Axillary Lymph Node Micrometastases Research Articles

The Prognostic Significance of Axillary Lymph-Node Micrometastases in Breast Cancer Patients

The Prognostic Significance of Axillary Lymph-Node Micrometastases in Breast Cancer Patients

The prognostic significance of axillary lymph-node micrometastases in breast cancer patients

Aims We analysed the results of regional community practice to determine the prognosis of axillary lymph-node micrometastases in women with breast cancer. Methods Patient data were retrieved from the population-based Eindhoven Cancer Registry in The Netherlands. Between 1975 and 1997, 10,111 patients were diagnosed as having invasive breast cancer. We compared three subgroups: patients without axillary involvement (the pN0 group), patients with axillary micrometastasis (≤2 mm, the pN1a group), and patients with a macro metastasis in only one lymph node (>2 mm, the pN1 group). Follow-up was completed until April 2002. Results The relative risk (RR) of dying comparing the pN1a group and the pN1 group to the pN0 group was 1.32 and 1.34, respectively. Excluding the adjuvantly treated patients, the RR of dying was 1.51 and 1.91, respectively for the pN1a group and the pN1 group vs. the pN0 group. Conclusion This outcome data of nearly 25 years of community practice show that breast cancer patients with axillary lymph node micrometastasis have a significantly worse survival rate than those without independent of age or tumour size. Adjuvant systemic therapy should be contemplated when treating these patients.

The clinical significance of axillary lymph node micrometastases in breast cancer

Objective To evaluate the clinical significancer of axillary lymph-node micrometastases, in the era of sentinel lymph node (SLN) biopsy. Data sources Searches of MEDLINE (1966–2003) and an extensive manual review of journals were performed using the key search terms breast cancer, axillary lymph-node micrometastases, micrometastatic disease, and SLN biopsy. Study selection All articles identified from the data sources were evaluated and all information deemed relevant was included for this review. Conclusions Axillary lymph-node micrometastases can be detected by serial sectioning, immunohistochemistry, or reverse transcriptase-polymerase chain reaction (RT-PCR). The presence of axillary SLN micrometastases is generally associated with a worse prognosis and is an indication for axillary lymph node dissection (ALND) and adjuvant therapy. The clinical significance of micrometastases identified by RT-PCR remains unknown and further research with longer follow-up is needed to ascertain the clinical implications of a positive result.

M34 actin regulatory protein is a sensitive diagnostic marker for early- and late-stage mammary carcinomas.

At present, there is no available molecular marker that reliably detects the earliest stages of epithelial transformation in the majority of patients affected with incipient breast carcinoma. Here we introduce M34 protein, a mammalian actin filament regulatory protein, as a highly sensitive and easily detected positive cellular marker for both early and late stages of breast carcinoma. In this study, 24 human lactation duct neoplasms from postmenopausal women, including fibroadenoma, ductal carcinoma in situ, intraductal lobular papilloma, and metastatic adenocarcinoma, were analyzed for the presence of M34 protein by histochemical staining of paraffin and fresh-frozen sections. All 24 neoplasias tested positive for M34, whereas none of the 4 normal breast tissues stained for the protein. M34 identification was strongly positive for transformed epithelium in all tumor types tested. Twelve precancerous lesions of fibroadenoma (n = 4), intraductal papilloma (n = 4), and incipient ductal carcinoma in situ (n = 4) all showed high levels of M34 staining, suggesting that precancerous tumors, as well as the earliest stages of mammary carcinoma, can be sensitively detected. Furthermore, anti-M34 antibody selectively stained all 12 advanced-stage metastatic adenocarcinoma cell masses and micrometastases in axillary lymph nodes tested. Single-cell micrometastases embedded in connective tissue or lymph node parenchyma could be clearly resolved by M34 with horseradish peroxidase staining. Lymphocytes, normal ductal endothelium, and vascular endothelial cells were M34-negative, as were muscle, nerve, and adipose tissues. Low-level M34 staining was detected in connective tissue fibroblasts, macrophages, and neutrophils. To our knowledge, no previously reported markers have shown high sensitivity of detection for both the earliest and most advanced stages of breast carcinoma. Consequently, M34 appears uniquely suited for diagnosis of the earliest stages of lactation duct transformation as well as for advanced-stage mammary carcinoma metastases in surgical margins and axillary lymph nodes.

Prognostic Significance of Axillary Lymph Node Micrometastases and Microvessel Count in Breast Cancer

Objective To investigate the influence of axillary lymph node micrometastases and the microvessel count on the prognosis of patients with breast cancer.

Occult micrometastases in axillary lymph nodes predict subsequent distant metastases in stage I breast cancer: a case-control study with 15-year follow-up.

The prognostic significance of occult axillary metastases was evaluated in patients with stage I breast cancer. Ninety-six patients with pT1 breast carcinoma who underwent axillary lymph node dissection had negative nodes in routine microscopic examination. Forty-eight patients developed distant metastases within 15 years after surgery (M group) and are compared to 48 age-matched patients who were disease-free for 15 years (NM group). We reexamined 1539 lymph nodes from these patients, using three levels and cytokeratin immunostain. Occult metastases were detected in 21 patients: 16 of 48 (34%) in the M group and 5 of 48 (11%) in the NM group (P =.007). All metastases measured 2.0 mm or less and were classified as micrometastases (>0.2 mm to 2.0 mm) in 11 cases and as individual tumor cells (individual cells or clusters measuring < or =0.2 mm) in 10 cases. Micrometastases were 10 times more frequent in the M group than in the NM group (10/48 vs. 1/48; P =.004). Although there was no difference in tumor size, histologic type, estrogen receptor status, or type of treatment between the two patient groups, tumors in the M group were of a higher grade, had higher mitotic index and showed lymphovascular invasion. In multiple logistic regression, only high mitotic index and presence of micrometastases showed an independent significant correlation with the subsequent occurrence of distant metastases. The presence of micrometastases (>0.2 to 2.0 mm) in axillary nodes is significantly associated with the development of distant metastases in patients with T1 breast cancer.

Clinical significance of occult micrometastases in axillary lymph nodes in "node-negative" breast cancer patients.

The most important subgroup of breast cancer patients for whom reliable prognostic indicators are needed is women without axillary lymph node metastases. We evaluated the clinical significance of occult micrometastases in axillary lymph nodes in 148 consecutive “node‐negative” breast cancer patients. The median age of the patients at surgery was 52 years and the median follow‐up period after surgery was 98.5 months. Occult micrometastases were detected in 21 of 148 patients (14.2%) by means of immunohistochemical analysis using AE1/3 antibody and a single unstained section after routine histopathological examination. Log‐rank tests indicated that the 7–year disease‐free survival (DFS) and overall survival (OS) rates by Kaplan‐Meier methods were significantly better in patients without occult micrometastases than in patients with occult micrometastases [DFS, 93% versus 71% (P=0.0009); OS, 96% versus 76% (P=0.0001)]. According to Cox's multivariate analysis, the presence of occult micrometastases had the most significant effect on DFS (P=0.0053) and OS (P=0.0035). These findings suggest that the presence of occult micrometastases is an independent and significant predictor of clinical outcome, and that their immunohistochemical detection after routine histopathological examination is useful for selecting the “node‐negative” breast cancer patient subgroup at high risk for relapse and death.

Micro-metastases in axillary lymph nodes: an increasing classification and treatment dilemma in breast cancer due to the introduction of the sentinel lymph node procedure.

Sentinel lymph node (SN) biopsy will increasingly replace axillary lymph node dissection (ALND) for staging in breast cancer. For daily practice, examination of the SN by serial sectioning (SS) and/or immunohistochemistry (IHC) is being promoted. Use of these techniques may result into stage migration due to the increased detection of micro-metastases. The consequence may be overshooting of patients with adjuvant therapy, as the prognostic relevance of (small) micro-metastases and isolated tumor cells is unclear. The prognostic impact of micro-metastases is determined by reviewing ALND studies with a follow up of at least 5 years, including more than 100 patients, before the SN era. Furthermore, studies in which conventionally haematoxylin-eosin (H&E) negative SNs are investigated for occult metastases by SS and/or IHC are reviewed. In only one of eight studies, occult metastases were an independent risk factor for reduced survival. The outcome is dependent on the size of the nodal metastasis. IHC and SS as used in the SN procedure indeed induce a shift from pNO to pN1a (according to TNM). By the thorough pathologic examination of the SN, isolated tumor cells and micro-metastases are more frequently detected. We propose to classify small micro-metastases (<0.5 mm) in a separate pN1a(min) category (min for minimal) to prevent stage migration. As the prognostic relevance of isolated tumor cells and (small) micrometastases has not been proven, the value of adjuvant therapy can be questioned for patients with otherwise good prognostic factors.

The Research on Prognostic Affection of Micrometastases in Axillary Lymph Nodes of Primary Breast Cancer

Abstract To study the prognostic affection of micrometastases in axillary lymph nodes of primary breast cancer.Methods Forty-five cases of stage Ⅰ to Ⅱ primary breast cancer in which axillary lymph nodes were metastatic negative by routine pathological examination were divided into two groups,one is died (25 cases),the other is alive (20 cases) through more than 10 years of follow-up.Sup-serial sections and immunohistochemistry techniques were used to re-examined the whole lymph nodes for micrometastases detection.Monoclonal antibody cytokeratin 19 was used as the primary reagents to identify tumor cells in lymph nodes.Results Immunostaining positive tumor cells were found in 13 cases of died group,while no positive tumor cell was found in alive group ( P 0 01). Conclusion Micrometastasis can affect patient sprognosis significantly.Micrometastases detection in lymph nodes of primary breast cancer is valuable theoretically and practically.

Selection of mRNA markers for detection of lymph node micrometastases in breast cancer patients.

The aim of this study was to search for specific and sensitive mRNA markers or a combination of markers for RT-PCR detection of micrometastases in axillary lymph nodes (LNs) from patients with breast cancer. LNs (n=177) from 17 patients were examined with Cytokeratin20 (CK20), melanoma-associated genes (MAGE1, MAGE3), carcinoembryonic antigen (CEA), prostate-specific antigen (PSA), mammaglobin (MGB1) and mammaglobin B (MGB2) as molecular markers. CK20, MAGE1 and MAGE3 were slightly positive in primary tumors and CEA, PSA, MGB1 and MGB2 were highly positive. MGB1 and MGB2 were 100% positive in HE-positive LNs while CEA and PSA were only 35.7% and 57.1% positive. MGB1 and MGB2 were also 30.1% and 17.8% positive in HE-negative nodes. Thus, MGB1 and MGB2 are specific and a combination of the two should be useful for detection of micrometastases in axillary LNs of breast cancer patients.

Mammaglobin B as a novel marker for detection of breast cancer micrometastases in axillary lymph nodes by reverse transcription-polymerase chain reaction.

A novel reverse transcription-polymerase chain reaction (RT-PCR) assay using mammaglobin B gene was developed for detection of breast cancer micrometastases in axillary lymph nodes. Fourteen primary breast cancers and 56 axillary lymph nodes from six patients with primary breast cancer and 15 control lymph nodes from non-cancer bearing patients were subjected to this assay. The transcript of mammaglobin B gene was detected in none of the control lymph nodes, but in all of the 14 primary breast cancers. Eleven out of the 56 lymph nodes from the patients, which were shown to be positive by histological examination, were also proven positive by this assay. On the other hand, fourteen of the 45 (31%) histologically negative lymph nodes were also shown to express mammaglobin B mRNA, which suggested the presence of micrometastases in these lymph nodes. RT-PCR using mammaglobin B gene could therefore be a useful tool for detection of micrometastases of breast cancer.

Axillary Node Micrometastases: Detection and Biologic Significance.

Axillary lymph node status is the single most important predictor of overall survival in patients with breast cancer. Standard histopathologic examination of regional lymph nodes relies on one microscopic section of each node to detect metastatic disease. The spectrum of metastatic disease in a lymph node ranges from complete replacement of the node by tumor to isolated nests of tumor cells in the subcapsular sinus. The clinical significance of micrometastases in axillary lymph nodes has changed over time. Micrometastases are defined by the American Joint Committee on Cancer as tumor foci less than or equal to 2 mm in greatest dimension. Retrospective studies of node-negative breast cancer patients employing intensive histopathologic examination of the axillary lymph nodes consistently show that up to a third of these patients are actually node positive. Studies published through the mid-1980s failed to show any significant effect of these micrometastases on survival. More recent studies (mid-1980s-1997) with more than 10 years of clinical follow-up have come to a different conclusion. It now appears that micrometastases are associated with a small, but statistically significant, decrease in tumor-free survival and overall survival, as compared with truly node-negative breast cancer patients. Additional slides stained with hematoxylin and eosin ("levels"), immunohistochemistry for cytokeratin proteins (found only in epithelial cells), and reverse transcriptase polymerase chain reaction for cytokeratin protein mRNA have all been used to detect micrometastases in recently published studies. The methodology utilized to detect micrometastases clearly affects the sensitivity of their detection. The current issue is the most appropriate method of detection of these small foci of tumor, given technical and cost considerations. The clinical significance of single malignant cells in the subcapsular sinus of lymph nodes, identified only by immunohistochemistry or molecular techniques, remains unclear.

Pathologic Examination of Sentinel Lymph Nodes in Breast Cancer

Lymphatic mapping with selective sentinel lymphadenectomy allows accurate pathologic examination of the nodes most likely to contain macro- or micrometastastic disease for staging and proper adjuvant chemotherapy. The hypothesis of SLN biopsies was histopathologically validated by Turner et al that if the node is tumor free by H&E and immunohistochemistry, the probability of non-SLN involvement is less than 0.1%. Giuliano et al and Veronesi et al reported that detection of metastases in SLNs by frozen section technique is 89% and 64%, respectively. At MCC, frozen section evaluation of SLN is not performed because of its potential loss of micrometastasis in the cryostat, freezing artifacts, sampling error, and perhaps radioactive contamination. Intraoperative detection of macro- or micrometastasis is critical because it enables conversion of patients with positive SLN to CLND in one surgical setting more cost-effectively. IIC of the lymph nodes has been used routinely in the diagnosis of hematologic malignancies and also in breast cancer as a useful method in many series. In the author's experience, IIC by Diff-Quik stain converted 100% of grossly positive and suspicious SLNs and 22% of grossly negative SLNs. The significance of detecting micrometastases in axillary lymph nodes using immunohistochemical techniques has been reported in many series. At the MCC, routine use of CKI on paraffin sections of grossly negative SLNs enabled the upstaging of 10.6% of patients from N0 to N1. Recent addition of intraoperative rapid CKI as an adjunct to complement Diff-Quik stain has proven to be more sensitive in detecting micrometastases than using Diff-Quik stain alone. IIC technique using either Diff-Quik stain or CKI requires intensive training and experience to avoid potential pitfalls and errors in interpretation. Evaluation of SLN should use methods that enhance the ability to detect micrometastasis, however, in a cost-effective manner. The cost-effectiveness of IIC by Diff-Quik stain is incomparable with frozen section evaluation. The added cost of routine immunohistochemical stain and perhaps multiple levels of H&E stain should be offset by the decreased costs of IIC and clinically by treating most patients in the outpatient settings. In summary, IIC by Diff-Quik stain is simple, rapid, and has excellent diagnostic accuracy in grossly positive and suspicious SLNs allowing cost-effective, immediate CLND. IIC by CKI is an extremely useful ancillary technique that complements Diff-Quik stain in detecting micrometastases particularly in low grade ductal or lobular carcinoma and low tumor cell volume. Appropriate combined use of both stains may lead to intraoperative nodal staging and cost-effective CLND. SLN mapping technology at MCC using IIC in conjunction with serial sections, entire tissue submission, routine use of CKI, and multiple levels of the SLN have led us to uncover micrometastasis in high-risk, traditionally node-negative patients. These results have encouraged investigators to pursue even more sensitive techniques to detect micrometastases, including molecular biology techniques such as RT-PCR. Experienced cytopathologists and active cytopathology services are required to avoid potential pitfalls in performing and interpreting IIC. More long-term follow-up and prospective trials are needed to determine the prognostic significance of upstaging by ancillary techniques, which may lead to a revision of the current TNM staging system.

Detection of occult breast cancer micrometastases in axillary lymph nodes using a multimarker reverse transcriptase-polymerase chain reaction panel

Background: Axillary lymph node status in breast cancer patients remains the single most important predictor of outcomes. Current methods of histopathologic analysis may be inadequate because 30% of node-negative patients recur. The purpose of this study was to test the hypothesis that a multigene reverse transcriptase-polymerase chain reaction (RT-PCR) panel provides a more sensitive method to detect axillary lymph node metastases than routine pathologic examination. Study Design: Sixty-one consecutive breast cancer patients were evaluated, with nine normal control patients. Nodes > 1 cm were bisected for histopathologic and RT-PCR analysis. Nodal tissue was homogenized, and total RNA was converted into cDNA with reverse transcriptase. Reverse transcriptase-polymerase chain reaction analysis was performed with primers specific for keratin-19, c-myc, prolactin inducible protein (PIP), and β-actin using ethidium bromide gel electrophoresis. Reverse transcriptase-polymerase chain reaction positive/pathology negative axillary lymph nodes were reevaluated using step sectioning and immunohistochemical staining. Results: Thirty-seven patients had pathologically negative axillary lymph nodes, of which 15 (40%) were positive by RT-PCR analysis. Two RT-PCR negative results (one probably from tissue processing error and the other secondary to sampling error) among the 24 histologically positive specimens were detected (8%). The number of patients in each pathologic stage was 26 patients in stage I; 18, stage IIA; 7, stage IIB; 7, stage IIIA; 3, stage IIIB; and 0 patients in stage IV. By RT-PCR staging, 8 of 26 patients went from stage I to IIA (30%), and 7 of 18 from stage IIA to IIB (39%). Of the RT-PCR positive individuals who were stage I by pathologic analysis, 100% were found to be c-myc positive, 0% keratin-19 positive, and 0% PIP positive; for stage IIIB patients these markers were 50%, 100%, and 100% respectively. Additionally, an increasing number of positive markers per specimen appeared to correlate with larger primary tumor size (p < 0.01) and decreased predicted 5-year survival (r = 0.950, p < 0.002). Conclusions: Multimarker RT-PCR analysis appears to be a readily available and highly sensitive method for the detection of axillary lymph node micrometastases. Longterm followup of RT-PCR positive patients will be required to determine its clinical relevance. If validated as a predictor of disease recurrence, this method would provide a powerful complement to routine histopathologic analysis of axillary lymph nodes.

Detection of micrometastases in axillary lymph nodes of node-negative breast cancer patients and its clinical significance

Monoclonal antibodies against cytokeratin (AE1/AE3) were applied as a probe, using APAAP immunohistochemistry technique to detect 635 lymph nodes from 45 breast cancer patients with negative lymph nodes. Micrometastases were identified in 14 lymph nodes of 9 cases (20%). A significant difference was found between cytokeratin staining positive group and cytokeratin staining negative group in disease-free and over-all Kaplan-Meier survival curves. The detection of micrometastases had more clinical value for T1, and T2 patients. One of 2 T1, cytokeratin positive cases relapsed while only 1 of 19 T1, negative cases relapsed within 5 years; three of 5 T2 cytokeratin positive cases relapsed while 1 of 17 negative cases did. The presence of micrometastases had the same value in predicting local recurrence and distant metastases.

Immunohistochemically Detected Lymph-Node Micrometastases in Breast Cancer and their Correlation with Prognostic Factors

: The prognostic value of immunohistochemically detected micrometastases (N1a-IHC) in conventionally negative lymph nodes (N0) and its association with newer prognostic factors is controversial. Axillary lymph nodes (n= 2,528) of 159 patients with pT1–T N0 M0-breast cancer were examined for micrometastases using a monoclonal cytokeratine antibody. In addition to the histological findings, estrogen and progesterone receptors (ER, PR), S-Phase, ploidy, EGF-R, p53, Ki-67, HER-2/neu oncoprotein, cathepsin D, and p52 were investigated. The mean follow up time was 51 ± 16 months. Micrometastases were detected in 53 of 2,528 (2.1%) lymph nodes. In 18 of 159 patients (11.3%) staged as N0 by conventional histology, one or more micrometastases were detected immunohistochemically. These patients have a prognostic disadvantage compared with N0-IHC-patients significant for distant metastases-free survival; (p =.003) and for overall survival (p =.006). Differences (p <.05) between N0-IHC- and N1a-IHC-tumors were found in tumor size, ER, EGF-R, and cathepsin D. Tumor size, grading “3,” and peritumoral vessel invasion, but not the detection of micrometastases, were confirmed as independent prognostic factors in node-negative patients by multivariate Cox regression analysis. Immunohistochemically detected micrometastases in axillary lymph nodes are of prognostic importance. However, they are not independent prognostic factors, because a correlation with other prognostic factors has been proven.

The detection of breast carcinoma micrometastases in axillary lymph nodes by means of reverse transcriptase-polymerase chain reaction.

The development of a sensitive method for the detection of breast carcinoma micrometastases in axillary lymph nodes is reported. The method was based on amplification of MUC1 mRNA, which encodes a core protein of polymorphic epithelial mucin, by a reverse transcriptase-polymerase chain reaction (RT-PCR). Total RNA, which was extracted from a breast carcinoma cell line (MCF-7), primary breast carcinomas, and axillary lymph nodes, was subjected to analysis of MUC1 mRNA expression by the RT-PCR method. MUC1 mRNA expression was detected by RT-PCR in MCF-7 cells and in all 15 primary breast carcinomas but not in control lymph nodes taken from patients with benign diseases. A serial dilution study revealed that MUC1 RT-PCR was a very sensitive method, detecting one MCF-7 cell per 1,000,000 lymph node cells. The detection sensitivity of MUC1 RT-PCR method was compared with that of immunohistochemical staining of an epithelial marker (polymorphic epithelial mucin). Fifty axillary lymph nodes were obtained from 15 patients with primary breast carcinomas, and metastasis in each lymph node was investigated by both methods. The immunohistochemical method demonstrated metastasis in nine lymph nodes, and MUC1 mRNA was detected in all of them. Of the 41 lymph nodes that were diagnosed to be devoid of metastasis by immunohistochemistry, MUC1 mRNA was expressed by 6 but not by the other 35, indicating the presence of micrometastases in these 6 lymph nodes that could be detected only by the MUC1 RT-PCR method. The MUC1 RT-PCR method is more sensitive than immunohistochemistry for the detection of micrometastases in axillary lymph nodes. This new method would be of practical value in selecting the patients at high risk for relapse from those who are histologically lymph node negative.

Detection of breast cancer micrometastases in axillary lymph nodes using the polymerase chain reaction (PCR)

Detection of breast cancer micrometastases in axillary lymph nodes using the polymerase chain reaction (PCR)

Prognostic significance of breast cancer axillary lymph node micrometastases assessed by two special techniques: reevaluation with longer follow-up.

Special techniques such as serial macroscopic sectioning (SMS) or immunohistochemical staining (IH) improve the detection rate of micrometastases but this detection is of value only if it improves the prediction of recurrence and survival. We first studied the prognosis of 120 patients with a single micrometastasis detected by SMS in a series of 1,680 primary operable breast carcinoma with a median follow-up of 7 years. A significant difference in recurrence (P = 0.005) and in survival (P = 0.0369) was found between node-negative patients and those with one single SMS micrometastasis, but SMS micrometastases were not a predicting factor by multivariate analyses according to the Cox model. We then studied the prognostic significance of patients with a micrometastasis detected by IH in node-negative carcinoma: 37 micrometastases from a series of 89 invasive lobular carcinoma (ILC) and 13 single micrometastases from a series of 129 invasive ductal carcinoma (IDC). In the ILC group, IH micrometastases had no prognostic value (median follow-up: 9.3 years). In the IDC group, IH micrometastases were correlated with recurrences (P = 0.01) and were the most significant predicting factor, but were less correlated with survival (median follow-up: 15.6 years). Three main points emerge from this study: (1) SMS micrometastases have a prognostic significance and macroscopic sectioning is recommended as a routine technique not requiring excessive work. (2) IH micrometastases in infiltrating lobular carcinoma have no prognostic significance. (3) The value of IH is debatable in infiltrating ductal carcinoma, since the technique is of principal use in predicting recurrences. It should therefore be carefully assessed vs other prognostic factors currently under study.

A preliminary report on the usefulness of monoclonal antibodies to CA 15-3 and MCA in the detection of micrometastases in axillary lymph nodes draining primary breast carcinoma.

The most critical factor affecting survival in patients with breast carcinoma is axillary nodal involvement. Monoclonal antibodies raised against specific human mammary tumour associated antigens may increase detection of micrometastases. This preliminary report examines two of these antigens; CA15-3 antigen and mucin-like carcinoma associated antigen (MCA) in the detection of such deposits. Specimens from 39 stage 1 (node negative) breast carcinoma patients were assessed. Two further 'negative' sections were stained with antisera to CA15-3 and MCA antigens. Micrometastases were detected in 5 patients and in each, MCA and CA15-3 identified the same micrometastases. 3 of these patients had disease progression compared with 3/34 of the remaining patients. The use of monoclonal antibodies to CA15-3 and MCA significantly (P less than 0.05) increases detection rates of micrometastases and this is associated with significantly worse disease-free survival rates (P less than 0.001).