International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationPredicting Likelihood of Having Four or More Positive Nodes in Patient With Sentinel Lymph Node-Positive Breast Cancer: A Nomogram Validation Study
Introduction
The rationale for performing axillary lymph node dissection (ALND) includes staging, improving regional control, predicting prognosis, and determining optimal adjuvant therapy 1, 2. At present, sentinel lymph node (SLN) biopsy is accepted as the standard approach for clinically node negative breast cancer (BC) patients (3). Completion axillary lymph node dissection (CALND) is performed if the SLN is positive. For various reasons, a subset of patients will not have undergone CALND, and additional therapeutic decisions must be made according to the SLN results. Parameters such as lymphovascular invasion (LVI), number of positive SLNs, overall metastasis size (OMS), and presence of extracapsular extension (ECE) have been evaluated to predict for the probability of residual disease in the axilla in SLN-positive patients 4, 5, 6, 7. Although systemic therapy decisions might not be influenced by the finding of additional nodal disease, the extent of adjuvant radiotherapy could be affected if four or more axillary nodes are positive. Patients with four or more positive axillary nodes have a greater risk of regional nodal failure and will benefit from the additional radiotherapy to the axillary apex and supraclavicular fossa 8, 9, 10, 11, 12. Katz et al.(13) developed a nomogram for predicting the presence of four or more involved axillary nodes for SLN-positive BC patients. It seeks to help in identifying patients with a low probability of having four or more nodes using the known pathologic features of their primary tumor and SLNs. The purpose of this study was to validate the accuracy of the Katz nomogram in BC patients with a positive SLN in our institution.
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Methods and Materials
We reviewed the information from the tumor registry database of patients who had undergone SLN mapping for BC between 1999 and 2007 at the Magee-Womens Hospital of the University of Pittsburgh Medical Center. A total of 309 patients with invasive BC, who had undergone SLN biopsy and CALND, were identified. Those patients with more than three positive SLNs were excluded. We excluded patients with fewer than six retrieved nodes in the axillary specimen because six nodes is the accepted minimal
Results
The patient and tumor characteristics are listed in Table 1. The median patient age was 54.3 years (range, 30–84). The mean tumor size was 2.18 cm (range, 0.2–8). Breast-conserving surgery was performed in 201 patients (65.1%). The histologic type was invasive ductal carcinoma in 267 (86.4%) and invasive lobular carcinoma in 42 (13.6%). Of the 309 patients, 152 (49.2%) had LVI surrounding the primary tumor. Twenty-one patients (6.7%) were negative for ER, PR, and Her2/neu. The micrometastasis
Discussion
The current standard of care for patients with a positive SLN is completion of Level 1 and 2 ALND. Nevertheless, ALND has several complications, including intercostal brachial nerve injury and upper extremity lymphedema. Accurate estimates of the likelihood of additional disease in the axilla can assist in decision-making about additional treatment. Scoring systems are useful and provide additional information for BC patients who decline CALND or who have medical comorbidities prohibiting
Conclusion
The results of our study have demonstrated that the Katz nomogram provides fairly accurate predictions for identifying patients with a low or high risk of four or more involved axillary lymph nodes in SLN-positive patients. Our findings have validated the Katz nomogram. This model should be tested and verified in additional, large, patient populations before it is widely accepted. Although nomograms developed at outside institutions should be used with caution when counseling patients regarding
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Cited by (19)
Development and external validation of a nomogram to predict four or more positive nodes in breast cancer patients with one to three positive sentinel lymph nodes
2020, BreastCitation Excerpt :While RNI may improve disease-free survival, the risk of lymphedema and lung fibrosis is higher than with WBI alone [10,11]. Table 4 summarizes previous nomograms that have been proposed for predicting the risk of ≥4 positive nodes [29–33]. The majority of patients in these studies had T1-2 tumor with 1–2 positive SLNs; the proportion with ≥4 positive nodes in the final pathology varied from 5.7% to 25.9%.
Potential impact of application of Z0011 derived criteria to omit axillary lymph node dissection in node positive breast cancer patients
2016, European Journal of Surgical OncologyCitation Excerpt :In case of micrometastases in the SN, the rate of additional positive nodes after ALND is about 20%, whereas with isolated tumor cells this rate is only 12%.9,10 Multiple studies have been conducted with the intention to identify a group of patients in whom an ALND could be omitted without negatively affecting the prognosis.11–13 However, the majority of these studies were based on retrospectively collected data, except for the recently published European Organization for Research and Treatment of Cancer (EORTC) AMAROS trial which states that axillary treatment in patients with a positive SN can also be done by radiotherapy.14
Predictors for extensive nodal involvement in breast cancer patients with axillary lymph node metastases
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Analysis of cellular and molecular factors at the tumoral margin related to sentinel and non-sentinel lymph node involvement in breast cancer
2015, Revista de Senologia y Patologia MamariaPrediction of metastatic breast cancer in non-sentinel lymph nodes based on metalloprotease-1 expression by the sentinel lymph node
2013, European Journal of CancerCitation Excerpt :These reports found that the incidence of non-SLNs metastasis increased as the metastases in the SLN increased in size,4,6–10 and also with increasing number of positive SLN,4,11,12 extracapsular extension of the SLN-metastasis13 or lymphovascular invasion of the primary tumour.8,9,14–16 In addition, several nomogram scores based on these factors have been defined to determine the risk of finding additional positive axillary nodes if axillary node dissection is performed.13,17–20 However, the results obtained using the cited nomogram scores are still unsatisfactory for clinical use.21,22
Clinical significance of minimal sentinel node involvement and management options
2010, Surgical Oncology Clinics of North AmericaCitation Excerpt :Unlike this model, which used only preoperative and intraoperative data, Katz and colleagues proposed a more comprehensive nomogram including primary tumor size, number of positive SLNs, lymphovascular invasion, lobular histology, extranodal extension, micro- versus macrometastasis, and whether or not more than 1 SLN was positive. Both of these models have been validated in independent series.36,45 The ACOSOG Z-0010 and the NSABP B-32 trials will shed significant light on the biologic significance of SLN metastases found by IHC and the clinical management of patients with micrometastatic disease.
Accepted as a poster presentation at San Antonio Breast Cancer Symposium 2008.
Conflict of interest: none.