentinel node: an association with an axillary presentation and an occult or a small primary invasive breast carcinoma

The concept of the sentinel node describes a primary or sentinel lymph node (SLN), which exists and through which tumour cells from a primary tumour in a particular location must first travel to spread to a particular regional lymph node group. In this series we present three patients presenting with a pathological axillary node associated with either an occult or very small primary breast cancer. In each case the primary tumour was found to have metastasised to the palpable node, however despite the significant enlargement of this node, no other axillary nodes were found to be affected on axillary node clearance. This has led us to postulate that the SLN in some cases contains unique characteristics that enable it to prevent further spread of the tumour up the lymphatic chain. Hence the term the competent sentinel node.

Is axillary clearance the standard of care for breast cancer patients with sentinel node involvement?

Sentinel node biopsy (SNB) has become accepted for staging the axilla in early breast cancer with avoidance of axillary lymph node dissection (ALND) in patients with negative SNB. For those with positive SNB, the standard surgical management is ALND; however, this approach is increasingly being challenged. The central problem is that it is not possible to preoperatively predict whether the SNB will be positive, and it is even more difficult to determine the likelihood of nonsentinel node positivity. Various histopathological features indicate increased risk of nonsentinel node metastasis, including size of SNB metastasis, presence of lymphovascular invasion, multifocality, number of involved sentinel nodes and, conversely, the number of negative sentinel nodes. These features have been combined to produce predictive nomograms but, understandably, these still lack precision. Presently, the decision to avoid ALND will depend upon both the clinician and the patient's impression of risk, but if either requires assurance that no residual axillary disease remains, a completion clearance will be required.

Sentinel lymph nodes in breast cancer after 10 years: rethinking basic principles

New techniques and treatments in medicine occasionally take on a life of their own. Sometimes, an idea's use is inherently obvious from the outset, sometimes not, in which case it becomes technology in search of an application. Identification of sentinel lymph nodes in breast cancer is a combination of these two options: to some extent the technique has been overused and its results overinterpreted. 10 years after the procedure's introduction and general acceptance, a few issues still deserve further discussion despite much published work on this topic. Use of sentinel-lymph-node identification has been extended to other organ systems, yet not all the lessons learned in the breast might apply to other sites. Review of the theory behind the technique and breast cancer experience to date is important. Many of the published controversies about sentinel lymph nodes in breast cancer can be resolved by consideration of the basic ideas underlying the procedure, which is the aim of this Essay.