The value of level III clearance in patients with axillary and sentinel node positive breast cancer

Breast Cancer Patients With Positive Apical or Infraclavicular/Ipsilateral Supraclavicular Lymph Nodes Should Be Excluded in the Application of the Lymph Node Ratio System

Aim: Increasing studies have demonstrated lymph node ratio (LNR) to be an accurate prognostic indicator in breast cancer and an alternative to pN staging; however, the AJCC-TNM staging system classified apical or infraclavicular/ipsilateral supraclavicular lymph node-positive (APN(+)) patients with a worse prognosis as the pN3 stage. Until now, different reports on LNR in breast cancer have ignored this possibility. Consequently, it is necessary to discuss the role of APN(+) patients in the LNR system to obtain a precise LNR that predicts the prognosis accurately.

Materials and Methods: We collected data on 10,120 breast cancer patients, including 3,936 lymph node-positive patients (3,283 APN(−) and 653 APN(+) patients), who visited our hospital from 2007 to 2012. Then we applied X-tile analysis to calculate cut-off values and conduct survival analysis and multivariate analysis to evaluate patients’ prognosis.

Results: We confirmed that some APN(+) patients were mis-subgrouped according to previously reported LNR, indicating that APN(+) patients should be excluded in the application of LNR to predict prognosis. Then we applied X-tile analysis to calculate two cut-off values (0.15 and 0.34) for LNR-APN(−) patients and conducted survival analysis and found that LNR-APN(−) staging was superior to pN staging in predicting the prognosis of APN(−) breast cancer patients.

Conclusion: From this study, we conclude that excluding APN(+) patients is the most necessary condition for effective implementation of the LNR system. LNR-APN(−) staging could be a more comprehensive approach in predicting prognosis and guiding clinicians to provide accurate and appropriate treatment.

Dissection of Level III Axillary Lymph Nodes in Breast Cancer

Axillary lymph node dissection is an indispensable step in modified radical mastectomy for breast cancer. It is the most reliable method and the golden standard to determine the status of axillary lymph nodes. It is also of great importance to evaluate the prognosis and develop treatment plans for breast cancer patients. Axillary lymph node dissection can be anatomically divided into levels I, II, and III. Level I and Level II axillary lymph dissection is the standard clinical treatment of axillary lymph nodes positive breast cancer, whereas level III axillary lymph node dissection has been controversial. Level III axillary lymph node metastasis is one of the important factors that can easily cause distant metastasis and recurrence. It is also an important index to estimate the prognosis of breast cancer patients. To facilitate the decision of whether or not to perform level III lymph node dissection, we reviewed the indications, complications, and surgical procedures of level III lymph node dissection.

Impact of the extent of axillary surgery in patients with N2-3 disease in the de-escalation era: a propensity score-matched study

BACKGROUND

Reduction of surgeries in axillary has been proved feasible in breast cancer with negative and limited involved axillary lymph nodes. However, for women with a heavy axillary burden, the extent of dissection is still arguable.

PATIENTS AND METHODS

From a total of 7042 patients with breast cancer who underwent surgical treatments between 2008 and 2014, 692 (9.85%) patients with the axillary staging of N2-3M0 were classified into Level I-II dissection group and Level I-III dissection group. 203 pairs of patients were matched by the propensity score.

RESULTS

The positive rate of level-III lymph nodes is 62.4% in patients who underwent Level I-III dissection. There are 67 (22.1%) patients who experienced rise in staging from N2 to N3 due to level-III dissection. With a median follow-up of 62.4 months, no significant difference was observed in RFS (P = 0.897), MFS (P = 0.610) and OS (P = 0.755) between level I-II group and level I-III group. The same results were observed in the independent analysis of neoadjuvant and non-neoadjuvant subgroups. The binary regression model showed the positivity of level-III is only associated with involved lymph nodes in level-II.

CONCLUSION

Additional level-III dissection has a limited impact on survival but still valuable in an accurate stage. The reduction of surgeries in axillary should be treated with discretion in breast cancer patients with a heavy axillary burden.

The application of methylene blue coloration technique in axillary lymph node dissection of breast cancer

Background

To analyze the associated factors that affect the coloration of methylene blue (MB) in axillary lymph node dissection (ALND) of patients with breast cancer and to explore the tracer effect of MB in high axillary lymph node metastasis, to guide surgical treatment.

Methods

We recruited 170 patients who underwent ALND, all of them were injected MB before operation. We analyzed the relationships between the clinical factors of age, body mass index (BMI), molecular typing, TNM staging, neoadjuvant chemotherapy, injection time and position and the MB coloration by univariate and multivariate analyses. A total of 84 cases were selected for observation of the application value of MB during intervention involving the lymph nodes upper axillary vein.

Results

Of 170 cases, 138 cases (81.17%) were colored. Univariate analysis showed that significant differences were observed between differing BMI’s (χ²=24.074, P<0.0001) and injection times (χ²=41.207, P<0.0001). Multivariate analysis showed that injection time (P=0.016) was the clinical factor associated with MB coloration. More than 60 minutes before surgery and MB injection, the possibility of methylene blue colored was 0.088 times higher than 10 minutes (P=0.010, 95% CI, 0.014, 0.554). MB was used to track the lymph node upper axillary vein with a sensitivity of 12.5%, a specificity of 100%, a false negative rate of 87.50%, and a false positive rate of 0; the kappa coefficient was 0.051 (χ²=0.679, P=0.404).

Conclusions

Among the clinical factors, MB coloration was worse more than 60 minutes before ALND. Using the technology of MB color, lymph nodes can be clearly identified. It has great guiding value for the doctors who learn the operation initially. However, it is still prudent to use MB for high lymph node dissection.

Level III axillary lymph nodes involvement in node positive breast cancer received neoadjuvant chemotherapy

OBJECTIVE

To investigate the incidence, associated factors and prognosis of level III node involvement for breast cancer with positive axillary lymph nodes after neoadjuvant chemotherapy.

METHODS

A consecutive series of 521 node positive T0-2 invasive breast cancer cases were included in this retrospective study. Axillary node metastases were proved by ultrasound guided needle biopsy (NB) if ultrasonographic abnormal node was detected or by sentinel node biopsy (SNB) if no abnormal node was detected. After 4 to 8 cycles of neoadjuvant chemotherapy (NCT）, axillary lymph nodes dissection included level III lymph nodes were completed for each case.

RESULTS

The pathologic complete response rate of axillary nodes was 31.1% (90/289) in NB positive subgroup. The incidence of residual positive level III lymph nodes were 9.0% (47/521). Multivariate analysis showed that node NB positivity (OR = 2.212, 95% CI: 1.022-4.787, P = 0.044), clinical tumor size >2 cm before NCT (OR = 2.672, 95% CI: 1.170-6.098, P = 0.020), and primary tumor non-response to neoadjuvant chemotherapy (OR = 1.718, 95% CI: 1.232-2.396, P = 0.001) were independent predictors of level III lymph nodes positivity. At median follow-up time of 30 months, the distant disease-free survival (DDFS) rate of level III node positive group was much lower than that of level III negative group (p = 0.011).

CONCLUSIONS

About 9% of node positive T0-2 breast cancer will have residual positive node in level III region after neoadjuvant chemotherapy. Node positivity proved by NB, large tumor size, and primary tumor non-response to neoadjuvant chemotherapy are independent predictors of level III lymph nodes positivity.

Intercostobrachial nerves as a novel anatomic landmark for dividing the axillary space in lymph node dissection

Purpose. Our aim was to assess the feasibility of using the intercostobrachial nerves (ICBNs) as a possible new anatomic landmark for axillaries lymph node dissection in breast cancer patients. Background Data Summary. The preservation of ICBN is now an accepted procedure in this type of dissection; however, it could be improved further to reduce the number of postoperative complications. The axillary space is divided into lower and upper parts by the ICBN-a thorough investigation of the metastasis patterns in lymph nodes found in this area could supply new information leading to such improvements. Methods. Seventy-two breast cancer patients, all about to undergo lymph node dissection and with sentinel lymph nodes identified, were included in this trial. The lymph nodes were collected in two groups, from lower and upper axillary spaces, relative to the intercostobrachial nerves. The first group was further subdivided into sentinel (SLN) and nonsentinel (non-SLN) nodes. All lymph nodes were tested to detect macro- and micrometastasis. Results. All the sentinel lymph nodes were found under the intercostobrachial nerves; more than 10 lymph nodes were located in that space. Moreover, when lymph nodes macrometastasize or micrometastasize above the intercostobrachial nerves, we also observe metastasis-positive nodes under the nerves; when the lower group nodes show no metastasis, the upper group is also metastasis free. Conclusions. Our results show that the intercostobrachial nerves are good candidates for a new anatomic landmark to be used in lymph node dissection procedure.