Breast cancer survival in relation to the metastatic tumor burden in axillary lymph nodes

Cancer metastasis through the lymphatic versus blood vessels

Whether cancer cells metastasize from the primary site to the distant sites via the lymphatic vessels or the blood vessels directly into the circulation is still under intense study. In this review article, we follow the journey of cancer cells metastasizing to the sentinel lymph nodes and beyond to the distant sites. We emphasize cancer heterogeneity and microenvironment as major determinants of cancer metastasis. Multiple molecules have been found to be associated with the complicated process of metastasis. Based on the large sentinel lymph node data, it is reasonable to conclude that cancer cells may metastasize through the blood vessels in some cases but in most cases, they use the sentinel lymph nodes as the major gateway to enter the circulation to distant sites.

Clinical implementation of artificial-intelligence-assisted detection of breast cancer metastases in sentinel lymph nodes: the CONFIDENT-B single-center, non-randomized clinical trial

Pathologists' assessment of sentinel lymph nodes (SNs) for breast cancer (BC) metastases is a treatment-guiding yet labor-intensive and costly task because of the performance of immunohistochemistry (IHC) in morphologically negative cases. This non-randomized, single-center clinical trial (International Standard Randomized Controlled Trial Number:14323711) assessed the efficacy of an artificial intelligence (AI)-assisted workflow for detecting BC metastases in SNs while maintaining diagnostic safety standards. From September 2022 to May 2023, 190 SN specimens were consecutively enrolled and allocated biweekly to the intervention arm (n = 100) or control arm (n = 90). In both arms, digital whole-slide images of hematoxylin-eosin sections of SN specimens were assessed by an expert pathologist, who was assisted by the 'Metastasis Detection' app (Visiopharm) in the intervention arm. Our primary endpoint showed a significantly reduced adjusted relative risk of IHC use (0.680, 95% confidence interval: 0.347-0.878) for AI-assisted pathologists, with subsequent cost savings of ~3,000 €. Secondary endpoints showed significant time reductions and up to 30% improved sensitivity for AI-assisted pathologists. This trial demonstrates the safety and potential for cost and time savings of AI assistance.

Impact of analysis of the sentinel lymph node by one-step nucleic acid amplification (OSNA) compared to conventional histopathology on axillary and systemic treatment: data from the Dutch nationwide cohort of breast cancer patients

PURPOSE

The outcome of the sentinel lymph node in breast cancer patients affects adjuvant treatment. Compared to conventional histopathology, analysis by one-step nucleic acid amplification (OSNA) harvests more micrometastasis, potentially inducing overtreatment. In this study we investigated the impact of OSNA analysis on adjuvant treatment, compared to histopathological analysis.

METHODS

Data from T1-3 breast cancer patients with sentinel nodes analysed between January 2016 and December 2019 by OSNA (OSNA group, n = 1086) from Zuyderland Medical Centre, the Netherlands, were compared to concurrent data from the Netherlands Cancer Registry (NKR) where sentinel nodes were examined by histology (histology group, n = 35,143). Primary outcomes were micro- or macrometastasis, axillary treatments (axillary lymph node dissection (ALND) or axillary radiotherapy (ART)), chemotherapy, and endocrine therapy. Statistics with Pearson Chi-square.

RESULTS

In the OSNA group more micrometastasis (14.9%) were detected compared to the histology group (7.9%, p < 0.001). No difference in axillary treatment between groups was detected (14.3 vs. 14.4%). In case of mastectomy and macrometastasis, ALND was preferred over ART in the OSNA group (14.9%) compared to the histology group (4.4%, p < 0.001). In cases of micrometastasis, no difference was seen. There was no difference in administration of adjuvant chemotherapy between groups. Endocrine treatment was administrated less often in the OSNA group compared to the histology group (45.8% vs. 50.8%, p < 0.002).

CONCLUSION

More micrometastasis were detected by OSNA compared to histopathology, but no subsequent increase in adjuvant axillary and systematic treatment was noticed. When performing mastectomy and OSNA, there was a preference for ALND compared to ART.

A Comprehensive Model Based on Dynamic Contrast-Enhanced Magnetic Resonance Imaging Can Better Predict the Preoperative Histological Grade of Breast Cancer Than a Radiomics Model

Background

Histological grade is an important prognostic factor for patients with breast cancer and can affect clinical decision-making. From a clinical perspective, developing an efficient and non-invasive method for evaluating histological grading is desirable, facilitating improved clinical decision-making by physicians. This study aimed to develop an integrated model based on radiomics and clinical imaging features for preoperative prediction of histological grade invasive breast cancer.

Methods

In this retrospective study, we recruited 211 patients with invasive breast cancer and randomly assigned them to either a training group (n=147) or a validation group (n=64) with a 7:3 ratio. Patients were classified as having low-grade tumors, which included grade I and II tumors, or high-grade tumors, which included grade III tumors. Three models were constructed based on basic clinical features, radiomics features, and the sum of the two. To assess diagnostic performance of the radiomics models, we employed measures such as receiver operating characteristic (ROC) curve, decision curve analysis (DCA), accuracy, sensitivity, and specificity, and the predictive performance of the three models was compared using the DeLong test and net reclassification improvement (NRI).

Results

The area under the curve (AUC) of the clinical model, radiomics model, and comprehensive model was 0.682, 0.833, and 0.882 in the training set and 0.741, 0.751, and 0.836 in the validation set, respectively. NRI analysis confirmed that the combined model was better than the other two models in predicting the histological grade of breast cancer (NRI=21.4% in the testing cohort).

Conclusion

Compared with the other models, the comprehensive model based on the combination of basic clinical features and radiomics features exhibits more significant potential for predicting histological grade and can better assist clinicians in optimal decision-making.

Negative Survival Impact of Occult Lymph Node Involvement in Small HER2-Positive Early Breast Cancer Treated by Up-Front Surgery

(1) Background: The independent negative prognostic value of isolated tumor cells or micro-metastases in axillary lymph nodes has been established in triple-negative breast cancers (BC). However, the prognostic significance of pN0(i+) or pN1mi in HER2-positive BCs treated by primary surgery remains unexplored. Therefore, our objective was to investigate the impact of pN0(i+) or pN1mi in HER2-positive BC patients undergoing up-front surgery on their outcomes. (2) Methods: We retrospectively analyzed 23,650 patients treated in 13 French cancer centers from 1991 to 2013. pN status was categorized as pN0, pN0(i+), pN1mi, and pNmacro. The effect of pN0(i+) or pN1mi on outcomes was investigated both in the entire cohort of patients and in pT1a-b tumors. (3) Results: Of 1771 HER2-positive BC patients included, pN status distributed as follows: 1047 pN0 (59.1%), 60 pN0(i+) (3.4%), 118 pN1mi (6.7%), and 546 pN1 macro-metastases (30.8%). pN status was significantly associated with sentinel lymph node biopsy, axillary lymph node dissection, age, ER status, tumor grade, and size, lymphovascular invasion, adjuvant systemic therapy (ACt), and radiation therapy. With 61 months median follow-up (mean 63.2; CI 95% 61.5-64.9), only pN1 with macro-metastases was independently associated with a negative impact on overall, disease-free, recurrence-free, and metastasis-free survivals in multivariate analysis. In the pT1a-b subgroup including 474 patients, RFS was significantly decreased in multivariate analysis for pT1b BC without ACt (HR 2.365, 1.04-5.36, p = 0.039) and for pN0(i+)/pN1mi patients (HR 2.518, 1.03-6.14, p = 0.042). (4) Conclusions: Survival outcomes were not adversely affected by pN0(i+) and pN1mi in patients with HER2-positive BC. However, in the case of pT1a-b HER2-positive BC, a negative impact on RFS was observed specifically for patients with pN0(i+) and pN1mi diseases, particularly among those with pT1b tumors without ACt. Our findings highlight the importance of considering the pN0(i+) and pN1mi status in the decision-making process when discussing trastuzumab-based ACt for these patients.

Prognostic factors in Luminal B-like HER2-negative breast cancer tumors

BACKGROUND

Molecular and genomic platforms can classify breast cancer intrinsic subtypeswith precision, however these are not widespread and immunohistochemical (IHC) classification is still used globally. This study aimed to evaluate the main clinical and pathologic prognostic factors for Luminal B-like HER2-negative breast cancer in our clinical setting.

METHODS

A retrospective review of early Luminal B-like HER2-negative breast cancer patients diagnosed in 2017 in our center was conducted. The main prognostic factors for relapse were evaluated, including patient's characteristics such as age, menopausal status, comorbidity index, personal and family history of breast cancer and obesity; tumor features such as size, histology and grade, oestrogen and progesterone receptor (PgR) status, HER2 status, Ki67 index and nodal involvement; and the given treatment. Cancer relapse during five years of follow-upwas considered the main outcome.

RESULTS

Fifty-six patients with early Luminal B-like HER2-negative breast cancer were included. Seven patients relapsed within five years of follow-up. Lymph node involvement at diagnosis and postoperatively were significantly associated with relapse (24,5% vs 71,43%p = 0.022; 38,8% vs 83,3%p = 0.004, respectively),although the number of pathologic positive lymph nodes was not associated with relapse occurrence (mean 1.5 in no-relapse group vs 0.8 in relapse group; p = 0.308).Other possible risk factors such as young age, premenopausal status, self-history of breast cancer, tumor size, histologic grade, PgR, or Ki 67 were not significantly associated with relapse. Additionally, the distribution of the number of positive nodes among relapse and no relapse groups(2,1 vs 1,8; p = 0.082) was not significant.

CONCLUSIONS

Lymph node involvement was the only prognostic factor in Luminal B-like HER2-negative breast cancer identified in this study, independently of the number of affected nodes.

A radiomics model development via the associations with genomics features in predicting axillary lymph node metastasis of breast cancer: a study based on a public database and single-centre verification

AIM

To evaluate the predictive performance of the radiomics model in predicting axillary lymph node (ALN) metastasis through the associations between radiomics features and genomic features in patients with breast cancer.

MATERIALS AND METHODS

Patients with breast cancer were enrolled retrospectively from a public database (111 patients as training group) and one hospital (15 patients as external validation group). The genomics features from transcriptome data and radiomics features from dynamic contrast-enhanced magnetic resonance imaging (MRI) were collected. Firstly, overlapping genes were identified using the Kyoto Encyclopedia of Genes and Genomes and differentially expressed gene analysis, while radiomics features were reduced using a data-driven method. Then, the associations between overlapping genes and retained radiomics features were assessed to obtain key pairs of radiomics-genomics features. Furthermore, the least absolute shrinkage and selection operator (LASSO) algorithm was used to detect the key-pairs features. Finally, radiomics and genomics models were constructed to predict ALN metastasis.

RESULTS

After using the hybrid data- and gene-driven selection method, key pairs of features were detected, which consisted of six radiomic features associated with four genomic features. The radiomics model exhibited comparable performance to the genomics model in predicting ALN metastasis (radiomic model: area under the curve [AUC] = 0.71, sensitivity = 77%, specificity = 56%; genomic model: AUC = 0.72, sensitivity = 85%, specificity = 74%). The four genomic features were enriched in six pathways and related to metabolism and human diseases.

CONCLUSION

The radiomics model established using the gene-driven hybrid selection method could predict ALN metastasis in breast cancer, which showed comparable performance to the genomics model.

Predicting axillary lymph node metastasis in breast cancer using the similarity of quantitative dual-energy CT parameters between the primary lesion and axillary lymph node

PURPOSE

To evaluate the similarity of quantitative dual-energy computed tomography (DECT) parameters between the primary breast cancer lesion and axillary lymph node (LN) for predicting LN metastasis.

MATERIALS AND METHODS

This retrospective study included patients with breast cancer who underwent contrast-enhanced DECT between July 2019 and April 2021. Relationships between LN metastasis and simple DECT parameters, similarity of DECT parameters, and pathological and morphological features were analyzed. ROC curve analysis was used to evaluate diagnostic ability.

RESULTS

Overall, 137 LNs (39 metastases and 98 non-metastases) were evaluated. Significant differences were observed in some pathological (nuclear grade, estrogen receptor status, and Ki67 index) and morphological characteristics (shortest and longest diameters of the LN, longest-to-shortest diameter ratio, and hilum), most simple DECT parameters, and all DECT similarity parameters between the LN metastasis and non-metastasis groups (all, P < 0.001-0.004). The shortest diameter of the LN (odds ratio 2.22; 95% confidence interval 1.47, 3.35; P < 0.001) and the similarity parameter of 40-keV attenuation (odds ratio, 2.00; 95% confidence interval 1.13, 3.53; P = 0.017) were independently associated with LN metastasis compared to simple DECT parameters of 40-keV attenuation (odds ratio 1.01; 95% confidence interval 0.99, 1.03; P =0.35). The AUC value of the similarity parameters for predicting metastatic LN was 0.78-0.81, even in cohorts with small LNs (shortest diameter < 5 mm) (AUC value 0.73-0.78).

CONCLUSION

The similarity of the delayed-phase DECT parameters could be a more useful tool for predicting LN metastasis than simple DECT parameters in breast cancer, regardless of LN size.

Clinicopathological characteristics and prognosis of microinvasive breast cancer: A population-based analysis

OBJECTIVES

Microinvasive breast cancer (MIBC) is a special type of breast cancer with a relatively low prevalence, of which the understanding remains controversial. In this article, we aimed to clarify the clinicopathological characteristics and prognosis of MIBC in the setting of different molecular subtypes and give feasible suggestions on clinical practice in MIBC.

METHODS

This study utilized the data from Surveillance, Epidemiology, and End Results (SEER) database. Patients were divided into subgroups based on the molecular subtypes, of which the clinicopathological characteristics were further undergone comparative analyses. Kaplan-Meier method and Cox proportional hazard regression analysis were employed to determine the prognosis of the subtypes, and to explore the prognostic factors. Patients were randomly assigned in a 7:3 ratio to the training and validation cohorts. The independent risk variables were then adopted to generate a nomogram to predict the 3- and 5-year survival probability.

RESULTS

A total of 4301 MIBC patients between 2010 and 2016 were obtained from the SEER database, which were subsequently separated into HR+/HER2- (n = 2598), HR+/HER2+ (n = 723), HR-/HER2+ (n = 633), and HR-/HER2- (n = 347) groups. The HR+/HER2+ group showed the best overall survival (OS) (81.28 months, 95% CI 80.45-82.11) compared with other groups (p = 0.0089). The application of radiotherapy in HR+/HER2- and HR+/HER2+ MIBC patients brought out additional survival benefit compared with those without radiotherapy (p < 0.0001 and p = 0.024, respectively). The prognosis among four subgroups with or without chemotherapy showed no statistical difference. Based on the curated nomogram, the high-score group exhibited a better OS compared with patients from the low-score group.

CONCLUSIONS

Profound heterogeneity was detected among different molecular subtypes in MIBC patients, of which HR+/HER2+ subtype presented the best prognosis. For HR-positive MIBC patients, increasing survival benefits could be retrieved from radiotherapy. Chemotherapy was not recommended for patients with MIBC. Individual-based protocols were introduced based on the nomogram which warranted further validation.

Dual-Energy Computed Tomography for Evaluation of Breast Cancer Follow-Ups: Comparison of Virtual Monoenergetic Images and Iodine-Map

Differentiating tumor tissue from dense breast tissue can be difficult. Dual-energy CT (DECT) could be suitable for making diagnoses at breast cancer follow-ups. This study investigated the contrast in DECT images and iodine maps for patients with breast cancer being followed-up. Chest CT images captured in 2019 were collected. Five cases of metastatic breast cancer in the lungs were analyzed; the contrast-to-noise ratio (for breast tissue and muscle: CNRb and CNRm, respectively), tumor-to-breast mammary gland ratio (T/B), and tumor-to-muscle ratio (T/M) were calculated. For 84 cases of no metastasis, monochromatic spectral and iodine maps were obtained to compare differences under various breast densities using the K-means algorithm. The optimal T/B, T/M, and CNRb (related to mammary glands) were achieved for the 40-keV image. Conversely, CNRm (related to lungs) was better for higher energy. The optimal balance was achieved at 80 keV. T/B, T/M, and CNR were excellent for iodine maps, particularly for density > 25%. In conclusion, energy of 80 keV is the parameter most suitable for observing the breast and lungs simultaneously by using monochromatic spectral images. Adding iodine mapping can be appropriate when a patient’s breast density is greater than 25%.

Detection of circulating tumour cells before and following adjuvant chemotherapy and long-term prognosis of early breast cancer

Background

The detection of circulating tumour cells (CTC) is prognostic for disease recurrence in early breast cancer (BC). This study aims to investigate whether this prognostic effect persists or varies over time.

Methods

The study population consisted of prospectively included stage I–III BC patients. The presence of CK19 mRNA-positive CTC in the peripheral blood was evaluated before and after adjuvant chemotherapy, using a real-time RT–PCR assay. Longitudinal samples were collected for a subset of patients.

Results

Baseline CTC data were available from 1220 patients, while 1132 had both pre- and post-therapy data. After a median follow-up of 134.1 months, CTC positivity at baseline was associated with shorter overall survival (OS; HR_adj = 1.72, 95% CI 1.34–2.21, p < 0.001). For disease-free survival, an interaction with time (p = 0.045) was observed. CTC positivity predicted early (within 5 years; HR_adj = 1.76, 95_% CI 1.33–2.32, p < 0.001) but not late recurrence (HR_adj = 1.10, 95% CI 0.79–1.53, p = 0.577). Following adjuvant chemotherapy, more patients converted from CTC-positive to CTC-negative than vice versa (p < 0.001). Ten-year OS was 68.6% for + /+ and 86.7% for −/− group (p < 0.001). CTC status at follow-up predicted disease recurrence.

Conclusion

CTC detection pre- and post-adjuvant chemotherapy is prognostic for early relapse, supporting investigations for novel adjuvant therapeutic approaches.

Epithelial-Cadherin Expression Is Associated With Better Recurrence-Free and Overall Survival in Invasive Lobular Breast Cancer in Mexican Women

Background

There are different clinicopathological characteristics that are associated with the prognosis in patients with breast cancer. To date, the prognostic valor of for epithelial cadherin (E cadherin) expression in invasive lobular breast cancer remains unknown.

Methods

A retrospective single-center study that included 207 patients with primary invasive lobular breast cancer was conducted. The primary outcome was to report the correlation of the different clinical pathological characteristics including the expression of epithelial-cadherin (E-cadherin) in invasive lobular breast cancer in Mexican women with recurrence-free survival (RFS) and overall survival (OS).

Results

After 11 years of follow-up of patients with invasive lobular breast cancer, RFS was 89.4% and OS of 96.1%. The best prognosis in RFS was in patients with negative nodes 95.2% (P = 0.0001) and OS was 98.6-100% (P = 0.0001). Regarding tumor size, an RFS of 98.3% was observed in those measuring ≤ 2 cm (P = 0.0001) and OS of 99.2% (P = 0.0001). Negative Her2 was related to an RFS of 92.1% (P = 0.0001), and had better OS of 98.3% (P = 0.0001). Ki67 proliferation index ≤ 14% was associated with an RFS of 93.2% (P = 0.005). Negative lymph vascular invasion (LVI) increases the RFS of 91.8% (P = 0.032). The rate of positive expression of E-cadherin was associated with an increase in the RFS of 97.4%, with a mean of 128.6 ± 2.4 months (95% confidence interval (CI): 123.75 - 133.45 months) compared to the absence of expression E-cadherin: signal log ratio (SLR) 68.9%, a mean of 95 ± 6 months (95% CI: 83.28 - 106.88 months), P <0.001. When the OS was analyzed, the presence of E-cadherin expression increased the OS of 100% vs. 86.9% with the absence, P = 0.015.

Conclusions

The prognostic impact of the different clinicopathological characteristics known worldwide was confirmed. Results of the analysis in the presented study indicate that positive expression of E-cadherin correlates with an improvement in OS and RFS in invasive lobular breast cancer in Mexican women.

Associations of hair dye and relaxer use with breast tumor clinicopathologic features: Findings from the Women's circle of Health Study

BACKGROUND

Building upon our earlier findings of significant associations between hair dye and relaxer use with increased breast cancer risk, we evaluated associations of select characteristics of use with breast tumor clinicopathology.

METHODS

Using multivariable-adjusted models we examined the associations of interest in a case-only study of 2998 women with breast cancer, overall and stratified by race and estrogen receptor (ER) status, addressing multiple comparisons using Bonferroni correction.

RESULTS

Compared to salon application of permanent hair dye, home kit and combination application (both salon and home kit application) were associated with increased odds of poorly differentiated tumors in the overall sample. This association was consistent among Black (home kit: OR 2.22, 95 % CI: 1.21-5.00; combination: OR 2.46, 95 % CI: 1.21-5.00), but not White women, and among ER+ (home kit: OR 1.47, 95 % CI: 0.82-2.63; combination: OR 2.98, 95 % CI: 1.62-5.49) but not ER-cases. Combination application of relaxers was associated with increased odds of tumors >2.0 cm vs. <1.0 cm (OR = 1.82, 95 % CI: 1.23-2.69). Longer duration and earlier use of relaxers and combination application of permanent hair dyes and relaxers were associated with breast tumor features including higher tumor grade and larger tumor size, which often denote more aggressive phenotypes, although the findings did not maintain significance with Bonferroni correction.

CONCLUSIONS

These novel data support reported associations between hair dye and relaxer use with breast cancer, showing for the first time, associations with breast tumor clinicopathologic features. Improved hair product exposure measurement is essential for fully understanding the impact of these environmental exposure with breast cancer and to guide risk reduction strategies in the future.

Breast cancer metastasis: immune profiling of lymph nodes reveals exhaustion of effector T cells and immunosuppression

Sentinel lymph nodes are the first nodes draining the lymph from a breast and could reveal early changes in the host immune system upon dissemination of breast cancer cells. To investigate this, we performed single-cell immune profiling of lymph nodes with and without metastatic cells. Whereas no significant changes were observed for B-cell and natural killer (NK)-cell subsets, metastatic lymph nodes had a significantly increased frequency of CD8 T cells and a skewing toward an effector/memory phenotype of CD4 and CD8 T cells, suggesting an ongoing immune response. Additionally, metastatic lymph nodes had an increased frequency of TIGIT (T-cell immunoreceptor with Ig and ITIM domains)-positive T cells with suppressed TCR signaling compared with non-metastatic nodes, indicating exhaustion of effector T cells, and an increased frequency of regulatory T cells (Tregs) with an activated phenotype. T-cell alterations correlated with the percentage of metastatic tumor cells, reflecting the presence of metastatic tumor cells driving T effector cells toward exhaustion and promoting immunosuppression by recruitment or increased differentiation toward Tregs. These results show that immune suppression occurs already in early stages of tumor progression.

Long non-coding RNA anti-differentiation non-coding RNA affects proliferation, invasion, and migration of breast cancer cells by targeting miR-331

We aimed to evaluate the effects of long-chain non-coding RNA (lncRNA) anti-differentiation non-coding RNA (ANCR) on the proliferation, invasion, and migration of breast cancer cells by targeting miR-331. Forty-eight breast cancer and paracancerous tissue samples were collected. LncRNA ANCR expressions in breast cancer and adjacent tissues, human breast cancer cells and mammary epithelial cells, and miR-331 expressions in interfering cell line MDA-MB-231 (MCF-7)-shANCR, negative control MDA-MB-231 (MCF-7)-shNC and blank control MDA-MB-231 (MCF-7) were detected by real-time quantitative PCR. The correlations between lncRNA ANCR expression and clinicopathological characteristics were analyzed. Cell proliferation was detected by MTT and colony formation assays. Invasion and migration were tested by Transwell and scratch assays, respectively. The targeting relationship between ANCR and miR-331 was analyzed using the TargetScan database, and their interaction was studied using a dual-luciferase reporter assay. The expression of lncRNA ANCR in breast cancer tissue was significantly lower than that in adjacent normal tissue (p < 0.05). LncRNA ANCR was lowly expressed in various human breast cancer cell lines, being lowest in high-metastatic cell line (MDA-MB-231HM) (p < 0.05). Silencing lncRNA ANCR significantly enhanced the proliferation and invasion capacities of breast cancer cells, and promoted their tumor formation abilities in nude mice (p < 0.05). ANCR bound miR-331 targetedly, and the former negatively regulated the expression of the latter. LncRNA ANCR is lowly expressed upon breast cancer, and inhibits cell proliferation, invasion, and migration in vitro and in vivo. LncRNA ANCR exerts antitumor effects by targetedly binding miR-331 and then inhibiting its expression.

Molecular mechanisms of cancer metastasis via the lymphatic versus the blood vessels

Cancer metastasis is the process by which primary cancer cells invade through the lymphatic or blood vessels to distant sites. The molecular mechanisms by which cancer cells spread either through the lymphatic versus blood vessels or both are not well established. Two major developments have helped us to understand the process more clearly. First, the development of the sentinel lymph node (SLN) concept which is well established in melanoma and breast cancer. The SLN is the first lymph node in the draining nodal basin to receive cancer cells. Patients with a negative SLN biopsy show a significantly lower incidence of distant metastasis, suggesting that the SLN may be the major gateway for cancer metastasis in these cancer types. Second, the discovery and characterization of several biomarkers including VEGF-C, LYVE-1, Podoplanin and Prox-1 have opened new vistas in the understanding of the induction of lymphangiogenesis by cancer cells. Cancer cells must complete multiple steps to invade the lymphatic system, some of which may be enabled by the evolution of new traits during cancer progression. Thus, cancer cells may spread initially through the main gateway of the SLN, from which evolving cancer clones can invade the blood vessels to distant sites. Cancer cells may also enter the blood vessels directly, bypassing the SLN to establish distant metastases. Future studies need to pinpoint the molecules that are used by cancer cells at different stages of metastasis via different routes so that specific therapies can be targeted against these molecules, with the goal of stopping or preventing cancer metastasis.

The lymphatic system and sentinel lymph nodes: conduit for cancer metastasis

The lymphatic system is a complicated system consisting of the lymphatic vessels and lymph nodes draining the extracellular fluid containing cellular debris, excess water and toxins to the circulatory system. The lymph nodes serve as a filter, thus, when the lymph fluid returns to the heart, it is completely sterile. In addition, the lymphatic system includes the mucosa-associated lymphoid tissue, such as tonsils, adenoids, Peyers patches in the small bowel and even the appendix. Taking advantage of the drainage system of the lymphatics, cancer cells enter the lymphatic vessels and then the lymph nodes. In general, the lymph nodes may serve as a gateway in the majority of cases in early cancer. Occasionally, the cancer cells may enter the blood vessels. This review article emphasizes the structural integrity of the lymphatic system through which cancer cells may spread. Using melanoma and breast cancer sentinel lymph node model systems, the spread of early cancer through the lymphatic system is progressive in a majority of cases. The lymphatic systems of the internal organs are much more complicated and difficult to study. Knowledge from melanoma and breast cancer spread to the sentinel lymph node may establish the basic principles of cancer metastasis. The goal of this review article is to emphasize the complexity of the lymphatic system. To date, the molecular mechanisms of cancer spread from the cancer microenvironment to the sentinel lymph node and distant sites are still poorly understood and their elucidation should take major priority in cancer metastasis research.

Omitting completion axillary lymph node dissection after detection of sentinel node micrometastases in breast cancer: first results from the prospective SENOMIC trial

BACKGROUND

Completion axillary lymph node dissection has been abandoned widely among patients with breast cancer and sentinel lymph node micrometastases, based on evidence from prospective RCTs. Inclusion in these trials has been subject to selection bias, with patients undergoing mastectomy being under-represented. The aim of the SENOMIC (omission of axillary lymph node dissection in SENtinel NOde MICrometases) trial was to confirm the safety of omission of axillary lymph node dissection in patients with breast cancer and sentinel lymph node micrometastases, and including patients undergoing mastectomy.

METHODS

The prospective SENOMIC multicentre cohort trial enrolled patients with breast cancer and sentinel lymph node micrometastases who had breast-conserving surgery or mastectomy at one of 23 Swedish hospitals between October 2013 and March 2017. No completion axillary lymph node dissection was performed. The primary endpoint was event-free survival, with a trial accrual target of 452 patients. Survival proportions were based on Kaplan-Meier survival estimates.

RESULTS

The trial included 566 patients. Median follow-up was 38 (range 7-67) months. The 3-year event-free survival rate was 96.2 per cent, based on 26 reported breast cancer recurrences, including five isolated axillary recurrences. The unadjusted 3-year event-free survival rate was higher than anticipated, but differed between patients who had mastectomy and those who underwent breast-conserving surgery (93.8 versus 97.8 per cent respectively; P = 0.011). Patients who underwent mastectomy had significantly worse tumour characteristics. On univariable Cox proportional hazards regression analysis, patients who had mastectomy without adjuvant radiotherapy had a significantly higher risk of recurrence than those who underwent breast-conserving surgery (hazard ratio 2.91, 95 per cent c.i. 1.25 to 6.75).

CONCLUSION

After 3 years, event-free survival was excellent in patients with breast cancer and sentinel node micrometastases despite omission of axillary lymph node dissection. Long-term follow-up and continued enrolment of patients having mastectomy, especially those not receiving adjuvant radiotherapy, are of utmost importance.

Lack of prognostic impact of sentinel node micro-metastases in endocrine receptor-positive early breast cancer: results from a large multicenter cohort☆

Background

Prognostic impact of lymph node micro-metastases (pN1mi) has been discordantly reported in the literature. The need to clarify this point for decision-making regarding adjuvant therapy, particularly for patients with endocrine receptor (ER)-positive status and HER2-negative tumors, is further reinforced by the generalization of gene expression signatures using pN status in their recommendation algorithm.

Patients and methods

We retrospectively analyzed 13 773 patients treated for ER-positive breast cancer in 13 French cancer centers from 1999 to 2014. Five categories of axillary lymph node (LN) status were defined: negative LN (pN0i−), isolated tumor cells [pN0(i+)], pN1mi, and pN1 divided into single (pN1 = 1) and multiple (pN1 > 1) macro-metastases (>2 mm). The effect of LN micro-metastases on outcomes was investigated both in the entire cohort of patients and in clinically relevant subgroups according to tumor subtypes. Propensity-score-based matching was used to balance differences in known prognostic variables associated with pN status.

Results

As determined by sentinel LN biopsy, 9427 patients were pN0 (68.4%), 546 pN0(i+) (4.0%), 1446 pN1mi (10.5%) and 2354 pN1 with macro-metastases (17.1%). With a median follow-up of 61.25 months, pN1 status, but not pN1mi, significantly impacted overall survival (OS), disease-free survival (DFS), metastasis-free survival (MFS), and breast-cancer-specific survival. In the subgroup of patients with known tumor subtype, pN1 = 1, as pN1 > 1, but not pN1mi, had a significant prognostic impact on OS. DFS and MFS were only impacted by pN1 > 1. Similar results were observed in the subgroup of patients with luminal A-like tumors (n = 7101). In the matched population analysis, pN1macro, but not pN1mi, had a statistically significant negative impact on MFS and OS.

Conclusion

LN micro-metastases have no detectable prognostic impact and should not be considered as a determining factor in indicating adjuvant chemotherapy. The evaluation of the risk of recurrence using second-generation signatures should be calculated considering micro-metastases as pN0.

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LN micro-metastases have no detectable prognostic impact.

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pN1 status, but not pN1mi, significantly impacted overall survival, disease-free survival, metastasis-free survival.

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In the subgroup of patients with known tumor subtype, pN1=1, as pN1>1, but not pN1mi, had a significant prognostic impact on OS.

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LN micro-metastases should not be considered as a determining factor in indicating adjuvant chemotherapy.

Long-Term Non-progression in Metastatic Breast Cancer Beyond 5 Years: Case Series and Review

Purpose of review

Metastatic breast cancer (MBC) was traditionally viewed as homogeneously progressive and incurable among all comers, but there is new evidence that MBC harbors a range of tumor molecular/immune subtypes and degrees of aggressiveness. Thus, MBC is not rapidly fatal in all affected patients.

Recent findings

A small subset of patients will attain long-term disease control, or undetectable disease, and will enjoy a prolonged survival with little disability from their disease or treatment. Though the term is controversial, some patients with long-term non-detectable disease may effectively be considered “cured”. To best advise treatment options in these patients, it is imperative to identify patients most likely to benefit from aggressive treatment.

Summary

In this review, we delineate the clinical, pathologic, and disease characteristics associated with long-term non-progression in MBC. We include a single institution case series of long-term non-progressive MBC patients and their characteristics as an example of the frequency of this sub-population of MBC. Future prospective trials are warranted to examine the utility of clinical characteristics as predictors of long-term survival in MBC.

Clinical effect of the pathological axillary assessment method in breast cancer without clinical nodal metastasis

BACKGROUND

This study aimed to assess the clinical effect of the pathological axillary assessment method in breast cancer without clinical lymph node metastasis.

METHODS

Data of patients with clinically node-negative breast cancer were retrospectively reviewed. The study period was divided into early (January 2000-July 2007) and late (August 2007-December 2014) periods based on the pathological assessment method used (single-sectional and detailed multi-sectional lymph node processing). In the late period, lymph nodes were evaluated at six levels including immunohistochemistry on each 1.5-2 mm interval section. The axillary diagnostic accuracy and role of chemotherapy were assessed.

RESULTS

In 1698 patients, 27 isolated tumor cells (ITCs), 39 micrometastases, and 205 macrometastases were noted. The sensitivity for pathological N0 diagnosis was dependent on clinical T stage, Tis (97.8%), T1 (83.0%), T2 (74.2%), T3 (54.5%), and T4 (63.6%). ITCs and micrometastases were detected only in the late period, and 84.7% and 91.6% of cases in the early and late period, respectively, did not have macrometastases. The 5-year disease-free interval (DFI) rates were 95.2% in node-negative cases, 98.4% in ITCs/micrometastases, and 91.4% in macrometastases (P < 0.001). In multivariate analysis, the predictor for DFI was estrogen receptor negativity (P = 0.013). Chemotherapy did not improve DFI in patients with node-positive breast cancer.

CONCLUSIONS

The detailed multi-sectional pathological assessment of axillary lymph nodes detected ITCs and micrometastases. Implementation of chemotherapy should not be based on the minimal nodal metastasis and this type of serially nodal sectioned processing had little clinical significance.

c-Jun NH2-terminal kinase suppression significantly inhibits the growth of transplanted breast tumors in mice

Objective

The current study investigated the effect of c-Jun NH2-terminal kinase (JNK) expression on the growth of transplanted breast cancer tumors in mice.

Methods

A breast cancer transplantation model was established in BALB/c mice, which were then treated with SP600125 (30 mg/kg) for 24 days. After sacrificing the mice, the inhibitory effects of SP600125 on breast cancer growth were calculated by weighing tumors. Moreover, vascular endothelial growth factor (VEGF) expression and the tumor microvascular density (MVD) were evaluated via immunohistochemistry. Cell apoptosis was also examined using a TUNEL kit.

Results

Compared with the findings in the control group, SP600125 treatment (30 mg/kg) obviously suppressed tumor growth during the 15-day observation period. SP600125 treatment markedly inhibited JNK mRNA expression. Furthermore, VEGF protein expression (50% vs. 100%) and MVD (18.27 ± 1.70 vs. 23.17 ± 4.02) were also significantly decreased by SP600125 treatment, whereas the apoptosis index was significantly higher in the treatment group (10.23 ± 1.97% vs. 4.53 ± 1.40%).

Conclusion

Inhibition of JNK signaling can significantly suppress the growth of transplanted breast tumors in mice.

Role of Sentinel Lymph Node Biopsy in Microinvasive Breast Cancer

BACKGROUND

Microinvasive ductal carcinoma (DCISM), defined as DCIS with a focus of invasive carcinoma ≤ 1 mm, can be managed similarly to pure DCIS; however, management of the axilla in DCISM has been a subject of debate. Reports in the literature differ on the utility and necessity of sentinel lymph node biopsy (SLNB) for DCISM. The aim of the present study was to identify risk factors for nodal disease in patients with DCISM, which can help develop a selective approach to SLNB in this patient population.

METHODS

The National Cancer Database was used to select patients with DCISM (pT1mi), diagnosed from 2012 to 2015, who underwent SLNB. Multivariable regression analysis was performed to determine associations between sentinel lymph node metastasis and relevant clinical variables.

RESULTS

Our cohort comprised of 2609 patients with pT1mi who underwent SLNB. Of these, 76 (2.9%) were found to have sentinel lymph node metastases on final pathology. Low/intermediate grade tumors were associated with decreased SLN metastasis (OR 0.50, CI 0.28-0.92). Age and receptor status of the tumor did not have a clear association in predicting SLN metastases.

CONCLUSIONS

The rate of sentinel node metastases in DCISM is low at only 2.9% in this national study. Tumor grade was identified as influencing the risk of SLN metastases. This information can factor into shared decision-making for SLNB in patients with DCISM.

Ki67 index in intrinsic breast cancer subtypes and its association with prognostic parameters

Objectives

Ki67 is the most commonly used marker to evaluate proliferative index in breast cancer, however no cutoff values have been clearly defined for high ki67 index. Cancer management should be according to loco-regional profile; therefore, we aimed to determine ki67 index in 1951 cases of intrinsic breast cancer subtypes and its association with other prognostic parameters in our set up.

Results

Triple negative breast cancers showed highest ki67 index (mean 50.9 ± 23.7%) followed by Her2neu (mean 42.6 ± 21.6%) and luminal B cancers (mean 34.9 ± 20.05%). Metaplastic and medullary breast cancers significantly showed higher ki67 index as compared to ductal carcinoma, NOS. No significant association of ki67 index was noted with any of the histologic parameters in different subtypes of breast cancer expect for tumor grade. Although, ki67 index is a valuable biomarker in breast cancer, however no independent prognostic significance of ki67 could be established in our study.

21-Gene Recurrence Score Assay Could Not Predict Benefit of Post-mastectomy Radiotherapy in T1-2 N1mic ER-Positive HER2-Negative Breast Cancer

Introduction: It is still controversial whether post-mastectomy radiotherapy (PMRT) is necessary for women with T1-2 N1mic ER-positive HER2-negative breast cancer. The 21-gene recurrence score (RS) assay has been validated in T1-2 N1 breast cancer to be prognostic of locoregional recurrence (LRR) and overall survival (OS). This study aims to evaluate the predict value of 21-gene recurrence score assay for the benefit of PMRT in T1-2 N1mic ER-positive HER2-negative breast cancer.

Methods: A population-based cohort study was performed on women with T1-2 N1mic ER-positive HER2-negative breast cancer who underwent mastectomy and were evaluated using the 21-gene RS in the Surveillance, Epidemiology, and End Results (SEER) registry between 2004 and 2015. Clinical characteristics as well as OS and breast cancer-specific survival (BCSS) were compared between patients with and without PMRT in patients with a Low-, Intermediate-, and High-RS. Multivariate COX regression analysis was performed to investigate if the 21-gene RS assay could predict benefit of PMRT in this group of breast cancer patients.

Results: A total of 1571 patients met the criteria of our study and were enrolled, including 970 patients in the Low-Risk group (score <18), 508 in the Intermediate-Risk group (score 18–30), and 93 patients in the High-Risk group (score >30). In the High-Risk group, there were more patients with age ≥50 (87.0 vs. 64.3%, P = 0.040) and received chemotherapy with a borderline significance (91.3 vs. 72.9%, P = 0.066) in the PMRT subgroup than in the no PMRT subgroup. In all three groups, OS was comparable between the PMRT subgroup and the no PMRT subgroup. Furthermore, multivariate analysis did not show any OS benefit for PMRT based on the 21-gene recurrence score.

Conclusion: This study showed that the 21-gene RS assay was not able to predict the benefit of PMRT for OS in women with T1-2 N1mic ER-positive HER2-negative breast cancer. However, further prospective larger sample-size trials are warranted to determine if a benefit exists.

Minimal prognostic significance of sentinel lymph node metastasis in patients with cT1-2 and cN0 breast cancer

Background

The prognostic value of sentinel lymph node (SLN) metastases may be minimized by the limited disease burden of lymph node metastases and tailoring adjuvant therapy based on breast cancer biology. The aim of this study is to assess the prognostic significance of SLN metastasis in patients with cT1–2N0M0 breast cancer.

Patients and methods

Between January 2006 and December 2015, 582 patients underwent SLN biopsy for cT1–2N0M0 breast cancers. cN0 was essentially diagnosed by ultrasound sonography. The prognostic values of SLN metastases were retrospectively evaluated.

Results

Among 582 patients with cT1–2N0M0 breast cancer, 111 patients (19.1%) were positive for SLN metastasis, including 39 cases (6.7%) of micrometastasis and 72 cases (12.4%) of macrometastases. The median size of SLN metastasis was 3.0 mm (range 0.2–16 mm, mean 4.1 mm). In log-rank test, presence of SLN metastasis was not associated with breast cancer recurrence (p = 0.21); 5-year and 10-year recurrence-free survival (RFS) were 93.0% and 96.5%, and 93.0% and 90.4% in the SLN-positive and SLN-negative groups, respectively. In the propensity score matching cohort (n = 178), there was no significant difference in RFS between the SLN-positive and SLN-negative groups (p = 0.90). In Cox regression analysis, a continuous value of Ki67 expression was a significant prognostic factor (HR 1.03; 95% CI 1.01–1.05, p = 0.017).

Conclusion

SLN metastasis has a minimal impact on RFS for patients with cT1–2N0M0 breast cancer in the modern medical era. A proliferation marker is a better factor for poor prognosis than the presence of SLN metastases in this population.

Electronic supplementary material

The online version of this article (10.1186/s12957-019-1585-9) contains supplementary material, which is available to authorized users.

Breast Cancer Tissue Markers, Genomic Profiling, and Other Prognostic Factors: A Primer for Radiologists

An understanding of prognostic factors in breast cancer is imperative for guiding patient care. Increased tumor size and more advanced nodal status are established independent prognostic factors of poor outcomes and are incorporated into the American Joint Committee on Cancer (AJCC) TNM (primary tumor, regional lymph node, distant metastasis) staging system. However, other factors including imaging findings, histologic evaluation results, and molecular findings can have a direct effect on a patient's prognosis, including risk of recurrence and relative survival. Several microarray panels for gene profiling of tumors are approved by the U.S. Food and Drug Administration and endorsed by the American Society of Clinical Oncology. This article highlights prognostic factors currently in use for individualizing and guiding breast cancer therapy and is divided into four sections. The first section addresses patient considerations, in which modifiable and nonmodifiable prognostic factors including age, race and ethnicity, and lifestyle factors are discussed. The second part is focused on imaging considerations such as multicentric and/or multifocal disease, an extensive intraductal component, and skin or chest wall involvement and their effect on treatment and prognosis. The third section is about histopathologic findings such as the grade and presence of lymphovascular invasion. Last, tumor biomarkers and tumor biology are discussed, namely hormone receptors, proliferative markers, and categorization of tumors into four recognized molecular subtypes including luminal A, luminal B, human epidermal growth factor receptor 2-enriched, and triple-negative tumors. By understanding the clinical effect of these prognostic factors, radiologists, along with a multidisciplinary team, can use these tools to achieve individualized patient care and to improve patient outcomes. ^©RSNA, 2018.

Protein and DNA evidences of HCMV infection in primary breast cancer tissues and metastatic sentinel lymph nodes

BACKGROUND AND OBJECTIVE

Breast cancer is the leading cause of death in women worldwide. There are evidences that human cytomegalovirus (HCMV) infection is associated with several malignant tumors. This study aims to investigate the infection of human cytomegalovirus (HCMV) in a large sample of breast cancer patients, and conduct a correlation analysis of clinical and pathological factors, to provide evidence for whether HCMV infection is associated with breast cancer development, progression and metastasis.

MATERIALS AND METHODS

A total of 438 tissue samples (including breast cancer tissue, paracancerous tissue and sentinel lymph node [SLN] tissue) obtained from 146 patients who were diagnosed with breast cancer and intraoperatively underwent unilateral axillary SLN biopsy at the Affiliated Hospital of Qingdao University from June 2013 to June 2014 were included into this study. These tissue samples were divided into two groups: SLN positive group and SLN negative group. The clinical information is collated and numbered. Normal breast tissues of 40 patients with cyclomastopathy were taken as controls. The expressions of HCMV immediate-early (IE) and late antigen (LA) proteins of breast cancer tissues, paracancerous tissues, SLN tissues and normal breast tissues were analyzed by immunohistochemistry, and HCMV infection of the samples was graded according to the percentage of the positive cells, and HCMV IE2 mRNA expression was detected by reverse transcription polymerase chain reaction. The clinical data were collated and statistically analyzed.

RESULTS

HCMV IE and LA proteins were highly expressed in all breast cancer tissue samples. IE proteins were detected in 47.9% (70/146) of paracancerous tissue samples, and LA proteins were detected in 53.4% (78/146) of paracancerous tissue samples. IE and LA proteins were expressed in 92.6% of metastatic SLN samples (62/68) and in most of the tumor cells. Inflammatory cells in 60% (42/70) of non-metastatic samples were positive for HCMV. HCMV DNA was present in 100% of breast cancer tissue samples, 50% of paracancerous tissue samples, and 91% of metastatic SLN samples; but this was not present in HCMV negative and non-metastatic SLN samples. Differences in HCMV infection, and estrogen receptor-α, progesterone receptor, Elston classification, Ki67 percentage, Her-2 and Luminal type and other clinical indicators were not statistically significant.

CONCLUSION

HCMV infection is common in breast cancer tissues, paracancerous tissues and SLN tissues. The severity of HCMV infection varied markedly with tissue type. HCMV infection might be associated with metastasis and invasion of breast cancer. The expression of HCMV IE2 was associated to breast cancer and lymph node metastasis. The expression level of estrogen receptor-α was related to HCMV infection.

Axillary Sentinel Lymph Nodes in Breast Cancer: Quantitative Evaluation at Dual-Energy CT

Purpose To evaluate the diagnostic performance of quantitative parameters derived from dual-energy CT for the preoperative diagnosis of metastatic sentinel lymph nodes (SLNs) in participants with breast cancer. Materials and Methods For this prospective study, dual-phase contrast agent-enhanced CT was performed in female participants with breast cancer from June 2015 to December 2017. Quantitative dual-energy CT parameters and morphologic parameters were compared between metastatic and nonmetastatic SLNs. The quantitative parameters were fitted to univariable and multivariable logistic regression models. The diagnostic role of morphologic and quantitative parameters was analyzed by receiver operating characteristic curves and compared by using the McNemar test. Results This study included 193 female participants (mean age, 47.6 years ± 10.1; age range, 22-79 years). Quantitative dual-energy CT parameters including slope of the spectral Hounsfield unit curve (λ_Hu) measured at both arterial and venous phases, normalized iodine concentration at both arterial and venous phase, and normalized effective atomic number at the venous phase were higher in metastatic than in nonmetastatic SLNs (P value range, ≤.001 to .031). Univariable and multivariable logistic regression analyses showed that venous phase λ_Hu (in Hounsfield units per kiloelectron-volt) was the best single parameter for the detection of metastatic SLNs. The accuracy of the venous phase λ_Hu for detecting metastatic SLNs was 90.5% on a per-lymph node basis and 87.0% on a per-patient basis. The accuracy and specificity at venous phase λ_Hu was higher than their counterparts in the morphologic parameters (P < .001). Conclusion Dual-energy CT is a complementary means for the preoperative identification of sentinel lymph nodes metastases in participants with breast cancer. © RSNA, 2018 Online supplemental material is available for this article.

[The major debate: Micrometastases and breast cancer - To be for nodal irradiation]

Standard of care in breast cancer management is well-defined. However, some gray zones still exist, in particular adjuvant radiotherapy indications in case of pN1mi breast cancer. Here we propose to define their prognosis, to underpin the benefit of adjuvant treatments in such patients' management and to define lymphedema risk, which is the most common late side effect of locoregional treatments.

Prognostic significance of further axillary dissection in breast cancer patients with micrometastases & the number of micrometastases: a SEER population-based analysis

Aim:

To investigate the benefits of axillary dissection in patients with micrometastases.

Methods:

A review of data from the Surveillance, Epidemiology, and End Results database was performed from 2004 to 2013. Kaplan–Meier curves, Cox regression models, and propensity score matching were utilized to comprehensively evaluate the cohort.

Results:

Multivariate analysis after propensity score matching showed that patients with one to two micrometastases did not substantially benefit from axillary lymph node dissection in breast cancer-specific survival (p = 0.725). However, a subgroup analysis indicated that axillary dissection may benefit estrogen receptor-negative patients. Moreover, patients who carried three micrometastases had a significantly lower crude hazard ratio in breast cancer-specific survival.

Conclusion:

Axillary lymph node dissection may have advantages in high-risk micrometastatic patients. Patients with three micrometastases should be treated with caution.

The current study demonstrated that among patients undergoing breast-conserving surgery following radiation with T1–T2 invasive breast cancer and one to two nodal micrometastases, there was no difference in the breast cancer-specific survival for patients with and without axillary lymph node dissection. Although negative results of the Z0011 and International Breast Cancer Study Group 23–01 trials have been reported, high-risk micrometastatic patients (e.g., estrogen receptor negative, young age) may be candidates for radical axillary treatment according to the unclear radiation field and higher recurrence rate. The preliminary assessment of  three micrometastatic patients showed a lower breast cancer-specific survival than patients with one to two micrometastases. This study provides a novel perspective to the American Joint Committee on Cancer with respect to micrometastases.

Survival of Node-negative Breast Cancer Patients Treated at the University Medical Centre Maribor in the Period 2000-2009

Introduction

Breast cancer is increasingly diagnosed in the early stages without regional nodal involvement. The aim of the present study was to determine the 5-year overall (OS) and breast cancer specific survival (BCSS) for patients with node-negative breast cancer treated at the University Medical Centre Maribor, and compare it with survival at the national level.

Methods

Medical records were searched for information on patients with lymph node-negative invasive breast cancer who received primary treatment at the University Medical Centre Maribor in the period 2000–2009. Information on all Slovenian node-negative breast cancer patients diagnosed in the same period was obtained from the Cancer Registry of Republic of Slovenia. Time trends in survival were assessed by comparing the periods 2000–2004 and 2005–2009.

Results

The 5-year OS and BCSS of patients treated in Maribor in the period 2000–2009 were 92.3% (95% CI, 90.5%– 94.1%) and 96.4% (95% CI, 95.2%–97.6%), respectively, and did not differ from the corresponding OS and BCSS for Slovenian patients. Although the improvement in OS for patients from Maribor diagnosed in the period 2005–2009 compared to 2000–2004 did not reach statistical significance (HR 0.73; 95% CI, 0.51–1.05; p=0.086), BCSS significantly improved over the same time periods (HR 0.53; 95% CI, 0.30–0.94; p=0.028).

Conclusions

Survival of node-negative breast cancer patients treated at the University Medical Centre Maribor is comparable to survival of corresponding patients at the national level. The rising number of long-term breast cancer survivors places additional importance on survivorship care.

Locoregional treatment of early breast cancer with isolated tumor cells or micrometastases on sentinel lymph node biopsy

The advent of sentinel lymph-node technique has led to a shift in lymph-node staging, due to the emergence of new entities namely micrometastases (pN1mi) and isolated tumor cells [pN0(i+)]. The prognostic significance of this low positivity in axillary lymph nodes is currently debated, as is, therefore its management. This article provides updates evidence-based medicine data to take into account for treatment decision-making in this setting, discussing the locoregional treatment in pN0(i+) and pN1mi patients (completion axillary dissection, axillary irradiation with or without regional nodes irradiation, or observation), according to systemic treatment, with the goal to help physicians in their daily practice.

Low-Volume Lymph Node Metastasis Discovered During Sentinel Lymph Node Mapping for Endometrial Carcinoma

PURPOSE

The aim of this study was to characterize treatment patterns and oncologic outcomes in patients with low-volume lymph node metastasis (isolated tumor cells [ITCs] and micrometastasis [MM]) discovered during sentinel lymph node (SLN) mapping for endometrial carcinoma.

METHODS

We identified endometrial cancer cases treated surgically from September 2005 to April 2013 in which SLN mapping was performed. MM was defined as tumor within a lymph node measuring >0.2 mm but <2.0 mm, and ITCs were those measuring ≤0.2 mm.

RESULTS

Overall, 844 patients, with a median age of 61 years (range 30-90), met the inclusion criteria. Histology was as follows: endometrioid, 724 (85.8 %) patients; serous, 104 (12.3 %) patients; and clear cell, 16 (1.9 %) patients. The median number of lymph nodes resected was six (range 0-60), and the median number of SLNs was two (range 0-15). Overall, 753 (89.2 %) patients were node-negative, 23 (2.7 %) had ITCs only, 21 (2.5 %) had MM only, and 47 (5.6 %) had macrometastasis. Adjuvant chemotherapy was administered to 106 (14 %) of 753 node-negative patients, 19 (83 %) of 23 patients with ITCs, 17 (81 %) of 21 patients with MM, and 42 (89 %) of 47 with macrometastasis. Median follow-up was 26 months (range 0-108). Three-year recurrence-free survival was as follows: node-negative patients, 90 % (±1.5); ITCs only, 86 % (±9.4); MM only, 86 % (±9.7); and macrometastasis, 71 % (±7.2) [p < 0.001].

CONCLUSIONS

Patients with ITCs and MM frequently received adjuvant chemotherapy and had improved oncologic outcomes in comparison to those with macrometastasis to the lymph nodes. Further prospective study is needed to determine optimal post-resection management in patients with ITCs or MM alone.

Isolated tumor cells and micrometastases in regional lymph nodes in stage I to II endometrial cancer

Objective

The aim of this study was to clarify the clinical significance of isolated tumor cells (ITCs) or micrometastasis (MM) in regional lymph nodes in patients with International Federation of Gynecology and Obstetrics (FIGO) stage I to II endometrial cancer.

Methods

In this study, a series of 63 patients with FIGO stage I to II were included, who had at least one of the following risk factors for recurrence: G3 endometrioid/serous/clear cell adenocarcinomas, deep myometrial invasion, cervical involvement, lympho-vascular space invasion, and positive peritoneal cytology. These cases were classified as intermediate-risk endometrial cancer. Ultrastaging by multiple slicing, staining with hematoxylin and eosin and cytokeratin, and microscopic examination was performed on regional lymph nodes that had been diagnosed as negative for metastases.

Results

Among 61 patients in whom paraffin-embedded block was available, ITC/MM was identified in nine patients (14.8%). Deep myometrial invasion was significantly associated with ITC/MM (p=0.028). ITC/MM was an independent risk factor for extrapelvic recurrence (hazard ratio, 17.9; 95% confidence interval [CI], 1.4 to 232.2). The 8-year overall survival (OS) and recurrence-free survival (RFS) rates were more than 20% lower in the ITC/MM group than in the node-negative group (OS, 71.4% vs. 91.9%; RFS, 55.6% vs. 84.0%), which were statistically not significant (OS, p=0.074; RFS, p=0.066). Time to recurrence tended to be longer in the ITC/MM group than in the node-negative group (median, 49 months vs. 16.5 months; p=0.080).

Conclusions

It remains unclear whether ITC/MM have an adverse influence on prognosis of intermediate-risk endometrial cancer. A multicenter cooperative study is needed to clarify the clinical significance of ITC/MM.

[Is there a rationale for regional node irradiation in pN1mi and pN0(i+) breast tumours?]

The advent of sentinel lymph node technique has led to a shift in lymph node staging, due to the emergence of new entities, namely micrometastases and isolated tumour cells. In addition, the therapeutic role of axillary lymph node dissection is more and more questioned and radiotherapy has been shown to be equivalent to complementary axillary lymph node dissection in patients without clinical node involvement. This article looks at the literature in favour of performing axillary irradiation in patients with pN1mi stage breast cancer who have undergone a mastectomy without a complementary axillary lymph node dissection, and in favour of abstention of any further treatment of the axilla in patients with pN0(i+) or pN1mi tumours who have undergone breast conserving surgery and a sentinel lymph node procedure followed by systemic treatment. The impact of regional lymph nodes irradiation in case of axillary involvement 2mm or less is also discussed.

[Regional treatment for axillary lymph node micrometastases of breast cancer]

In patients with breast cancer, axillary lymph node micrometastasis detection has been more frequent with a better definition since the introduction of the sentinel node procedure. In this review, we focus on pN1mi micrometastasis and review the literature in order to determine factors involved in making the decision of a regional treatment.

Clinical significance of breast cancer micrometastasis in the sentinel lymph node

The advantages of sentinel lymph node biopsy (SLNB) in breast cancer patients include an enhanced pathological examination of a small number of sentinel lymph nodes (SLNs), which permits more frequent detection of micrometastasis and isolated tumor cells (ITCs). At the same time, however, SLNB raises two new concerns: whether minimal SLN involvement has a significant impact on survival and whether patients with such minimal involvement should undergo further axillary dissections. Two large randomized studies, ACOSOG Z0011 and IBCSG 23-01, have demonstrated that axillary lymph node dissection (ALND) can be avoided for select SLN-positive patients. However, for patients with macrometastasis in SLN or who do not meet the inclusion criteria of the two studies, ALND is still the standard management. On the other hand, previous studies appear to disagree on the prognostic significance of minimal SLN involvement. One of the reasons for this discrepancy is the great variability among pathological examinations for SLN. The OSNA method, which is a fast molecular detection procedure targeting cytokeratin 19 (CK19) mRNA, has the advantage of reproducibility among institutions and the capability to examine a whole lymph node within 30-40 min. This novel method may thus be able to overcome the issue of variability among conventional pathological examinations.

The prognostic role of circulating tumor cells in heavily pretreated individuals with a low life expectancy

AIMS

Studies of circulating tumor cells (CTCs) have generally recruited individuals with newly diagnosed metastatic cancer, with recent data also indicating their prognostic value in the adjuvant setting. Their role in dying patients has not been established.

EXPERIMENTAL

CTCs were measured in 43 individuals with metastatic breast cancer estimated to have less than 6 months to live who had exhausted standard therapeutic options.

RESULTS

Those with a CTC count of ≤ 100 had a median of 182 days to live, compared with those with a CTC count of >100 who had a median of 17 days until death (p = 0.009, log rank, HR: 3.1, 95% CI: 1.4-7.3).

CONCLUSION

A CTC count of >100 is associated with imminent death. Provided external validity is demonstrated, such information would be useful for patients and their families who often request specific prognostic clarity and could improve the quality of end-of-life care.

Evolution of sentinel lymph node biopsy in breast cancer, in and out of vogue?

Sentinel lymph node biopsy (SLNB) was introduced 2 decades ago and thereafter validated for routine surgical management of breast cancer, including cases treated with neoadjuvant chemotherapy. As the number of lymph nodes for staging has decreased, pathologists have scrutinized SLN with a combination of standard hematoxylin and eosin, levels, immunohistochemistry (IHC), and molecular methods. An epidemic of small-volume metastases thereby arose, leading to modifications in the American Joint Committee on Cancer staging to accommodate findings such as isolated tumor cells (ITC) and micrometastases. With the goal of determining the significance of these findings, retrospective followed by prospective trials were performed, showing mixed results. The ACOSOG Z10 and NSABP B-32 trials both independently showed that ITC and micrometastases were not significant and thus discouraged the use of levels and IHC for detecting them. However, the Surveillance Epidemiology and End Results database showed that patients with micrometastases had an overall decreased survival. In addition, the MIRROR (Micrometastases and ITC: Relevant and Robust or Rubbish?) trial, showed that patients with ITC and micrometastases treated with adjuvant therapy had lower hazard ratios compared with untreated patients. Subsequently, the ACOSOG Z0011 trial randomized patients with up to 2 positive SLN to axillary lymph node dissection (ALND) or not, all treated with radiation and chemotherapy, showing no difference in survival or recurrence rates between the 2 groups and causing a shift from ALND. As the rate of ALND has declined, the necessity of performing levels, IHC, frozen section, and molecular studies on SLN needs to be revisited.