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Wang XE, Bi Z, Zhang J, Wang YS. Nomograms for metastasis of non-sentinel lymph nodes or more than three lymph nodes in patients with one or two positive sentinel lymph nodes. Front Oncol 2024; 14:1413936. [PMID: 38835388 PMCID: PMC11148251 DOI: 10.3389/fonc.2024.1413936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 04/30/2024] [Indexed: 06/06/2024] Open
Abstract
Purpose The purpose of this study was to provide advice for the indication of regional nodal irradiation (RNI) in patients with one to two positive sentinel lymph nodes (SLNs) without axillary lymph node dissection (ALND). Methods We conducted a retrospective study in Shandong Cancer Hospital, Fudan University Shanghai Cancer Center, and West China Hospital. Logistic analysis was performed in order to explore the influencing factors of positive non-SLNs (NSLNs) and >3 positive nodes among patients with one to two SLNs+. Then, nomograms were constructed. Results Between May 2010 and 2020, among the 2,845 patients with one to two SLNs+ undergoing ALND (1,992 patients in the training set and 853 patients in the validation set), there were 34.3% harbored NSLNs+ and 15.6% harbored >3 positive nodes. Multivariate analysis showed that cN stage, the number of positive/negative SLN, pathological tumor stage, lympho-vascular invasion (LVI), multicenter, and molecular subtypes were significantly associated with NSLN metastasis. Similarly, multivariate analysis also showed that cN stage, the number of positive/negative SLNs, pathological tumor stage, and LVI could be independent predictors of >3 positive nodes. Then, nomograms for NSLN metastasis and >3 positive nodes were constructed using these parameters, respectively. Conclusions The nomograms will be useful in estimating positive NSLNs and >3 positive nodes, and they might provide advice for the optimization of RNI.
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Affiliation(s)
- Xue-Er Wang
- The Third Department of Breast Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Zhao Bi
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Jin Zhang
- The Third Department of Breast Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Yong-Sheng Wang
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
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Samreen N, Dhage S, Gerber NK, Chacko C, Lee CS. Imaging and Management of Internal Mammary Lymph Nodes. JOURNAL OF BREAST IMAGING 2020; 2:530-540. [PMID: 38424849 DOI: 10.1093/jbi/wbaa046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Indexed: 03/02/2024]
Abstract
Internal mammary lymph nodes (IMLNs) account for approximately 10%-40% of the lymphatic drainage of the breast. Internal mammary lymph nodes measuring up to 10 mm are commonly seen on high-risk screening breast MRI examinations in patients without breast cancer and are considered benign if no other suspicious findings are present. Benign IMLNs demonstrate a fatty hilum, lobular or oval shape, and circumscribed margins without evidence of central necrosis, cortical thickening, or loss of fatty hilum. In patients with breast cancer, IMLN involvement can alter clinical stage and treatment planning. The incidence of IMLN metastases detected on US, CT, MRI, and PET-CT ranges from 10%-16%, with MRI and PET-CT demonstrating the highest sensitivities. Although there are no well-defined imaging criteria in the eighth edition of the American Joint Committee on Cancer Staging Manual for Breast Cancer, a long-axis measurement of ≥ 5 mm is suggested as a guideline to differentiate benign versus malignant IMLNs in patients with newly diagnosed breast cancer. Abnormal morphology such as loss of fatty hilum, irregular shape, and rounded appearance (which can be quantified by a short-axis/long-axis length ratio greater than 0.5) also raises suspicion for IMLN metastases. MRI and PET-CT have good sensitivity and specificity for the detection of IMLN metastases, but fluorodeoxyglucose avidity can be seen in both benign conditions and metastatic disease. US is helpful for staging, and US-guided fine-needle aspiration can be performed in cases of suspected IMLN metastasis. Management of suspicious IMLNs identified on imaging is typically with chemotherapy and radiation, as surgical excision does not provide survival benefit and is performed only in rare cases.
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Affiliation(s)
- Naziya Samreen
- NYU Langone Health, Department of Radiology, Garden City, NY
| | - Shubhada Dhage
- New York University School of Medicine, Department of Surgery, New York, NY
| | - Naamit Kurshan Gerber
- New York University School of Medicine, Department of Radiation Oncology, New York, NY
| | - Celin Chacko
- NYU Langone Health, Department of Radiology, Garden City, NY
| | - Cindy S Lee
- NYU Langone Health, Department of Radiology, Garden City, NY
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Bitencourt A, Rossi Saccarelli C, Morris EA, Flynn J, Zhang Z, Khan A, Gillespie E, Cahlon O, Mueller B, Cuaron JJ, McCormick B, Powell SN, Plitas G, Razavi P, Pinker K, Riedl CC, Sutton EJ, Braunstein LZ. Regional Lymph Node Involvement Among Patients With De Novo Metastatic Breast Cancer. JAMA Netw Open 2020; 3:e2018790. [PMID: 33034638 PMCID: PMC7547365 DOI: 10.1001/jamanetworkopen.2020.18790] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Regional nodal irradiation (RNI) for node-positive breast cancer reduces distant metastases and improves survival, albeit with limited reduction in regional nodal recurrences. The mechanism by which RNI robustly reduces distant metastases while modestly influencing nodal recurrences (ie, the presumed target of RNI) remains unclear. OBJECTIVE To determine whether some distant metastases putatively arise from occult regional nodal disease and whether regional recurrences otherwise remain largely undetected until an advanced cancer presentation. DESIGN, SETTING, AND PARTICIPANTS This cohort study examined patients presenting with de novo stage IV breast cancer to the Memorial Sloan Kettering Cancer Center in New York, New York, from 2006 to 2018. Medical records were reviewed to ascertain clinicopathological parameters, including estrogen receptor status and survival. Pretreatment positron emission tomography-computed tomography (PET-CT) imaging was reviewed to ascertain the extent of regional nodal involvement at metastatic diagnosis using standard nodal assessment criteria. A subset underwent regional lymph node biopsy for diagnostic confirmation and served to validate the radiographic nodal assessment. Data analysis was performed from October 2019 to February 2020. EXPOSURES Untreated metastatic breast cancer. MAIN OUTCOME AND MEASURES The primary outcome was the likelihood of regional nodal involvement at the time of metastatic breast cancer presentation and was determined by reviewing pretreatment PET-CT imaging and lymph node biopsy findings. RESULTS Among 597 women (median [interquartile range] age, 53 [44-65] years) with untreated metastatic breast cancer, 512 (85.8%) exhibited regional lymph node involvement by PET-CT or nodal biopsy, 509 (85%) had involvement of axillary level I, 328 (55%) had involvement in axillary level II, 136 (23%) had involvement in axillary level III, 101 (17%) had involvement in the supraclavicular fossa, and 96 (16%) had involvement in the internal mammary chain. Lymph node involvement was more prevalent among estrogen receptor-negative tumors (92.4%) than estrogen receptor-positive tumors (83.6%). Nodal involvement at the time of metastatic diagnosis was not associated with overall survival. CONCLUSIONS AND RELEVANCE These findings suggest that a majority of patients with de novo metastatic breast cancer harbor regional lymph node disease at presentation, consistent with the hypothesis that regional involvement may precede metastatic dissemination. This is in alignment with the findings of landmark trials suggesting that RNI reduces distant recurrences. It is possible that this distant effect of RNI may act via eradication of occult regional disease prior to systemic seeding. The challenges inherent in detecting isolated nodal disease (which is typically asymptomatic) may account for the more modest observed benefit of RNI on regional recurrences. Alternative explanations of nodal involvement that arises concurrently or after metastatic dissemination remain possible, but do not otherwise explain the association of RNI with distant recurrence.
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Affiliation(s)
- Almir Bitencourt
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Imaging, A. C. Camargo Cancer Center, Sao Paulo, Brazil
| | - Carolina Rossi Saccarelli
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiology, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Elizabeth A. Morris
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jessica Flynn
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Atif Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Erin Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Boris Mueller
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John J. Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Simon N. Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - George Plitas
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Pedram Razavi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katja Pinker
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher C. Riedl
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Elizabeth J. Sutton
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lior Z. Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Yang Z, Lan X, Huang Z, Yang Y, Tang Y, Jing H, Wang J, Zhang J, Wang X, Gao J, Wang J, Xuan L, Fang Y, Ying J, Li Y, Huang X, Wang S. Development and external validation of a nomogram to predict four or more positive nodes in breast cancer patients with one to three positive sentinel lymph nodes. Breast 2020; 53:143-151. [PMID: 32823167 PMCID: PMC7451418 DOI: 10.1016/j.breast.2020.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/26/2020] [Accepted: 08/04/2020] [Indexed: 11/29/2022] Open
Abstract
Objective To develop a nomogram for predicting the possibility of four or more positive nodes in breast cancer patients with 1–3 positive sentinel lymph nodes (SLN). Materials and methods Retrospective analysis of data of patients from two institutions was conducted. The inclusion criteria were: invasive breast cancer; clinically node negative; received lumpectomy or mastectomy plus SLN biopsy followed by axillary lymph node dissection (ALND); and pathologically confirmed T1-2 tumor, with 1–3 positive SLNs. Patients from one institution formed the training group and patients from the other the validation group. Univariate and multivariate analyses were performed to identify the predictors of four or more positive nodes. These predictors were used to build the nomogram. The area under the receiver operating characteristic curve (AUC) was calculated to assess the accuracy of the model. Results Of the 1480 patients (966 patients in the training group, 514 in the validation group), 306 (20.7%) had four or more positive nodes. Multivariate stepwise logistic regression showed number of positive (p < .001) and negative SLN (p < .001), extracapsular extension (p < .001), pT stage (p = .016), and tumor location in outer upper quadrant (p = .031) to be independent predictors of four or more positive nodes. The nomogram was built using these five factors. The AUC was 0.845 in the training group and 0.804 in the validation group. Conclusion The proposed nomogram appears to accurately estimate the likelihood of four or more positive nodes and could help radiation oncologists to decide on use of regional nodal irradiation (RNI) for breast cancer patients with 1–3 positive nodes but no ALND. Five predictors of four or more positive nodes in breast cancer patients were identified. A nomogram was built using these five factors. The nomogram was validated on an external cohort. The proposed nomogram predicts four or more positive nodes with high accuracy. The nomogram can help in decision making on use of regional nodal irradiation.
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Affiliation(s)
- Zhuanbo Yang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Xiaowen Lan
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China; Department of Radiation Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Zhou Huang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China; Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Yong Yang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yu Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Hao Jing
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jianyang Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jianghu Zhang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Xiang Wang
- Breast Surgery Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jidong Gao
- Breast Surgery Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jing Wang
- Breast Surgery Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Lixue Xuan
- Breast Surgery Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yi Fang
- Breast Surgery Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jianming Ying
- Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yexiong Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Xiaobo Huang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China; Department of Radiation Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China; Department of Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China.
| | - Shulian Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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