Non-metastatic Axillary Lymph Nodes Research Articles

Nonmetastatic Axillary Lymph Nodes Have Distinct Morphology and Immunophenotype in Obese Patients with Breast Cancer at Risk for Metastasis

Obese breast cancer patients have worse outcomes than their normal weight counterparts, with a 50% to 80% increased rate of axillary nodal metastasis. Recent studies suggest a link between increased lymph node adipose tissue and breast cancer nodal metastasis. Further investigation into potential mechanisms underlying this link may reveal potential prognostic utility of fat-enlarged lymph nodes in breast cancer patients. This study uses a deep learning model to identify morphological differences in non-metastatic axillary nodes between obese, node-positive and node-negative breast cancer patients. The model was developed using nested cross-validation on 180 cases and achieved an AUC of 0.67 in differentiating patients using hematoxylin and eosin stained whole-slide images. The top predictive patches from the slides according to the model were reviewed by a pathologist and their morphological differences were quantified. This analysis showed an increased average adipocyte size (p-value=0.004), increased white space between lymphocytes (p-value<0.0001), and increased red blood cells (p-value<0.001) in non-metastatic lymph nodes of node-positive patients. Preliminary immunohistochemistry analysis on a subset of 30 patients showed a trend of decreased CD3 expression and increased leptin expression in fat-replaced axillary lymph nodes of obese, node-positive patients. These findings suggest a novel direction to further investigate the interaction between lymph node adiposity, lymphatic dysfunction, and breast cancer nodal metastases, highlighting a possible prognostic tool for obese breast cancer patients.

CD68 and CD83 immune populations in non-metastatic axillary lymph nodes are of prognostic value for the survival and relapse of breast cancer patients.

The foremost cause of death of breast cancer (BC) patients is metastasis, and the first site to which BC predominantly metastasizes is the axillary lymph node (ALN). Thus, ALN status is a key prognostic indicator at diagnosis. The immune system has an essential role in cancer progression and dissemination, so its evaluation in ALNs could have significant applications. In the present study we aimed to investigate the association of clinical-pathological and immune variables in the primary tumour and non-metastatic ALNs (ALNs-) of a cohort of luminal A and triple-negative BC (TNBC) patients with cancer-specific survival (CSS) and time to progression (TTP). We analysed the differences in the variables between patients with different outcomes, created univariate and multivariate Cox regression models, validated them by bootstrapping and multiple imputation of missing data techniques, and used Kaplan-Meier survival curves for a 10-years follow-up. We found some clinical-pathological variables at diagnosis (tumour diameter, TNBC molecular profile and presence of ALN metastasis), and the levels of several immune markers in the two studied sites, to be associated with worse CSS and TTP. Nevertheless, only CD68 and CD83 in ALNs- were confirmed as independent prognostic factors for TTP. The study identified the importance of macrophage and dendritic cell markers as prognostic factors of relapse for BC. We highlight the importance of studying the immune response in ALNs-, which could be relevant to the prediction of BC patients' outcome.

The role of diffusion-weighted imaging MRI in differentiation between benign and malignant axillary lymphadenopathy in clinically TNM stages I and II breast cancer

Objective To investigate diffusion-weighted imaging (DWI) in differentiation of metastatic from nonmetastatic axillary lymph nodes (ALNs) in clinically stages I and II breast cancer. Patients and methods A total of 255 ALNs from 30 female patients with histologically proved breast cancer were assessed by 1.5 T scanner. DWI was implemented at b values of 50, 400, and 800 s/mm2. Short-axis diameter, presence of fatty hilum, and apparent diffusion coefficient (ADC) values (minimum and maximum and mean) of metastatic and nonmetastatic ALNs were compared. Cutoff ADC values to discriminate between benign and malignant ALNs were analyzed with receiver coefficient characteristic (receiver operating characteristic) curves. Results The final histopathological examination revealed 69.4% (n = 177) metastatic and 30.6% (n = 78) nonmetastatic ALNs. There was no statistically significant difference in short-axis diameter between the two groups (P = 0.82). However, there was a significantly correlation between loss of fatty hilum and presence of metastases (P Conclusion DWI-MRI and ADC values are promising imaging methods that can assess metastatic ALNs in early breast cancer with high sensitivity, specificity, and accuracy.

Tumor Cell Microenvironment and Microvessel Density Analysis in MALT Type Lymphoma.

MALT type lymphoma belongs to marginal zone lymphoma (MZL). MALT lymphomas' inflammatory microenvironment contributes to the pathogenesis of this cancer. In this study, we analyzed and quantified the tumor inflammatory microenvironment in MALT lymphoma samples and in healthy controls, and the microvessel content by immunohistochemistry and morphometric estimation. Biopsy specimens from MALT type lymphoma patients and from non-metastatic axillary lymph nodes (CTRL) were analyzed by immunochemistry in order to quantify CD3, CD4, CD8, CD68, CD163, tryptase, CD34, and Ki67 positive cells. A substantial increase in the number of cells that were positive for the above markers and microvascular density (MVD) were observed in the MALT group. We also found a positive correlation between microvessels and CD8+ cells and between CD8+ cells and M2 type macrophages, while tryptase+ mast cells correlated with CD4+ cells. The mitotic proliferation index Ki67 was higher in MALT samples. The interactions between inflammatory cells in the tumor microenvironment and their correlation with angiogenesis is a useful tool in the development of new immunotherapy strategies.

Differences in the Immune Response of the Nonmetastatic Axillary Lymph Nodes between Triple-Negative and Luminal A Breast Cancer Surrogate Subtypes

Breast cancer (BC) comprises four immunohistochemical surrogate subtypes of which triple-negative breast cancer (TNBC) has the highest risk of mortality. Axillary lymph nodes (ALNs) are the regions where BC cells first establish before distant metastasis, and the presence of tumor cells in the ALN causes an immune tolerance profile that contrasts with that of the nonmetastatic ALN (ALN-). However, few studies have compared the immune components of the ALNs- in BC subtypes. The present study aimed to determine whether differences between immune populations in the primary tumor and ALNs- were associated with the luminal A or TNBC subtype. We evaluated a retrospective cohort of 144 patients using paraffin-embedded biopsies. The TNBC samples tended to have a higher histologic grade and proliferation index and had higher levels of immune markers compared with luminal A in primary tumors and ALNs-. Two methods for validating the multivariate analysis found that histologic grade, intratumoral S100 dendritic cells, and CD8 T lymphocytes and CD57 natural killer cells in the ALNs- were factors associated with TNBC, whereas CD83 dendritic cells in the ALNs- were associated with the luminal A subtype. In conclusion, we found that intratumoral regions and ALNs- of TNBC contained higher concentrations of markers related to immune tolerance than luminal A. This finding partially explains the worse prognosis of patients with TNBC.

Fat fractions from high-resolution 3D radial Dixon MRI for predicting metastatic axillary lymph nodes in breast cancer patients

PurposeTo assess diagnostic performance of fat fractions (FF) from high-resolution 3D radial Dixon MRI for differentiating metastatic and non-metastatic axillary lymph nodes in breast cancer patients. MethodHigh-resolution 3D radial Dixon MRI was prospectively performed on 1.5 T in 70 biopsy-verified breast cancer patients. 35 patients were available for analysis with histopathologic and imaging data. FF images were calculated as fat / in-phase. Two radiologists measured lymph node FF and assessed morphological features in one ipsilateral and one contralateral lymph node in consensus. Diagnostic performance of lymph node FF and morphological criteria were compared using histopathology as reference. Results22 patients had metastatic axillary lymph nodes. Mean lymph node FF were 0.20 ± 0.073, 0.31 ± 0.079, and 0.34 ± 0.15 (metastatic, non-metastatic ipsi- and non-metastatic contralateral lymph nodes, respectively). Metastatic lymph node FF were significantly lower than non-metastatic ipsi- (p < 0.001) and contralateral lymph nodes (p < 0.001). Area under the receiver operating characteristics curve for lymph node FF was 0.80 compared to 0.76 for morphological criteria (p = 0.29). Lymph node FF yielded sensitivity 0.91, specificity 0.69, positive predictive value (PPV) 0.83, and negative predictive value (NPV) 0.82, while morphological criteria yielded sensitivity 0.91, specificity 0.62, PPV 0.80, and NPV 0.80 (p = 0.71). Combining lymph node FF and morphological criteria increased diagnostic performance with sensitivity 1.00, specificity 0.67, PPV 0.86, NPV 1.00, and AUC 0.83. ConclusionsLymph node FF from high-resolution 3D Dixon images are a promising quantitative indicator of metastases in axillary lymph nodes.

The Immune Response in Nonmetastatic Axillary Lymph Nodes Is Associated with the Presence of Axillary Metastasis and Breast Cancer Patient Outcome

Tumor cells can modify the immune response in primary tumors and in the axillary lymph nodes with metastasis (ALN+) in breast cancer (BC), influencing patient outcome. We investigated whether patterns of immune cells in the primary tumor and in the axillary lymph nodes without metastasis (ALN-) differed between patients diagnosed without ALN+ (diagnosed-ALN-) and with ALN+ (diagnosed-ALN+) and the implications for clinical outcome. Eleven immune markers were studied using immunohistochemistry, tissue microarray, and digital image analysis in 141 BC patient samples (75 diagnosed-ALN+ and 66 diagnosed-ALN-). Two logistic regression models were derived to identify the clinical, pathologic, and immunologic variables associated with the presence of ALN+ at diagnosis. There are immune patterns in the ALN- associated with the presence of ALN+ at diagnosis. The regression models revealed a small subgroup of diagnosed-ALN+ with ALN- immune patterns that were more similar to those of the ALN- of the diagnosed-ALN-. This small subgroup also showed similar clinical behavior to that of the diagnosed-ALN-. Another small subgroup of diagnosed-ALN- with ALN- immune patterns was found whose members were more similar to those of the ALN- of the diagnosed-ALN+. This small subgroup had similar clinical behavior to the diagnosed-ALN+. These data suggest that the immune response present in ALN- at diagnosis could influence the clinical outcome of BC patients.

Predictive Value of Preoperative Multidetector-Row Computed Tomography for Axillary Lymph Nodes Metastasis in Patients With Breast Cancer

Introduction: Axillary lymph nodes (ALN) status is an essential component in tumor staging and treatment planning for patients with breast cancer. The aim of present study was to evaluate the predictive value of preoperative multidetector-row computed tomography (MDCT) for ALN metastasis in breast cancer patients.Methods: A total of 148 cases underwent preoperative MDCT examination and ALN surgery were eligible for the study. Logistic regression analysis of MDCT variates was used to estimate independent predictive factors for ALN metastasis. The prediction of ALN metastasis was determined with MDCT variates through receiver operating characteristic (ROC) analysis.Results: Among the 148 cases, 61 (41.2%) cases had ALN metastasis. The cortical thickness in metastatic ALN was significantly thicker than that in non-metastatic ALN (7.5 ± 5.0 mm vs. 2.6 ± 2.8 mm, P < 0.001). Multi-logistic regression analysis indicated that cortical thickness of >3 mm (OR: 12.32, 95% CI: 4.50–33.75, P < 0.001) and non-fatty hilum (OR: 5.38, 95% CI: 1.51–19.19, P = 0.009) were independent predictors for ALN metastasis. The sensitivity, specificity and AUC of MDCT for ALN metastasis prediction based on combined-variated analysis were 85.3%, 87.4%, and 0.893 (95% CI: 0.832–0.938, P < 0.001), respectively.Conclusions: Cortical thickness (>3 mm) and non-fatty hilum of MDCT were independent predictors for ALN metastasis. MDCT is a potent imaging tool for predicting ALN metastasis in breast cancer. Future prospective study on the value of contrast enhanced MDCT in preoperative ALN evaluation is warranted.

Diagnostic Value of Diffusion Weighted Magnetic Resonance Imaging in Evaluation of Metastatic Axillary Lymph Nodes in a Sample of Iranian Women with Breast Cancer

Objective:To evaluate the diagnostic value of diffusion weighted magnetic resonance imaging (DW-MRI) in assessment of metastases in axillary lymph nodes (ALNs) in a sample of Iranian women with breast cancer.Methods:A total of 50 axillary lymph nodes from 30 female patients with histologically verified breast cancer were assessed by 1.5 T MRI. DWI was implemented at b-values of 50, 400 and 800 s/mm2. Short axis diameter, presence of fatty hilum and apparent diffusion coefficient (ADC) values (min, max and mean) of metastatic and non-metastatic ALNs was compared. Cutoff ADC values to discriminate between benign and malignant axillary lymph nodes were analyzed with receiver coefficient characteristic (ROC) curves.Result:The final histopathological examination revealed 46% (n=23) metastatic and 54% (n=27) non-metastatic ALNs. There was no statistically significant difference in short axis diameter between the two groups (p = 0.537). However there was significantly correlation between loss of fatty hilum and presence of metastases (p < 0.001) and ADC values (0.255 ± 0.19×10-3 mm2/s vs 0.616 ±0.3×10-3 mm2/s (ADC min), 1.088 ± 0.22×10-3 mm2/s vs 1.497 ± 0.24×10-3 mm2/s (ADC max) and 0.824 ± 0.103 ×10-3 mm2/s vs 1.098 ± 0.23 ×10-3 mm2/s (ADC mean)) of metastatic ALNs were significantly lower than those of non-metastatic ALNs (p < 0.001). The optimal mean ADC cut-off value for differentiation between metastatic and non-metastatic ALNs was 0.904×10-3 mm2/s which had a higher specificity (88.9%) and accuracy (91.8%) as compared with ADC min and ADC max.Conclusion:DWI-MRI and ADC values are promising imaging methods which can assess metastatic ALNs in breast cancer with high sensitivity, specificity and accuracy.

The Diagnosis of Metastatic Axillary Lymph Nodes of Breast Cancer By Diffusion Weighted Imaging: a meta-analysis and systematic review.

BackgroundThe purpose of this meta-analysis was to evaluate the clinical significance of diffusion-weighted imaging in assessing the status of axillary lymph nodes in patients with breast cancer.MethodsWe searched the PubMed, Cochrane, and EMBASE databases, selected studies by inclusion and exclusion criteria, and assessed the quality of selected studies. We explored the source of heterogeneity; calculated sensitivity, specificity, positive and negative likelihood ratios, and pretest probability. A summary receiver operating characteristic curve was performed. Student’s t test was used to compare the different mean apparent diffusion coefficient values of different status lymph nodes.ResultsIn selected 10 studies, a total of 801 patients and 2305 lymph nodes were included following inclusion criteria. All scores of the quality assessment of the included studies were greater than or equal to 10 points. The sensitivity was 0.89 (95 % CI 0.79–0.95), the specificity was 0.83 (95 % CI 0.71–0.91), the positive and negative likelihood ratios were 3.86 (95 % CI 2.75–5.41) and 0.17 (95 % CI 0.09–0.32), the pretest probabilities were 53 and 54 %, the area under the curve were 0.93 (95 % CI 0.90–0.95), respectively. The mean apparent diffusion coefficient value of metastatic lymph nodes was significantly lower than that of nonmetastatic axillary lymph nodes.ConclusionsDiffusion-weighted imaging is a promising tool to discriminate between metastatic and nonmetastatic axillary lymph nodes. Combined with the mean apparent diffusion coefficient value, it can quantitatively diagnose lymph node metastases. Conducting large-scale, high-quality researches can improve the clinical significance of diffusion-weighted imaging to distinguish metastatic and nonmetastatic axillary lymph nodes in patients with breast cancer and provide the evidence to assess the status of axillary lymph nodes.

Abstract 218: The new and rapid technique of detecting breast cancer cells using new fluorescent probe ‘gGlu-HMRG’ and its clinical application

Abstract Method After spraying with gGlu-HMRG reagent to the samples, we took images within 5 minutes and analyzed the fluorescence intensity of them. Comparing the changes of fluorescence intensity and pathological evaluations, we examined how this fluorescent method could reflect the pathological status in resected breast tissues (n = 108 from 36 cases), margins of breast conserving surgery specimens (n = 7 from 5 cases) and axillary lymph nodes (n = 149 from 38 cases). Result 1. The sensitivity and specificity were 92% and 94% respectively for binary classification (normal / abnormal) of various breast tissues. 2. We could detect all malignant lesions in the surface of surgical margins of breast conserving surgery specimens. Additionally, we could detect large tumor-free lesions as fluorescent negative regions. 3. The sensitivity and specificity were 97% and 79% respectively for diagnosing metastatic and non-metastatic axillary lymph nodes. Discussion and conclusion It was well feasible to distinguish breast tumor tissues from normal surrounding tissues by this new method. Since it is simple and non-tissue-destructive, it could be readily adopted in the clinical setting. We anticipate that it will reduce costs and the burden on histopathology services in the intraoperative pathological diagnosis of breast conserving surgery and sentinel lymph node biopsy. This technical innovation enable us to visualize tumor cells in the body intraoperatively and evolve the cancer surgery that needs the complete resection of cancer cells. *1 Urano, Y. et al. Rapid cancer detection by topically spraying a γ-glutamyltranspeptidase-activated fluorescent probe. Sci. Trans. Med. 3, 110ra119 (2011). Citation Format: Yoshiaki Shinden, Hiroki Ueo, Taro Tobo, Ayako Ganachi, Hisateru Komatsu, Sho Nambara, Tomoko Saito, Masami Ueda, Hidenari Hirata, Shotaro Sakimura, Yuki Takano, Ryutaro Uchi, Tomohiro Iguchi, Hidetoshi Eguchi, Keishi Sugimachi, Yoko Kubota, Yuichiro Kai, Yuko Kijima, Shoji Natsugoe, Hiraki Ueo, Yasuteru Urano, Koshi Mimori. The new and rapid technique of detecting breast cancer cells using new fluorescent probe ‘gGlu-HMRG’ and its clinical application. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 218. doi:10.1158/1538-7445.AM2015-218

Diffusion weighted images of metastatic as compared with nonmetastatic axillary lymph nodes in patients with newly diagnosed breast cancer

To investigate the ability of diffusion weighted images (DWI) to differentiate between metastatic and nonmetastatic axillary lymph nodes (LNs) in patients with newly diagnosed breast cancer. From January 2010 to February 2012, DWI was performed at b values of 0 and 800 for 16 metastatic LNs from 16 patients with breast cancer, and 20 nonmetastatic LNs from 20 women without breast cancer. The metastatic LNs were proven by ultrasound (US) guided core biopsy and the same LNs were identified on MRI by comparing the US images with MR images. Nonmetastatic LNs were verified by the stability in size and shape for at least 2 years on MRI. The apparent diffusion coefficient (ADC) value of the metastatic and nonmetastatic axillary LNs was compared. Receiver-operating-characteristics (ROC) analysis was performed to evaluate the diagnostic performance of the ADC value in differentiating between metastatic and nonmetastatic axillary LNs. The mean ADC value was 0.746 × 10(-3) for metastatic LNs and 1.033 × 10(-3) for nonmetastatic LNs (P < 0.001). The area under the ROC curve was 0.884. The sensitivity and specificity for differentiating metastatic from nonmetastatic axillary LNs using a cutoff ADC value of 0.852 were 85% and 81%, respectively. There is a statistically significant difference between the ADC values of pathologically proven metastatic LNs and nonmetastatic LNs. DWI and ADC values are a useful tool for differentiating metastatic from nonmetastatic axillary LNs.

Sentinel lymph node biopsy in breast cancer surgery

Axillary lymph node status is one of the most reliable prognostic factors of long-term survival in breast cancer surgery. Metastatic involvement of the axillary lymph nodes is also crucial in the decision making of potentially useful adjuvant treatment. Until the last decade, Axillary Lymph Nodes Dissection (ALND) was performed in order to obtain the regional lymphatic system staging. In case of non-metastatic spread, that kind of surgery was limited only to this purpose; no further oncological benefits were obtained and the patients were exposed to several comorbidities affecting this type of surgery. Complications after ALND are reported in 15-30% of cases. They are well known and range from early bleeding, infection, symptomatic nerve damage, and longstanding limb lymph-edema with an incredible impairment of the quality of life.The Sentinel Lymph Node (SLN) theory holds that the SLNs are the first nodes draining lymph from an anatomic region (i.e. the breast) where metastatic disease will most likely to be found. If that node is found to be cancer free, the entire lymphatic system is likely to be cancer free; if it is metastatic, there is an elevated chance of finding more metastatic nodes. Thanks to the application of this hypothesis, several patients over the last 10-15 years have avoided unnecessary major demolitive surgery. To obtain accurate evaluation of the SLN a multidisciplinary dedicated team is necessary. This procedure has been internationally validated and the false negative rate is nowadays less than 5% when performed by expert hands. Dedicated breast surgeons working in a high-volume centres are necessary to reach satisfactory confidence in performing this very specialised procedure in order to obtain an accurate staging. The number of women presenting to the breast oncology units is continuously increasing and the implementation of screening programs has been crucial in detecting numerous patients (more than 75%) with early disease and non-metastatic axillary lymph nodes. The practice of the SLN is clearly able to offer those patients an accurate staging with low comorbidities, preserving their quality of life.

Expression of CXCR4 and SDF-1α in Primary Breast Cancers and Metastatic Lymph Nodes

Purpose: A CXCR4/stroma derived factor-1α(SDF-1α , CXCL12) interaction is involved in many metastatic cancer mechanisms, including breast cancer. The primary objectives of this study were to investigate the correlation between CXCR4 and axillary lymph node metastasis and to clarify the interaction between CXCR4 in primary tumor cells and SDF-1αin metastatic lymph nodes. An analysis of the correlation between CXCR4, SDF-1αand clinicopathologic features was also performed. Methods: Representative areas from 44 invasive ductal carcinomas were selected for construction of tissue microarrays using a 5 mm punch. Breast cancers (n=44), metastatic axillary lymph nodes (n=18) and non-metastatic axillary lymph nodes (n=26) were immunohistochemically stained for CXCR4, SDF-1α , estrogen receptor (ER), progesterone receptor (PR) and HER2. The parameters of age, tumor size, nuclear grade, histologic grade, lymph node status and pathologic node (pN) stage pN0 to pN3 were evaluated. Results: CXCR4 expression was negatively correlated with increased age (p=0.005) and positively correlated with a large tumor size (p=0.043) and PR expression (p=0.027). CXCR4 expression was not correlated with metastatic lymph nodes (p=0.079) and SDF-1 αexpression in metastatic lymph nodes (p=0.062). However, CXCR4 nuclear positivity is correlated with lymph node metastasis (p=0.044). SDF-1αwas not correlated with any clinicopathologic feature in a statistically significant manner. Conclusion: An evaluation of young age, large tumor size and PR expression helps predict lymph node metastasis and poor prognosis. Expression of CXCR4 nuclear positivity is correlated with a poor prognosis.

Association between the expression of IL-10 and T cell activation proteins loss in early breast cancer patients

Breast cancer patients may express abnormal cellular immune responses affecting their immunological competence. The analysis of immunological parameters may be useful as indicators of T cell function. To determine the expression of lymphocyte activation proteins and cytokines in tumor and non-metastatic axillary lymph nodes, 30 breast cancer patients were monitored. CD3 polypeptides, PTKs (protein tyrosine kinases) and phosphorylated tyrosines were studied by Western Blot and cytokines mRNA expression was determined by RT-PCR (reverse transcription-polymerase chain reaction). This group of patient had shown high immunohistochemistry expression of IL-10 in tumors. Activation proteins were mainly expressed in involved lymph nodes comparing with their expression in tumors. The differences in expression of CD3 polypeptides and p56(lck) between both locations were significant. There was no statistical association between PTKs and IL-10 in the tumor but more than 50% of cases who express IL-10 lost p56(lck), p59(fyn). A direct association between IL-10 and CD3-polypeptides was observed, however 52.2% of patients who express IL-10 did not express 41 kDa CD3-zeta form. IL-10 mRNA was detected in more than 50% of tumors contrary to the prevalence of type 1 cytokines in regional nodes (40%). The lack of expression of lymphocyte activations proteins and the high expression of IL-10 suggest a downregulation on T cells function in the tumors. These results are useful in order to understand the local immune response that would be key in the control of the tumor progression.