Prognostic value of nodal ratios in node-positive breast cancer: a compiled update

Prognostic value of axillary lymph node metastases in invasive lobular breast carcinoma

BACKGROUND

Axillary lymph node involvement is a well-established prognostic factor for recurrence in breast cancer, specifically the number of nodes affected and the ratio of the number of affected nodes to the number of harvested nodes for non-specific invasive breast cancer (invasive ductal carcinoma). However, there is limited information on the impact of lymph node involvement in the case of invasive lobular carcinoma.

OBJECTIVES

our study aimed to evaluate the prognostic impact of lymph node involvement on overall survival and distant metastatic-free survival according to the number of nodes affected and the ratio of positive nodes (LNR) for patients managed for invasive lobular carcinoma.

METHODS

This is a monocentre, comparative, observational study of patients managed for invasive lobular carcinoma at the Gynaecology Department of the University Hospital Center of Tours between January 1, 2007 and December 31, 2018. The LNR cut-off values used were: low risk if LNR ≤ 0.2; intermediate risk if LNR > 0.2 and ≤ 0.65, and high risk for LNR >0.659.

RESULTS

Our study demonstrated a significant difference in overall survival and distant metastasis free survival (p < 0.0001). The 5-years Overall survival was 94 % for N0 patients, 92.4 % for low-risk patients, 85.6 % for intermediate-risk patients and 58.5 % for high-risk patients. The 5-year distant metastasis-free survival was 98.2 % for N0 patients, 95.9 % for low-risk patients, 80.1 % for intermediate-risk patients, and 60.3 % for high-risk patients. Multivariate analysis identified age, invasive lobular histologic type, presence of clinical inflammation, and intermediate and high risk classes of LNR ratio as independent factors affecting overall survival. For metastatic-free survival, the presence of clinical inflammation, the presence of LVSI and the low, intermediate, or high-risk classes of LNR ratio were identified as independent factors. However, age and invasive lobular histologic type did not appear to be independent factors affecting metastatic-free survival.

CONCLUSION

Our study highlights the significant prognostic impact of lymph node involvement in patients with invasive lobular carcinoma. The LNR ratio can be used as a reliable predictor of overall survival and metastatic-free survival in these patients.

Gini's mean difference and the long-term prognostic value of nodal quanta classes after pre-operative chemotherapy in advanced breast cancer

Gini's mean difference (GMD, mean absolute difference between any two distinct quantities) of the restricted mean survival times (RMSTs, expectation of life at a given time limit) has been proposed as a new metric where higher GMD indicates better prognostic value. GMD is applied to the RMSTs at 25 years time-horizon to evaluate the long-term overall survival of women with breast cancer who received neoadjuvant chemotherapy, comparing a classification based on the number (pN) versus a classification based on the ratio (LNRc) of positive nodes found at axillary surgery. A total of 233 patients treated in 1980–2009 with documented number of positive nodes (npos) and number of nodes examined (ntot) were identified. The numbers were categorized into pN0, npos = 0; pN1, npos = [1,3]; pN2, npos = [4,9]; pN3, npos ≥ 10. The ratios npnx = npos/ntot were categorized into Lnr0, npnx = 0; Lnr1, npnx = (0,0.20]; Lnr2, npnx = (0.20,0.65]; Lnr3, npnx > 0.65. The GMD for pN-classification was 5.5 (standard error: ± 0.9) years, not much improved over a simple node-negative vs. node-positive that showed a GMD of 5.0 (± 1.4) years. The GMD for LNRc-classification was larger, 6.7 (± 0.8) years. Among other conventional metrics, Cox-model LNRc's c-index was 0.668 vs. pN's c = 0.641, indicating commensurate superiority of LNRc-classification. The usability of GMD-RMSTs warrants further investigation.

The role of different lymph node staging systems in predicting prognosis and determining indications for postmastectomy radiotherapy in patients with T1-T2pN1 breast carcinoma

PURPOSE

Based on the risk of locoregional recurrence (LRR), postmastectomy radiotherapy (PMRT) is recommended in T1-T2pN1 breast carcinoma (BC). We aimed to elucidate our institutional strategies underlying selection of these patients for PMRT. In the no-PMRT subset, we compared various lymph node (LN) staging systems' abilities to predict 5‑year overall and locoregional-free survival (OS/LRFS).

METHODS

We retrospectively enrolled 548 women with T1-T2pN1 BC undergoing mastectomy and axillary LN dissection. Depending on PMRT delivery, the participants were divided into the PMRT and no-PMRT groups. Predictors of OS/LRFS were calculated for the no-PMRT group only. Based on Cox regression modelling, the number of positive LNs (PLN), negative LNs (NLN), LN ratio (LNR), log odds of PLN (LODDS), and modified LNR (mLNR) were modelled, each respectively, with OS model covariates (age, grade III, lymphovascular invasion [LVI], tumor size, hormone receptor [HR] status) and LRFS model covariates (age, grade III, LVI). The C‑statistic, Akaike information criterion, and likelihood ratio χ² of the models were compared.

RESULTS

Median follow-up was 60.5 (18-82), 61 (28-82), and 60 (18-80) months for the entire cohort, PMRT, and no-PMRT group, respectively. The PMRT and no-PMRT groups had comparable OS (p = 0.235). LRFS was better (p = 0.030) in the PMRT group comprising 105 subjects (19.16%) who were younger, more likely to have a higher-grade, HR-, HER2+ tumors, more PLNs, fewer NLNs, Ki-67 ≥ 20%, LVI, and extranodal extension (p ≤ 0.001). In the no-PMRT group, LNR-based OS/LRFS models exhibited superior prognostic performance.

CONCLUSION

In early-stage BC patients undergoing mastectomies, LN dissections and no PMRT, we propose LNR-based multivariable models to predict OS/LRFS with superior accuracy.

Modified lymph node ratio improves the prognostic predictive ability for breast cancer patients compared with other lymph node staging systems

Background

Metastatic regional lymph nodes (LN) is a strong predictor of worse long-term outcome. Therefore, different LN staging systems have been proposed in recent years. In this study, we proposed a modified lymph node ratio (mLNR) as a new lymph node staging system and then compared the prognostic performance of mLNR with American Joint Committee on Cancer N stage, lymph node ratio (LNR) and log odds of metastatic lymph nodes in breast cancer patients.

Methods

Breast cancer patients who underwent surgery between 2004 and 2012 were identified from the Surveillance, Epidemiology, and End Results database. Restricted cubic spline functions were calculated to characterize the association between variables and the risk of death. The Cox proportional hazards models were constructed to assess the predictive ability of different lymph node staging systems using the Akaike’s Information Criterion (AIC) and Harrell’s concordance index (C-index).

Results

A total of 264,096 breast cancer patients were enrolled and 187,785 (71.1%) patients had a limited number of LNs harvested. In the limited LN harvest cohort, the prognostic performance of LNR decreased and mLNR could greatly solve this problem. In addition, among the entire cohort, mLNR modeled as a continuous value had the best predictive ability (AIC: 922021.9 and C-index: 0.727) than other lymph node staging systems.

Conclusions

The predictive ability of LNR is restricted by a limited LN harvest. However, mLNR shows superiority to LNR and other lymph node staging systems especially in a limited LN harvest cohort, making mLNR the most powerful lymph node staging systems.

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We selected 264,096 patients, which is enough to support our conclusion.

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We used two indexes to fully verify the fit of different lymph staging systems.

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The mLNR improved the prognostic predictive ability best.

Lymph Node Ratio (LNR): Predicting Prognosis after Neoadjuvant Chemotherapy (NAC) in Breast Cancer Patients

Objective

Axillary lymph node status is an important prognostic factor in breast cancer (BC). Residual nodal disease burden after neoadjuvant chemotherapy (NAC) is one of the important prognostic factors to determine the prognosis and in the treatment of BC. Lymph node ratio (LNR) defined as the ratio of the number of positive lymph nodes to total excised axillary lymph nodes, may be a stronger determinant of prognosis than pN in axillary nodal staging, although there is very limited data evaluating its prognostic value in the setting of NAC. In this cohort of patients, we studied the utility of LNR in predicting recurrence and overall survival (OS) after NAC.

Materials and Methods

An Institutional cancer registry was queried from 2009 to 2014 for women with axillary node-positive BC with no evidence of distant metastasis, and who received NAC followed by surgery for loco-regional treatment (axillary dissection with breast conserving surgery or total mastectomy). Patients with axillary complete response were excluded. Locoregional recurrence (LRR), distant recurrence (DR) and overall survival (OS) rates were reviewed regarding pN and LNR.

Results

A total of 179 patients were analyzed. Median follow up time was 24 [25%, 75%: 13-42] months. Patients with pN1 in comparison to pN2 and pN3 had lower rate of LRR (9% vs. 15% and 14%, respectively; p=0.41), lower rate of DR (14% vs. 25% and 27%, respectively, p=0.16) and increased rate of OS (89% vs. 79% and 78%, respectively, p=0.04). In comparison to patients with LNR >20%, patients with LNR ≤20% had lower LRR (9% vs. 14%, p=0.25), lower DR (13% vs. 27%, p=0.01) and improved OS (89% vs. 79%, p=0.02) rates. In the pN1 group, patients who had a LNR >20% had higher DR (22% vs. 14%, p=0.48) rates in comparison to patients with LNR ≤20%. In ER/PR (+) patients who had LNR ≤20% DR was 6% compared with 23% in patient who had LNR >20% (p=0.02), and in triple negative patients' OS rate was significantly better compared the LNR less/equal or more than 20% (71% vs 33%, p=0.001).

Conclusion

Our study demonstrated that LNR adds valuable information for the prognosis after NAC and this additional information should be considered when deciding further treatment and follow-up for patients who had residual tumor burden on the axilla. This observation should be tested in a larger study.

Grade-lymph node ratio predicts the survival of breast cancer in different molecular types: A surveillance, epidemiology, and end results population-based analysis

The prognostic value and conflicting results of metastatic lymph node ratio (mLNR) on breast cancer have aroused an increasing concern. We aimed to evaluate the imperative of mLNR classification and prognostic factors in breast cancer with molecular subtypes.This study uses the database of surveillance, epidemiology, and end results (SEER) to investigate the imperative for reliable mLNR classification and critical prognostic factors in breast cancer with different molecular subtypes.The prognostic characteristics for disease-specific survival (DSS) of breast cancer were investigated in the SEER cohort (n = 3651). mLNR (P = .017) and histology grade (P < .001) were independent factors. A novel grade-lymph node ratio (G-R) staging system was proposed for breast cancer prognosis. The receiver operating characteristic curves revealed that the G-R staging system had an accurate 1-, 3-, and 5-year DSS prediction. Further stratification analysis with molecular subtypes of breast cancer (Luminal and TNBC) first proved robust prognostic values of the G-R staging system among molecular subtypes.The current population-based cohort demonstrated the capacity of mLNR serving as a critical prognostic factor. Also, G-R staging system has the potential to be regarded as reliable classification for breast cancer patients with different molecular subtypes.

Clinical Significance of Lymph-Node Ratio in Determining Supraclavicular Lymph-Node Radiation Therapy in pN1 Breast Cancer Patients Who Received Breast-Conserving Treatment (KROG 14-18): A Multicenter Study

This study evaluated the clinical significance of the lymph-node ratio (LNR) and its usefulness as an indicator of supraclavicular lymph-node radiation therapy (SCNRT) in pN1 breast cancer patients with disease-free survival (DFS) outcomes. We retrospectively analyzed the clinical data of patients with pN1 breast cancer who underwent partial mastectomy and taxane-based sequential adjuvant chemotherapy with postoperative radiation therapy in 12 hospitals (n = 1121). We compared their DFS according to LNR, with a cut-off value of 0.10. The median follow-up period was 66 months (range, 3–112). Treatment failed in 73 patients (6.5%) and there was no significant difference in DFS between the SCNRT group and non-SCNRT group. High LNR (>0.10) showed significantly worse DFS in both univariate and multivariate analyses (0.010 and 0.033, respectively). In a subgroup analysis, the effect of SCNRT on DFS differed significantly among patients with LNR > 0.10 (p = 0.013). High LNR can be used as an independent prognostic factor for pN1 breast cancer patients treated with partial mastectomy and postoperative radiotherapy. It may also be useful in deciding whether to perform SCNRT to improve DFS.

Evaluating the Prediction of Breast Cancer Survival Using Lymph Node Ratio

Purpose

Previous oncological studies showed that lymph node ratio (LNR) (ratio of number of lymph nodes that tested positive for metastasis to the total number of lymph nodes examined) is a negative indicator of cancer survival. The American Joint Committee on Cancer (AJCC) staging system incorporates tumor size, lymph node involvement, and metastasis in a comprehensive model of cancer progression, but LNR alone has been shown to outperform the AJCC system in prognostic and survival predictions for various types of cancer. The effectiveness of LNR has not been evaluated in breast cancer staging. Evaluating LNR for predicting cancer staging in breast cancer has the potential to improve treatment recommendations.

Methods

The Surveillance, Epidemiology, and End Results dataset was used to identify 10,655 breast cancer patients who underwent nodal evaluation from 2010 to 2013, and their LNRs were calculated. Descriptive statistics of lymph node evaluation in the patients are provided. Logistic regression with LNR as the continuous independent variable was conducted to determine whether LNR could predict cancer progression, coded as regional or distant. Analysis was conducted using SPSS version 24.

Results

Patient's mean age was 59.43±18.62. Logistic regression analysis revealed that for every 1.3% increase in LNR, the odds of falling into the distant stage of the TNM staging system increased by 13.7% (odds ratio, 14.73; 95% confidence interval, 12.00-18.08).

Conclusion

LNR, while correlated with breast cancer staging, serves as a better predictor of survival. Precision staging can influence treatment modality, and improved treatments can significantly improve quality of life. Additional research and diagnostic examinations using LNR as a potential tool for accurate staging in breast cancer patients are warranted.

The lymph node ratio as an independent prognostic factor for node-positive triple-negative breast cancer

BACKGROUND

We aimed to evaluate the prognostic value of the lymph node ratio (LNR) in patients with axillary lymph node-positive triple-negative breast cancer (TNBC).

METHODS

The prognostic efficacy was investigated in the first cohort from the Surveillance, Epidemiology, and End Results (SEER) dataset (n=4114) and was further validated in an independent cohort from Fudan University Shanghai Cancer Center (n=417). Patients were classified into low-, medium- and high-risk LNR groups.

RESULTS

Multivariate analysis revealed that the LNR was an independent predictor of overall survival (hazard ratio (HR) for high-risk LNR: 3.24; 95% confidence interval (CI): 2.56 to 4.09) and breast cancer-specific survival (HR for high-risk LNR: 3.57; 95% CI: 2.76 to 4.62) in the SEER population and also for disease-free survival (HR for high-risk LNR: 4.29; 95% CI: 2.24-8.21) in the validation population. Subgroup analysis revealed that patient classification according to the LNR could discriminate among groups of patients with different survival rates based on pathological nodal (pN) staging.

CONCLUSION

The LNR shows potential for use as an additional prognostic factor for TNBC patients with positive lymph node involvement. Considering the heterogeneity of TNBC, use of the LNR might allow for optimization of the pN staging system and should be considered when making treatment decisions.

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.

Surgical treatment of advanced penile cancer

Purpose

To evaluate the therapeutic effect of surgery in patients with advanced penile cancer, who have a dismal prognosis.

Patients and methods

Between September 2007 and July 2015, we treated 12 patients with surgical therapy.

Results

The median follow-up period for all the patients was 16 months (range 4–60 months). The outcome and concomitant symptoms were analyzed, and the survival rates were calculated. Three of the patients are currently alive. The median overall survival of the patients was 9 months (range 4–13 months).

Conclusion

The present results suggest that surgery is a valuable treatment option for patients with advanced penile cancer. The prognosis of advanced penile cancer is closely related to lymph node and distant metastases. Flap repair can solve the problem of large area skin defect. Advanced penile cancer is difficult to treat regardless of chemotherapy or radiotherapy, and surgery cannot prolong the lives of patients. However, the dissection of lesions and repair of large area skin defects can dramatically improve the quality of life of patients, especially those with locally advanced disease without distant metastasis.

Using the Lymph Node Ratio to Evaluate the Prognosis of Stage II/III Breast Cancer Patients Who Received Neoadjuvant Chemotherapy and Mastectomy

Purpose

This study was conducted to investigate the prognostic value of lymph node ratio (LNR) in stage II/III breast cancer patients who undergo mastectomy after neoadjuvant chemotherapy.

Materials and Methods

Clinical and pathological data describing stage II/III breast cancer patients were included in this retrospective study. The primary outcomes were locoregional recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS).

Results

Among 277 patients, there were 43 ypN0, 64 ypN1, 89 ypN2, and 81 ypN3 cases. Additionally, there were 43, 57, 92 and 85 cases in the LNR 0, 0.01-0.20, 0.21-0.65, and > 0.65 groups, respectively. The median follow-up was 49.5 months. Univariate analysis showed that both ypN stage and LNR were prognostic factors of LRFS, DMFS, DFS, and OS (p < 0.05). Multivariate analysis showed that LNR was an independent prognostic factor of LRFS, DMFS, DFS, and OS (p < 0.05), while ypN stage had no effect on prognosis (p > 0.05).

Conclusion

The integrated use of LNR and ypN may be suitable for evaluation the prognosis of stage II/III breast cancer patients who undergo mastectomy after neoadjuvant chemotherapy.

Additional prognostic value of lymph node ratio over pN staging in different breast cancer subtypes based on the results of 1,656 patients

PURPOSE

Although the impact of lymph node ratio (LNR: ratio of metastatic to resected LNs) in breast cancer (BC) has been investigated, its prognostic value in molecular subtypes remains unclear. Our aim was to evaluate the impact of LNR compared to pN-stage in BC subtypes.

PATIENTS/METHODS

We analyzed the impact of LNR and pN-stage on disease-free (DFS) and overall survival (OS) in 1,656 patients with primary BC who underwent primary axillary surgery (removal of ≥10 LNs) between 1998 and 2011. The cut-off points for LNR were previously published. Using immunohistochemical parameters tumors were grouped in luminalA, luminalB/HER2-, luminalB/HER2+, HER2+ and triple negative (TNBC).

RESULTS

For the entire cohort 5/10-year DFS and OS rates were 88/77% and 88/75%, respectively. LNR and pN-stage were independent prognostic parameters for DFS/OS in multivariate analysis in the entire cohort and each molecular subgroup (p < 0.001). However, increasing LNR seemed to discriminated 10-year DFS slightly better than pN-stage in luminalA (intermediate/high LNR 65/44% versus pN2/pN3 71/53%), luminalB/HER2- (intermediate/high LNR 48/24% versus pN2/pN3 41/42%), and TNBC patients (intermediate/high LNR 49/24% versus pN2/pN3 56/33%).

CONCLUSIONS

LNR is an important prognostic parameter for DFS/OS and might provide potentially more information than pN-stage in different molecular subtypes.

The classification of invasive carcinoma of the breast

The classification of invasive breast carcinoma assists diagnosis, allows for comparison of different patient groups in clinical trials and facilitates epidemiological analysis. For the individual patient, accurate tumor classification informs clinical decision-making with emphasis on assessment of prognosis and treatment formulation. Tumor grade is an independent prognostic indicator and is calculated by assessing specific tumor characteristics microscopically. The Tumor Node Metastasis staging system, produced by the American Joint Committee on Cancer Union for International Cancer Control, combines information about the primary tumor size, the status of the regional lymph nodes and the presence or absence of distant metastases at diagnosis to classify disease. In recent years, the use of gene expression profiling technology has led to the development of the molecular classification of breast cancer and has highlighted the importance of hormone receptor and HER2 oncogenic pathways, with particular reference to targeted chemotherapy. Tumor typing involves the identification of 'no special type' carcinoma with variable clinical, histological and molecular characteristics and 'special type' carcinomas that are usually associated with a particular set of prognostic and predictive indices. Some special type carcinomas have unique biological features that influence diagnostic investigation and clinical management.

Lymph node ratio assessment of brain metastasis in early breast cancer cases

BACKGROUND

Ten to 30% of early breast cancer (EBC) patients develop brain metastasis (BM) during their follow-up. In this study, we aimed to evaluate importance of the lymph node ratio (LNR) in development of BM in EBC cases.

MATERIALS AND METHODS

Ninety patients whom had axillary metastases in lymph nodes at their initial diagnosis and developed BM during 5-year follow-up were detected in 950 EBC patients. LNR values were calculated for all patients and after categorization into 4 molecular sub-types as luminal A, luminal B HER-2 (+), HER-2 overexpressing and basal- like. Comparison was with control group patients who had similar characteristics.

RESULTS

In the comparison of all molecular sub-types of LNR, 54.9% and 28.4% values were found in patients with and without BM respectively (p<0.001). In the comparison of the LNR with control groups, a statistically significant differences were found with luminal A with BM (p=0.001), luminal B HER-2 (p=0.001), HER-2 overexpressing (p=0.027) and basal-like groups (p<0.001). In the evaluation of patients with BM, the highest ratio was found in the basal-like group (67.9%) and there was a statistically significant difference between this group and the others (p=0.048).

CONCLUSIONS

EBC patients developing BM within 5 years follow- up had significantly higher LNRs for all molecular sub-types, especially in the basal-like group. Larger scale studies are now needed for evaluating LNR prognostic importance for EBC regarding BM development.

Clinical significance of lymph node ratio in locally advanced breast cancer molecular subtypes

BACKGROUND

The ratio of metastatic to dissected lymph nodes (lymph node ratio; LNR) is a sensitive and superior prognostic factor for lymph node evaluation, but its relationship to cancer subtypes is unclear.

PATIENTS AND METHODS

Data from 469 patients with axillary lymph node metastasis out of 640 early breast cancer cases were retrospectively analyzed. They were classified into 4 molecular subtypes; luminal A, luminal B HER2(+), HER2 overexpression, basal-like. LNRs were compared between groups and with other prognostic factors.

RESULTS

The distribution of LNRs was 35.2% in luminal A, 43.2% in luminal B HER2(+), 46.9% in HER2 over-expression, and 39.1% in basal-like. A significant difference was found between luminal A and HER2 over-expression subtypes (p = 0.023). LNR was significantly correlated with tumor size and lymphovascular invasion, but not with other prognostic factors including menopausal status, laterality, grade, and perineural invasion. An LNR of 29.8% was defined as the cut-off value, and significant differences in survival rates were identified accordingly between basal-like and both luminal A (p = 0.003) and luminal B HER2(+) (p = 0.04).

CONCLUSION

The LNR differs between some molecular subtypes of breast cancer, and it correlates with certain prognostic factors and survival. These data support using the LNR to assess breast cancer patients.

Using the lymph nodal ratio to predict the risk of locoregional recurrence in lymph node-positive breast cancer patients treated with mastectomy without radiation therapy

Background

To evaluate the prognostic value of axillary lymph node ratio (LNR) as compared to the number of involved nodes (pN stage) in patients with axillary lymph node-positive breast cancer treated with mastectomy without radiation.

Methods

We performed a retrospective analysis of the clinical data of patients with stage II-III node-positive breast cancer (N=1068) between 1998 and 2007. Locoregional recurrence-free survival (LRFS) and overall survival (OS) were compared based on the LNR and pN staging.

Results

A total of 780 cases were classified as pN1, 183 as pN2, and 105 as pN3. With respect to LNR, 690 cases had a LNR from 0.01-0.20, 269 cases a LNR from 0.21-0.65, and 109 cases a LNR > 0.65. The median follow-up time was 62 months. Univariate analysis showed that both LNR and pN stage were prognostic factors of LRFS and OS (p<0.05). Multivariate analysis indicated that LNR was an independent prognostic factor of LRFS and OS (p<0.05). pN stage had no significant effect on LRFS or OS (p>0.05). In subgroup analysis, the LNR identified groups of patients with different survival rates based on pN stage.

Conclusions

LNR is superior to pN staging as a prognostic factor in lymph node-positive breast cancer after mastectomy, and should be used as one of the indications for adjuvant radiation therapy.

Prognostic value of metastatic axillary lymph node ratio for Chinese breast cancer patients

OBJECTIVE

The prevalence of breast cancer varies among countries and regions. This retrospective study investigated the prognostic value of the lymph node ratio (LNR) compared with the number of positive lymph nodes (pN) in Chinese breast cancer patients.

METHODS

The medical records of female breast cancer patients (N = 2591) were retrospectively evaluated. The association of LNR and TMN staging system were compared with respect to overall, disease-free, and distant metastasis-free survival.

RESULTS

Out of 2591 patients, 2495 underwent modified radical surgery and 96 received breast conserving surgery. All patients had adjuvant chemotherapy following surgery. The median follow up period 66.9 months (range 5-168 months). The 5-year and 10-year overall survival rates were 89.3% and 78.8%, respectively, and 5-year disease-free survival and distant metastasis-free survival rates were 81.6% and 83.5%, respectively. Univariate analysis indicated that in general T, pN, LNR, as well as tumor expression of the estrogen receptor, progesterone receptor, and HER2 were associated with overall, disease-free, and distant metastasis-free survival (all P-values <0.05). Mutlivariate analysis found pN stage and LNR were independent predictors of overall, disease-free, and distant metastasis-free survival (all P-values <0.001). If pN stage and LNR were both included in a multivariate analysis, LNR was still an independent prognostic factor for overall, disease-free, and distant metastasis-free survival (all P-values <0.001).

CONCLUSION

Our findings support the use of LNR as a predictor of survival in Chinese patients with breast cancer, and that LNR is superior to pN stage in determining disease prognosis.

Lymph node metastases and prognosis in penile cancer

Lymph node status is a key prognostic factor in penile squamous cell carcinoma. Recently, growing evidence indicates a multimodality approach consisting of neoadjuvant chemotherapy followed by consolidation surgery improves the outcome of locally advanced penile cancer. Thus, accurate estimation of survival probability in node-positive penile cancer is critical for treatment decision making, counseling of patients and follow-up scheduling. This article reviewed evolving developments in assessing the risk for cancer progression based on lymph node related variables, such as the number of metastatic lymph nodes, bilateral lymph node metastases, the ratio of positive lymph nodes, extracapsular extension of metastatic lymph nodes, pelvic lymph node metastases, metastatic deposit in sentinel lymph nodes and N stage in TNM classification. Controversial issues surrounding the prognostic value of these nodal related predictors were also discussed.

The prognostic value of lymph node cross-sectional cancer area in node-positive breast cancer: a comparison with N stage and lymph node ratio

The number of positive axillary lymph nodes (LNs) is the only node-related factor for prognostic evaluation of breast cancer recognized by AJCC (TNM staging). However, N staging may not completely reflect LN tumor involvement due to the erroneous count of LNs in the presence of matted LNs and different tumor volume in LNs. Additionally, the positive/total LN ratio (LNR) has been shown to outperform N staging in survival prediction. In our study, to better quantify the tumor involvement of axillary LNs, we measured the cross-sectional cancer area (CSCA) of the positive LNs in 292 breast cancer patients diagnosed between 1998 and 2000 in our institution and compared its prognostic value to that of number of positive LNs (metLN)/N stage and LNR. Statistical analyses of these three LN-related factors were performed by Kaplan-Meier method and multivariate Cox's regression model. Patients were divided into three groups based on the different LN CSCA (<50, 50–500, and >500 mm²), or LNR (<0.1, 0.1–0.65, and >0.65), or N stage (N1–N3). Multivariate analysis demonstrated LNR was the most significant LN-related survival predictor with hazard ratio (HR) 25.0 (P = 0.001), compared to the metLN (HR 0.09, P = 0.052) and CSCA (HR 2.24, P = 0.323).

Long-term outcome of breast cancer patients with one to two nodes involved - application of nodal ratio

Nodal ratio (NR) is defined as the number of involved nodes to the number of nodes examined. There is limited information on the application of NR on population data. Previous reports in breast cancer generally analyzed one to three positive axillary nodes as a single group. This study investigates whether one to three positive axillary nodes is a homogeneous group in prognosis by comparing one to two positive nodes to three positive nodes. The population-based registry of a Canadian province from 1981 through 1995 was searched. As the reliability of nodal assessment depends on the number of nodes sampled, we also studied the subgroup of patients with greater than or equal to eight nodes dissected. Of a total of 5,996 breast cancer patients, 1187 had one to three positive axillary nodes. The 263 patients with three positive nodes compared to the 924 patients with one to two nodes fared worse with a significantly reduced cause-specific survival (CSS) and overall survival (OS). Patients with one to two positive nodes had similar CSS (p=0.31) and OS (p=0.63). Among those with greater than or equal to eight nodes dissected, there were 677 patients with one to two positive nodes. CSS and OS were not significantly different between one versus two positive nodes (p=0.16 and 0.34, respectively), but with NR, the corresponding p values were 0.0068 and 0.08, respectively. The cutoff value of NR 0.15 was found to be most useful and confirmed by the validation dataset. NR is able to segregate patients better than the absolute number of positive nodes used in the current staging system. NR should be incorporated into the staging system.

Does the axillary lymph node ratio have any added prognostic value over pN staging for South East Asian breast cancer patients?

Introduction

Lymph node ratio (LNR, i.e. the ratio of the number of positive nodes to the total number of nodes excised) is reported to be superior to the absolute number of nodes involved (pN stage) in classifying patients at high versus low risk of death following breast cancer. The added prognostic value of LNR over pN in addition to other prognostic factors has never been assessed.

Methods

All patients diagnosed with lymph node positive, non-metastatic invasive breast cancer at the National University Hospital (Singapore) and University of Malaya Medical Center (Kuala Lumpur) between 1990–2007 were included (n = 1589). Overall survival of the patients was estimated by the Kaplan Meier method for LNR [categorized as low (>0 and <0.2), intermediate (0.2–0.65) and high (>0.65–1)] and pN staging [pN1, pN2 and pN3]. Adjusted overall relative mortality risks associated with LNR and pN were calculated by Cox regression. The added prognostic value of LNR over pN was evaluated by comparing the discriminating capacity (as indicated by the c statistic) of two multivariate models, one including pN and one including LNR.

Results

LNR was superior to pN in categorizing mortality risks for women ≥60 years, those with ER negative or grade 3 tumors. In combination with other factors (i.e. age, treatment, grade, tumor size and receptor status), substituting pN by LNR did not result in better discrimination of women at high versus low risk of death, neither for the entire cohort (c statistic 0.72 [0.70–0.75] and 0.73 [0.71–0.76] respectively for pN versus LNR), nor for the subgroups mentioned above.

Conclusion

In combination with other prognosticators, substitution of pN by LNR did not provide any added prognostic value for South East Asian breast cancer patients.

Lymph Node Ratio

St. Gallen 2005 expert consensus guideline modified its criteria for the risk category of breast cancer (BC) patients by integrating a combination of lymph nodes with metastasis (positive lymph nodes [PLNs]) and HER-2/neu status of tumor. Recently, some studies have shown that lymph node ratio (LNR), defined as the ratio of axillary lymph nodes with tumor metastasis to the total lymph nodes dissected, was a better independent prognostic indicator than PLN and should be considered as an alternative to the status of regional lymph nodes in the staging of breast cancer (pN). In the current study, the authors retrospectively reviewed 1095 primary BC patients with PLN and assessed the prognostic effect of LNR measured by relapse-free survival and overall survival to explore the feasibility of LNR and HER-2/neu status in stratifying the risk category of BC. Our results indicate that although by univariate analysis and when assessed as single covariate in multivariate analysis, both PLN and LNR were independent prognostic factors, PLN lost its significance when combined with LNR as covariates. A cutoff value of LNR = 0.30 was identified to show high accuracy in separating patients based on their survivals. The risk categories defined by LNR combined with HER-2/neu status were compatible to those defined by the PLN in combination with HER-2/neu status. LNR was a strong prognostic predictor of node-positive BC patients, superior to PLN. It should be considered as a new factor to couple with HER-2/neu status in defining risk category of BC patients.

Targeting pancreatic cancer stem cells for cancer therapy

Pancreatic cancer (PC) is the fourth most frequent cause of cancer death in the United States. Emerging evidence suggests that pancreatic cancer stem cells (CSCs) play a crucial role in the development and progression of PC. Recently, there is increasing evidence showing that chemopreventive agents commonly known as nutraceuticals could target and eliminate CSCs that have been proposed as the root of the tumor progression, which could be partly due to attenuating cell signaling pathways involved in CSCs. Therefore, targeting pancreatic CSCs by nutraceuticals for the prevention of tumor progression and treatment of PC may lead to the development of novel strategy for achieving better treatment outcome of PC patients. In this review article, we will summarize the most recent advances in the pancreatic CSC field, with particular emphasis on nutraceuticals that target CSCs, for fighting this deadly disease.

Number of lymph nodes evaluated: prognostic value in pancreatic adenocarcinoma

INTRODUCTION

The impact of the number of lymph node (LN) evaluated pathologically on accurate staging is unknown. Our primary aim was to determine a minimum number of evaluated LN needed to provide accurate staging of pancreatic cancer.

METHODS

Four hundred ninety-nine patients underwent a curative pancreatectomy for pancreatic adenocarcinoma cancer from 1981-2007. The probability of understaging a patient as N0 was estimated based on the number of LN evaluated. The prognostic value of LN ratio (LNR) was assessed.

RESULTS

Survival for node-negative (pN0) patients with <11 LN examined was worse than for pN0 patients with ≥11 LNs with a hazard ratio (95 % CI) of 1.33 (1.1-1.7, p = 0.01) with 3-year survivals of 32 vs. 50%, respectively. Three-year survival for pN1 patients with <11 nodes evaluated was similar to pN1 patients with ≥11 nodes (25 vs. 30%). LNR ≥ 0.17 predicted worse survival with hazard ratio of 1.76 (1.3-2.4, p = 0.001) than LNR < 0.17; 3-year survivals were 37 vs. 19%.

CONCLUSION

Patients with "N0" disease with <11 LN evaluated pathologically have worse survival, suggesting that metastatic nodes were missed by evaluating too few nodes. For pN1 patients, LNR stratifies survival of patient cohorts more accurately. Adequate staging of pancreatic cancer requires pathologic evaluation of ≥11 LNs.

The prognostic impact of the ratio of positive lymph nodes on survival of epithelial ovarian cancer patients

BACKGROUND AND OBJECTIVES

To study the prognostic significance of ratio of positive to examined lymph nodes (LNR) on survival of patients with node positive epithelial ovarian cancer (NPEOC).

METHODS

Data were obtained from Surveillance, Epidemiology, and End Results Program (SEER) from 1988 to 2006, and analyzed using Kaplan-Meier survival and Cox regression proportional hazard methods. Patients were divided into: stage IIIC group 1 (no macroscopic peritoneal disease), stage IIIC group 2 (macroscopic peritoneal disease), and stage IV.

RESULTS

A total of 6,310 women were included. The 5-year survival for stage IIIC groups 1, 2, and stage IV was 55.4%, 35.5%, and 20.3%, respectively (P < 0.001). Increasing LNR (<10%, 10-50%, and >50%) was associated with decreased survival from 51.5% to 38.1% to 27.0%, respectively, (P < 0.001). On multivariate analysis, LNR was an independent prognostic factor for survival after adjusting for extent of peritoneal disease, stage, grade, race, age, extent of lymphadenectomy and absolute number of positive nodes.

CONCLUSIONS

The impact of increasing LNR was strongly related to survival, especially in patients with no macroscopic peritoneal disease. Stratification of this subpopulation of node positive EOC based on nodal burden provides a significant prognostic value that may be considered in future staging and aid in management decisions.

Age and axillary lymph node ratio in postmenopausal women with T1-T2 node positive breast cancer

PURPOSE

The purpose of this article was to examine the relationship between age and lymph node ratio (LNR, number of positive nodes divided by number of examined nodes), and to determine their effects on breast cancer (BC) and overall mortality.

METHODS

Women aged ≥50 years, diagnosed in 1988-1997 with a unilateral histologically confirmed T1-T2 node positive surgically treated primary nonmetastatic BC, were selected from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER). Generalized Additive Models for Location Scale and Shape (GAMLSS) were used to evaluate the age-LNR relationship. Cumulative incidence functions and multivariate competing risks analysis based on model selection by the Bayesian Information Criterion (BIC) were used to examine the effect of age and LNR on mortality. Low LNR was defined as ≤0.20, mid-LNR 0.21-0.65, and high LNR >0.65.

RESULTS

GAMLSS showed a nonlinear LNR-age relationship, increasing from mean LNR 0.26-0.28 at age 50-70 years to 0.30 at 80 years and 0.40 at 90 years. Compared with a 9.8% [95% confidence interval (CI) 8.8%-10.8%] risk of BC death at 5 years in women aged 50-59 years with low LNR, the risk in women ≥80 years with low LNR was 12.6% [95% CI 10.1%-15.0%], mid-LNR 18.1% [13.9%-22.1%], high LNR 29.8% [22.7%-36.1%]. Five-years overall risk of death increased from 40.8% [37.5%-43.9%] by low LNR to 67.4% [61.4%-72.4%] by high LNR. The overall mortality hazard ratio for age ≥80 years with high LNR was 7.49 [6.54-8.59], as compared with women aged 50-59 years with low LNR.

CONCLUSION

High LNR combined with older age was associated with a threefold increased risk of BC death and a sevenfold increased hazard ratio of overall mortality.