Axillary lymph node metastases in patients with small carcinomas of the breast: is accurate prediction possible?

The variability of aggressiveness of grade 1 breast cancer

BACKGROUND

Grade 1 breast cancer represents the lowest grade of invasive breast cancer and is associated with a low risk of recurrence and distant metastasis. However, when grade 1 breast cancer is associated with lymph node involvement, the prognosis may be worse than that of grade 1 breast cancer without lymph node involvement.

METHOD

The study population included all patients who were managed in our institution between January 1, 2007 and December 31, 2013 for grade 1 breast cancer . We compared patients who had lymph node involvement to those who had no lymph node involvement.

RESULTS

During the study period 291 grade 1 carcinomas were included of which 23% had associated positive lymph node involvement. Overall survival did not differ significantly between patients without lymph node involvement and those with lymph node involvement, nor was there a significant difference in the risk of local recurrence free survival. However, a significant difference was found in survival without distant metastasis with a significant level of a p at 0.029.

CONCLUSION

Our findings confirm that tumor size and LVSI are strong predictors of axillary lymph node involvement, which is a key determinant of distant metastasis-free survival.

Risk Factors for False-Negative and False-Positive Results of Magnetic Resonance Computer-Aided Evaluation in Axillary Lymph Node Staging

PURPOSE

The aims of this study were to investigate the false-negative and false-positive results on magnetic resonance (MR) computer-aided evaluation (CAE) in axillary lymph node (ALN) staging and to evaluate the related factors in patients with invasive breast cancer.

METHODS

From July 2011 to May 2014, 103 invasive breast cancer patients who underwent preoperative MR-CAE were included. False MR-CAE results in ALN staging were compared in terms of clinicopathologic features, baseline mammography, and breast ultrasonography. Logistic regression analyses were used to evaluate independent factors related to false results.

RESULTS

For MR-CAE, the false-negative and false-positive results of ALN metastasis were 6.8% and 33.3%, respectively. On multivariate analysis, spiculated tumor margin (P = 0.016) and positive lymphovascular invasion (P = 0.020) were associated with false-negative results, and circumscribed tumor margin (P = 0.017) and negative lymphovascular invasion (P = 0.036) were associated with false-positive results for ALN metastasis.

CONCLUSIONS

Tumor margin and lymphovascular invasion are the key factors that affect the false MR-CAE results in ALN staging.

Apparent diffusion coefficient value in invasive ductal carcinoma at 3.0 Tesla: is it correlated with prognostic factors?

OBJECTIVE

To investigate the correlation between apparent diffusion coefficient (ADC) values and prognostic factors in patients with invasive ductal carcinoma (IDC).

METHODS

48 lesions belonging to 47 patients with histopathologically proven IDC were examined using conventional MR and diffusion-weighted imaging at a 3.0-T system. All of the patients had modified radical mastectomies or breast-sparing surgery plus axillary lymph node dissection. The ADC values acquired from the ADC maps consisted of six different b-values (0, 50, 100, 500, 1000 and 1500 s mm(-2)) and were compared with the patients' ages, tumour size, histological grade of the lesions, tumour localization, lesions' distance to skin surface and nipples, the existence of axillary lymph node involvement, the number of involved axillary lymph nodes, oestrogen/progesterone receptor status, peritumoral lymphovascular invasion status and the existence of human epidermal growth factor 2 (c-erbB-2) overexpression.

RESULTS

A statistically significant relationship was found regarding axillary lymph node involvement (p = 0.027), and oestrogen/progesterone receptor status (p = 0.013). No significant relationship was detected regarding other prognostic factors (p > 0.05).

CONCLUSION

Among various prognostic factors, ADC values were significantly correlated with only axillary lymph node positivity and oestrogen/progesterone receptor status.

ADVANCES IN KNOWLEDGE

In the present study, the relationship between ADC values of IDC lesions that are acquired at a high magnetic field (3.0 T) system by using multiple b-values and some specific prognostic factors that were not evaluated before in the medical literature was investigated.

Assessment of the Memorial Sloan-Kettering Cancer Center nomogram to predict sentinel lymph node metastases in a Dutch breast cancer population

AIM

Sentinel lymph node (SLN) biopsy is an accepted alternative to axillary lymph node dissection to assess the axillary tumour status in breast cancer patients. Memorial Sloan-Kettering Cancer Center (MSKCC) developed a nomogram to predict the likelihood of SLN metastases in breast cancer patients. Nomogram performance was tested on a Dutch population.

METHODS

Data of 770 breast cancer patients who underwent successful SLN biopsy were collected. SLN metastases were present in 222 patients. A receiver operating characteristic (ROC) curve was drawn and the area under the curve was calculated to assess the discriminative ability of the MSKCC nomogram. A calibration plot was drawn to compare actual versus nomogram-predicted probabilities.

RESULTS

The area under the ROC curve for the predictive nomogram was 0.67 (95% confidence interval 0.63-0.72) as compared to 0.75 in the original population. The nomogram was well-calibrated in the Dutch population.

CONCLUSIONS

In a Dutch population, the MSKCC nomogram estimated risk of sentinel node metastases in breast cancer patients well (i.e. calibration) with reasonable discrimination (area under ROC curve). Nomogram performance on core needle biopsy data has to be evaluated prospectively.

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.

Decision analysis to assess the efficacy of routine sentinel lymphadenectomy in patients undergoing prophylactic mastectomy

BACKGROUND

Patients who have invasive breast cancer identified after prophylactic mastectomy (PM) require axillary lymph node dissection (ALND) for lymph node staging (ie, directed ALND). Because the majority of these patients will be lymph node negative, sentinel lymphadenectomy (SLND) has been advocated at the time of PM to avoid the sequelae of unnecessary ALND. The objective of this study was to compare the efficacy of 2 surgical strategies, routine SLND versus directed ALND, in PM patients.

METHODS

A decision-analytic model was created to compare the 2 surgical strategies. Model estimates were derived from a systematic literature review. The endpoints that were examined to compare the 2 strategies were the number of SLNDs performed per breast cancer detected, the number of SLNDs attempted to avoid 1 ALND in a lymph node-negative patient with occult invasive cancer, and the number of axillary complications associated with each strategy.

RESULTS

The prevalence of invasive cancer in patients undergoing PM was estimated at 1.9%. At this rate, 37 SLNDs were performed per 1 breast cancer detected, and 73 SLNDs were required to avoid 1 ALND in a lymph node-negative PM patient. In 1 model scenario, the probability of complications per breast cancer detected was 9-fold greater with the SLND strategy than with the directed ALND strategy (2.7 vs 0.3). The complication rates for the 2 strategies become equivalent in the model scenario when the prevalence of occult invasive cancer was projected to 28%.

CONCLUSIONS

Routine SLND for patients undergoing PM is not warranted given the large number of procedures required to benefit 1 patient and the potential complications associated with performing SLND in all patients.

Predictors of axillary lymph node metastasis in breast cancer: A systematic review

AIMS

To review the established and emerging techniques in axillary lymph node prediction and explore their potential impact on clinical practice. To reliably identify patients in whom axillary lymph node surgery, including SLNB, can be safely omitted.

METHODS

Searches of PubMed were made using the search terms "axilla" (or "axillary"), "lymph", "node" and "predictor" (or "prediction"). Articles from abstracts and reports from meetings were included only when they related directly to previously published work.

FINDINGS

There are numerous studies in which the predictive utility of biomarkers as determinants of axillary lymph node status have been investigated. Few of these have specifically addressed the attributes of the primary tumour which could offer much potential for the prediction of tumour metastasis to the axillary lymph nodes.

CONCLUSIONS

Currently, no single marker is sufficiently accurate to obviate the need for formal axillary staging using SLNB or axillary clearance.

A clinicopathological scoring system to select breast cancer patients for sentinel node biopsy

BACKGROUND

Selecting patients for sentinel node biopsy, based on grade and size of the primary tumour, often results in the need for a second operation of axillary clearance since intra-operative pathological assessment of sentinel node is in its evolution at present. It may be possible to refine the clinical criteria to select patients for the type of axillary surgery.

AIM

By using a score based on clinicopathological predictors of axillary lymph node involvement, we hypothesise that it may be possible to identify patients at high or low risk of nodal involvement. This information can be used to assist patients to make informed decision regarding risks and benefits of sentinel node biopsy or axillary clearance.

PATIENTS AND METHODS

A score was devised based on the clinicopathological variables of 113 patients to assess the likelihood of lymph node positivity. This score was validated on an independent data set of 89 patients who underwent sentinel node biopsy and axillary surgery. Based on the score, patients were divided into two groups, high score and low score groups. For the low score group, lymph node positivity was 18% for the original score and 24% for the validation score. Lymph node positivity rate was 67% for the high score group for the original series and 65% for the validation series of patients.

CONCLUSION

A clinicopathological scoring system can assist in selecting patients with breast cancer for sentinel node biopsy.

Primary tumor characteristics predict sentinel lymph node macrometastasis in breast cancer

Selective sentinel lymphadenectomy (SSL) is rapidly becoming the standard of care in the surgical management of patients with early breast cancer. Sentinel lymph node macrometastasis has been well documented in the literature to have a higher risk of nonsentinel node tumor involvement when compared to micrometastasis. The aim of our study was to determine the primary tumor characteristics associated with sentinel node macrometastasis that will allow us to preoperatively determine this subgroup of patients at risk. This study was a retrospective review of 644 patients who underwent successful SSL as part of their surgical treatment of breast cancer at the University of California San Francisco Carol Franc Buck Breast Care Center from November 1997 to August 2003. All patients underwent preoperative lymphoscintigraphy followed by wide excision or mastectomy and sentinel lymphadenectomy with or without axillary lymph node dissection. One hundred twenty-two patients had positive sentinel nodes on histology. Micrometastasis was present in 43 of these patients and macrometastasis in the remaining 79. Statistical analysis showed that a tumor size greater than 15 mm, poor tubule formation by the tumor cells, and lymphovascular invasion were significantly associated with sentinel node macrometastasis. A high mitotic count showed a trend but was not significant in our study. Patients with a tumor size greater than 15 mm, poor tubule formation, and lymphovascular invasion are at risk of having sentinel node macrometastasis. These patients can be identified preoperatively based on imaging and biopsy criteria, allowing the option of selective intraoperative pathologic evaluation of the sentinel node and immediate completion axillary dissection as necessary.

Probability of axillary lymph node metastasis when sentinel lymph node biopsy is negative in women with clinically node negative breast cancer: a Bayesian approach

BACKGROUND

Although sentinel lymph node biopsy(SLNB)is highly accurate in predicting axillary nodal status in patients with breast cancer, it has been shown that the procedure is associated with a few false negative results. The risk of leaving metastatic nodes behind in the axillary basin when SLNB is negative should be estimated for an individual patient if SLNB is performed to avoid conventional axillary lymph node dissection(ALND).

METHODS

A retrospective analysis of 512 women with T1-3N0M0 breast cancer was conducted to derive a prevalence of nodal metastasis by T category as a pre-test(i.e., before SLNB)probability and to examine potential confounders on the relationship between T category and axillary nodal involvement. Probability of nodal metastasis when SLNB was negative was estimated by means of Bayes' theorem which incorporated the pre-test probability and sensitivity and specificity of SLNB.

RESULTS

Axillary nodal metastasis was observed in 6.1% of T1a-b, 25.1% of T1c, 28.7% of T2, 35.0% of T3 tumors. Point estimates for the probability of nodal involvement when SLNB was negative ranged from 0.3-1.3% for T1a-b, 1.6-6.3% for T1c, 2.0-7.5% for T2, and 2.6-9.7% for T3 tumors with representative sensitivities of 80%, 85%, 90% and 95%, respectively. The risk may be higher when the tumor involves the upper outer quadrant of the breast, while it may be lower for an underweight woman.

CONCLUSIONS

The probability of axillary lymph node metastasis when SLNB is negative can be estimated using a Bayesian approach. Presenting the probability to the patient may guide the decision of surgery without conventional ALND.

Contemporary management of breast cancer

Breast cancer is a heterogenous disease with significant variations in biologic potential, ranging from small, low-grade, DCIS discovered mammographically with essentially no impact on patient survival to rapidly growing, palpable, locally advanced invasive breast cancer with clinically palpable nodal metastasis. The current challenge is to identify the clinical, pathologic, and molecular factors that determine the biologic potential of a particular breast cancer. Although size, nodal status, histologic grade, age, surgical margin, and hormone receptor status of breast cancer are the most important prognostic factors, the focus of research must be beyond these factors to other nonspecific prognostic information. Bone marrow micrometastasis may be an important factor to help predict outcome (7a) and the complement of sentinel node biopsy, bone marrow analysis, and primary tumor features may allow physicians to better select therapy. With increased understanding of the individual molecular events that control the invasive potential of a particular cancer, practitioners should be better able to predict more accurately which patients have little risk of recurrent disease or metastasis and would be best served by surgery alone versus patients who have a high risk of recurrent and metastatic disease and who should receive multimodality care.

A treatment scale for axillary management in breast cancer

BACKGROUND

We have investigated a method, the Kaufman axillary treatment scale (KATS), to help assign patients with a clinically negative axilla to one of three current options of axillary management: standard axillary dissection, sentinel node sampling followed by axillary dissection if the sentinel node is positive, or no axillary surgery at all. The KATS score uses preoperative data to guide the choice of axillary treatment.

METHODS

The KATS score is calculated by adding the preoperative values of tumor size, patient age, and pathologic grade. Values range from 1 to 4 for size (1 to 9 mm, 10 to 14 mm, 15 to 19 mm, and 20 to 30 mm), 1 to 3 for age (70 years and over, 50 to 69 years, less than 50 years), and 1 to 2 for grade (low or not low) to calculate the score. The KATS score ranges from 3 to 9. We have applied this score against the SEER (Surveillance, Epidemiology, and End Results) tumor registry of 529 patients with invasive breast cancer with known pathologic data. We then validated it by applying it to our own set of 190 patients using preoperative data. The chi-square test and logistic regression analysis were used for P values (all two sided), univariate and multivariate analysis, odds ratio and confidence intervals utilizing SPSS statistics software.

RESULTS

In the SEER database using American Joint Committee on Cancer pathologic size alone, no sizable group was identified with a positive node rate neither below 8% (T1a) nor above 48% (T2). KATS scores of 3 and 4 (68 patients, group 1) identify patients with an average node positive rate of 4.4% (P <0.02, group 1 versus 2). Those patients with KATS scores of 5, 6, and 7 (341 patients, group 2) carry an average node positive rate of 22% (P <0.001, group 2 versus 3). KATS scores of 8 and 9 (120 patients, group 3) identify patients with an average node positive rate of 50% (P <0.001, group 3 versus 1). Similar results were found on our own group of 190 patients using preoperative available data. KATS scores of 3 or 4 (11 patients, group 1) had no positive nodes. Group 2 (100 patients, KATS score 5, 6, and 7) had an average 30% node positive rate. Group 3 (79 patients, KATS score 8 and 9) had 61% node positive rate. The KATS score allows the clinician to separate patients into three axillary management groups. Group 1 are those patients who may need no axillary surgery at all. Group 2 are patients who would benefit from sentinel node mapping. Group 3 has a node positive rate (61%) similar to that of clinically palpable nodes (since not all clinically palpable nodes are positive). Group 3 patients may be considered for standard axillary dissection, similar to the palpable node patient. If group 3 patients have sentinel node mapping, more than half of these patients require axillary dissection and the impact of false negative sentinel node procedures may become clinically significant.

CONCLUSIONS

An axillary treatment score has been developed to aid in the triage of patients toward reasonable axillary treatment choices for the benefit of the patient. The KATS score is a guideline and not a mandate. The KATS score attempts to use breakpoints that are both clinically practical and validated by scientific data. Like many other attempts to categorize patients, there is a continuum of data points along any variable. The treating physician utilizing the full array of available data on each patient makes the final clinical decision of axillary management.

Predictors of positive axillary lymph nodes after sentinel lymph node biopsy in breast cancer

OBJECTIVE

The purpose of this study was to determine the factors that predict the presence of metastasis in nonsentinel lymph nodes (SLN) when the SLN is positive.

METHODS

A prospective database was analyzed and included patients who underwent SLN biopsy for invasive breast cancer from July 1997 to August 2000 (n = 442). One hundred (22.6%) patients had one or more positive SLNs, and were analyzed to determine factors that predicted additional positive axillary nodes.

RESULTS

Of the 100 patients with a positive SLN, 40 patients (40%) had additional metastasis in non-SLNs. The only significant variables that predicted non-SLN metastasis were tumor lymphovascular invasion (P = 0.004), extranodal extension (P < 0.001), and increasing size of the metastasis within the SLN (P = 0.011). In analyzing just those patients who had lymphovascular invasion, extranodal extension, and a SLN metastasis > 2mm, 92% were found to have additional positive nodes.

CONCLUSIONS

In patients with invasive breast cancer and a positive sentinel lymph node, lymphovascular invasion, extranodal extension, and increasing size of the metastasis all significantly increase the frequency of additional positive nodes.