Predictive Factors for Non-Sentinel Lymph Node Metastasis in Patients with ACOSOG Z0011 Criteria

Predictive value of chest computed tomography for axillary lymph node metastasis in patients with breast cancer: A retrospective cohort study

Purpose: This study aimed to evaluate the predictive value of preoperative chest computed tomography (CT) for axillary lymph node (ALN) metastasis in patients with breast cancer.Methods: CT features of ALNs were retrospectively reviewed in 212 patients with breast cancer who underwent preoperative chest CT examination and ALN dissection. Primary tumor size and CT characteristics of ALNs (cortical thickness, cortical shape, the presence or absence of contrast enhancement of ALNs, and the presence or absence of perinodal infiltration) were recorded and analyzed. A nomogram was developed to visualize the associations between the predictors and each ALN status endpoint.Results: Of 212 patients, 95 (44.8%) had ALN metastasis. Primary tumor size and CT characteristics of ALNs were identified as predictors of ALN metastasis. The nomogram comprising primary tumor size and cortical shape was a good validation model for predicting ALN metastasis. The sensitivity, specificity, and accuracy of the nomogram for predicting ALN metastasis were 88.4%, 79.5%, and 83.5%, respectively.Conclusion: Using preoperative chest CT scans, a nomogram combining the cortical shape of ALNs with the primary tumor size showed good performance in predicting ALN metastasis.

Effect of non-sentinel metastasis on adjuvant treatment decisions and survival in Z0011 eligible non-screened detected breast cancer population

BACKGROUND

The Z0011 trial results have shown that axillary lymph node dissection (ALND) can be avoided in cT1-2 patients undergoing breast conservation surgery with 1-2 metastatic sentinel lymph nodes (SLNs). We compared the clinicopathological characteristics of the Z0011 eligible non-screen detected breast cancer patients' cohort with the Z0011 trial study population. Additionally, we have explored the effect of non-sentinel metastasis on adjuvant treatment decisions and survival.

METHODS

The details of early breast cancer (EBC) patients fulfilling Z0011 eligibility criteria were retrieved from a prospectively maintained database (2013-2017) and electronic medical records. We used Statistical Package for the Social Sciences 25 and Stata V15 for the data analysis.

RESULTS

128/194 (66%) sentinel lymph node biopsy positive patients had fulfilled the Z0011 inclusion criteria. Compared to the Z0011 study, our cohort patients were younger, with more aggressive disease (higher T2, Grade 3), had a higher rate of macrometastasis (82.8% versus 58.8%) and non-SLN metastasis (48% versus 27%). The information gained by ALND had changed decisions for chemotherapy in 3% and no change of radiotherapy in Z0011 eligible patients. Further nodal positivity in completion ALND was not significantly associated with overall survival (p = 0.86) and disease-free survival (p = 0.5).

CONCLUSION

Z0011 eligible Indian EBC patients are significantly different from the Z0011 study population, with younger age of presentation, higher grade, a higher rate of both SLN macro metastasis and non-SLN positivity. The impact of non-sentinel metastasis on adjuvant treatment decisions and survival is minimal.

Establishment of risk prediction nomogram for ipsilateral axillary lymph node metastasis in T1 breast cancer

:To establish and verify a risk prediction nomogram for ipsilateral axillary lymph node metastasis in breast cancer stage T1 （mass ≤ 2 cm）. :The clinicopathological data of 907 patients with T1 breast cancer who underwent surgical treatment from January 2010 to June 2015 were collected，including 573 cases from the Second Affiliated Hospital of Zhejiang University School of Medicine （modeling group） and 334 cases from Zhejiang University Lishui Hospital （verification group）. The risk factors of ipsilateral axillary lymph node metastasis were analyzed by univariate and multivariate logistic regression. The influencing factors were used to establish a nomogram for predicting ipsilateral axillary lymph nodes metastasis in T1 breast cancer. The model calibration，predictive ability and clinical benefit in the modeling group and the verification group were analyzed by C index，receiver operating characteristic curve，calibration curve and decision curve analysis （DCA） curve，respectively. :Univariate analysis showed that lymph node metastasis was related with primary tumor size，vascular tumor thrombus，Ki-67，histopathological grade，and molecular type （<0.05 or <0.01）. Multivariate logistic regression analysis showed that the primary tumor > vascular tumor thrombus，Ki-67 positive，estrogen receptor （ER） positive，and histopathological grade 2-3 were independent risk factors of axillary lymph node metastasis （<0.05 or <0.01）. Based on the independent risk factors，a nomogram prediction model was established. The C indexes of the model group and the validation group were 0.739 （95%:0.693-0.785） and 0.736 （95%:0.678-0.793），respectively. The calibration curve and DCA curve of the modeling group and the verification group indicated that the model was consistent and had good clinical benefit. :Primary tumor size，histopathological grade，vascular tumor thrombus，Ki-67，and ER status are predictors of ipsilateral axillary lymph node metastasis in T1 breast cancer. The established prediction nomogram can effectively predict the risk of ipsilateral axillary lymph node metastasis in T1 breast cancer，which can be used as a reference for individualized axillary management.

Residual lymph node tumour burden following removal of a single axillary sentinel lymph with macrometastatic disease in women with screen-detected invasive breast cancer

Background

Women with screen-detected invasive breast cancer who have macrometastatic disease on axillary sentinel lymph node biopsy (SLNB) are usually offered either surgical axillary node clearance (ANC) or axillary radiotherapy. These treatments can lead to significant complications for patients. The aim of this study was to identify a group of patients who may not require completion ANC.

Methods

Data from the NHS Breast Screening Programme between 1 April 2012 and 31 March 2017 were interrogated to identify women with invasive breast carcinoma and a single sentinel lymph node (SLN) with macrometastatic disease who subsequently proceeded to completion ANC. Univariable and multivariable analyses were performed to identify patients with a single positive SLN who had no further lymph node metastasis on ANC.

Results

Of the 2401 women included in the cohort, the presence of non-sentinel node disease was significantly affected by: the number of nodes obtained at SLNB (odds ratio (OR) 0.49 for retrieval of more than 1 node), invasive size of tumour (OR 1.63 for size greater than 20 mm), surgical treatment (OR 1.34 for mastectomy), human epidermal growth factor receptor (HER) 2 status (OR 0.71 for HER2 positivity), and patient age (OR 1.10 for age less than 50 years; OR 1.46 for age greater than 70 years). Patients aged less than 70 years, with tumour size smaller than 2 cm, more than one node retrieved on SLNB, and who had breast-conserving surgery had a lower chance of positive non-sentinel nodes on completion ANC compared with other patients.

Conclusion

This study, of a purely screen-detected breast cancer cohort, identified a subset of patients who may be spared completion ANC in the event of a single axillary SLN with macrometastasis.

Omission of axillary lymph node dissection in patients who underwent total mastectomy with 1 or 2 metastatic lymph nodes

Purpose

Sentinel lymph node biopsy (SLNB) is the standard axillary procedure in early breast cancer patients. In a randomized trial, the survival rates were not different when axillary lymph node dissection (ALND) was omitted in patients with 1 or 2 lymph node metastases who underwent breast conserving surgery. This study aimed to compare the outcomes in patients who underwent total mastectomy (TM) with 1 or 2 metastatic nodes according to the types of axillary surgery.

Methods

In total, 79,058 patients registered in the Korean Breast Cancer Society database who underwent TM were included in the analysis. The inclusion criteria were history of TM and SLNB, pathologic T stage 1 or 2, clinically negative axillary lymph nodes, 1 or 2 metastatic axillary lymph nodes, no radiation therapy, and no neoadjuvant therapy. We divided the patients into the SLNB only and SLNB + ALND groups. The groups were matched by propensity scores. We retrospectively analyzed the differences in the overall survival (OS) between the 2 groups.

Results

A total of 883 patients were matched in a 1:4 ratio for the SLNB only and SLNB + ALND groups in the cohort from 1999 to 2014. There were no significant differences in OS between the 2 groups (P = 0.413). Subgroup analysis revealed a significant survival benefit in the SLNB + ALND group in the T2 subgroup (P = 0.013).

Conclusion

OS did not differ between the 2 groups in early breast cancer patients with 1 or 2 metastatic axillary lymph nodes who underwent TM. Omission of ALND may be considered in selected patients.