Extracapsular extension is associated with increased ratio of metastatic to examined lymph nodes in axillary node-positive breast cancer

Extranodal Tumor Deposits in the Axillary Fat Indicate the Need for Axillary Dissection Among T1-T2cN0 Patients with Positive Sentinel Nodes

BACKGROUND

The American College of Surgeons Oncology Group (ACOSOG) Z0011 trial demonstrated the safety of omitting axillary lymph node dissection (ALND) in T1-T2cN0 patients with fewer than three positive sentinel nodes (SLNs) undergoing breast-conservation therapy. While microscopic extracapsular extension (mECE) > 2 mm is associated with increased nodal burden, the significance of extranodal tumor deposits (ETDs) in the axillary fat is uncertain.

METHODS

Consecutive patients with T1-T2cN0 breast cancer undergoing sentinel node biopsy and ALND for SLN metastases from January 2010 to December 2018 were identified. ETDs were defined as intravascular tumor emboli or metastatic deposits in the axillary fat. Clinicopathologic characteristics and nodal burden were compared by ETD status.

RESULTS

Among 1114 patients, 113 (10%) had ETDs: 81 (72%) were intravascular tumor emboli and 32 (28%) were soft tissue deposits. Patients with ETDs had larger tumors (median 2.2 vs. 2.1 cm; p = 0.033) and more often had mECE (83% vs. 44%; p < 0.001). On univariable analysis, presence of ETDs (odds ratio [OR] 9.66, 95% confidence interval [CI] 6.36-14.68), larger tumors (OR 1.47, 95% CI 1.25-1.72), and mECE (OR 10.73, 95% CI 6.86-16.78) were associated with four or more additional positive non-SLNs (NSLNs; all p < 0.001). On multivariable analysis, ETDs remained associated with four or more positive NSLNs (OR 5.67, 95% CI 3.53-9.08; p < 0.001). ETDs were strongly associated with four or more positive NSLNs (OR 7.15, 95% CI 4.04-12.67) among patients with one to two positive SLNs (n = 925).

CONCLUSIONS

Among T1-T2cN0 patients with SLN metastases, ETDs are strongly associated with four or more positive NSLNs at ALND. Even among those who may otherwise meet the criteria for omission of ALND, the presence of ETDs in axillary fat warrants consideration of ALND.

Rate of metastasis in examined lymph nodes as a predictor of extracapsular extension in patients with axillary node-positive breast cancer

BACKGROUND

The status of the axillary lymph nodes is an important factor in the prognosis and treatment of breast cancer. Extracapsular extension (ECE) is the spread of lymphatic tumor cells beyond the capsule of an axillary lymph node. Recent studies have demonstrated that ECE is a strongly unfavorable prognostic factor.

OBJECTIVE

In the present study, we investigated whether the rate of metastasis among examined lymph nodes can be used to predict ECE in patients with axillary node-positive breast cancer.

METHODS

The subjects were 95 women with axillary node-positive breast cancer. The numbers of lymph nodes removed (examined) and lymph nodes involved were recorded. The cut-off values, area under the curve, sensitivity, and specificity were calculated with the receiver operating characteristic curve technique for ability of the rate of metastasis to examined lymph nodes to predict ECE.

RESULTS

The rate of metastasis to examined lymph nodes was significantly greater in patients with ECE than in patients without ECE [0.57 (0.03-1.00) vs. 0.22 (0.04-1.00), respectively, p: 0.001]. Similarly, the presence of vascular infiltration was significantly higher in patients with ECE than in those without ECE [30 (73.2%) vs. 25 (47.2%) respectively, p: 0.010]. On the other hand, other variables did not differ between the groups (p>0.05). When the cut-off value was ≥0.23, the sensitivity and specificity of the rate of metastasis to examined lymph nodes were 80.49% and 55.56%, respectively. The area under the curve was 0.697 (95% confidence interval: 0.594-0.787, p: 0.004).

CONCLUSION

Our results suggest that rate of metastasis among examined lymph nodes is a predictor of ECE in patients with axillary node-positive breast cancer.

Prognostic significance of the degree of extranodal extension in patients with penile carcinoma

This study sought to assess the prognostic significance of the degree of extranodal extension (ENE) and several other risk factors in pathological ENE penile carcinoma. We analyzed prospectively collected data on a consecutive series of 31 chemotherapy-naive patients with proven ENE who underwent therapeutic regional lymphadenectomy. Postoperative external radiotherapy was then performed. We studied the extent of ENE utilizing a novel grading system and correlated patient grades with their outcome measures. ENE was graded as 1 - if the capsule of the lymph node (LN) was ruptured less than one-third of its circumference or 2 - if the capsule was disrupted more than one-third of its circumference or the entire LN was disrupted. We estimated overall survival (OS) using the Kaplan-Meier method. Multivariate analysis was performed according to the Cox proportional hazards model using factors that were identified as statistically significant in univariate analysis. The incidence rate of ENE was 51.8% in patients with pathological node-positive carcinoma of the penis. The median OS and 5-year survival were 18 months (95% confidence interval (CI), 14.4-21.6) and 23%, respectively. Prognostic variables on univariate analysis were ENE grade 2, ≥ 3 LNs with ENE, maximal LN ≥ 35 mm, ≥ 5 positive LNs and pelvic LN involvement. On multivariate analysis, only ENE grade 2 remained associated with decreased OS (hazard ratio (HR): 6.50). In conclusion, patients with ENE have a poor outcome, and ENE grade 2 is an independent predictive factor of poor OS in patients with pathological ENE penile carcinoma.

The extent of extracapsular extension may influence the need for axillary lymph node dissection in patients with T1-T2 breast cancer

BACKGROUND

Whether extracapsular extension (ECE) of tumor in the sentinel lymph node (SLN) is an indication for axillary lymph node dissection (ALND) in patients managed by American College of Surgeons Oncology Group Z0011 criteria is controversial. Here we examine the correlation between ECE in the SLN and disease burden in the axilla.

METHODS

Patients meeting Z0011 clinicopathologic criteria (pT1-2, cN0 with <3 positive SLNs) were selected from a prospectively maintained database (2006-2013). Chart review documented the presence and extent of ECE. Neoadjuvant chemotherapy patients were excluded. Comparisons were made by presence and extent (≤2 vs. >2 mm) of ECE.

RESULTS

Of 11,730 patients, 778 were pT1-2, cN0 with <3 positive SLNs without ECE, and 331 (2.8 %) had ECE. Of these, 180 had ≤2 mm and 151 had >2 mm of ECE. Patients with ECE were older (57 vs. 54 years; p = 0.001) and had larger (2.0 vs. 1.7 cm; p < 0.0001), multifocal (p = 0.006), hormone receptor-positive tumors (p = 0.0164) with lymphovascular invasion (p < 0.0001). Presence and extent of ECE were associated with greater axillary disease burden; 20 and 3 % of patients with and without ECE, respectively, had ≥4 additional positive nodes at completion ALND (p < 0.0001), and 33 % of patients with >2 mm ECE had ≥4 additional positive nodes at completion ALND, compared with 9 % in the <2 mm group (p < 0.0001). On multivariate analysis, >2 mm of ECE was the strongest predictor of ≥4 positive nodes at completion ALND (odds ratio 14.2).

CONCLUSIONS

Presence and extent of ECE were significantly correlated with nodal tumor burden at completion ALND, thus suggesting that >2 mm of ECE may be an indication for ALND or radiotherapy when applying Z0011 criteria to patients with metastases in <3 SLNs. ECE reporting should be standardized to facilitate future studies.

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.

Gastrointestinal cancer metastasis and lymphatic advancement

The role of angiogenesis in the growth of solid tumors is well established, but the role of lymphatic vessels and the relationship between lymphangiogenesis and tumor spread are less clear. Recently, the molecular pathway that signals lymphangiogenesis and specific markers for lymphatic endothelium have been discovered; however, the lymphatic pathway of cancer metastasis is only partly clarified. Several investigators from the mid 20th century indicated the existence of lymphatico-venous communications, and some observed the retrograde filling of lymph flow and lymphatico-venous communication in obstructive lymphopathy. In the 1960s Burn reported the importance of lymphovenous communication in his clinical and animal experimental data. Thus, the role of potential peripheral lymphatico-venous communication must be considered in the mechanism of cancer metastasis. We observed the lymphatico-venous (portal) communication, as well as lymph retention and reflux, in a rat model of mesenteric lymph vessel obstruction. Based on the phenomenon of lymphatico-venous communication and lymph flow reflux by lymphatic obstruction, we speculate that tumor cell obstruction in the lymph system will lead to the establishment of liver and/or peritoneal metastasis. Clinically, we observed extranodal cancer invasion in a model of lymphatic obstruction, and noted a strong relationship between extranodal invasion and liver or peritoneal metastasis. Thus, the existence of peritoneal and liver metastasis via a lymphatic pathway should be considered.

Clinicopathologic features of sentinel node metastases predictive of positive axillary clearance in grade 1 invasive breast carcinoma

BACKGROUND

Sentinel node (SN) biopsy is widely used to stage breast carcinoma and, when positive, typically leads to axillary clearance (AC).

AIMS

This study assesses clinicopathologic features of grade 1 breast carcinoma SNs with the aim of identifying a group of patients, who are likely to have a negative AC and can, therefore, safely be spared further surgery.

RESULTS

Two hundred and forty-seven patients with grade 1 invasive carcinoma were identified, of whom 29 had a positive SN. Four patients (13.8%) had a positive AC. Positive AC occurred in 3 of 6 (50%) patients whose SN showed extranodal extension (EE), but in only 1 of 23 (4.3%) patients without EE. All patients were staged as pN1(sn) following SN biopsy: only one, who had a 5.27 mm metastasis with EE, was pN2 following AC.

CONCLUSIONS

Extranodal extension is a significant predictor of a positive AC in this group. In its absence, AC did not alter the post-SN biopsy pN stage.