Extracapsular extension of the sentinel lymph node metastasis: a predictor of nonsentinel node tumor burden

Anatomical site and size of sentinel lymph node metastasis predicted additional axillary tumour burden and breast cancer survival

AIMS

Sentinel lymph node (SLN) biopsy is the current standard assessment for tumour burden in axillary lymph node (ALN). However, not all SLN+ patients have ALN metastasis. The prognostic implication of SLN features is not clear. We aimed to evaluate predictive factors for ALN metastasis and the clinical value of SLN features.

METHODS AND RESULTS

A total of 228 SLN+ and 228 SLN- (with matched year and grade) cases were included. Clinicopathological features in SLN, ALN and primary tumours, treatment data and survival data were analysed according to ALN status and outcome. Except for larger tumour size and the presence of LVI (both P < 0.001), no significant differences were found in SLN- and SLN+ cases. Only 31.8% of SLN+ cases with ALN dissection had ALN metastasis. The presence of macrometastases (MaM), extranodal extension (ENE), deeper level of tumour invasion in SLN and more SLN+ nodes were associated with ALN metastasis (P ≤ 0.025). Moreover, isolated tumour cells (ITC) and level of tumour invasion in SLN were independent adverse prognostic features for disease-free survival and breast cancer-specific survival, respectively. Interestingly, cases with ITC located in the subcapsular region have better survival than those in cortex (OS: χ²  = 4.046, P = 0.044).

CONCLUSIONS

Our study identified features in SLN, i.e. the level of tumour invasion at SLN and tumour size in SLN as useful predictors for both ALN metastasis and breast cancer outcome. The presence of ITC, particularly those with a deeper invasion in SLN, portended a worse prognosis. Proper attention should be taken for their management.

Extranodal extension, an international survey on its evaluation and reporting in breast cancer patients

Lymph node metastasis is the most important prognostic factor for breast cancer patients. In addition to the number of nodes involved and the largest metastatic focus, extranodal extension (ENE) is also used to subclassify breast cancer patients into different risk groups. More recently, pathologists are required to report the size/extent of ENE per the new CAP guideline, as it seems to be associated with more axillary nodal burden and/or a worse prognosis. Although the definition of ENE is largely understood and agreed upon among pathologists around the world, evaluation and reporting for the size of ENE are not. To understand current practice, we conducted an international survey among pathologists who are interested in breast pathology. A total of 70 pathologists responded. The results showed that (1) 98% of the participants reported the presence or absence of ENE and 61% also reported the size of ENE in millimeter (mm). (2) There was no uniform method of measuring the size of ENE; 47% measured the largest dimension regardless of orientation, while 30% measured the largest perpendicular distance from the capsule. (3) The most common factors affecting the accuracy in diagnosis of ENE are the presence of lymphovascular invasion (LVI), lack of capsule integrity, and the presence of fatty hilar or fatty replacement of a lymph node. (4) 71% felt that the H&E stain is adequate to evaluate ENE, deeper levels and IHC analysis for vascular and cytokeratin markers can be helpful if needed. (5) 75% agreed that there is an urgent need to standardize the measurement and reporting for ENE. Our survey highlights the variation in ENE evaluation and the need for its standardization in breast cancer patients with axillary node metastasis.

Beyond N staging in colorectal cancer: Current approaches and future perspectives

Traditionally, lymph node metastases (LNM) evaluation is essential to the staging of colon cancer patients according to the TNM (tumor–node–metastasis) system. However, in recent years evidence has accumulated regarding the role of emerging pathological features, which could significantly impact the prognosis of colorectal cancer patients. Lymph Node Ratio (LNR) and Log Odds of Positive Lymph Nodes (LODDS) have been shown to predict patients’ prognosis more accurately than traditional nodal staging and it has been suggested that their implementation in existing classification could help stratify further patients with overlapping TNM stage. Tumor deposits (TD) are currently factored within the N1c category of the TNM classification in the absence of lymph node metastases. However, studies have shown that presence of TDs can affect patients’ survival regardless of LNM. Moreover, evidence suggest that presence of TDs should not be evaluated as dichotomic but rather as a quantitative variable. Extranodal extension (ENE) has been shown to correlate with presence of other adverse prognostic features and to impact survival of colorectal cancer patients. In this review we will describe current staging systems and prognostic/predictive factors in colorectal cancer and elaborate on available evidence supporting the implementation of LNR/LODDS, TDs and ENE evaluation in existing classification to improve prognosis estimation and patient selection for adjuvant treatment.

Update on sentinel node pathology in breast cancer

Pathologic examination of the sentinel lymph nodes (SLNs) in patients with breast cancer has been impacted by the publication of practicing changing trials over the last decade. With evidence from the ACOSOG Z0011 trial to suggest that there is no significant benefit to axillary lymph node dissection (ALND) in early-stage breast cancer patients with up to 2 positive SLNs, the rate of ALND, and in turn, intraoperative evaluation of SLNs has significantly decreased. It is of limited clinical significance to pursue multiple levels and cytokeratin immunohistochemistry to detect occult small metastases, such as isolated tumor cells and micrometastases, in this setting. Patients treated with neoadjuvant therapy, who represent a population with more extensive disease and aggressive tumor biology, were not included in Z0011 and similar trials, and thus, the evidence cannot be extrapolated to them. Recent trials have supported the safety and accuracy of sentinel lymph node biopsy (SLNB) in these patients when clinically node negative at the time of surgery. ALND remains the standard of care for any amount of residual disease in the SLNs and intraoperative evaluation of SLNs is still of value for real time surgical decision making. Given the potential prognostic significance of residual small metastases in treated lymph nodes, as well as the decreased false negative rate with the use of cytokeratin immunohistochemistry (IHC), it may be reasonable to maintain a low threshold for the use of cytokeratin IHC in post-neoadjuvant cases. Further recommendations for patients treated with neoadjuvant therapy await outcomes data from ongoing clinical trials. This review will provide an evidence-based discussion of best practices in SLN evaluation.

PLUS: Predicting cancer metastasis potential based on positive and unlabeled learning

Metastatic cancer accounts for over 90% of all cancer deaths, and evaluations of metastasis potential are vital for minimizing the metastasis-associated mortality and achieving optimal clinical decision-making. Computational assessment of metastasis potential based on large-scale transcriptomic cancer data is challenging because metastasis events are not always clinically detectable. The under-diagnosis of metastasis events results in biased classification labels, and classification tools using biased labels may lead to inaccurate estimations of metastasis potential. This issue is further complicated by the unknown metastasis prevalence at the population level, the small number of confirmed metastasis cases, and the high dimensionality of the candidate molecular features. Our proposed algorithm, called Positive and unlabeled Learning from Unbalanced cases and Sparse structures (PLUS), is the first to use a positive and unlabeled learning framework to account for the under-detection of metastasis events in building a classifier. PLUS is specifically tailored for studying metastasis that deals with the unbalanced instance allocation as well as unknown metastasis prevalence, which are not considered by other methods. PLUS achieves superior performance on synthetic datasets compared with other state-of-the-art methods. Application of PLUS to The Cancer Genome Atlas Pan-Cancer gene expression data generated metastasis potential predictions that show good agreement with the clinical follow-up data, in addition to predictive genes that have been validated by independent single-cell RNA-sequencing datasets.

Metastasis is the major cause of cancer-related deaths, and evaluations of metastasis risk are essential for tailored treatment of cancer patients. Existing methods often build a classifier using the clinical metastasis diagnoses as binary responses or detect genomic features significantly associated with metastasis-related survival outcomes. However, these methods tend to identify genomic predictors that have little consistency across different cancer types. Thus, there is an urgent need for a powerful tool to characterize the cancer metastasis potential applicable across a wide span of cancer types. Computational assessment of metastasis potential based on large-scale transcriptomic cancer data is challenging because metastasis events are not always clinically detectable, which results in biased estimations of metastasis potential. Our proposed algorithm, called PLUS, considers patients with metastasis diagnosis as positive instances and the remainder as unlabeled instances, meaning they are either metastatic or non-metastatic. Such a classifier given by PLUS rendered concordance between the predicted cancer metastasis and observed metastasis survival outcomes in the follow-up data for almost all cancer types considered. The selected genes were found to perform functions consistent with experimental research findings and are capable of clustering the single cells based on their levels of metastasis potential.

Prevalence of extracapsular extension in metastatic sentinel lymph nodes in breast cancer

INTRODUCTION

Axillary lymph node involvement is recognized as a key prognostic factor for invasive breast cancer. Retrospective analyzes have shown that extracapsular extension (ECE) is correlated with negative prognostic factors in this neoplasia.

OBJECTIVE

to evaluate the measurement of ECE and its relationship with the number of affected non-sentinel lymph nodes, as well as to investigate the association between ECE with other clinical and pathological prognostic factors.

METHODS

This is a cross-sectional observational study carried out from January 2015 to June 2019, at the Breast Surgical Oncology service of Liga Contra o Cancer (LIGA), in Natal, Brazil. A total of 150 patients were included in the study and were divided into three groups: absence of ECE, ECE less than or equal to 2 mm and ECE greater than 2 mm.

RESULTS

The mean age was 58 years for the group with ECE and 57 years for the group without ECE. Most of the patients were mixed race (66.7%), had no family history of breast cancer (64%) and underwent quadrantectomy (64.5%). Regarding the characteristics of the disease, most presented a histological report compatible with Invasive Carcinoma of the non-special type (IC NST) (87.5%), histological grade II (52.7%), negative Lymphovascular invasion (LVI) (52.7%), Tumor Size T1 (<2.0 cm) (52%) and Luminal B molecular subtype (36.7%). Regarding sentinel lymph nodes: 103 patients (68.7%) had ECE and 1 positive sentinel lymph node was identified in most cases. There was a statistically significant association between the presence of ECE and of being mixed race (p = 0.03), between ECE and LVI (p = 0.05) and between ECE and a greater number of positive non-sentinel lymph nodes (p < 0.001).

CONCLUSION

Our study showed that ECE> 2 mm is associated with increased axillary nodal load compared to groups without ECE and ECE ≤ 2 mm in sentinel node biopsy in patients who met the Z0011 criteria.

[Strategies in case of metastatic sentinel lymph node in breast cancer]

Management strategy of micro or macro metastatic sentinel lymph node(s) (SLNs) in breast cancer has dramatically changed over the past ten years and the publication of five randomized trials results: ACOSOG Z0011, IBCSG 23-01, and AATRM comparing axillary lymph node dissection (ALND) versus SLNs biopsy alone; and AMAROS and OTOASOR comparing ALND versus axillary radiotherapy. Despite methodological limitations of several of these trials, notably ACOSOG Z0011, the international recommendations (ASCO, NCCN) and the expert consensus of St Gallen do not recommend the performance of a complementary ALND in case of macro or micro metastatic SLN, if all ACOSOG Z0011 inclusion criteria are met. Moreover, in the context of a mastectomy, with one or two positive SLN and a wall irradiation indication, an axillary radiotherapy can be proposed as an alternative to ALND. Additionally, ALND is also indicated in extracapsular involvement or when three or more SLNs are metastatic. This change in strategy led to a significant decrease on the number of ALNDs performed and resulted on the abandon of SLNs extemporaneous examination. In France, there are no national recommendations on axillary management in the context of SLN involvement. Moreover, a multitude of different local guidelines, led to very heterogeneous practices in our country. The next evolution on axillary management strategy will be the implementation of a SLNs procedure after neoadjuvant chemotherapy (NAC) for patients with lymph node involvement proven before NAC and for whom NAC has allowed axillary downstaging.

Clinical Implications of Lymph Node Metastasis in Colorectal Cancer: Current Status and Future Perspectives

Lymph node metastasis is regarded as an indubitable prognostic factor for predicting disease recurrence and survival in patients with colorectal cancer. Lymph node status based on examination of a resected specimen is a key element of the current staging system and is also a crucial factor to determine use of adjuvant chemotherapy after surgical resection. However, the current tumor-node-metastasis (TNM) staging system only incorporates the number of metastatic lymph nodes in the N category. Numerous attempts have been made to supplement this simplified N staging including lymph node ratio, distribution of metastatic lymph nodes, tumor deposits, or extracapsular invasion. In addition, several attempts have been made to identify more specific prognostic factors in resected colorectal specimens than lymph node status. In this review, we will discuss controversies in lymph node staging and factors that may influence survival beyond lymph node status.

Assessment of intratumor immune-microenvironment in colorectal cancers with extranodal extension of nodal metastases

BACKGROUND

No data is available on the molecular background of the extra-nodal extension (ENE) of lymph node metastasis (LN) in colorectal cancer (CRC).

METHODS

A series of 22 ENE-positive CRCs was considered and three samples per case were selected (the primary CRC, an ENE-negative and an ENE-positive metastatic LN). Samples (n = 66) were analysed by immunohistochemistry for PD-L1, CD4, CD8, CD68 and CD80. Fifteen out of twenty-two cases were further profiled through a hotspot multigene mutational custom panel, including 164 hotspot regions of AKT1, APC, BRAF, CTNNB1, KIT, KRAS, NRAS, PDGFRA, PIK3CA, PTEN and TP53 genes.

RESULTS

A significantly higher percentage of CD4-, CD8- and CD68-positive cells was observed at the invasive front of both CRCs and in ENE in contrast with what observed at the core of both CRCs and their matched nodal metastases. ENE was also characterized by a significantly higher number of CD80-positive cells. No significant difference was observed in PD-L1 distribution among the different specimens. Fourteen out of 15 CRCs (93%) showed at least a driver mutation. The most frequently mutated gene was TP53 (n = 8 tumors), followed by APC (n = 6), BRAF (n = 4), KRAS, NRAS and PIK3CA (n = 2). In 11 out of 15 CRCs (73%) the mutational profiling of the primary tumor was consistent with what obtained from the two matched LNs.

CONCLUSIONS

A heterogeneous intratumor immune-microenvironment has been observed in ENE-positive CRCs, which are characterized by an increased leukocytic infiltration at the ENE invasive front.

A quantitative analysis of tumour characteristics in breast cancer patients with extranodal extension in non-sentinel nodes

BACKGROUND

The presence of extranodal extension (ENE) is well documented as a predictor of non-sentinel lymph node (NSLN) metastasis. The ACOSOG Z0011 trial (2011) concluded that patients who satisfy criteria including the absence of sentinel lymph node (SLN) ENE can forgo axillary clearance (AC). Currently there are no studies analysing the rate of ENE in NSLN metastasis in which the sentinel node was positive but had no ENE. Determining this incidence will help determine if current paradigms are resulting in residual ENE in NSLN metastasis by forgoing AC based on the Z0011 trial..

METHODS

This study determined incidence of ENE at NSLN metastasis in patients with a positive SLN biopsy without ENE in 162 symptomatic breast cancer patients who underwent AC between 2009 and 2014 at Cork University Hospital Breast Cancer Service, a teaching hospital of University College Cork.

RESULTS

Of 965 sentinel node biopsies performed 251 were identified as SLN positive, 162 (64.5%) underwent further AC. Of the 162 patients, 56.8% (92/162) were positive for ENE at SLN, of these 57.6% (53/92) had NSLN metastasis versus 17.1% (12/70) in the ENE-negative group (χ² test; P < 0.001). On adjusted analysis, ENE at the SLN was a significant predictor of NSLN metastasis (odds ratio [OR] 8.63; 95% confidence interval [CI] 3.26-22.86; P < 0.001). The incidence of NSLN-ENE in patients without SLN-ENE was 1/70 (1.4%) compared with 33.7% (31/92) in patients who had ENE at the SLN (χ² test; P < 0.001).

CONCLUSION

ENE at the SLN is an independent predictor of NSLN involvement; its absence significantly reduces the likelihood of ENE in NSLN metastasis..

Factors Influencing Non-sentinel Node Metastasis in Patients with Macrometastatic Sentinel Lymph Node Involvement and Validation of Three Commonly Used Nomograms

OBJECTIVE

Omitting axillary lymph node dissection (ALND) in a subgroup of patients with sentinel lymph node (SLN) metastasis is becoming a widely accepted practice. Avoiding the well-known complications of ALND is the sole aim without compromising the curative intention of surgery.

MATERIALS AND METHODS

The data were probed for breast cancer patients that were operated on between February 2014 and June 2016. SLN biopsies were performed in 507 patients and out of 157 patients who underwent ALND for a metastatic SLN, 151 were found eligible for the analyses as having macrometastatic (>2mm) SLN. MD Anderson, Memorial Sloan Kettering Cancer Center and Helsinki nomograms were also tested in our patient population.

RESULTS

Pathologic tumor size greater than 2 cm, the ratio of metastatic SLN to dissected SLN, metastatic tumor greater than 1 cm and tumors that extended outside the SLN's capsule were found to be associated with non-sentinel node metastasis in both univariate and multivariate tests. MD Anderson nomogram performed well with an area under the curve (AUC) value of 0.72.

CONCLUSION

Our results suggest that ALND should be considered in patients with macrometastatic SLN greater than 10 mm in size, have extracapsular extension, have metastatic SLNs at a rate of more than 50% and whose primary tumor is greater than 2 cm.

Novel rapid-immunohistochemistry using an alternating current electric field for intraoperative diagnosis of sentinel lymph nodes in breast cancer

Axillary lymph node status and pathological diagnosis of sentinel lymph nodes (SLNs) is a prognostic factor that influences management of postoperative therapy. Recent reports indicate that one-step nucleic acid amplification and hematoxylin and eosin (HE)-stained frozen sections are effective for intraoperative diagnosis of SLNs. In the present study, we report a rapid-immunohistochemical staining (R-IHC) method that enables intraoperative detection of SLN metastases within 16 min using an anti-cytokeratin antibody. This is the first report on SLN diagnosis using R-IHC in patients with breast cancer. We prospectively examined 160 dissected SLNs from 108 breast cancer patients who underwent surgery at our institute. The dissected SLNs were sectioned and conventionally stained with HE or immunohistochemically labeled with anti-cytokeratin antibody using R-IHC procedures. Intraoperative R-IHC analyses were completed within 16 min, after which diagnoses were made by two pathologists. The total time required for intraoperative diagnosis was about 20 min. In this study series, R-IHC detected four metastatic SLNs that were undetected using conventional HE staining (4/20, 20.0%). Compared with subsequent permanent diagnosis, R-IHC offered 95.2% sensitivity and 100% specificity. These findings indicate R-IHC is a clinically applicable technique that enables precise and quick intraoperative detection of micro- and macrometastasis in breast cancer.

Sentinel Lymph Nodes for Breast Carcinoma: A Paradigm Shift

CONTEXT

-Sentinel lymph node biopsy has been established as the new standard of care for axillary staging in most patients with invasive breast carcinoma. Historically, all patients with a positive sentinel lymph node biopsy result underwent axillary lymph node dissection. Recent trials show that axillary lymph node dissection can be safely omitted in women with clinically node negative, T1 or T2 invasive breast cancer treated with breast-conserving surgery and whole-breast radiotherapy. This change in practice also has implications on the pathologic examination and reporting of sentinel lymph nodes.

OBJECTIVE

-To review recent clinical and pathologic studies of sentinel lymph nodes and explore how these findings influence the pathologic evaluation of sentinel lymph nodes.

DATA SOURCES

-Sources were published articles from peer-reviewed journals in PubMed (US National Library of Medicine) and published guidelines from the American Joint Committee on Cancer, the Union for International Cancer Control, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network.

CONCLUSIONS

-The main goal of sentinel lymph node examination should be to detect all macrometastases (>2 mm). Grossly sectioning sentinel lymph nodes at 2-mm intervals and evaluation of one hematoxylin-eosin-stained section from each block is the preferred method of pathologic evaluation. Axillary lymph node dissection can be safely omitted in clinically node-negative patients with negative sentinel lymph nodes, as well as in a selected group of patients with limited sentinel lymph node involvement. The pathologic features of the primary carcinoma and its sentinel lymph node metastases contribute to estimate the extent of non-sentinel lymph node involvement. This information is important to decide on further axillary treatment.

Extra-nodal extension is a significant prognostic factor in lymph node positive breast cancer

Presence of lymph node (LN) metastasis is a strong prognostic factor in breast cancer, whereas the importance of extra-nodal extension and other nodal tumor features have not yet been fully recognized. Here, we examined microscopic features of lymph node metastases and their prognostic value in a population-based cohort of node positive breast cancer (n = 218), as part of the prospective Norwegian Breast Cancer Screening Program NBCSP (1996–2009). Sections were reviewed for the largest metastatic tumor diameter (TD-MET), nodal afferent and efferent vascular invasion (AVI and EVI), extra-nodal extension (ENE), number of ENE foci, as well as circumferential (CD-ENE) and perpendicular (PD-ENE) diameter of extra-nodal growth. Number of positive lymph nodes, EVI, and PD-ENE were significantly increased with larger primary tumor (PT) diameter. Univariate survival analysis showed that several features of nodal metastases were associated with disease-free (DFS) or breast cancer specific survival (BCSS). Multivariate analysis demonstrated an independent prognostic value of PD-ENE (with 3 mm as cut-off value) in predicting DFS and BCSS, along with number of positive nodes and histologic grade of the primary tumor (for DFS: P = 0.01, P = 0.02, P = 0.01, respectively; for BCSS: P = 0.02, P = 0.008, P = 0.02, respectively). To conclude, the extent of ENE by its perpendicular diameter was independently prognostic and should be considered in line with nodal tumor burden in treatment decisions of node positive breast cancer.

Extra-nodal extension of sentinel lymph node metastasis is a marker of poor prognosis in breast cancer patients: A systematic review and an exploratory meta-analysis

Invasive breast cancer is the most common malignancy in women. Its most common site of metastasis is represented by the lymph nodes of axilla, and the sentinel lymph node (SLN) is the first station of nodal metastasis. Axillary SLN biopsy accurately predicts axillary lymph node status and has been accepted as standard of care for nodal staging in breast cancer. To date, the morphologic aspects of SLN metastasis have not been considered by the oncologic staging system. Extranodal extension (ENE) of nodal metastasis, defined as extension of neoplastic cells through the nodal capsule into the peri-nodal adipose tissue, has recently emerged as an important prognostic factor in several types of malignancies. It has also been considered as a possible predictor of non-sentinel node tumor burden in SLN-positive breast cancer patients. We sought out to clarify the prognostic role of ENE in SLN-positive breast cancer patients in terms of overall and disease-free survival by conducting a systematic review and meta-analysis. Among 172 screened articles, 5 were eligible for the meta-analysis; they globally include 624 patients (163 ENE+ and 461 ENE-) with a median follow-up of 58 months. ENE was associated with a higher risk of both mortality (RR = 2.51; 95% CI: 1.66-3.79, p < 0.0001, I(2) = 0%) and recurrence of disease (RR = 2.07, 95% CI: 1.38-3.10, p < 0.0001, I(2) = 0%). These findings recommend the consideration of ENE from the gross sampling to the histopathological evaluation, in perspectives to be validated and included in the oncologic staging.

Decline in Frozen Section Diagnosis for Axillary Sentinel Lymph Nodes as a Result of the American College of Surgeons Oncology Group Z0011 Trial

CONTEXT

-Results of the American College of Surgeons Oncology Group Z0011 trial showed that patients with early-stage breast cancer and limited sentinel node metastasis treated with breast conservation and systemic therapy did not benefit from axillary lymph node dissection. Subsequently, most pathology departments have likely seen a decrease in frozen section diagnosis of sentinel lymph nodes.

OBJECTIVE

-To determine the effect of the Z0011 trial on pathology practice and to examine the utility of intraoperative sentinel lymph node evaluation for this subset of patients.

DESIGN

-Pathology reports from cases of primary breast cancer that met Z0011 clinical criteria and were initially treated with lumpectomy and sentinel lymph node biopsy from 2009 to 2015 were collected. Clinicopathologic data were recorded.

RESULTS

-Sentinel lymph node biopsies sent for frozen section diagnosis occurred in 22 of 22 cases (100%) in 2009 and 15 of 22 cases (68%) in 2010 during the pre-Z0011 years, and in 3 of 151 cases (2%) collected in 2011 through 2015, considered to be post-Z0011 years. Of the 151 post-Z0011 cases, 28 (19%) had sentinel lymph nodes with metastasis, and 147 (97%) were spared axillary lymph node dissection.

CONCLUSIONS

-Following Z0011, intraoperative sentinel lymph node evaluation has significantly decreased at our institution. Prior to surgery, all patients had clinically node-negative disease. After sentinel lymph node evaluation, 97% (147 of 151) of the patients were spared axillary lymph node dissection. Therefore, routine frozen section diagnosis for sentinel lymph node biopsies can be avoided in these patients.

Factors Influencing Non-sentinel Node Involvement in Sentinel Node Positive Patients and Validation of MSKCC Nomogram in Indian Breast Cancer Population

Current guidelines recommend completion axillary lymphnode dissection (ALND) when sentinel lymphnode (SLN) contains metastatic tumor deposit. In consequent ALND sentinel node is the only node involved by tumor in 40-70 % of cases. Recent studies demonstrate the oncologic safety of omitting completion ALND in low risk patients. Several nomograms (MSKCC, Stanford, MD Anderson score, Tenon score) had been developed in predicting the likelihood of additional nodes metastatic involvement. We evaluated accuracy of MSKCC nomogram and other clinicopathologic variables associated with additional lymph node metastasis in our patients. A total of 334 patients with primary breast cancer patients underwent SLN biopsy during the period Jan 2007 to June 2014. Clinicopathologic variables were prospectively collected. Completion ALND was done in 64 patients who had tumor deposit in SLN. The discriminatory accuracy of nomogram was analyzed using Area under Receiver operating characteristic curve (ROC). SLN was the only node involved with tumor in 69 % (44/64) of our patients. Additional lymph node metastasis was seen in 31 % (20/64). On univariate analysis, extracapsular infiltration in sentinel node and multiple sentinel nodes positivity were significantly associated (p < 0.05) with additional lymph node metastasis in the axilla. Area under ROC curve for nomogram was 0.58 suggesting poor performance of the nomogram in predicting NSLN involvement. Sentinel nodes are the only nodes to be involved by tumor in 70 % of the patients. Our findings indicate that multiple sentinel node positivity and extra-capsular invasion in sentinel node significantly predicted the likelihood of additional nodal metastasis. MSKCC nomogram did not reliably predict the involvement of additional nodal metastasis in our study population.

Extracapsular invasion of sentinel lymph nodes is not associated with disease recurrence in breast cancer

The purpose of this study was to evaluate the presence of extracapsular invasion (ECI) in positive sentinel lymph nodes (SLNs) as a predictor of disease recurrence in breast cancer. SLN biopsy was performed on 318 breasts of 316 breast cancer patients, of which 50 (15.7%) had positive SLNs. Six (12.0%) of these 50 cases had disease recurrence. The clinicopathologic features of these cases were reviewed. The ECI at SLNs was not significantly associated with disease recurrence. The recurrence-free interval by Kaplan-Meier curves did not differ significantly among patients with and without ECI at SLNs. On the other hand, metastasis at non-SLNs was observed in 12 cases (24.0%) among the 50 cases with positive SLNs, and in the non-SLN metastasis group there were 7 patients with ECI at non-SLNs. Three of 7 cases with ECI at non-SLNs had disease recurrence and none of those 5 without ECI at non-SLNs had disease recurrence. Our current study suggests that the presence of ECI at metastatic SLNs is not associated with recurrent disease in breast cancer. Our results also imply that patients with ECI at positive non-SLNs have a high risk of disease recurrence.

Prognostic impact and implications of extracapsular lymph node involvement in colorectal cancer: a systematic review with meta-analysis

BACKGROUND

The extranodal extension (ENE) of nodal metastasis (i.e. the extension of tumor cells through the nodal capsule into the perinodal adipose tissue) has recently emerged as an important prognostic factor in different types of malignancies. However, the tumor-node-metastasis (TNM) staging system for colorectal cancer does not consider it as a prognostic parameter. Therefore, we conducted a systematic review and meta-analysis to determine the prognostic role of ENE in patients with lymph node-positive colorectal cancer.

MATERIALS AND METHODS

Two independent authors searched PubMed and SCOPUS until 7 January 2015 without language restrictions. Prospective studies reporting data on prognostic parameters in subjects with colorectal cancer, comparing participants with the presence of ENE (ENE+) versus only intranodal extension (ENE-) were eligible. Data were summarized using risk ratios (RRs) for the number of deaths/recurrences and hazard ratios (HRs) together with 95% confidence intervals (CIs) for time-dependent risk related to ENE+, adjusted for potential confounders.

RESULTS

Thirteen studies including 1336 patients were identified with a median follow-up of 4.7 years. ENE was associated with a higher T stage and tumor grading. In addition, ENE was associated with a significantly increased risk of all-cause mortality (RR = 1.75; 95% CI 1.42-2.16, P < 0.0001, I(2) = 60%; HR = 1.69, 95% CI 1.32-2.17, P < 0.0001, I(2) = 46%) and of recurrence of disease (RR = 2.07, 95% CI 1.65-2.61, P < 0.0001, I(2) = 47%; HR = 2.31, 95% CI 1.54-3.44, P < 0.0001, I(2) = 48%).

CONCLUSIONS

Based of these results, in colorectal cancer, ENE should be considered from the gross sampling to the pathology report, as well as in future oncologic staging systems.

Do the ACOSOG Z0011 Criteria Affect the Number of Sentinel Lymph Nodes Removed?

INTRODUCTION

We sought to determine if adoption of the Z0011 criteria was associated with removal of more sentinel lymph nodes (SLNs).

METHODS

In a retrospective review of a prospective database of breast cancer patients treated at our institution from 2006 to 2013, we identified 5213 eligible patients who elected to undergo breast-conserving surgery; 2372 were treated pre-Z0011 and 2841 post-Z0011. Clinicopathologic factors were collected, and univariate and multivariate models were fit to identify variables associated with number of SLNs removed.

RESULTS

Median patient age, 60 years, did not differ between groups. Median tumor size was similar in both groups: 1.1 (0.05-5.0) cm in the pre-Z0011 group and 1.2 (0.1-5.2) cm in the post-Z0011 group. The mean number of SLNs excised in the pre-Z0011 patients was 2.8 compared with 2.9 in post-Z0011 patients (p = 0.01). Three or fewer lymph nodes were removed in 1771 (75 %) pre-Z0011 patients compared with 2006 (71 %) post-Z0011 patients (p = 0.01). Factors associated with the removal of more SLNs on multivariate analysis included adoption of ACOSOG Z0011 criteria (p = 0.03), young age (p ≤ 0.0001), and large tumor size (p = 0.0005). Axillary lymph node dissection (ALND) was performed in 379 (16 %) patients pre-Z0011 compared with 68 (2 %) node-positive post-Z0011 patients (p < 0.0001).

CONCLUSIONS

Since the adoption of Z0011 criteria, we found significantly fewer patients undergoing ALND for positive SLNs. We noted a significant, slight shift in the removal of ≥4 SLNs. The Z0011 criteria were not associated with a clinically significant increase in the number of SLNs removed.

Extranodal Extension on Sentinel Lymph Node Dissection: Why should we Treat it Differently?

American College of Surgeons Oncology Group Z0011 concluded that axillary lymph node dissection (ALND) may be avoided in selected patients with breast cancer with limited axillary nodal metastasis on sentinel lymph node dissection (SLND). However, patients with extranodal extension (ENE) were excluded to the follow existing standard of care, which is completion ALND. The significance of ENE detected on SLND is not well defined. Our objective was to determine the impact of ENE found on SLND on nonsentinel lymph node (NSLN) metastasis, recurrence, and overall mortality. We evaluated patients with breast cancer treated at a tertiary cancer center from 2005 to 2012. SLND was performed in 655 patients. Of those, 478 of 655 (73.0%) patients had no SLN metastases, 124 of 655 (18.9%) had SLN metastases without ENE (SLN-ENE), and 53 of 655 (8.1%) had SLN metastases with ENE (SLN1ENE). Of patients undergoing ALND, NSLN metastasis was detected in 37 of 84 (44.0%) of patients in the SLN-ENE group and 26 of 45 (57.8%) patients in the SLN1ENE group ( P = 0.14). On adjusted analyses, ENE was associated with increased disease recurrence (odds ratio [OR], 5.48; 95% confidence interval [CI], 1.23 to 24.48; P = 0.03) as well as increased overall mortality (OR, 8.16; 95% CI, 1.72 to 38.63; P = 0.01). In conclusion, ENE is associated with increased overall axillary nodal burden, disease recurrence, and overall mortality.

The extent of extracapsular extension may influence the need for axillary lymph node dissection in patients with T1-T2 breast cancer

BACKGROUND

Whether extracapsular extension (ECE) of tumor in the sentinel lymph node (SLN) is an indication for axillary lymph node dissection (ALND) in patients managed by American College of Surgeons Oncology Group Z0011 criteria is controversial. Here we examine the correlation between ECE in the SLN and disease burden in the axilla.

METHODS

Patients meeting Z0011 clinicopathologic criteria (pT1-2, cN0 with <3 positive SLNs) were selected from a prospectively maintained database (2006-2013). Chart review documented the presence and extent of ECE. Neoadjuvant chemotherapy patients were excluded. Comparisons were made by presence and extent (≤2 vs. >2 mm) of ECE.

RESULTS

Of 11,730 patients, 778 were pT1-2, cN0 with <3 positive SLNs without ECE, and 331 (2.8 %) had ECE. Of these, 180 had ≤2 mm and 151 had >2 mm of ECE. Patients with ECE were older (57 vs. 54 years; p = 0.001) and had larger (2.0 vs. 1.7 cm; p < 0.0001), multifocal (p = 0.006), hormone receptor-positive tumors (p = 0.0164) with lymphovascular invasion (p < 0.0001). Presence and extent of ECE were associated with greater axillary disease burden; 20 and 3 % of patients with and without ECE, respectively, had ≥4 additional positive nodes at completion ALND (p < 0.0001), and 33 % of patients with >2 mm ECE had ≥4 additional positive nodes at completion ALND, compared with 9 % in the <2 mm group (p < 0.0001). On multivariate analysis, >2 mm of ECE was the strongest predictor of ≥4 positive nodes at completion ALND (odds ratio 14.2).

CONCLUSIONS

Presence and extent of ECE were significantly correlated with nodal tumor burden at completion ALND, thus suggesting that >2 mm of ECE may be an indication for ALND or radiotherapy when applying Z0011 criteria to patients with metastases in <3 SLNs. ECE reporting should be standardized to facilitate future studies.

Measuring the impact of the American College of Surgeons Oncology Group Z0011 trial on breast cancer surgery in a community health system

BACKGROUND

The American College of Surgeons Oncology Group Z0011 trial has been lauded as practice changing. We sought to identify its impact on breast cancer surgery in the community hospital setting.

METHODS

A retrospective review was performed from 8 community hospitals identifying patients with invasive breast cancer meeting the Z0011 criteria. The primary outcome measures were the rate of completion axillary lymph node dissection (ALND) and performance of intraoperative sentinel lymph node (SLN) analysis over time.

RESULTS

A total of 1,125 lumpectomies with SLN biopsies were performed with 180 subjects meeting inclusion criteria. Performance of ALND (P < .0001) and intraoperative SLN analysis (P < .0001) declined during each time period. Patients more likely to undergo ALND included those with extracapsular extension (odds ratio [OR] 12.8, 95% confidence interval [CI] 2.5 to 67.1) and those who underwent reoperative surgery (OR 10.8, 95% CI 2.6 to 44.4) or intraoperative SLN analysis (OR 5.1, 95% CI 1.2 to 21.9).

CONCLUSION

American College of Surgeons Oncology Group Z0011 trial has been rapidly practice changing in the community hospital setting.

Patterns of nodal staging during breast conservation surgery in the medicare patient: will the ACOSOG Z0011 trial change the pattern of care?

ACOSOG Z0011 spares axillary dissection (AD) in breast conservation surgery (BCS) patients with T1/T2 tumors and 1-2 positive nodes. Current patterns of care and the impact of Z0011 on AD versus additional surgery rates for Medicare patients undergoing BCS are unknown. SEER data linked to Medicare claims for 1999-2005 were reviewed for women with invasive nonmetastatic breast cancer who underwent nodal staging on the same day as BCS. There were 3,280 women with T1/T2 tumors and positive nodes who underwent same-day nodal staging; 2,532 (77.2 %) of these women had 1-2 positive nodes. Assuming 25.7 % have extracapsular extension, 651 women would require AD. However, 1,881 women, or 57.4 % of those with T1/T2 tumors and positive nodes, would be spared AD. Meanwhile, among the 748 women having ≥ 3 positive nodes, 579 underwent same-day AD, but under Z0011, would now wait for permanent section. A total of 160 of these women underwent re-excision or completion mastectomy at a later date anyway, when delayed AD could be performed. The remaining 419 women with ≥ 3 positive nodes would require an additional surgery date for the sole purpose of completion AD. The Z0011 paradigm would consequently necessitate an additional surgery date for 1,070 (651 + 419) women, or 32.6 % of those with T1/T2 tumors and positive nodes. The Z0011 paradigm appears to increase the number of Medicare patients undergoing BCS who require an additional surgery date but decrease the number requiring AD to a greater extent. Future changes in the use of AD or axillary irradiation may yet modify that impact substantially.

Extranodal metastasis is a powerful prognostic factor in patients with adenocarcinoma of the esophagogastric junction

BACKGROUND AND OBJECTIVES

The purpose of this study is to estimate the effect of extranodal metastasis (EM) on recurrence and survival in patients with adenocarcinoma of the esophagogastric junction (AEG) after curative resection.

METHODS

Clinical data from 284 node-positive AEG patients who underwent curative resection were reviewed. Univariate and multivariate analyses were conducted to elucidate the effect of EM on recurrence-free survival (RFS) and overall survival (OS).

RESULTS

EM was detected in 70 (24.6%) of the 284 cases. It had a significant correlation with tumor size, Lauren type, histopathological grading, depth of tumor invasion, number of metastatic nodes, lymph node ratio, and TNM stage. The 5-year RFS and OS rates were 22.2% and 24.3%, respectively. Patients with EM had a significantly decreased RFS (16 vs. 36 months, P < 0.001) and OS (23 vs. 41 months, P < 0.001) compared with those without EM. Multivariate analyses identified EM as an independent prognostic factor (P = 0.003 and 0.001, respectively).

CONCLUSION

The presence of EM increases recurrence probability and reduces OS probability of AEG patients with lymph node metastasis. EM is a powerful prognostic factor reflecting a particularly aggressive biological behavior. Better understanding of EM status can help clinicians with regard to treatment decision and prognosis evaluation.

Detailed stratification of TNM stage III rectal cancer based on the presence/absence of extracapsular invasion of the metastatic lymph nodes

BACKGROUND

The presence/absence of extracapsular invasion in metastatic lymph nodes has been reported as being significantly correlated with the prognosis in a wide variety of cancers. However, the influence of extracapsular invasion in the metastatic lymph nodes on the prognosis in patients with stage III rectal cancer has not yet been investigated.

OBJECTIVE

We investigated the presence/absence of extracapsular invasion in the metastatic nodes of the relevant main/lateral lymph node group in patients with rectal cancer to determine the usefulness of this parameter for stratifying the prognosis of patients with stage III rectal cancer.

DESIGN

This was a single-institution study.

SETTINGS

This study was conducted at a single institution.

PATIENTS

We enrolled 101 consecutive patients with stage III rectal cancer who had undergone curative surgery with extended lymph node dissection and investigated the presence/absence of extracapsular invasion in the regional metastatic lymph nodes to determine the usefulness of such stratification for a more precise prediction of the patient prognosis.

MAIN OUTCOME MEASURES

The main outcomes measured were the disease-free and overall survival rates.

RESULTS

Univariate analysis revealed a significantly poorer prognosis, in terms of both the disease-free survival rate (p = 0.003) and overall survival rate (p = 0.008), of the pN3-extracapsular invasion-positive cases in comparison with the pN3-extracapsular invasion-negative cases. Multivariate analysis revealed the presence/absence of extracapsular invasion in the metastatic lymph nodes as the only variable that was statistically significantly associated with the disease-free survival rate (p = 0.011).

LIMITATIONS

This was a retrospective study in a small number of patients from a single institution. There were no comparator groups.

CONCLUSIONS

Detailed stratification of pN3 cases based on the presence/absence of extracapsular invasion in metastatic lymph nodes has the potential to contribute significantly to more available prediction of the prognosis of patients with stage III colorectal cancer.

Evaluation of extra capsular lymph node involvement in patients with extra-hepatic bile duct cancer

Background

Lymph node metastasis is one of the most important prognostic factors for extra-hepatic bile duct carcinoma (ExHBDC). Extra capsular lymph node involvement (ExCLNI) is the extension of cancer cells through the nodal capsule into the perinodal fatty tissue. The prognostic impact of ExCLNI has been shown to be significant mainly in head and neck malignancies. Recently, the prognostic impacts of ExCLNI have evaluated in gastrointestinal malignancies. However no data is available regarding the incidence and prognostic significance of extra-capsular lymph node involvement (ExCLNI) in resectable ExHBDCs. The aim of the present study is first to evaluate the incidence of ExCLNI in surgically-treated ExHBDCs and second, to determine the prognostic impact of ExCLNI in patients with surgically-treated ExHBDCs.

Methods

A total of 228 patients (110 cases of hilar cholangiocarcinoma and 118 cases of distal cholangiocarcinoma) with surgically-treated ExHBDCs were included in this retrospective study. ExCLNI was defined as the extension of cancer cells through the nodal capsule into the perinodal fatty tissue. The existence of ExCLNI and its prognostic value were analyzed as a subgroup of lymph node metastasis.

Results

ExCLNI was detected in only 22% of patients with lymph node metastasis of surgically-treated ExHBDC. The presence of ExCLNI correlated with distal cholangiocarcinoma (p = 0.002). On univariate analysis for survival, perineural invasion, vascular invasion, histological grade, and lymph node metastasis were statistically significant factors. On multivariate analysis, only lymph node metastasis was identified as a significant independent prognostic factor in patients with resectable ExHBDC. Subgroups of lymph node metastasis including the presence of ExCLNI, location of lymph node metastasis, and the number of lymph node metastasis had no statistically significant impact on survival.

Conclusion

ExCLNI was present in only 22% of the LNM (7% of overall patients) in patients with surgical treated ExHBDCs. And ExCLNI would have no impact on the survival of patients with surgically-treated ExHBDCs.

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.

Predictors of non-sentinel lymph node metastasis in breast cancer patients with positive sentinel lymph node (Pilot study)

BACKGROUND

Sentinel Lymph Node Biopsy (SLNB) procedure was found to be an accurate method of staging the axilla in patients with early stage breast cancer. The standard of care for breast cancer patients with positive SLN metastasis includes complete Axillary Lymph Node Dissection (ALND). However, in 40-70% of patients, the SLN is the only involved axillary node. Factors predicting non SLN metastasis should be identified in order to define subgroups of patients with positive SLN in whom the axilla may be staged by SLNB alone.

OBJECTIVES

To identify the factors predicting metastatic involvement of the non-SLNs in breast cancer patients having SLN metastasis.

PATIENTS AND METHODS

Data were collected and analyzed from 80 patients with early stage invasive breast cancer (T1, T2, N0, M0) who underwent SLNB at the Surgical Oncology Department, Kuwait Cancer Control Center (KCCC) between November 2004 and February 2009. SLNB was performed using a combined technique (radioactive colloid, and blue dye) in the majority of cases. In some cases, only one technique was used. Complete ALND was performed in the case of failure of SLN identification and in patients with positive SLN. Multiple variables (patient, tumor, and SLN characteristics) were tested as possible predictors of nonsentinel lymph node metastasis.

RESULTS

The mean age of patients at diagnosis was 46.6years. The median tumor size was 2cm. The SLN identification rate was 96.2% (77 out of 80 patients). The SLN was positive in 24 patients (31%), and half of these showed evidence of capsular invasion. The median number of SLNs removed was two. The median number of positive SLNs was one. The incidence of non-SLN metastasis associated with positive SLN was 50% (12 out of 24 patients). Lymphovascular invasion was found to be the only factor associated with non-SLN metastases. In addition, two trends were observed, though they did not reach the statistical significance: the first is that the majority of patients having capsular invasion of the SLN (8 out of 12 patients, 67%) had positive non-SLN metastasis, and the second is that the patients having more than one SLN metastasis were more likely to have non-SLN metastasis (4 out of 5, 80%).

CONCLUSION

In the current pilot study, only the lymphovascular invasion in the area of the primary tumor was found to be significantly related to the nonsentinel lymph node metastasis. There was a tendency toward higher incidence of nonsentinel lymph node metastasis associated with the number of positive SLN and capsular invasion of SLN, though this did not reach the statistical significance. This could be attributed to the small number of patients recruited. Further evaluation of the predictors of nonsentinel lymph node metastasis on a larger number of patients is required. The validation of these predictors in prospective studies may enable approximately half of early stage breast cancer patients with positive SLN to be staged with SLNB alone while avoiding the morbidity of unnecessary ALND.

The prognostic impact of extracapsular lymph node involvement in rectal cancer patients: Implications for staging and adjuvant treatment strategies

Limited data suggest that extracapsular lymph node involvement (LNI) has a negative prognostic impact in gastrointestinal malignancies. The aim of this study was to assess the prevalence and prognostic impact of LNI in patients with primary resected rectal cancer. Between 1997 and 2007, 243 rectal cancer patients underwent surgical therapy without neoadjuvant treatment at our Department. Of these, 12 (5%) patients received transanal endoscopic microsurgery and were not included for further analyses. In the remaining patients, a (low) anterior resection was performed in 79% and an abdominoperineal rectal amputation in 21%. The total number of analyzed lymph nodes and the number of metastatic lymph nodes with/without extracapsular LNI were determined and the prognostic impact of LNI was assessed. The median number of analyzed lymph nodes was 14. In total, 59% of patients were node-negative, 18% of patients were node-positive without extracapsular LNI and 23% of patients were node-positive with extracapsular LNI. A positive lymph node status with extracapsular LNI was significantly correlated with a poorer T-, N- and M-category, grading and more frequent lymphatic vessel infiltration compared with node-negative or node-positive without extracapsular LNI patients (p<0.001). The overall 5-year survival rate of node-negative patients was 75%, for node-positive without extracapsular LNI patients 69% and for node-positive with extracapsular LNI patients 36% (p<0.001). By multivariate analysis, the N-category with extracapsular LNI was characterized as an independent prognostic factor. Extracapsular lymph node involvement reveals an independent negative prognostic impact in patients with rectal cancer undergoing surgical therapy. Staging systems for rectal cancer should include the implementation of extracapsular lymph node involvement.

Lymph node metastases and prognosis in oesophageal carcinoma--a systematic review

Oesophageal cancer is the 7th most common cause of cancer-related death in the developed world and the incidence of oesophageal adenocarcinoma is now the fastest growing of any gastrointestinal cancer. Lymph node involvement is the single most important prognostic factor in oesophageal cancer. Imaging to determine the extent of lymph node involvement and plan treatment often requires a combination of modalities to avoid under-staging. The 7th edition of the staging system released by the International Union Against Cancer (IUCC) has stratified lymph node involvement according to the number of lymph nodes involved and redefined its groupings for location of metastatic lymph node involvement. This review discusses the prognostic and treatment implications of these modifications and explores micrometastatic lymph node involvement, capsular infiltration and lymph node ratio as possible additions to the staging system.

Process of distant lymph node metastasis in colorectal carcinoma: implication of extracapsular invasion of lymph node metastasis

BACKGROUND

We previously demonstrated that extracapsular invasion (ECI) at a metastatic sentinel node was significantly associated with the presence of positive non-sentinel nodes in patients with breast cancer. However, the mechanism of metastatic spreading of tumor cells to distant lymph nodes in patients with colorectal carcinoma is not fully understood. In this study, we investigated the factors that may determine the likelihood of additional regional lymph node metastasis when metastasis is found in nodes at the N1 site in colorectal cancer, especially focusing on the presence of ECI.

METHODS

Two hundred and twenty-eight consecutive patients who underwent colorectal resection were identified for inclusion in this study, of which 37 (16.2%) had positive lymph nodes at the N1 site. Six of these 37 cases had additional metastasis in N2 site lymph nodes. We reviewed the clinicopathological features of these cases and performed statistical analysis of the data.

RESULTS

In the univariate analysis ECI at the N1 site was the only factor significantly associated with the presence of cancer cells in the N2 site. Other factors, including number of positive lymph nodes, lymphovascular invasion of the primary tumor, tumor size and tumor depth of invasion, were not associated with metastatic involvement at the N2 site.

CONCLUSIONS

Our results suggest that the presence of ECI at metastatic lymph nodes at the N1 site is correlated with further metastasis at the N2 site. These findings imply the possibility that ECI might indicate the ability of colorectal tumor cells to disseminate to distant lymph nodes.

Extracapsular invasion as a risk factor for disease recurrence in colorectal cancer

AIM: To evaluate the presence of extracapsular invasion (ECI) in positive nodes as a predictor of disease recurrence disease in colorectal cancer.

METHODS: Two hundred and twenty-eight consecutive patients who underwent colorectal resection were identified for inclusion in this study, of which 46 had positive lymph nodes. Among 46 cases with stage IIIcolorectal cancer, 16 had ECI at positive nodes and 8 had disease recurrence. The clinical and pathological features of these cases were reviewed.

RESULTS: In the univariate analysis, the number of positive lymph nodes and depth of tumor invasion were significantly associated with the presence of ECI at positive nodes. Multivariate analysis demonstrated that only ECI was a predictor of recurrence. The recurrence-free interval differed significantly among patients with ECI at positive nodes.

CONCLUSION: Our results suggest that ECI at metastatic nodes can identify which cases are at high risk of short-term disease recurrence in colorectal 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.

Neoadjuvant chemoradiotherapy for esophageal cancer: Impact on extracapsular lymph node involvement

AIM: To assess the effects of neoadjuvant chemoradiotherapy (CRT) on the presence of extracapsular lymph node involvement (LNI) and its prognostic value in patients with resected esophageal cancer.

METHODS: Two hundred and ninety-eight patients with advanced esophageal cancer underwent esophagectomy between 1997 and 2006. One hundred and ninety patients (63.8%) were treated with neoadjuvant CRT prior to resection. A total of 986 metastatic LNs were examined. Survival of the patients was analyzed according to intra- and extra-capsular LNI.

RESULTS: Five-year survival rate was 22.5% for the entire patient population. Patients with extracapsular LNI had a 5-year survival rate of 16.7%, which was comparable to the 15.8% in patients with infiltrated nodes of the celiac trunk (pM1lymph). In contrast to patients treated with surgery alone, neoadjuvant therapy resulted in significantly (P = 0.001) more patients with pN0/M0 (51.6% vs 25.0%). In 17.6% of the patients with surgery alone vs 16.8% with neoadjuvant CRT, extracapsular LNI was detected. Neoadjuvant therapy does not reduce the occurrence of extracapsular LNI.

CONCLUSION: Extracapsular LNI is an independent negative prognostic factor not influenced by neoadjuvant CRT. In a revised staging system for esophageal cancer, extracapsular LNI should be considered.

The predicted probability of having positive non-sentinel lymph nodes in patients who received neoadjuvant chemotherapy for large operable breast cancer

The accuracy of the nomogram in women with positive sentinel nodes following neoadjuvant chemotherapy (NCT) is unknown. The aim of this study was to evaluate the accuracy of the nomogram in patients receiving NCT. Between December 1999 and December 2005, we identified 233 patients who had a positive sentinel lymph node biopsy (SLNB) and complete axillary lymph node dissection at Magee-Womens Hospital of University of Pittsburgh Medical Center. Thirty-two patients (14%) had presented with clinically N0 breast cancer (BC) for which NCT was administered. The computerised BC nomogram was used to calculate the probability of non-sentinel node metastases utilising tumour size before NCT and after NCT for the same patient. The discrimination of the nomogram was assessed by calculating the area under (AUC) the receiver operating characteristic curve (ROC). The median patient age was 51.5 (range: 39-66) years in the NCT group of patients. Twelve patients (37%) had positive axillary non-sentinel lymph nodes (NSLNs). The nomogram was first validated in our institution for 201 patients without NCT and the predicted accuracy of the nomogram by the AUC was 0.73. The area under the ROC was identical regardless of whether pre- or posttreatment tumour size was used to determine predicted probability of NSLN metastases (0.66). The predictive accuracy of the nomogram was found to have less power for patients receiving NCT (0.66) than the non-NCT group of patients.

Extracapsular tumor spread and the risk of local, axillary and supraclavicular recurrence in node-positive, premenopausal patients with breast cancer

BACKGROUND

Extracapsular tumor spread (ECS) has been identified as a possible risk factor for breast cancer recurrence, but controversy exists regarding its role in decision making for regional radiotherapy. This study evaluates ECS as a predictor of local, axillary, and supraclavicular recurrence.

PATIENTS AND METHODS

International Breast Cancer Study Group Trial VI accrued 1475 eligible pre- and perimenopausal women with node-positive breast cancer who were randomly assigned to receive three to nine courses of classical combination chemotherapy with cyclophosphamide, methotrexate, and fluorouracil. ECS status was determined retrospectively in 933 patients based on review of pathology reports. Cumulative incidence and hazard ratios (HRs) were estimated using methods for competing risks analysis. Adjustment factors included treatment group and baseline patient and tumor characteristics. The median follow-up was 14 years.

RESULTS

In univariable analysis, ECS was significantly associated with supraclavicular recurrence (HR = 1.96; 95% confidence interval 1.23-3.13; P = 0.005). HRs for local and axillary recurrence were 1.38 (P = 0.06) and 1.81 (P = 0.11), respectively. Following adjustment for number of lymph node metastases and other baseline prognostic factors, ECS was not significantly associated with any of the three recurrence types studied.

CONCLUSIONS

Our results indicate that the decision for additional regional radiotherapy should not be based solely on the presence of ECS.

The prognostic significance of extracapsular lymph node involvement in node positive patients with colonic cancer

AIMS

In colonic cancer the prognostic significance of extracapsular lymph node involvement (LNI) is not established and is therefore the objective of this study.

METHODS

Between January 1994 and May 2005, all patients who underwent resection for primary colonic cancer with lymph node metastasis were reviewed. All resected lymph nodes were re-examined to assess extracapsular LNI. In uni- and multivariate analysis disease-free survival (DFS) was correlated with various clinicopathologic factors.

RESULTS

One hundred and eleven patients were included. In 58 patients extracapsular LNI was identified. Univariate analysis revealed that pN-stage (5-year DFS pN1 vs. pN2: 65% vs. 14%, p<0.001), extracapsular LNI (5-year DFS intracapsular LNI vs. extracapsular LNI: 69% vs. 41%, p=0.003), and lymph node ratio (5-year DFS <0.176 vs. > or =0.176: 67% vs. 42%, p=0.023) were significant prognostic indicators. Among these variables pN-stage (hazard ratio 3.5, 95% confidence interval [CI]: 1.72-7.42) and extracapsular LNI (hazard ratio 1.98, 95% CI: 1.00-3.91) were independent prognostic factors. Among patients without extracapsular LNI, those receiving adjuvant chemotherapy had a significantly better survival (p=0.010). In contrast, chemotherapy did not improve DFS in patients with extracapsular LNI.

CONCLUSION

Together with pN2 stage, extracapsular LNI reflects a particularly aggressive behaviour and has significant prognostic potential.

Prognostic significance of extracapsular lymph node involvement in patients with adenocarcinoma of the ampulla of Vater

Background

Lymphatic dissemination is an important predictor of survival in patients with adenocarcinoma of the ampulla of Vater. The incidence and clinical consequences of extracapsular lymph node involvement (LNI) in patients who undergo resection are unknown.

Methods

In a consecutive series of 160 patients with adenocarcinoma of the ampulla of Vater, 75 (46·9 per cent) had positive lymph nodes (N1). The relation of extracapsular LNI with tumour stage and number of positive nodes was evaluated and its prognostic significance analysed.

Results

Extracapsular LNI was identified in 44 (59 per cent) of the 75 patients. Median overall survival was 30 and 18 months in patients with intracapsular and extracapsular LNI respectively (P = 0·015). The 5-year overall survival rate was 20 and 9 per cent respectively, compared with 59 per cent in patients without LNI (N0). Extracapsular LNI and tumour differentiation were independent prognostic factors for survival. In patients with N1 disease, extracapsular LNI was the only significant prognostic factor for recurrent disease after radical resection (R0).

Conclusion

The presence of extracapsular LNI identifies a subgroup of patients who have a significantly worse prognosis. Adjuvant therapy is advised following resection in these patients.

Solitary positive sentinel lymph node accompanied by negative sentinel lymph node(s) is predictive of a negative completion axillary lymph node dissection

BACKGROUND

Many patients with a positive sentinel lymph node (SLN) have a negative axillary lymph node dissection (ALND). We hypothesized that a solitary positive SLN associated with at least 1 negative SLN is predictive of a negative completion ALND. Omission of ALND may be possible in these patients.

METHODS

A retrospective review of 392 consecutive patients who underwent SLNB was performed. The 78 (20%) SLN-positive patients were divided into 4 groups: group 1: solitary positive SLN associated with at least 1 negative SLN; group 2: more than 1 positive SLN with at least 1 negative SLN; group 3: solitary positive SLN with no additional SLNs; and group 4: more than 1 positive SLN and all SLNs positive.

RESULTS

Excluding extracapsular extension, only 3% of group 1 patients had a positive ALND. Positive ALND was found in 15% of group 2, 29% of group 3, and 77% of group 4.

CONCLUSIONS

A solitary positive SLN accompanied by additional negative SLN(s) is predictive of a negative completion ALND.

[Sentinel node biopsy in invasive breast cancer in 2007]

Sentinel lymph node (SN) biopsy for breast cancer has been introduced in the mid-1990s and it has now been performed on thousands of patients. This procedure has been rapidly adopted around the world by surgical specialists in clinical practice as a diagnostic procedure instead of the axillary lymph node dissection. The diffusion of the SN mapping in routine must be careful by respecting some principles of methodology and especially of training, in order to maintain its irreversible development. However, the advent of this mini-invasive technique revealed new questions, which the concept of the SN procedure raises: can we increase the current indications? Could axillary lymph node dissection be avoided in patients with metastatic SN? What is the morbidity of the biopsy of the SN? Which is the prognostic value of micrometastatis discovered by the diffusion of the ultra-stadification of the SNs? The GS procedure is a diagnostic method the reliability of which is now on accepted in its usual indications (tumours in place, small size breast tumour without palpable adenopathy). The value of the axillary dissection after metastatic SN is the subject of debates and controversies although axillary dissection remains recommended. So the use of scores or predictive nomograms is currently developed to select the patients being able not to justify of complementary axillary dissection, and seems promising.

Prediction of nonsentinel lymph node metastasis in sentinel node–positive breast carcinoma

The incidence of nonsentinel (NSN) lymph node metastases in patients with a tumor-positive sentinel (SN) lymph node varies greatly from 20% to 70% in the published literature. Current practice is that most patients with a positive SN (micro- and macrometastases) undergo a complete axillary dissection. However, it has been shown by other investigators that a large number of patients with a positive SN do not necessarily need a complete axillary dissection. In this analysis, we reviewed the pathology slides from 58 patients who had undergone SN and axillary node dissection. The tumor size, histologic parameters, receptor (estrogen and progesterone), and HER-2neu oncoprotein expression were noted. Student t test and Fisher exact test were used for statistical analysis. Of 58 patients, 19 (32.7%) had NSN metastases. Primary tumor size (P < .002), size of SN metastatic tumor (P < .03), and the presence of extracapsular tumor extension (P < .0001) were associated significantly with NSN metastases. We have shown in this study that it would be possible to predict the NSN status based on primary tumor size, size of SN metastatic tumor, and presence of SN extracapsular tumor extension.

A systematic review on the significance of extracapsular lymph node involvement in gastrointestinal malignancies

AIMS

The impact of extracapsular lymph node involvement (LNI) has been studied for several malignancies, including gastrointestinal malignancies. Aim of this study was to assess the current evidence on extracapsular LNI as a prognostic factor for recurrence in gastrointestinal malignancies.

METHODS

The Cochrane Database of systematic reviews, the Cochrane central register of controlled trials, and MEDLINE databases were searched using a combination of keywords relating to extracapsular LNI in gastrointestinal malignancies. Primary outcome parameters were incidence of extracapsular LNI and overall five-year survival rates.

FINDINGS

Fourteen manuscripts were included, concerning seven oesophageal, three gastric, one colorectal, and three rectal cancer series with a total of 1528 node positive patients. The pooled incidence of extracapsular LNI was 57% (95% CI: 53-61%) for oesophageal cancer, 41% (95% CI: 36-47%) for gastric cancer, and 35% (95% CI: 31-40%) for rectal cancer. In nine of the 14 studies a multivariate analysis was performed. In eight of these nine studies extracapsular LNI was identified as an independent risk factor for recurrence.

CONCLUSION

Extracapsular LNI is a common phenomenon in patients with gastrointestinal malignancies. It identifies a subgroup of patients with a significantly worse long-term survival. This systematic review highlights the importance of assessing extracapsular LNI as a valuable prognostic factor. Pathologists and clinicians should be aware of this important feature.