Incidence Of Axillary Lymph Node Metastasis Research Articles

Pre-operative Conventional Ultrasound and Sonoelastography Evaluation for Predicting Axillary Lymph Node Metastasis in Patients with Malignant Breast Lesions

The objective of our study was to evaluate the association between the sonoelastography features of breast tumor and axillary lymph node metastasis (ALNM) in patients with breast cancer. In a cohort of 106 women with breast cancer, the conventional ultrasound features and elasticity parameters by elasticity imaging and Virtual Touch Tissue Imaging & Quantification (VTIQ) were retrospectively analyzed. Ultrasound and elastography findings were compared with pathologic axillary lymph node status. Receiver operating characteristic curve analysis was used to evaluate diagnostic performance. Pathologically, the overall incidence of ALNM was 39.6% (42/106) in the final analysis. ALNM was significantly more frequent in tumors with elasticity imaging scores >4.5, maximal shear wave velocity values (Smax) >6.42 m/s and mean shear wave velocity values (Smean) >5.66 m/s, respectively. The sensitivity, specificity and accuracy were 78.6%, 54.7% and 64.2% for elasticity imaging score; 85.7%, 54.7% and 67.0% for Smax; and 59.5%, 79.7% and 71.7% for Smean, respectively Elastography features, including elasticity imaging score and VTIQ, can be used to supplement conventional ultrasound to predict ALNM in patients with breast cancers.

Can Clinically Node-Negative Breast Cancer Patients with Suspicious Axillary Lymph Nodes at Ultrasound But Negative Fine-Needle Aspiration Be Approached as Having Node-Negative Disease?

Few data exist to elucidate whether patients with a suspicious axillary lymph node (ALN) at ultrasound but a negative fine-needle aspiration result (FNA group) can be managed as having ultrasound node-negative disease (AUN group). This study compared various ALN statuses between the AUN and FNA groups to guide further ALN management. Patients who had clinical T1-2N0 breast cancer treated with sentinel lymph node (SLN) biopsy were retrospectively analyzed. The ALN metastasis status, SLN status, and non-SLN metastasis rates in the entire population and the patients with one or two positive SLNs were compared between the AUN and FNA groups. A total of 1007 patients (886 AUN and 121 FNA patients) were eligible for the final analysis: The incidence of ALN metastasis did not differ between the AUN group (16.5%) and the FNA group (21.5%) (P=0.170). In addition, three or more metastases were found in only 2.4% of the AUN patients and 3.3% of the FNA patients (P=0.405). The non-SLN metastasis rate was 22.6% (33/146) in the AUN group and 19.2% (5/26) in the FNA group (P=0.699). For the patients with one or two positive SLNs, the rate of non-SLN metastasis was similar between the AUN group (19.6%, 27/138) and the FNA group (12.5%, 3/24) (P=0.591). Patients with a suspicious ALN at ultrasound but a negative FNA result had ALN statuses similar to those of the ultrasound node-negative patients, indicating that these patients can be treated as having ultrasound node-negative disease.

Is the sentinel lymph node biopsy more sensitive for the identification of positive lymph nodes in breast cancer than the axillary lymph node dissection?

Since the routine clinical use of the sentinel lymph node (SLN) procedure, questions have been raised concerning an increase in the overall percentage of node-positive patients. The goal of our study was to compare the sensitivity of the SLN procedure and the axillary lymph node dissection (ALND) for the identification of positive lymph nodes in breast cancer.The incidence of axillary node metastasis in SLNB and ALND specimens from patients undergoing operative treatment of a primary breast carcinoma was compared retrospectively.Logistic regression models were used to analyze the effect of various predictors on the presence of positive lymph nodes. We constructed a multivariate model including the procedure and these predictors that have shown to be related to lymph node involvement in univariate analysis. The probability of finding positive lymph nodes was thus calculated in both groups correcting for relevant predictors of lymph node involvement.The SLNB group included 830 patients, the ALND group 320. In a multivariate analysis, adjusting for the number of foci, tumor location in the breast, tumor size, LVI, ER, PR, tumor grade and histological subtype, the probability of finding positive lymph nodes was higher with SLNB procedure than with an ALND. However, this difference was not statistically significant (OR 0.7635; CI 0.5334-1.0930, p 0.1404).For comparable tumors, SLNB procedure is at least as sensitive as ALND for detecting positive lymph nodes.

The clinical value of tumor FDG uptake for predicting axillary lymph node metastasis in breast cancer with clinically negative axillary lymph nodes

The aim of this study was to evaluate the clinical value of 18F-fluorodeoxyglucose (FDG) uptake and the clinicopathological or immunohistochemical findings of the primary tumor to predict axillary lymph node (ALN) metastasis in breast cancer with clinically negative ALN. This study retrospectively enrolled 104 women (49.43 ± 9.9 years) having breast cancer with clinically negative ALN using all types of preoperative imaging modalities including ultrasonography, FDG positron emission tomography, and magnetic resonance imaging. All cases of breast cancer in this study were proven as invasive ductal carcinoma with ≥1 cm in size. The final diagnosis of ALN status was confirmed by permanent pathology after operation. Among 104 breast cancers with clinically negative ALN, 21 breast cancers (20.2 %) were proven to have ALN metastasis. The ROC curve analysis showed that the best cut-off value of SUVmax for identifying ALN metastasis was 9.8 with 33.3 % sensitivity and 92.8 % specificity (AUC = 0.656; p = 0.027). The multivariable analysis revealed that primary tumors with SUVmax >9.8 (p = 0.011) and D2-40 positivity (p = 0.027) were independently associated with ALN metastasis with odds ratios of 5.516 (CI 1.475-20.6333) and 3.409 (CI 1.154-10.072), respectively. Our study demonstrates that the incidence of ALN metastasis in even rigorously clinically evaluated breast cancer without suspiciously positive ALN is still not negligible, and while a high SUVmax of the primary tumor may be associated with a higher incidence of ALN metastasis in breast cancer with clinically negative ALN, a low SUVmax does not exclude ALN metastasis.

Axillary Lymph Node Status in Multicentric Breast Tumors and Breast Tumors with Nipple Involvement

Background: Axillary lymph node dissection plays an important role in breast cancer management in terms of staging, prediction of prognosis, determination of adjuvant therapy, and local control of the primary tumor. The objective of this study was to evaluate the axillary lymph node involvement in multicentric breast tumors and breast tumors with nipple involvement in comparison with unifocal tumors. Patients and Methods: We reviewed the records of 267 patients with stage I or IIA disease. The rates of axillary lymph node metastasis (ALNM) in patients with unifocal tumors, multicentric tumors, or nipple involvement were compared. Results: 209 (78%) patients had unifocal tumors, 24 (8%) had multicentric tumors, and 34 (12%) had nipple involvement. The incidence of ALNM was 9.76% in patients with unifocal tumors, 24.84% in patients with multicentric tumors, and 36.71% in patients with nipple involvement. Hence, the incidence of ALNM was significantly higher in patients with nipple involvement or multicentric tumors than in patients with unifocal tumors. Conclusion: Our data suggest that compared to unifocal tumors, breast tumors with nipple involvement or multiple foci show a significantly higher incidence of ALNM which is a predictor of a poor prognosis.

Predictors of axillary lymph node metastases in early breast cancer and their applicability in clinical practice

PurposeLymph node involvement is the most important prognostic factor in breast cancer. It is a multifactorial event determined by patient and tumour characteristics. The purpose of this study was to determine clinical and pathological factors predictive for axillary lymph node metastasis (ALNM) in patients with early breast cancer and to build a model to portend lymph node involvement. MethodsWe evaluated 1300 consecutive patients surgically treated in our institution (2007–2009) for cT1-T2 invasive breast cancer. The patient and tumour characteristics evaluated included: age at diagnosis, number of foci, histologic grade, location, tumour size, histologic subtype, lymphovascular invasion (LVI), estrogen-receptor (ER), progesterone-receptor (PR) and Her-2 status. Univariate and multivariate analyses were performed. Factors significantly associated with ALNM by univariate analysis plus histologic subtype were included in the multivariate analysis. ResultsBy univariate analysis, the incidence of ALNM was significantly associated with the presence of LVI (P < 0.0001), larger tumour size (P < 0.0001), higher histologic grade (P < 0.0001), retroareolar or lateral location in the breast (P < 0.0001), multiple foci (P = 0.0002) and in patients who underwent an axillary lymph node dissection. We found no effect of age, ER⁄PR nor HER-2 status. By multivariate analysis, ALNM was significantly associated with the presence of LVI (P < 0.0001), larger tumour size (P < 0.0001), axillary lymph node dissection (P = 0.0003), retroareolar and lateral tumour location in the breast (P = 0.0019) and the presence of multiple foci (P = 0.0155). ConclusionsLVI and tumour size emerged as the most powerful independent predictors of ALNM, followed by the location of the tumour in the breast and the presence of multiple foci.

P5-14-21: Predicting the Status of the Axillary Lymph Nodes in 1300 Consecutive Patients with Early Breast Cancer Treated in a Single Institution.

Abstract Purpose. Lymph node involvement is the most important prognostic factor in breast cancer. It is a multifactorial event determined by tumour and patient characteristics. Several predictors of axillary lymph node metastasis (ALNM) in breast cancer have been described. The purpose of this study was to determine clinical and pathological factors predictive for ALNM in patients with early breast cancer and to build a model to portend lymph node involvement. Methods. We evaluated 1300 consecutive patients surgically treated in our institution (2007-2009) for cT1-T2 invasive breast cancer. The patient and tumour characteristics evaluated included: age at diagnosis, number of foci, histologic grade, location, tumour size, histologic subtype, lymphovascular invasion (LVI), estrogen-receptor (ER), progesterone-receptor (PR) and Her2 status. Univariate and multivariate analyses were performed. Factors significantly associated with lymph node metastasis by univariate analysis and histologic subtype were included in the multivariate model. We validated our model with the same 1300 patients on the basis of a multivariable logistic regression model containing the variables, using a correction factor. Results. By univariate analysis, the incidence of ALNM was significantly higher in patients with a tumour with LVI (P &amp;lt; 0.0001), larger tumours (P &amp;lt; 0.0001), tumours with a higher histologic grade (P &amp;lt; 0.0001), tumours located retroareolar or lateral in the breast (P &amp;lt; 0.0001), tumours with multiple foci (P = 0.0002) and in patients who underwent an axillary lymph node dissection. We found no effect of ER/PR nor HER-2 status. By multivariate analysis, lymph node involvement was significantly associated with the presence of lymphovascular invasion (P &amp;lt; 0.0001), larger tumour size (P &amp;lt; 0.0001), axillary lymph node dissection (P = 0.0003), retroareolar and lateral tumour location in the breast (P = 0.0019) and the presence of multiple foci (P = 0.0155). The discrimination of the model, calculated by the area under the curve (AUC), was 0.778. Conclusions. LVI and tumour size emerged as most powerful independent predictors of ALNM. A model with an AUC of 0.50 is equivalent to the toss of a coin, a model with an AUC &amp;gt; 0.70 is considered as good. In conclusion, our result is not perfect in discrimination which raises further questions. It is clear that underlying mechanisms of ALNM remain to be elucidated. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-14-21.

Predictive Factors Affecting Axillary Lymph Node Metastasis in Patients with Invasive Breast Carcinoma of 1 cm or Less

Purpose: Although screening MMG leads to increase of early small breast cancer, axillary lymph node metastasis is still an important prognsotic factor in these patients. The aim of this study is to evaluate the incidence and predictors for axillary lymph node metastasis in patients with invasive breast carcinoma of 1 ㎝ or less. Methods: A retrospective analysis was made of 144 patients who underwent resection of primary tumor and axillary procedures between January 1999 and August 2009 for breast cancer of 1 ㎝ or less in size. Patients were divided into two groups according to axillary node metastasis and clinicopathologic factors including age, palpable mass during physical examination, location of tumor, multifocality, tumor size, histologic type, extensive in situ component, histologic grade, nuclear grade, lymphovascular invasion, hormonal receptor status, and C-erbB-2 status were compared. Results: Twenty-eight (19.4%) patients of all 144 patients had metastasis in the axillary lymph node. Three variables such as multifocality (P=0.023), histologic high grade (P=0.033), presence of lymphovascular invasion (P=0.002) were found to be significant in univariate analysis. In a multivariate logistic regression analysis, however, multifocality (P=0.022) and presence of lymphovascular invasion (P=0.007) were independent predictors of axillary lymph node metastasis. Conclusion: The incidence of axillary lymphnode metastasis of breast cancer 1 ㎝ or less in size was 19.4%. Although the size of invasive breast carcinoma is less than 1 ㎝, if the tumor presented lymphovascular invasion or multifocality, axillary lymph node dissection might prove better than sentinel node biopsy.

Can We Skip Sentinel Lymph Node Biopsy in Patients Who Have Microinvasive Breast Cancer?

Abstract Background: Sentinel lymph node(SLN) biopsy in patients with ductal carcinoma in situ(DCIS) was controversial. We may skip SLN biopsy when we performed conserving operation with small sized DCIS. But sometimes we can find DCIS with micro-invasive breast cancer (MIC) after operation. Should another operation be performed? We determined the incidence of positive axillary lymph node (ALNs) in patients with MIC, and the predictive factors of ALNs metastasis in these patients. Methods: Between July 1989 and January 2008, 9046 patients had operations performed on invasive breast cancers at Asan Medical Center. From July1989 to February 2003, ALND was performed to surgically stage the axilla. Since May 2003, SNB has been routinely performed for all cases. Patients who were treated with neoadjuvant chemotherapy and those who had no identifiable ALNs at surgery were excluded from the study. We retrospectively checked clinical and pathologic variables including diagnosis, patient demographics, size of DCIS, grade, multi-focal lesion, hormone receptor status, lymphatic invasion status etc. Results: 265 patients were identified with microinvasive (pathologic stage T1mic) breast cancer. Among these patients, 12 patients didn't have ALN study. 2 patients had bilateral MIC. The research was conducted on the remaining 255 cases. There were 13 cases of ALN metastases identified in this group of patients(5%). Young age (p=0.006), multifocal lesion (p=0.040) and lymphatic invasion (p&amp;lt;0.0001) were predictive factors for ALN metastases. There was no incidence of metastatic ALNs among the old age (≥50) patients of this group. Conclusion: As the incidence of ALN metastases in MIC patients is very small, particularly in those who had no lymphatic invasion, single lesion and among old age patients. So we think conservative treatment is one of the available options for these patients. However, due to the size of the subject group in this study, it needs to be validated through extensive prospective research. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1019.

Screening for breast cancer: some clinical aspects.

There is little doubt that screening by palpation and mammography will reduce the mortality from breast cancer. Most of the studies have been designed to test survival difference and, following diagnosis, patients were treated by a variety of surgeons and methods. We present clinical and pathological data on 32 asymptomatic patients who were screened and found to have breast cancer. Investigation and treatment was performed by one surgeon according to a defined protocol. We confirm that mammography is a more sensitive diagnostic tool than palpation and describe how a review of the patient with the suspicious mammogram will increase the incidence of palpable tumours. We stress the importance of fine-needle aspiration cytology as a diagnostic and localization method. The low incidence of axillary node metastasis in patients with invasive carcinoma is described. More importantly, no patient in this series required treatment by mastectomy. In our experience patients with breast cancer detected by screening are eminently suitable for treatment by breast conservation.

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AbstractDOI 10.1002/cncr.11163

Factors Affecting Axillary Lymph Node Metastases in Patients with T1 Breast Carcinoma

The purpose of this study was to determine factors associated with the incidence of axillary lymph node metastases (ALNM) in T1 tumors and cases in which axillary dissection could be omitted. Data from 195 patients with T1 primary invasive breast cancer (size ≤2 cm) who underwent either mastectomy or wide local excision of the tumor and axillary dissection were reviewed. ALNM was found in 59 of 195 patients with T1 tumors (30.3%). Tumor size was found to be the only independent predictor of ALNM, having a directly analogous relationship with the probability of invaded nodes: T1a (≤5 mm) tumors had 0 per cent ALNM, whereas T1b (5 mm &lt; T1b ≤ 10 mm) and T1c (10 mm &lt; T1c ≤ 20 mm) tumors had 25.7 per cent and 33.8 per cent ALNM respectively. Among the other factors studied (patient age, tumor site, hormone receptor status, histologic type, and grade of the tumor) only the histologic grade of the tumor cells appeared to correlate with the incidence of lymph node involvement, but this was not statistically significant. In conclusion only tumor size has statistically significant correlation with the incidence of ALNM. Routine axillary dissection could be omitted only in patients at minimal risk of ALNM (ductal carcinoma in situ and T1a) and when treatment decisions were not influenced by lymph node status (e.g., elderly patients with clinically negative axilla). Axillary dissection (at least levels I and II) should be performed in all cases with primary invasive breast cancer with tumor size &gt;5 mm.

Le marquage lymphatique et la biopsie du ganglion sentinelle axillaire dans 243 cancers invasifs du sein sans ganglion palpable.Expérience du centre hospitalier Lyon-Sud

Study aim: To evaluate the effect of intraoperative lymph node mapping and sentinel lymph node dissection (SLND) on the axillary staging of patients with N0 breast carcinoma. Two techniques were used: blue dye alone (Evans Blue and Patent Blue) and combined technique (blue dye and isotope). Methods: The incidence of axillary node metastasis in axillary lymph node dissection (ALND) and SLND was compared prospectively. Multiple sections of each SLN were examined by HPS staining and immunohistochemical techniques. Two sections of each non sentinel node in ALND specimens were examined by routine HPS staining. Results: 243 patients underwent ALND after SLN biopsy. The SLN detection rate was 225/243 cases (92.59%): 89.94% with blue dye alone and 100% with the combined technique. The false-negative rate was less than 2%. Conclusion: SN biopsy is an accurate staging technique for N0 breast cancer. SLN biopsy with multiple sections and immunohistochemical staining of the SLN can identify significantly more patients with lymph node metastases than ALND with routine HPS staining.

Histopathological Predictors of Axillary Lymph Node Metastases in Patients with Breast Cancer.

BACKGROUND: A tumor 30 mm or less in diameter is a standard candidate for breast conserving surgery (BCS) in Japan. Axillary lymph node metastases (ALNM) is the most important prognostic factor for survival in patients with breast cancer, but the role of axillary node dissection has been controversial. Histopathological predictive factors of axillary lymph node involvement have not been established. The purpose of this study was to determine the association between the incidence of ALNM and histopathological factors by univariate and multivariate analysis METHODS: Sixty-five patients with noninvasive ductal carcinoma, and 993 patients with tumors 30 mm or less in diameter who underwent axillary dissection between 1988 and 1997 at our institute were reviewed. The association between ALNM and 13 histopathological factors (size, age, histological subtype, histological invasiveness, lymphatic invasion, vascular invasion, macroscopic classification, histological daughter mass, ductal spread, ER, PgR, p-53, and c-erbB-2) were analyzed by univariate and, when significant, by multivariate analysis. RESULTS: Only one patient with noninvasive ductal carcinoma had ALNM, and 33.1% of 993 patients with a tumor 30 mm or less in size had ALNM. Multivariate analysis identified six factors as independent predictors for ALNM: lymphatic invasion, size, histological invasiveness, macroscopic classification, age and histological daughter mass. CONCLUSION: Axillary lymph node dissection can be omitted in patients with noninvasive ductal carcinoma. Histopathological features of tumors 30 mm or less in diameter can be used to estimate the risk of ALNM, and routine axillary node dissection might be spared in selected patients at minimal risk of ALNM, if the treatment decision is not influenced by lymph node status, such as in elderly patients.

Breast conservation for mammographically occult carcinoma.

Preoperative mammography is an essential part of the evaluation of patient eligibility for breast conserving therapy. It is uncertain whether factors that contribute to the nonvisualization of carcinoma on mammograms are indications for mastectomy. The purpose of this study was to determine if the failure to identify clinically evident carcinoma on a mammogram is a contraindication to breast conserving therapy. An analysis of 268 women with 269 clinically evident carcinomas who were treated from June 1988 to September 1993 was performed. Contraindications to breast preservation included multicentric tumors, diffuse indeterminate microcalcifications, pregnancy, prior irradiation to the breast region, the inability to achieve negative margins after two surgical procedures, and a large tumor to breast ratio. Mammographically occult tumors (MO) were present in 52 patients (19%). The mean age of patients with MO tumors was 52 versus 57 for mammographically evident (ME) tumors (p = 0.009), but the incidence by decade did not vary. Special histologic tumor types were more frequent among MO than ME tumors (13.5% vs. 1.8%, p < 0.001). Tumor size, the incidence of axillary node metastases, and stage did not vary. An equal proportion of patients with MO and ME tumors were candidates for breast preservation (67% vs. 70%), and a large tumor to breast ratio was the most common contraindication in both groups. Even with modem mammographic technology, MO tumors remain a significant problem. This study did not demonstrate an association between MO tumors and factors such as size, unfavorable histology, or multicentricity which would preclude the use of breast conserving therapy. These results support the treatment of MO tumors with breast conserving surgery after a detailed clinical evaluation.

Predictors of axillary lymph node metastases in patients with T1 breast carcinoma

BACKGROUND Axillary lymph node metastases (ALNM) are the most important predictor of survival in patients with T1 breast carcinoma. Due to a relatively low incidence of axillary metastasis in tumors ≤ 2 cm, the role of axillary lymph node dissection for these patients has been questioned. The purpose of this study was to determine the association between the incidence of ALNM and 11 clinical/pathologic factors by univariate and multivariate analysis. METHODS The authors reviewed data from 918 patients with T1 breast carcinoma who underwent level I/II axillary dissection between 1979 and July 1995. The association between the incidence of ALNM and 11 clinical/ pathologic factors (size, lymph/vascular invasion, nuclear grade, S-phase, ploidy, palpability, age, estrogen receptor status, progesterone receptor status, HER-2/neu, and histology) was analyzed by univariate and, when significant, by multivariate analysis. RESULTS Approximately 23% of the 918 patients with T1 breast carcinoma had ALNM. Multivariate analysis identified four factors as independent predictors of ALNM: lymph/vascular invasion (P < 0.0001), tumor palpability (P < 0.0001), nuclear grade (P = 0.0004), and tumor size (P = 0.01). Among the 117 patients with nonpalpable, nonhigh grade tumors ≤ 1 cm without lymph/vascular invasion, the incidence of ALNM was only 3%. However, the 43 patients with T1c tumors with all 3 additional risk factors had a 49% incidence of ALNM. CONCLUSIONS Clinical and pathologic features of the primary tumor can be used to estimate the risk of ALNM in patients with T1 breast carcinoma. Such a risk assessment might facilitate appropriate management. Routine axillary dissection can be omitted in patients at minimal risk of ALNM, if the treatment decision is not influenced by lymph node status. Axillary lymph node dissection should be performed routinely for all patients with lesions > 1 cm. [See editorial counterpoint on pages 1856-61 and reply to counterpoint on pages 1862-4, this issue.] Cancer 1997; 79:1918-22. © 1997 American Cancer Society.

Predictors of axillary lymph node metastases in patients with T1 breast carcinoma

Axillary lymph node metastases (ALNM) are the most important predictor of survival in patients with T1 breast carcinoma. Due to a relatively low incidence of axillary metastasis in tumors < or = 2 cm, the role of axillary lymph node dissection for these patients has been questioned. The purpose of this study was to determine the association between the incidence of ALNM and 11 clinical/pathologic factors by univariate and multivariate analysis. The authors reviewed data from 918 patients with T1 breast carcinoma who underwent level I/II axillary dissection between 1979 and July 1995. The association between the incidence of ALNM and 11 clinical/pathologic factors (size, lymph/vascular invasion, nuclear grade, S-phase, ploidy, palpability, age, estrogen receptor status, progesterone receptor status, HER-2/neu, and histology) was analyzed by univariate and, when significant, by multivariate analysis. Approximately 23% of the 918 patients with T1 breast carcinoma had ALNM. Multivariate analysis identified four factors as independent predictors of ALNM: lymph/vascular invasion (P < 0.0001), tumor palpability (P < 0.0001), nuclear grade (P = 0.0004), and tumor size (P = 0.01). Among the 117 patients with nonpalpable, nonhigh grade tumors < or = 1 cm without lymph/vascular invasion, the incidence of ALNM was only 3%. However, the 43 patients with T1c tumors with all 3 additional risk factors had a 49% incidence of ALNM. Clinical and pathologic features of the primary tumor can be used to estimate the risk of ALNM in patients with T1 breast carcinoma. Such a risk assessment might facilitate appropriate management. Routine axillary dissection can be omitted in patients at minimal risk of ALNM, if the treatment decision is not influenced by lymph node status. Axillary lymph node dissection should be performed routinely for all patients with lesions > 1 cm. [See editorial counterpoint on pages 1856-61 and reply to counterpoint on pages 1862-4, this issue.]

Improved Axillary Staging of Breast Cancer with Sentinel Lymphadenectomy

The authors evaluated the effect of intraoperative lymphatic mapping and sentinel lymphadenectomy (SLND) on the axillary staging of patients with carcinoma of the breast. The accurate staging of patients with breast cancer is essential to guide management and determine prognosis. The authors previously reported the feasibility and accuracy of SLND in breast carcinoma. Sentinel lymphadenectomy identifies the first ("sentinel") axillary lymph node draining the site of a primary tumor; because this node is the most likely site of axillary metastasis, histopathologic examination of the sentinel node correlates well with examination of the entire axillary contents. The current study compares SLND with standard axillary lymphadenectomy (ALND) for the staging of breast carcinoma. The incidence of axillary node metastasis and micrometastasis in SLND and ALND specimens from patients undergoing operative treatment of a primary breast carcinoma was compared prospectively. Multiple sections of each sentinel lymph node in SLND specimens were examined by hematoxylin and eosin (H&E) staining and by immunohistochemical techniques using antibodies to cytokeratin. One or two sections of each nonsentinel lymph node in ALND specimens were examined by routine H&E staining. One hundred thirty-four patients underwent ALND (ALND group), and 162 underwent successful SLND followed by completion ALND (SLND group). Both groups were similar with respect to age (median, 55 and 54 years, respectively), palpable primary tumors (54.5% and 59.3%, respectively), palpable axillary nodes (5.2% and 7.4%, respectively), size of primary tumor (median, 1.5 cm in each group), and total number of axillary lymph nodes examined (median, 19 and 21, respectively). The number of patients with axillary metastasis was 39 (29.1%) in the ALND group and 68 (42.0%) in the SLND group (p < 0.03). Of these, 4 of 39 (10.3%) ALND patients (3.0% of all ALND patients) and 26 of 68 (38.2%) SLND patients (16.0% of all SLND patients) had micrometastasis (< or = 2 mm), a highly significant difference (p < 0.0005) Sentinel lymphadenectomy with multiple sectioning and immunohistochemical staining of sentinel nodes increases the accuracy of axillary staging in breast cancer and can identify significantly more patients with lymph nodes metastases, especially micrometastases, than can ALND with routine histopathologic processing of lymph nodes.

Staging and treatment of clinically occult breast cancer.

Five hundred fifty-seven biopsies were performed for clinically occult mammary lesions, detected by mammography as clustered calcifications or nonpalpable masses within the breast. One hundred seventy-five cancers were demonstrated within this group, including 106 invasive carcinomas, 10 microinvasive carcinomas, 45 in situ ductal carcinomas, and 14 lobular carcinomas in situ (lobular neoplasia). No patient with in situ or microinvasive carcinoma had evidence of axillary node metastases in 33 specimens studied. However, a disturbingly high proportion of those patients with invasive carcinomas, approximately 35%, had histologically confirmed axillary node metastases, despite the small size of the primary tumors. These observations suggest that the use of the term "minimal" cancer is misleading when applied to invasive carcinoma. Staging systems for breast cancer have been imprecise when referring to nonpalpable lesions. Cancers detected as clustered calcifications only or as areas of parenchymal distortion without an accompanying mass are properly considered as T-0 cancers, with a suggested T-0(m) to indicate that the lesion was detected by mammography. However, when the mammogram indicates the presence of a mass that proves to be malignant, although the clinical examination may have been negative, the cancer should be staged according to the size of the mass on the mammogram, with the notation that it was detected by mammography, e.g., T-1(m), T-2(m), etc. The incidence of axillary node metastases even in these so-called occult cancers is significant, so that recommendations for treatment for any invasive cancer, regardless of its size, must take these observations into account. Similarly, the incidence of multifocal sites of cancer within the breast, even in the noninvasive cancers encountered, must be remembered when treatment is suggested.

Relationship of necrosis and tumor border to lymph node metastases and 10-year survival in carcinoma of the breast

The pathologic findings of 330 patients with invasive carcinoma of the breast who were followed for 10 years after radical mastectomy was reviewed. The presence or absence of necrosis and the character of the border of the tumor were two factors which were observable in all cases. Necrosis in the carcinoma was associated with a higher mortality rate, a higher incidence of axillary node metastases, and a higher mortality rate in patients with axillary node metastases than were primary carcinomas without necrosis. Tumors with necrosis and a root border showed significantly more aggressive behavior than did those tumors with a rounded border and no necrosis.