The role of the number of uninvolved lymph nodes in predicting locoregional recurrence in breast cancer

Negative Lymph Node Is an Independent Prognostic Factor for Stage III Gastric Cancer Patients After Curative Gastrectomy: A Surveillance, Epidemiology, and End Results-Based Study

BACKGROUND

Negative lymph node (NLN)' s prognostic impact on stage III gastric cancer (GC) patients after curative gastrectomy has not been rigorously studied. We aimed to explore the relationship between NLNs count and outcomes of stage III GC patients.

METHODS

We retrospectively investigated stage III gastric cancer cases between 2008 and 2018 from Surveillance, Epidemiology, and End Results (SEER) database. Variables were compared by chi2 test. Kaplan-Meier methods and COX proportional hazard models were used to ascertain independent prognostic factors. Survival differences among the subgroups were analyzed to assess the effects of NLN count on overall survival (OS) in stage III GC patients.

RESULTS

2373 patients with curative gastrectomy for stage III GC were identified. Univariate analysis demonstrated that NLNs count >14 was associated better 5-year OS (43.7% VS 23.1%, P< .001) comparing with the NLNs count ≤ 14. Subgroup analysis showed that the NLNs count could predict survival in both node-negative and node-positive patients. Multivariate analysis revealed NLNs count is an independent prognostic factor.

CONCLUSIONS

The NLNs count is an independent prognostic factor for survival in stage III gastric cancer patients after curative gastrectomy and should be recommended for clinical applications.

Is Pathologic Axillary Staging Valid If Lymph Nodes Are Less than 10 with Axillary Lymph Node Dissection after Neoadjuvant Chemotherapy?

Introduction: The aim of this study was to evaluate the prognostic value of the number of lymph nodes removed in breast cancer patients who undergo axillary lymph node dissection (ALND) after neoadjuvant chemotherapy (NAC). Methods: We included patients who were diagnosed with invasive breast cancer and cytology with proven involved axillary node metastasis at diagnosis and treated with NAC followed by curative surgery at Samsung Medical Center between January 2007 and December 2015. The primary outcomes were disease-free survival (DFS) and overall survival (OS). Results: Among 772 patients with NAC and ALND, there were 285 ypN0, 258 ypN1, 135 ypN2, and 94 ypN3 cases. The median follow-up duration was 69.0 months. The group with less than 10 lymph nodes number (<10 nodes group) included 123 patients and the group with 10 or more lymph nodes number (≥10 nodes group) included 649 patients. There were no significant differences in DFS (p = 0.501) or OS (p = 0.883) between the two groups. In the ypN0 subgroup, the <10 nodes group had worse DFS than ≥10 nodes group (p = 0.024). In the ypN1 subgroup, there were no significant differences in DFS (p = 0.846) or OS (p = 0.774) between the two groups. In the ypN2 subgroup, the <10 nodes group had worse DFS (p = 0.025) and OS (p = 0.031) than ≥10 nodes group Conclusion: In ypN0 and ypN2 subgroups, breast cancer patients with less than 10 lymph nodes number in ALND after NAC might be considered for additional staging or closer surveillance when compared to patients with 10 or more than lymph node.

MRI Radiomics of Breast Cancer: Machine Learning-Based Prediction of Lymphovascular Invasion Status

RATIONALE AND OBJECTIVES

In patients with breast cancer (BC), lymphovascular invasion (LVI) status is considered an important prognostic factor. We aimed to develop machine learning (ML)-based radiomics models for the prediction of LVI status in patients with BC, using preoperative MRI images.

MATERIALS AND METHODS

This retrospective study included patients with BC with known LVI status and preoperative MRI. The dataset was split into training and unseen testing sets by stratified sampling with a 2:1 ratio. 2D and 3D radiomic features were extracted from contrast-enhanced T1 weighted images (C+T1W) and apparent diffusion coefficient (ADC) maps. The reliability of the features was assessed with two radiologists' segmentation data. Dimension reduction was done with reliability analysis, multi-collinearity analysis, removal of low-variance features, and feature selection. ML models were created with base, tuned, and boosted random forest algorithms.

RESULT

A total of 128 lesions (LVI-positive, 76; LVI-negative, 52) were included. The best model performance was achieved with tunning and boosting model based on 3D ADC maps and selected four radiomic features. The area under the curve and accuracy were 0.726 and 63.5% in the training data, 0.732 and 76.7% in the test data, respectively. The overall sensitivity and positive predictive values were 68% and 69.6% in the training data, 84.6% and 78.6% in the test data, respectively.

CONCLUSION

ML and radiomics based on 3D segmentation of ADC maps can be used to predict LVI status in BC, with satisfying performance.

Quantitative analysis of shear wave elastic heterogeneity for prediction of lymphovascular invasion in breast cancer

OBJECTIVE

To evaluate the correlation between elastic heterogeneity (EH) and lymphovascular invasion (LVI) in breast cancers and assess the clinical value of using EH to predict LVI pre-operatively.

METHODS

This retrospective study consisted of 376 patients with breast cancers that had undergone shear wave elastography (SWE) with virtual touch tissue imaging quantification between June 2017 and June 2018. The EH was determined as the difference between the averaged three highest and three lowest shear wave value. Clinicalpathological parameters including histological type and grades, LVI, axillary lymph node status and molecular markers (estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2 and Ki-67) were reviewed and recorded. Relationship EH and clinicalpathological parameters was investigated respectively. The diagnostic performance of EH in distinguishing LVI or not was analyzed.

RESULTS

At multivariate regression analysis, only EH (p = 0.017) was positively correlated with LVI in all tumors. EH (p = 0.003) and Ki-67 (p = 0.025) were positively correlated with LVI in tumors ≤ 2 cm. None of clinicalpathological parameters were correlated with LVI in tumors > 2 cm (p > 0.05 for all). Using EH to predict LVI in tumors ≤ 2 cm, the sensitivity and negative predictive value were 93 and 89% respectively.

CONCLUSION

EH has the potential to be served as an imaging biomarker to predict LVI in breast cancer especially for tumors ≤ 2 cm.

ADVANCES IN KNOWLEDGE

There was no association between LVI and other most commonly used elastic features such as SWV_mean and SWV_max. Elastic heterogeneity is an independent predictor of LVI, so it can provide additional prognostic information for routine preoperative breast cancer assessment.For tumors ≤ 2cm, using EH value higher than 1.36 m/s to predict LVI involvement, the sensitivity and negative predictive value can reach to 93% and 89%, respectively, suggesting that breast cancer with negative EH value was more likely to be absent of LVI.

Role of Metastatic Lymph Nodes to Totally Removed Lymph Nodes Ratio in Breast Cancer?

Aim

To determine prognostic ratio of metastatic lymph nodes to totally removed lymph nodes (MLN/TRLN) on overall and progression-free survival with diagnosis of breast cancer.

Material and method

Radiation Oncology department of Kayseri Training and Research Hospital, relationship of MLN/TRLN between prognosis and other prognostic factors was evaluated in T1-3 and N1-3 non-metastatic breast cancer patients.

Results

Two hundred female patients and 5 male patients with an average age of 56 years were enrolled in this study. Of all patients, 63.4% of the patients were postmenopausal and modified radical mastectomy was performed in 96.6% of them. While 93.2% of the patients were diagnosed with invasive ductal carcinoma, 52.7% of them had clinical N1 disease, 62% of them were staged as T2, 94% of them received chemotherapy and 57.1% of them received hormonal therapy. Metastatic lymph node ratio below 0.2 was 48.8%, between 0.21–0.65 it was 35.1% and above 0.65% it was 16.1%. Five-year Overall survival and progression-free survival rates were 76% and 58% respectively. Statistically significant difference was found between MLN/TRLN and age (p = 0.044), chemotherapy (p = 0.039), pathological lymph nodes (p <0.001) according to Pearson's Chi-Squared test. Factor affecting overall survival was Progesterone receptor status (p = 0.021) and for progression-free survival they were gender (p = 0.003) and human epidermal growth factor receptor 2 (p = 0.018). Univariate and multivariate analysis found that gender (p = 0.04, OR 5.9, CI: 1.7–19.6) and lymph node (p = 0.05, OR: 1.4, CI: 0.9–2.1) were significant factors affecting progression-free survival.

Conclusion

MLN/TRLN was shown to have no effect on prognosis in non-metastatic breast cancer patients due to small number of patients and short follow-up period.

Negative Lymph Node Count Predicts Survival of Resected Non-small Cell Lung Cancer

PURPOSE

The purpose of this study was to explore the association between the negative lymph node (NLN) count and survival, as well as compare the prognostic value of the positive lymph node (PLN) count, lymph node ratio (the PLN count/total lymph nodes examined, LNR), and NLN count in patients with non-small cell lung cancer (NSCLC).

METHODS

We identified patients diagnosed with NSCLC between 2005 and 2011 from the Surveillance, Epidemiology, and End Results database. Outcomes of interest were lung cancer-specific survival (LCSS) and overall survival (OS). Cases were divided into several groups based on the PLN count, NLN count, and LNR. The prognostic significance of the PLN count, NLN count, and LNR models was analyzed with the Kaplan-Meier method and the Cox regression model.

RESULTS

39,959 patients with surgical resection for NSCLC were identified. Univariate analysis demonstrated that a greater count of NLNs was associated with better LCSS (P < 0.001) and OS (P < 0.001). Subgroup analysis showed that the NLN count could predict survival in both node-negative and node-positive patients. Multivariable analysis revealed that the NLN count was an independent prognostic factor for LCSS and OS.

CONCLUSION

The NLN count is an independent prognostic factor of OS and LCSS in patients with NSCLC, as well as the PLN count and LNR. The prognostic value of the PLN count, NLN count, and LNR shows no difference.

Value of digital mammography in predicting lymphovascular invasion of breast cancer

Background

Lymphovascular invasion (LVI) has never been revealed by preoperative scans. It is necessary to use digital mammography in predicting LVI in patients with breast cancer preoperatively.

Methods

Overall 122 cases of invasive ductal carcinoma diagnosed between May 2017 and September 2018 were enrolled and assigned into the LVI positive group (n = 42) and the LVI negative group (n = 80). Independent t-test and χ2 test were performed.

Results

Difference in Ki-67 between the two groups was statistically significant (P = 0.012). Differences in interstitial edema (P = 0.013) and skin thickening (P = 0.000) were statistically significant between the two groups. Multiple factor analysis showed that there were three independent risk factors for LVI: interstitial edema (odds ratio [OR] = 12.610; 95% confidence interval [CI]: 1.061–149.922; P = 0.045), blurring of subcutaneous fat (OR = 0.081; 95% CI: 0.012–0.645; P = 0.017) and skin thickening (OR = 9.041; 95% CI: 2.553–32.022; P = 0.001).

Conclusions

Interstitial edema, blurring of subcutaneous fat, and skin thickening are independent risk factors for LVI. The specificity of LVI prediction is as high as 98.8% when the three are used together.

Postmastectomy radiation therapy in early breast cancer: Utility or futility?

Postmastectomy radiation therapy (PMRT) has been shown to reduce the risk of locoregional recurrence (LRR), in patients with locally advanced breast cancer who are considered of high-risk because of large tumors (>5 cm) or presence of axillary lymph-node involvement, as well as to reduce breast cancer mortality. However, controversy still remains with respect to indication of PMRT in case of early-stages invasive tumors. This review aims to analyze the impact that PMRT has on final results in women with breast tumors in different scenarios that would otherwise be considered as early breast cancer, such as extensive DCIS, tumors without axillary lymph-node involvement or with minimal microscopic nodal-involvement. The existence of risk factors including young age, premenopausal status, and presence of lymphovascular invasion (LVI), high grade or tumor size >2 cm has been associated with an increased risk of LRR in these patients at early-stages and advises to consider PMRT in selected cases.

Can a subgroup at high risk for LRR be identified from T1-2 breast cancer with negative lymph nodes after mastectomy? A meta-analysis

Purpose: To identify a subgroup at high risk for loco-regional recurrence (LRR) from T1-2 breast cancer with negative lymph nodes (N0) after mastectomy by using a meta-analysis.Methods and materials: Published studies on the relationship between clinical features and LRR of breast cancer were identified from public databases, including PubMed, EMBASE, and the Cochrane Library. High-risk features for LRR in this patient population were defined based on the pooled results of meta-analysis.Results: For the meta-analysis, a total of 11244 breast cancers with pT1-2N0 after mastectomy from 20 publications were included for analysis. The pooled results indicated that age (hazard ratio (HR) 1.77, P=0.001), lymphovascular invasion (LVI) (HR 2.23, P<0.001), histologic grade (HR 1.66, P<0.001), HER2 status (HR 1.65, P=0.027), menopausal status (HR 1.36, P=0.015), and surgical margins (HR 2.56, P=0.014) were associated with a significantly increased risk of developing LRR in this patient population group, but not for tumor size (HR 1.32, P=0.23), systematic therapy (HR 1.67, P=0.20), and hormonal receptor status (HR 1.04, P=0.73).Conclusion: In the current study, patients with young age, positive LVI, high histologic grade, HER-2 positive, premenopausal, and positive surgical margins have an increased risk of developing LRR. Further prospective trials are needed to clearly define the role of adjuvant postmastectomy radiotherapy in T1-2N0 breast cancer at high risk of developing LRR.

Individualized Prediction of Survival Benefit from Postmastectomy Radiotherapy for Patients with Breast Cancer with One to Three Positive Axillary Lymph Nodes

PURPOSE

There still exist some arguments regarding the use of postmastectomy radiotherapy (PMRT) for patients with breast cancer carrying one to three positive axillary lymph nodes considering the heterogeneity of this cohort. Here, we developed a prognostic nomogram to estimate the probability of long-term outcome in patients receiving or not receiving PMRT in order to assist in making individually locoregional treatment decisions for this particular cohort.

METHODS

Altogether, 20,336 women, aged 18 to 80 years, diagnosed with breast cancer, and carrying one to three positive nodes were identified in the Surveillance, Epidemiology, and End Results (SEER) database. We applied multivariant Cox hazard model to determine the impact of covariates on disease-specific survival (DSS) and overall survival (OS). Then, the nomogram was built accordingly. Internal and external validations were performed to examine the accuracy of nomograms.

RESULTS

Age of diagnosis, tumor grade, size, estrogen and progesterone receptor status, and number of positive nodes were independent factors of DSS and OS in the multivariate analysis. Incorporating these factors into the constructed nomogram showed high accuracy when predicting 5- and 10-year survival, with internally and externally bootstrap-corrected concordance indexes in the range of 0.6 to 0.8.

CONCLUSION

Besides the number of involved nodes, extra variables existed as predictors of survival outcomes in this cohort; therefore, the recommendation of PMRT or no PMRT requires comprehensive consideration. This clinically validated nomogram provided a useful tool that could aid decision making by estimating DSS and OS benefits from PMRT, useful in predicting 5- and 10-year DSS and OS for patients with one to three positive nodes after mastectomy.

IMPLICATIONS FOR PRACTICE

This study evaluated population-based data to identify prognostic factors associated with patients with breast cancer with one to three lymph nodes and help clinicians to weigh the benefit of postmastectomy radiotherapy (PMRT). Surveillance, Epidemiology, and End Results (SEER) data were used to develop a prognostic nomogram to predict the likelihood of long-term survival with and without PMRT in order to optimize the individual locoregional control strategy for this particular cohort. This clinically validated nomogram provides a useful tool to predict 5- and 10-year disease-specific survival and overall survival for patients with one to three positive nodes and can aid tailored clinical decision making by estimating predicted benefit from PMRT.

Post Mastectomy Radiation for Stage II Breast Cancer Patients with T1/T2 Lesions

Objective

Post mastectomy radiation (PMR) is usually recommended for T3 or N2 breast cancer (BC). The role of PMR for stage II BC with T1/T2 lesions remains controversial. The aim of this study was to assess the role of PMR in this subgroup of patients.

Materials and Methods

A retrospective analysis of a prospectively collected database of all stage II BC patients treated with mastectomy at our institution between the years 2005-2008 was performed. Demographics, disease-free survival rates were compared between the patients receiving radiation vs. those who were not irradiated.

Results

Eighty-two patients underwent mastectomies for stage II disease with a T1/T2 lesion. Twenty-two of those (27%) received PMR. Loco regional recurrence (LRR) occurred only in the non -irradiated (NR) group. A Kaplan Meier analysis of time to LRR in the NR group was performed. Mean time to local failure was 78.9 months, 6% at 3 years and 13% at 5 years. The time to LRR was significantly lower in the estrogen receptor (ER) negative group compared to the ER positive group (64 vs. 82 months, p=0.029). LRR free rate at 5 years was 100% in low grade tumors vs. 53% in high grade tumors, (p=0.001). In a Cox regression multivariate analysis none of those factors maintained significance.

Conclusion

ER negative status, high grade and node negativity were associated with LRR. A prospective trial randomizing stage II BC patients with T1/T2 lesions, negative hormone receptors and high-grade tumors to PMR following mastectomy arm vs. no radiation arm is recommended.

Examined and positive lymph nodes counts and lymph nodes ratio are associated with survival in major salivary gland cancer

BACKGROUND

We aimed to investigate the prognostic role of examined (dissected) lymph nodes (ELNs), negative LNs (NLNs), and positive (metastatic) LNs (PLNs) counts and LN ratio (LNR = PLNs/ELNs×100) in patients with major salivary gland cancer (SGC).

METHODS

Data were retrieved for major SGC patients diagnosed between 1988 and 2011 from Surveillance, Epidemiology, and End Results program.

RESULTS

We have included 5446 patients with major SGC. Most patients had parotid gland cancer (84.61%). Patients having >18 ELNs, >4 PLNs, and >33.33% LNR were associated with a worse survival. Moreover, older age, male patients, grade IV, distant stage, unmarried patients, submandibular gland cancer, and received chemotherapy but not received surgery were significantly associated with a worse survival.

CONCLUSIONS

We demonstrated that patients with >18 ELNs and >4 PLNs counts, and >33.33% LNR were high-risk group patients. We strongly suggest adding the ELNs and PLNs counts and/or LNR into the current staging system.

Prognostic factors predicting recurrence in invasive breast cancer: An analysis of radiological and clinicopathological factors

BACKGROUND/OBJECTIVE

The purpose of this study was to perform a comprehensive analysis of the radiological and clinicopathological factors that could predict recurrence of invasive breast cancer who underwent curative surgery without neoadjuvant chemotherapy.

METHODS

Three hundred and sixty-four consecutive women who underwent preoperative mammography, ultrasound, and breast magnetic resonance imaging for newly diagnosed invasive breast cancers and curative surgery between January and December 2010 were included. We analyzed the radiological findings of each modality and reviewed the histopathological features. A Cox proportional hazards model was used to determine the association between the radiological and clinicopathological parameters and disease-free survival (DFS).

RESULTS

During the median follow-up period of 5.3 years, 23 patients (6.3%) developed recurrences: locoregional recurrence in six patients, contralateral breast recurrence in three patients, and distant recurrences in 14 patients. Microcalcifications on mammography showed a tendency towards worse DFS. The multivariate Cox regression analysis showed that presence of lymphovascular invasion (LVI) (p = 0.006), negative progesterone receptor (PR) status (p < 0.001), and positive CK5/6 expression (p = 0.015) were independent significant variables predictive of worse DFS.

CONCLUSION

Understanding the prognostic factors in patients with invasive breast cancer may provide considerable practical information about future treatment strategies.

Negative Lymph Node Count and Lymph Node Ratio Are Associated With Survival in Male Breast Cancer

BACKGROUND

Male breast cancer (MBC) is usually diagnosed at late stages and therefore has a worse prognosis than female breast cancer (FBC). MBC is also more likely to have lymph node (LN) involvement than FBC.

MATERIALS AND METHODS

We sought to determine the prognostic role of the examined lymph node (LN), negative LN (NLN), and positive LN counts and the LN ratio (LNR), defined as (positive LNs/ENLs), on the survival rate among MBC patients. We performed a large population-based study using the data from the Surveillance, Epidemiology, and End Results program.

RESULTS

Older age, black race, stage IV disease, ≤ 1 NLN, and a > 31.3% LNR were significantly associated with worse survival across all prediction models. Moreover, we demonstrated a decreased risk of mortality in MBC patients across the MBC-specific survival model (hazard ratio, 0.98; 95% confidence interval, 0.96-0.998; P = .03) and 10-year MBC-specific survival model (hazard ratio, 0.98; 95% confidence interval, 0.96-0.999; P = .04).

CONCLUSION

MBC has had an augmented incidence over the years. We found several independent predictors of MBC survival, including age, race, stage, NLNs, and the LNR. We strongly suggest adding the NLN count and/or LNR into the current staging system. Further studies are needed to provide information on the mechanisms underlying the association between the NLN count and MBC survival and the LNR and MBC survival.

Increasing negative lymph node count predicts favorable OS and DSS in breast cancer with different lymph node-positive subgroups

Adequate lymph node evaluation is recommended for optimal staging in patients with malignant neoplasms including breast cancer. However, the role of negative lymph nodes (LNs) remains unclear in breast cancer according to N substage (N1, N2, and N3). In this study, for the first time, we analyzed the prognostic significance of negative LNs in breast cancer patients. A critical relationship was observed between negative LN count and survival, independent of patient characteristics and other related molecular variables including estrogen receptor (PR) status, progesterone receptor (ER) status, human epidermal growth factor receptor 2 (HER2) status, depth of tumor invasion and degree of differentiation. This research is of great importance in providing more information about the prognosis of breast cancer by statistical analysis of negative lymph nodes and can serve as a useful supplement to the current pathological system.

Should all breast cancer patients with four or more positive lymph nodes who underwent modified radical mastectomy be treated with postoperative radiotherapy? A population-based study

Postmastectomy radiotherapy (PMRT) has become a standard adjuvant postoperative therapy for breast cancer patients with four or more positive lymph nodes. However, some studies have demonstrated that some subgroups of the breast cancer patients with four or more positive lymph nodes did not benefit substantially from PMRT. Therefore, it is of great necessity to identify whether all breast cancer patients with four or more positive lymph nodes who underwent modified radical mastectomy be treated with PMRT. In our study, we first established a prognostic model using the Surveillance Epidemiology and End Results (SEER) database between 1998 and 2001. Univariate and multivariate Cox models were used to assess the prognostic factors, and five risk factors individually associated with prognosis including AJCC stage, AJCC T, Grade, ER status, PR status. Prognostic index of PMRT were defined as the number of risk factor (NRF). The NRF scores correlated well with overall survival of PMRT even if the patients were in the sub-poor prognosis group. Then the prognostic model was validated using the SEER database between 2006 and 2009, and the same results were obtained. In conclusion, different from others studies, our study demonstrated that all patients with four or more positive lymph nodes after modified radical mastectomy need to be treated with PMRT ever if the patients belonged to AJCC T4 in a poor prognosis group.

Identifying accessible prognostic factors for breast cancer relapse: a case-study on 405 histologically confirmed node-negative patients

BACKGROUND

Histologically, node-negative breast cancer generally have a good prognosis. However, 10 to 30% of the cases present local relapses or metastasis. This group of people has high chances of remission if detected early. The aim of this study is to identify financial affordability for developing countries to adjust treatment.

METHODS

We selected 405 patients with histologically confirmed node-negative breast cancer in our institution between January 2001 and December 2003. Patients with metastasis were excluded. The statistical analysis was conducted using SPSS ver. 18 (SPSS, Inc., Chicago, Illinois).

RESULTS

The medial age was 51 years old. The medial tumor size was 35.4 mm. Clinically, 67.2% of the patients were staged cT2 and 63.2%, cN1i. Breast conservation was achieved in 41% of cases. In the histologic examination, the medial size was 30 mm. Grade III tumors were found in 50.1% of patients and positive hormonal receptors in 53.4%. The mean number of lymph nodes was 14. Eight patients had neoadjuvant chemotherapy. Adjuvant locoregional radiation and adjuvant chemotherapy were prescribed respectively in 70.6 and 64.4% of cases. 59.7% had adjuvant hormonal therapy. The follow-up showed 17.7% cases of relapse either locally or in a metastatic way in a mean time of 57.4 months. The disease-free survival at 5 years was 82.1%, and the overall survival for the same period was 91.5%. The histologic tumor size and the grade and number of lymph node dissected were shown to be influencing the disease-free survival. Radiation therapy and hormone therapy showed improved disease-free survival and overall survival.

CONCLUSION

Our study found interesting results that may help personalize the treatment especially for patient living in underdeveloped countries, but further studies are needed to evaluate those and more accessible prognostic factors for a more accessible healthcare.

Are there patients with T1 to T2, lymph node-negative breast cancer who are "high-risk" for locoregional disease recurrence?

BACKGROUND

Indications for postmastectomy radiotherapy (PMRT) in patients with T1 to T2, lymph node-negative (N0) breast cancer with "high-risk" features are controversial. The European Organization for Research and Treatment of Cancer (EORTC) 22922 and National Cancer Institute of Canada Clinical Trials Group MA20 trials reporting improved 10-year disease-free survival with lymph node irradiation included patients with high-risk N0 disease, but, to the authors' knowledge, benefits in patients receiving modern systemic therapy are uncertain.

METHODS

The authors retrospectively identified patients with T1 to T2N0 disease who were treated with mastectomy from January 2006 through December 2011. High-risk features included age <40 years, multifocality/multicentricity, lymphovascular invasion, medial/central tumor location, and high nuclear grade.

RESULTS

Among 672 eligible patients, only 15 received PMRT and were excluded. Of the remaining 657 patients, 187 (28%) had 1 high-risk feature and 449 patients (68%) had ≥ 2 high-risk features. A total of 36 patients with unknown tumor grade were excluded from risk analysis. Approximately 98% of patients underwent sentinel lymph node biopsy alone and 86% received adjuvant systemic therapy. At a median of 5.6 years of follow-up, the locoregional disease recurrence (LRR) rate was 4.7% (31 patients). Increasing tumor size was found to be associated with LRR (hazard ratio, 1.70; P = .006), whereas other high-risk features were not (all P > .05). Receipt of systemic therapy decreased the LRR rate (hazard ratio, 0.40; P = .03). Although crude LRR rates increased from 3.8% to 9.4% with 1 versus ≥ 4 high-risk features, the number of risk factors was not found to be significantly associated with LRR (P = .54).

CONCLUSIONS

In the current study, a low crude LRR rate (4.7%) was observed in a large unselected cohort of patients with T1 to T2N0 breast cancer with high-risk features who were treated with mastectomy and systemic therapy without PMRT. Although increasing tumor size and the omission of systemic therapy were found to be predictive, other features did not confer a higher LRR risk either independently or together, and do not by themselves mandate the use of PMRT in this patient population. Cancer 2017;123:2626-33. © 2017 American Cancer Society.

Possible benefits from post-mastectomy radiotherapy in node-negative breast cancer patients: a multicenter analysis in Korea (KROG 14-22)

PURPOSE

This study was performed to identify a subset of patients who may benefit from post-mastectomy radiotherapy (PMRT) among node-negative breast cancer patients.

MATERIALS AND METHODS

We retrospectively reviewed 1,828 patients with pT1-2N0 breast cancer, treated with mastectomy without PMRT from 2005 to 2010 at 10 institutions. Univariate and multivariate analyses for locoregional recurrence (LRR) and any first recurrence (AFR) were performed according to clinicopathologic factors and biologic subtypes.

RESULTS

During a median follow-up period of 5.9 years (range: 0.7-10.4 years), 98 patients developed AFR (39 isolated LRR, 13 LRR with synchronous distant metastasis, and 46 isolated distant metastasis), and 52 patients developed LRR. The 7-year LRR and AFR rates were 3.8% and 6.7%, respectively. Multivariate analysis revealed that age of ≤ 40 years (p<0.001) and T2 stage (p=0.013) were independent risk factors for LRR. The 7-year LRR rates were 2.5% with no risk factors, 4.5% with one risk factor, and 12.4% with two risk factors. Multivariate analysis for AFR revealed that age of ≤ 40 years (p<0.001), T2 stage (p<0.001), and triple-negative biological subtype (p=0.045) were independent risk factors for AFR. The 7-year AFR rates were 3.9% with no risk factors, 8.4% with one risk factor, and 15.7% with two to three risk factors.

CONCLUSIONS

Mastectomy without PMRT is a sufficient local treatment for pT1-2N0M0 breast cancer. Nevertheless, PMRT might be considered for patients with two or three risk factors, among those of young age, with T2 tumors, and with the triple-negative biological subtype based on LRR and AFR.

Better survival in PMRT of female breast cancer patients with >5 negative lymph nodes: A population-based study

Many studies have confirmed the role of postmastectomy radiotherapy (PMRT) for breast cancer patients with at least 4 lymph nodes invasion in the postoperative therapy. Recently, the number of negative lymph nodes (NLNs) has been increasingly paid attention to and recognized as a prognostic indicator in different kinds of caners. Therefore, it is very necessary to study the association between the number of NLNs and the prognosis of PMRT in breast cancer patients. In our study, we used Surveillance, Epidemiology, and End Results (SEER) population-based data and identified 16,686 breast cancer patients to explore their correlation. The ROC curve and the log-rank χ test were applied to determine the appropriate cutoff point of the number of NLNs and 5 was selected as the cutoff point. Furthermore, the cutoff point 5 was validated as an independent prognostic factor affecting cancer-specific survival (CSS) and overall survival (OS) in breast cancer patients, as confirmed by both univariate and multivariate analysis (P < 0.001). In addition, subgroup analysis showed that the number of NLNs >5 can be a prognostic indicator in patients with PMRT according to different clinical variables (all, P < 0.001). Importantly, our results showed that PMRT obviously improved CSS and OS in patients regardless of the number of NLNs (P < 0.001). In conclusion, our study showed the number of NLNs is an independent prognostic factor for breast cancer patients with PMRT, and those who have higher number of NLNs have an increased CSS and OS.

Lymph Node Ratio Analysis After Neoadjuvant Chemotherapy is Prognostic in Hormone Receptor-Positive and Triple-Negative Breast Cancer

BACKGROUND

Lymph node ratios (LNR), the proportion of positive lymph nodes over the number excised, both defined as ranges and single ratio values are prognostic of outcome. Little is known of the prognostic value of LNR after neoadjuvant chemotherapy (NAC) according to molecular subtype.

METHODS

From 2003 to 2014, patients who underwent definitive surgery after NAC were identified. LNR was calculated for node-positive patients who received axillary dissection or had at least 6 nodes removed. DFS was calculated using the Kaplan-Meier log rank test for yp N0-3 status, LNR categories (LNRC) ≤0.20 (low), 0.21-0.65 (intermediate), >0.65 (high), and single LNR values.

RESULTS

Of 428 NAC recipients, 263 were node negative and 165 (38.6 %) node positive: ypN1 = 97 (58.8 %), ypN2 = 43 (26.1 %), and ypN3 = 25 (15.2 %). Among node-positive cancers, the median number of LN removed was 14 (range, 6-51) and the median LNR was 0.22 (range, 0.03-1.0). Nodal stage was inversely associated with 5-year DFS: 91.5 % (ypN0), 74.5 % (ypN1), 49.8 % (ypN2), and 50.7 % (ypN3) (p < 0.001). LNRC was similarly inversely associated with DFS: 69.1 % (low), 71.4 % (intermediate), 49.3 % (high) (p < 0.001). Significant associations between LNRC and DFS were demonstrated in hormone receptor (HR)-positive and triple negative breast cancer (TNBC) subtypes, p = 0.02 and p = 0.003. A single-value LNR ≤ 0.15 in node-positive, HR-positive (94.1 vs 67.7 %; p = 0.04) and TNBC (94.1 vs 47.8 %; p = 0.001) groups was also significant.

CONCLUSIONS

Residual nodal disease after NAC, analyzed by LNRC or LNR = 0.15 cutoff value, is prognostic and can discriminate between favorable and unfavorable outcomes for HR-positive and TNBC cancers.

Identification of Risk Factors for Locoregional Recurrence in Breast Cancer Patients with Nodal Stage N0 and N1: Who Could Benefit from Post-Mastectomy Radiotherapy?

INTRODUCTION

The locoregional recurrence (LRR) rate was reported as high as approximately 20% in stage I-II breast cancer following mastectomy. To investigate the risk factors for LRR in pT1-2N0-1 breast cancer patients treated with mastectomy but not radiation, and to define a subgroup of patients at high risk of LRR who may benefit from postmastectomy radiotherapy (PMRT).

METHODS AND MATERIALS

In total, 390 patients with pT1-2N0M0 (n = 307) and pT1-2N1M0 (n = 83) breast cancer who underwent total mastectomy without adjuvant radiotherapy from 2002 to 2011 were enrolled in the study.

RESULTS

After a median follow-up period of 5.6 years (range, 0.6-11.3 years), 21 patients had 18 systemic relapses and 12 LRRs including six in the chest wall and eight in the regional nodal area. The 5-year LRR-free survival (LRRFS) rates were 97.0% in pN0, 98.8% in pN1, and 97.4% in all patients. Multivariate analysis revealed that age < 50 years (Hazard Ratio, 11.4; p = 0.01) and no adjuvant chemotherapy (Hazard Ratio, 10.2; p = 0.04) were independent risk factors for LRR in pN0 patients. Using these factors, the 5-year LRRFS rates were 100% without any risk factors, 96.4% with one risk factor, and 86.7% with two risk factors. In pN1 patients, multivariate analysis revealed that having a hormone receptor negative tumor (Hazard Ratio, 18.3; p = 0.03) was the only independent risk factor for LRR. The 5-year LRRFS rates were 100.0% for luminal type, and 92.3% for non-luminal type cancer.

CONCLUSION

Patients with pT1-2N0-1 breast cancer who underwent total mastectomy without PMRT could be stratified by nodal stage and risk factors for LRR. PMRT may have of value for node negative patients aged less than 50 years and who are not treated with adjuvant chemotherapy, and for non-luminal type patients with one to three positive nodes.

Whose Disease Will Recur After Mastectomy for Early Stage, Node-Negative Breast Cancer? A Systematic Review

Effective local control is associated with improved overall survival, particularly for women with early-stage cancers. No other local therapy is typically offered to women with T1-2 N0 breast cancer after mastectomy, although in select women the 5-year local recurrence rate can be as high as 20%. Therefore, accurately predicting the women who are at highest risk for recurrence after mastectomy will identify those who might benefit from more aggressive adjuvant treatment. A systematic search was conducted identifying risk factors associated with locoregional recurrence, including age, menopausal status, receptor status, lymphovascular invasion (LVI), margin status, use of systemic therapy, size, grade, and genomic classifer score. Although associations varied among studies, the risk factors most consistently identified were age ≤ 40 years, LVI, positive/close margin, and larger tumor size. In women with multiple high risk factors, risk of local recurrence was as high as 20% at 10 years. Additional multicenter studies are needed to investigate risk factors for locoregional recurrence after mastectomy without radiotherapy in T1-2N0 breast cancer. Consideration of additional adjuvant local therapy might be warranted in a subset of women at high risk of local recurrence.

No clear effect of postoperative radiotherapy on survival of breast cancer patients with one to three positive nodes: a population-based study

BACKGROUND

In published radiotherapy trials, the failure rate in the control arm among patients with one to three positive nodes is high compared with that seen with modern adjuvant treatments. Therefore, the generalizability of the results has been questioned. The aim of the present study was to compare relative survival in breast cancer patients between two Swedish regions with screening mammography programs and adjuvant treatment guidelines similar with the exception of the indication of radiotherapy for patients with one to three positive nodes.

PATIENTS AND METHODS

Between 1989 and 2006, breast cancer patients were managed very similarly in the west and southeast regions, except for indication for postoperative radiotherapy. In patients with one to three positive nodes, postmastectomy radiotherapy was generally given in the southeast region (89% of all cases) and generally not given in the west region (15% of all cases). For patients with one to three positive nodes who underwent breast-conserving surgery, patients in the west region had breast radiotherapy only, while patients in the southeast region had both breast and lymph nodes irradiated.

RESULTS

The 10-year relative survival for patients with one to three positive lymph nodes was 78% in the west region and 77% in the southeast region (P = 0.12). Separate analyses depending on type of surgery, as well as number of examined nodes, also revealed similar relative survival.

CONCLUSION

Locoregional postoperative radiotherapy has well-known side-effects, but in this population-based study, there was little or no influence of this type of radiotherapy on survival when one to three lymph nodes were involved.

Progesterone Receptor Status and Clinical Outcome in Breast Cancer Patients with Estrogen Receptor-Positive Locoregional Recurrence

Aims and background

The aim of this retrospective multicenter study was to evaluate the impact of progesterone receptor (PgR) loss on locoregional recurrence in patients with estrogen receptor (ER)-positive primary breast cancer and ER-positive locoregional recurrence.

Patients and Methods

Eight Italian oncology centers collected data from consecutive patients with ER-positive breast cancer and a subsequent ER-positive locoregional recurrence.

Results

Data were available for 265 patients diagnosed with breast cancer between 1990 and 2009. Median metastasis-free survival was 111 months in patients with PgR-positive primary tumors and locoregional recurrence (PgRpos), 38 months in patients with PgR-negative primary tumors and locoregional recurrence (PgRneg), and 63 months in patients with PgR-positive primary tumors and PgR-negative locoregional recurrence (PgRloss). In multivariate analysis, PgR status was independently associated with metastasis-free survival, with a hazard ratio of 2.84 (95% CI 1.34-6.00) for PgRneg compared with PgRpos, and 2.93 (95% CI: 1.51-5.70) for PgRloss compared with PgRpos.

Conclusions

PgR absence was found to be a negative prognostic factor in breast cancer patients with ER-positive locoregional recurrence. Thus, PgR status could be a biological marker in ER-positive recurrent breast cancer.

Number of negative lymph nodes can predict survival after postmastectomy radiotherapy according to different breast cancer subtypes

Purpose: To assess the prognostic value of the number of negative lymph nodes (NLNs) in breast cancer patients with positive axillary lymph nodes after mastectomy and its predictive value for radiotherapy efficacy of different breast cancer subtypes (BCS).

Methods: The records of 1,260 breast cancer patients with positive axillary lymph nodes who received mastectomy between January 1998 and December 2007 were reviewed. The prognostic impact and predictive value of the number of NLNs with respect to locoregional recurrence-free survival (LRFS), disease-free survival (DFS), and overall survival (OS) were analyzed.

Results: The median follow-up time was 58 months, and 444 patients (35.2%) received postmastectomy radiotherapy (PMRT). Univariate and multivariate Cox survival analysis indicated the number of NLNs was an independent prognostic factor of LRFS, DFS, and OS. Patients with a higher number of NLNs had better survival. PMRT improved the LRFS of patients with ≤ 8 NLNs ( p < 0.001), while failing to improve the LRFS of patients with > 8 NLNs (p = 0.075). In patients with luminal A subtype, PMRT improved the LRFS, DFS, and OS of patients with ≤ 8 NLNs, but in patients with > 8 NLNs only the LRFS was improved. For patients with luminal B subtype, PMRT only improved the LRFS of patients with ≤ 8 NLNs. The number of NLNs had no predictive value for the efficacy with PMRT in Her2+ and triple-negative subtypes.

Conclusions: The number of NLNs is a prognostic indicator in patients with node-positive breast cancer, and it can predict the efficacy of PMRT according to different BCS.

Number of negative lymph nodes is associated with disease-free survival in patients with breast cancer

BACKGROUND

The aim of this study was to evaluate the prognostic value of the number of negative lymph nodes (NLNs) in breast cancer patients after mastectomy.

METHODS

2,455 breast cancer patients who received a mastectomy between January 1998 and December 2007 were retrospectively reviewed. The prognostic impact of the number of NLNs with respect to disease-free survival (DFS) was analyzed.

RESULTS

The median follow-up time was 62.0 months, and the 5-year and 10-year DFS was 87.1% and 74.3%, respectively. The DFS of patients with >10 NLNs was significantly higher than that of patents with ≤10 NLNs, and the 5-year DFS rates were 87.5% and 69.5%, respectively (P < 0.001). Univariate Cox analysis showed that the NLN count (continuous variable) was a prognostic factor of DFS (hazard ratio [HR] = 0.913, 95% confidence interval [CI]: 0.896-0.930, P < 0.001). In multivariate Cox analysis, patients with a higher number of NLNs had a better DFS (HR = 0.977, 95% CI: 0.958-0.997, P = 0.022). Subgroup analysis showed that the NLN count had a prognostic value in patients at different pT stages and pN positive patients (log-rank P < 0.001). However, it had no prognostic value in pN0 patients (log-rank P = 0.684).

CONCLUSIONS

The number of NLNs is an independent prognostic factor of DFS in breast cancer patients after mastectomy, and patients with a higher number of NLNs have a better DFS.

Number of negative lymph nodes can predict survival of breast cancer patients with four or more positive lymph nodes after postmastectomy radiotherapy

Background

This study was conducted to assess the prognostic value of the number of negative lymph nodes (NLNs) in breast cancer patients with four or more positive lymph nodes after postmastectomy radiotherapy (PMRT).

Methods

This retrospective study examined 605 breast cancer patients with four or more positive lymph nodes who underwent mastectomy. A total of 371 patients underwent PMRT. The prognostic value of the NLN count in patients with and without PMRT was analyzed. The log-rank test was used to compare survival curves, and Cox regression analysis was performed to identify prognostic factors.

Results

The median follow-up was 54 months, and the overall 8-year locoregional recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS) were 79.8%, 50.0%, 46.8%, and 57.9%, respectively. The optimal cut-off points for NLN count was 12. Univariate analysis showed that the number of NLNs, lymph node ratio (LNR) and pN stage predicted the LRFS of non-PMRT patients (p < 0.05 for all). Multivariate analysis showed that the number of NLNs was an independent prognostic factor affecting the LRFS, patients with a higher number of NLNs had a better LRFS (hazard ratio = 0.132, 95% confidence interval = 0.032-0.547, p =0.005). LNR and pN stage had no effect on LRFS. PMRT improved the LRFS (p < 0.001), DMFS (p = 0.018), DFS (p = 0.001), and OS (p = 0.008) of patients with 12 or fewer NLNs, but it did not any effect on survival of patients with more than 12 NLNs. PMRT improved the regional lymph node recurrence-free survival (p < 0.001) but not the chest wall recurrence-free survival (p = 0.221) in patients with 12 or fewer NLNs.

Conclusions

The number of NLNs can predict the survival of breast cancer patients with four or more positive lymph nodes after PMRT.

Electronic supplementary material

The online version of this article (doi:10.1186/s13014-014-0284-5) contains supplementary material, which is available to authorized users.

Axillary metastasis from an occult tubal serous carcinoma in a patient with ipsilateral breast carcinoma: a potential diagnostic pitfall

Axillary nodal metastasis from a nonmammary neoplasia is much rarer than diseases associated with a primary breast carcinoma. However, this has to be considered in the differential diagnosis of nodal disease in patients with a history of breast cancer. Here, we report the case of a 73-year-old female with a past medical history of breast cancer, presenting with an ipsilateral axillary metastatic carcinoma. The immunohistochemical profile of the metastatic lesion was consistent with a high grade serous carcinoma. After undergoing a total abdominal hysterectomy and salpingo-oophorectomy, thorough pathological examination revealed two microscopic foci of serous carcinoma in the right fallopian tube, not detectable by preoperative magnetic resonance imaging. In this context, the poorly differentiated appearance of the metastatic tumor and positive staining for estrogen receptor, might lead to a misdiagnosis of metastatic breast carcinoma. As the therapeutic implications differ, it is important for the pathologist to critically assess axillary lymph node metastases, even in patients with a past history of ipsilateral breast carcinoma and no other known primary tumors.

No difference in dose distribution in organs at risk in postmastectomy radiotherapy with or without breast implant reconstruction

The aim of this study was to quantify the variation in doses to organs at risk (ipsilateral lung and heart) and the clinical target volume (CTV) in the presence of breast implants. In this retrospective cohort study, patients were identified through the National Breast Cancer Register. Consecutive breast cancer patients undergoing mastectomy between 2009 and 2011 and completing a full course of postmastectomy radiotherapy (PMRT) were eligible. All included patients (n = 818) were identified in the ARIA© oncology information system and further stratified for immediate breast reconstruction (IBR+, n = 162) and no immediate breast reconstruction (IBR-, n = 656). Dose statistics for ipsilateral lung, heart and CTV were retrieved from the system. Radiation plans for patients with chest wall (CW) only (n = 242) and CW plus lymph nodes (n = 576) irradiation were studied separately.

The outcome variables were dichotomized as follows: lung, V_20Gy ≤ 30% vs. V_20Gy > 30%; heart, D_mean ≤ 5 Gy vs. D_mean > 5 Gy; CTV, V_95% ≥ median vs. V_95% < median.

In the univariate and multivariate regression models no correlation between potential confounders (i.e. breast reconstruction, side of PMRT, CW index) and the outcome variables was found. Multivariate analysis of CW plus lymph nodes radiation plans, for example, showed no association of breast reconstruction with dosimetric outcomes in neither lung nor heart- lung V_20Gy (odds ratio [OR]: 0.6, 95%CI, 0.4 to 1.0, p = 0.07) or heart D_mean (OR: 1.2, 95%CI, 0.5 to 3.1, p = 0.72), respectively.

CTV was statistically significantly larger in the IBR+ group (i.e. included breast implant), but no correlation between the implant type and dosimetric characteristics of the organs at risk was revealed.

In the current study, the presence of breast implants during postmastectomy radiotherapy was not associated with increased doses to ipsilateral lung and heart, but CTV definition and its dosimetric characteristics urge further evaluation.

Patterns and risk factors for locoregional failures after mastectomy for breast cancer: an International Breast Cancer Study Group report

BACKGROUND

Rates and risk factors of local, axillary and supraclavicular recurrences can guide patient selection and target for postmastectomy radiotherapy (PMRT).

PATIENTS AND METHODS

Local, axillary and supraclavicular recurrences were evaluated in 8106 patients enrolled in 13 randomized trials. Patients received chemotherapy and/or endocrine therapy and mastectomy without radiotherapy. Median follow-up was 15.2 years.

RESULTS

Ten-year cumulative incidence for chest wall recurrence of >15% was seen in patients aged <40 years (16.1%), with ≥4 positive nodes (16.5%) or 0-7 uninvolved nodes (15.1%); for supraclavicular failures >10%: ≥4 positive nodes (10.2%); for axillary failures of >5%: aged <40 years (5.1%), unknown primary tumor size (5.2%), 0-7 uninvolved nodes (5.2%). In patients with 1-3 positive nodes, 10-year cumulative incidence for chest wall recurrence of >15% were age <40, peritumoral vessel invasion or 0-7 uninvolved nodes. Age, number of positive nodes and number of uninvolved nodes were significant parameters for each locoregional relapse site.

CONCLUSION

PMRT to the chest wall and supraclavicular fossa is supported in patients with ≥4 positive nodes. With 1-3 positive nodes, chest wall PMRT may be considered in patients aged <40 years, with 0-7 uninvolved nodes or with vascular invasion. The findings do not support PMRT to the dissected axilla.

[Radiotherapy for breast cancer: which strategy in 2012?]

Postoperative radiotherapy remains essential in breast cancer in 2012. After conserving surgery, it reduces local recurrence risks from 50 to 70%, both for ductal carcinoma in situ and invasive cancers. This was confirmed in several randomized trials and three meta-analyses. The boost increases local control in invasive cancers, but its role should be better defined in ductal carcinoma in situ. Among the latter, there is no clearly identified subgroup for which radiotherapy could be avoided. Local recurrence risk factors are now well-identified both for ductal carcinoma in situ and invasive cancers, with an inclusion, for the latter, of new molecular subgroups. After mastectomy, radiotherapy reduces local recurrence rates from 60 to 70%, especially among patients with axillary nodal involvement, with, in parallel, a 7 to 9% increased survival rate. In order to reduce the waiting list and to avoid under treatment, especially in the elderly, several hypofractionated radiotherapy schemes have been developed for several years. Three randomized trials confirmed similar results to classical radiotherapy. For ten years, several techniques of partial breast irradiation have been developed, with various doses and treated volumes. The optimal indications should be defined according to the new international guidelines.

Value of the metastatic lymph node ratio for predicting the prognosis of non-small-cell lung cancer patients

BACKGROUND

The aim of this study was to investigate the relation between the metastatic lymph node ratio (LNR) and the prognosis of non-small-cell lung cancer (NSCLC).

METHODS

A total of 301 patients with N1 or N2 NSCLC who underwent complete pulmonary resection were analyzed retrospectively. The correlations between the LNR and clinical and pathologic data were analyzed using χ(2) test analysis. The prognostic value of the LNR was calculated by univariate Kaplan-Meier survival analysis and multivariate Cox proportional hazard model analysis. The risk groups were classified by a combination of the LNR and pN stage.

RESULTS

The LNR was correlated with age, smoking status, pathologic type, subcarinal lymph node, clinical staging, N stage (P < 0.05), and the number of positive lymph nodes and positive lymph node stations (P < 0.0001). In the univariate analysis, the LNR played an important role in predicting overall survival (OS) (P < 0.0001) and disease-free survival (P < 0.0001) by Kaplan-Meier survival analysis. In the multivariate analysis, high LNR (>18%) was an independent poor prognostic factor for OS [hazard ratio (HR) 2.5034, 95% confidence interval (CI) 1.6096-3.8933, P < 0.0001] and DFS (HR 1.9023, 95% CI 1.2465-2.9031, P = 0.0031). Stratification into high-, medium-, and low-risk groups-based on high-risk factors (LNR > 18%, N2) intermediate-risk factors (LNR > 18%, N1 or LNR < 18%, N2), and low-risk factors (LNR < 18%, N1)-could efficiently predicted outcomes (P < 0.0001) of patients with lymph node-positive NSCLC.

CONCLUSIONS

The combination of the LNR and pN status provides a valuable help with prognosis. However, these results must be evaluated further in a large prospective randomized clinical trial.

Prognostic value of number of removed lymph nodes, number of involved lymph nodes, and lymph node ratio in 7502 breast cancer patients enrolled onto trials of the Austrian Breast and Colorectal Cancer Study Group (ABCSG)

PURPOSE

The number of removed axillary lymph nodes and the ratio of involved to removed lymph nodes are described as independent prognostic factors beside the absolute number of involved lymph nodes in breast cancer patients. The correlation between these factors and prognosis were investigated in trials of the Austrian Breast and Colorectal Cancer Study Group (ABCSG).

METHODS

This retrospective analysis is based on the data of 7052 patients with endocrine-responsive breast cancer who were randomized in four trials of the ABCSG in the years 1990-2006 and underwent axillary lymph node dissection. The prognostic value of number of removed nodes (NRN), number of involved nodes (NIN), and ratio of involved to removed nodes (lymph node ratio, LNR) concerning recurrence-free survival and overall survival was analyzed.

RESULTS

A total of 2718 patients had node-positive disease. No correlation was found between NRN and prognosis. Increasing NIN and LNR were significantly associated with worse recurrence-free survival and overall survival in univariate and multivariate analyses (P < .001). Only in the subgroup of patients with one to three positive lymph nodes and treated with mastectomy (n = 728) was LNR an additional prognostic factor in univariate and multivariate analyses.

CONCLUSIONS

For breast cancer patients stringently medicated in the framework of prospective adjuvant clinical trials and requiring a mandatory minimum of removed nodes, NRN does not influence prognosis, and LNR is not superior to NIN as prognostic factor. In patients with one to three positive lymph nodes and mastectomy, LNR could play a role as an additional prognostic factor.

Prognostic Significance of the Number of Removed and Metastatic Lymph Nodes and Lymph Node Ratio in Breast Carcinoma Patients with 1-3 Axillary Lymph Node(s) Metastasis

We evaluated the prognostic significance of lymph node ratio (LNR), number of metastatic lymph nodes divided by number of removed nodes in 924 breast carcinoma patients with 1-3 metastatic axillary lymph node(s). The most significant LNR threshold value separating patients in low- and high-risk groups with significant survival difference was 0.20 for disease-free survival (P < 0.001), 0.30 for locoregional recurrence-free survival (P < 0.001), and 0.15 for distant metastasis-free survival (P < 0.001), and the patients with lower LNR had better survival. All three LNR threshold values had independent prognostic significance in Cox analysis (P < 0.001 for all three of them). In conclusion, LNR is a useful tool in separating breast carcinoma patients with 1-3 metastatic lymph node(s) into low- and high-risk prognostic groups.

Hospital volume and prognosis among Norwegian breast cancer patients enrolled in adjuvant trials

BACKGROUND

Several studies have reported an association between breast cancer unit volume and prognosis. We hypothesize that this may be due to inappropriate coping with the recommended guidelines for adjuvant therapy rather than improper breast cancer surgery provided at smaller units.

METHODS

A cohort of 1131 patients with operable breast cancer (pT(1-2) and positive axillary lymph nodes, stage II) enrolled between 1984 and 1994 were analyzed. The women had participated in one of three prospective trials on adjuvant endocrine treatment and were enrolled from 50 centers in Norway. The hospitals were categorized into four groups according to the annual number of surgically treated breast cancer patients reported to the national discharge database in 1990. The hospitals were also stratified according to whether they are university or non-university hospitals. To assess the effect of unit size on patient outcome, local recurrence rates and overall survival were compared in women treated at units with different patient volumes.

RESULTS

The median time from study enrolment to the end of the study was 10.5 years. Relapse-free survival and overall survival did not differ significantly between the hospital groups based on the surgical workload or between university and non-university hospitals.

CONCLUSIONS

Patient volume or teaching status of a hospital did not have any impact on the prognosis of pre- or postmenopausal stage II breast cancer patients included in the adjuvant endocrine trials. Our data support the hypothesis that differences in survival related to patient volume at the treatment units may be explained by inappropriate adjuvant systemic treatment.

The impact of age on outcome in early-stage breast cancer

Multiple studies have shown that breast-conserving therapy (BCT) and mastectomy have equivalent outcomes for large populations of women with early-stage breast cancer. For individual treatment decisions, however, it is important to appreciate the heterogeneity of disease. Recent molecular studies have suggested that "breast cancer" includes biologically distinct classes of disease; although these molecular distinctions are important, other patient-related factors also affect outcome and influence prognosis. One of the most important of these patient factors is the age of the patient at diagnosis. Numerous studies have shown very different breast cancer outcomes based on patient age; younger women typically have more aggressive tumors that are more likely to recur both locoregionally and distantly, and older women more commonly have less aggressive disease. The overall disease-specific outcomes, techniques, and doses for adjuvant radiation therapy and toxicity of treatments should be discussed within the context of age because breast cancer is a very different disease based on this factor. Arguments can be made that more aggressive locoregional therapy is warranted in populations of young women with breast cancer and perhaps less aggressive therapy in the elderly.

Variation in hormone receptor and HER-2 status between primary and metastatic breast cancer: review of the literature

IMPORTANCE OF THE FIELD

Hormone and human epidermal growth factor receptor 2 (HER-2) receptors are two important pharmaceutical targets that affect the survival of patients with metastatic breast cancer. Discordance of hormone and HER-2 receptors were reported in a series of studies. Receptor status was reported to change in both directions, yet alteration occurs mostly in the loss of positivity for both receptors. We do not know both the exact mechanism of this process or the contribution rate of technical mistakes; a number of mechanisms might be responsible. Factors suggested include: tumor heterogeneity, clonal selection of tumor cell subpopulations, genetic instability of tumor cells, local or systemic treatments, the time interval between primary tumor and metastasis, receptor status determination techniques, and the site of metastasis.

AREAS COVERED IN THIS REVIEW

Studies of estrogen, progesterone and HER-2 receptor discordance between primary and metastasis of breast cancer are summarized. Laboratory evaluation of estrogen, progesterone and HER-2 receptors, and possible causes of receptor discordance, are summarized. Literature data are reviewed; the major shortcoming of these studies is that they are mostly retrospective.

WHAT THE READER WILL GAIN

The reader will read a concise literature review about the studies on estrogen, progesterone and HER-2 receptor discordances between primary and metastasis of breast cancer.

TAKE HOME MESSAGE

We do not know whether the changes in receptor expression account for a true biological phenomenon or may result from inconsistent measurement. However, in light of current data, for the treatment plans that target the receptors, biopsy specimen from the metastatis of breast cancer must also be evaulated for alterations in the receptor status.

Efficient reduction of loco-regional recurrences but no effect on mortality twenty years after postmastectomy radiation in premenopausal women with stage II breast cancer - a randomized trial from the South Sweden Breast Cancer Group

PURPOSE

To study long term loco-regional and distant recurrence rate and survival after post-mastectomy radiotherapy in combination with oral cyclophosphamide in premenopausal women with stage II breast cancer.

STUDY DESIGN

A three-armed randomized multicenter phase III trial comparing 1) Radiotherapy (RT) 2) RT+ oral cyclophosphamide for one year (RT+C) and 3) Oral cyclophosphamide only (C). Radiotherapy was administered, in 20 fractions, to 48Gy to the axilla and parasternal lymph nodes, 45Gy to infra- and supraclavicular fossae and 38Gy to the chest wall. Cyclophosphamide was prescribed as 12 courses of 130mg/m(2) od for 14 days every 4 weeks.

PATIENTS AND METHODS

367 patients from 15 surgical departments in Southern Sweden, representing 80% of all eligible patients, were included in the trial between 1978-1983. Median age was 47 years, median tumour size was 25mm, and 33% of the patients were lymph node negative. Median follow-up time was 24 years.

RESULTS

RT reduced the risk at twenty years for loco-regional recurrence in C-treated patients at twenty years with 75% (13.9% vs. 3.5%). The risk reduction was highly significant in both N0 and N+ patients. No reduction in systemic disease or mortality was observed.

CONCLUSION

Post-mastectomy radiotherapy reduced loco-regional recurrences in this premenopausal population, but no effect was seen on mortality with 20 years follow-up.

Predicting survival and early clinical response to primary chemotherapy for patients with locally advanced breast cancer using DCE-MRI

PURPOSE

To evaluate dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) as a tool for early prediction of response to neoadjuvant chemotherapy (NAC) and 5-year survival in patients with locally advanced breast cancer.

MATERIALS AND METHODS

DCE-MRI was performed in patients scheduled for NAC (n = 24) before and after the first treatment cycle. Clinical response was evaluated after completed NAC. Relative signal intensity (RSI) and area under the curve (AUC) were calculated from the DCE-curves and compared to clinical treatment response. Kohonen and probabilistic neural network (KNN and PNN) analysis were used to predict 5-year survival.

RESULTS

RSI and AUC were reduced after only one cycle of NAC in patients with clinical treatment response (P = 0.02 and P = 0.08). The mean and 10th percentile RSI values before NAC were significantly lower in patients surviving more than 5 years compared to nonsurvivors (P = 0.05 and 0.02). This relationship was confirmed using KNN, which demonstrated that patients who remained alive clustered in separate regions from those that died. Calibration of contrast enhancement curves by PNN for patient survival at 5 years yielded sensitivity and specificity for training and testing ranging from 80%-92%.

CONCLUSION

DCE-MRI in locally advanced breast cancer has the potential to predict 5-year survival in a small patient cohort. In addition, changes in tumor vascularization after one cycle of NAC can be assessed.