Risk Of Axillary Metastases Research Articles

Clustering Molecular Subtypes in Breast Cancer, Immunohistochemical Parameters and Risk of Axillary Nodal Involvement.

(1) Background: To establish similarities in the risk of axillary lymph node metastasis between different groups of women with breast cancer according to immunohistochemical (IHC) parameters. (2) Methods: Data was collected retrospectively, from 2000 to 2013, of 1058 node-positive breast tumours. All patients were divided according to the St Gallen 2013 criteria and IHC features. The proportion of axillary involvement (pN > pN0; pN > pN1mi; pN > pN1) was calculated for each group. Similarities in axillary nodal dissemination were explored by cluster analysis and association between IHC and risk of axillary disease was studied with multivariate analysis. (3) Results: Among clinico-pathological surrogates of intrinsic subtypes, axillary involvement was more frequent in Luminal-B like HER2 negative (45.8%) and less frequent in Luminal-B HER2 positive (33.8%; p = 0.044). Axillary macroscopic involvement was more frequent in Luminal-B like HER2 negative (37.9%) and HER2 positive (37.8%) and less frequent in Luminal-B HER2 positive (25.5%) and Luminal-A like (25.6%; p = 0.002). Axillary involvement ≥pN2 was significantly less frequent in Luminal-A like (7.4%; p < 0.001). Luminal-A with Luminal-B HER2 positive, and triple-negative with Erb-B2 overexpressing tumours were clustered together regarding any axillary involvement, macroscopic disease or ≥pN2. Among the defined subgroups, axillary metastases were more frequent when Ki67 was higher. In a multivariate analysis, Ki67>14% were associated with a risk of axillary metastases (HR: 1.31; 95% CI, 1.51–6.80; p < 0.037). (4) Conclusions: there are two lymphatic drainage pathways of the breast according to the expression of hormone receptor-related genes. Positive-ER tumors are associated with lower axillary involvement and negative-ER tumors and Ki67 > 14% with higher nodal involvement.

Abstract P1-01-21: Is it safe to skip intra-operative frozen section examination of sentinel lymph node for core biopsy-diagnosed DCIS?

Abstract Background Our initial experience on sentinel lymph node (SLN) biopsy with on-table frozen section examination has shown to be an accurate alternative to axillary dissection in the staging of invasive breast cancer. Patients with a preoperative diagnosis of ductal carcinoma in-situ (DCIS) by core biopsy follow a similar treatment pathway because the risk of axillary metastasis and histological upstaging in the final excisional specimen is not negligible. Intra-operative frozen section reporting facilitates axillary clearance in a single operation when necessary. However, with the declining role of completion axillary dissection for those with minimal SLN involvement, its significance in DCIS is questioned. Methods A retrospective analysis was performed for patients with core biopsy-diagnosed DCIS undergoing SLN biopsy at the time of definitive surgery. Those with evidence of microinvasion in the core biopsy specimen were excluded. SLN were identified by blue dye, radioactive isotope, or combined mapping technique, and examined by intra-operative frozen section. Full axillary dissection was performed if frozen section was positive for metastasis, whereas patients with failed SLN localization were spared from the procedure. All lymph nodes harvested would undergo further paraffin section with immuno-histochemical staining. The results of SLN biopsy in relation to the final pathology of the primary tumour and the axillary disease status were analysed. Results From March 2002 to March 2013, 297 patients who had a core biopsy diagnosis of DCIS underwent simultaneous SLN biopsy with their definitive excisional operation. SLN localization was successful in 283 patients (95.3%). Metastases in SLN were found in 19 (6.4%) of them. Axillary dissection, either in the same or second operative setting, was completed in 12 (4%) patients. Only four (1.3%) showed additional positive lymph nodes in the rest of axilla. All of these four patients had invasive disease revealed in their primary lesions upon final pathological assessment. Overall, 83 patients (27.9%) had histological upstaging from DCIS to microinvasive or invasive carcinoma. It was more commonly associated with the presence of a palpable (48.5% versus 21.6%, p = 0.0067) or radiological (46.3% versus 19.7%, p = 0.0047) mass lesion. Out of the 214 patients who remained in the category of “pure DCIS”, six (2.8%) had SLN metastases. Three proceeded to axillary dissection and their SLN were confirmed to be the only positive ones in the axilla. Conclusion Although SLN metastases were rare in patients with “pure DCIS”, underestimation of invasive disease was frequent on core biopsy. Performing SLN biopsy during definitive surgery for DCIS allowed correct nodal staging in a single operation. Nevertheless, in contrast to invasive carcinoma, frozen section examination could safely be foregone since the additional yield of completion axillary dissection was shown to be slim in “pure DCIS” even if SLN shows positive results. However, management of SLN in DCIS with high risk features should follow that of invasive breast cancer in view of the considerable chance of histological upstaging. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-21.

Axillary Lymph Node Status and Prognosis in Multifocal and Multicentric Breast Carcinoma

According to tumor-node-metastasis classification, tumor size should be based only on the largest tumor for multifocal and multicentric (MFMC) carcinomas. We estimated tumor size of MFMC carcinoma using either largest dimension of the largest tumor (dominant tumor size) or sum of the largest dimension of all tumors (aggregate tumor size), and compared the risk of axillary lymph node metastasis and prognosis between MFMC and unifocal carcinoma. We retrospectively reviewed the file records of 3,616 patients with MFMC (258 patients, 7.1%) and unifocal (3,358 patients) carcinoma. In T1 and T2 tumor subgroups, using dominant (p = 0.001 and p < 0.001) and aggregate (p = 0.017 and p = 0.004) tumor size axilla-positivity ratio was significantly higher in MFMC carcinoma compared with unifocal carcinoma. In stage I and II disease classified according to either dominant or aggregate tumor size, there was no significant survival difference between MFMC and unifocal carcinoma patients. In patients with stage III disease by dominant and aggregate tumor size disease-free survival was significantly worse in MFMC carcinoma compared with unifocal carcinoma (p = 0.036 and p = 0.041); multifocality and multicentricity had no independent prognostic significance (p = 0.074 and p = 0.079). The risk of axillary metastasis in MFMC carcinoma was higher than unifocal carcinoma, regardless of the method employed for tumor size estimation. MFMC carcinoma staged according to either dominant or aggregate tumor size had similar survival with unifocal carcinoma. We recommend using the largest dimension of the largest tumor in estimation of tumor size for MFMC carcinoma.

Linfonodo sentinela intramamário comprometido e axila livre: esvaziamento axilar ou conduta conservadora?

The sentinel lymph node biopsy is a standard treatment for patients with breast cancer and clinically negative axilla lymph node. The presence of an extra-axillary and intra-axillary (IM) sentinel lymph node (SLN) occurs in up to 2.6% of cases. In the presence of a metastatic IM SLN, axillary positivity may occur in up to 81% of cases. Due to the limited number of cases reported, there is no standard treatment for the association of metastatic SLN IM and non-metastatic axillary SLN . We add here two cases to the literature, one of them with metastatic disease in the axilla. The use of a nomogram demonstrated that the risk of axillary metastasis was less than 10% and the addition of these cases to the literature showed that in this situation the rate of axillary metastasis is 6.25%. We discuss the pros and cons of further axillary dissection in this situation.

Axillary staging: new approaches and treatment of minimal disease

Axillary staging is necessary since 30 to 40% of patients with curable breast cancer will have metastases in the axilla. Years ago, the most radical method of staging was performed: an axillary clearance. However, in patients with a negative axilla, who make up 60 to 70% of all patients, this lymph node dissection has no additional value. Today, with the sentinel node procedure it is possible to offer patients accurate staging of the axilla without the morbidity of axillary clearance. Discussion has now started about the fact that there are subgroups of patients in which the risk of axillary metastases is so low that axillary staging can be omitted. Furthermore, it is standard practice to perform axillary clearance in patients with positive sentinel lymph nodes. However, studies show that, of patients with a positive sentinel lymph node, 40 to 60% have no additional involved lymph nodes. The following dilemmas, which are all related to minimal disease, are therefore still open for debate and will be discussed in the presentation: Is a sentinel node procedure necessary when only minimal disease is present in the breast? Is axillary treatment necessary when only minimal disease is present in the node? What is the role of the PET/CT scan in axillary staging in minimal disease? How can we stage the axilla after primary systemic treatment when potentially only still minimal disease is present?

The Critical Role of Axillary Ultrasound and Aspiration Biopsy in the Management of Breast Cancer Patients with Clinically Negative Axilla

Sonographic evaluation of the axilla can predict node status in a significant proportion of clinically node-negative patients. This review focuses on the value of ultrasound followed by ultrasound-guided cytology in assessing the need for sentinel node mapping and conservative versus complete axillary dissections. Breast primaries from 168 sentinel node candidates were prospectively assessed for clinicopathologic variables associated with increased incidence of axillary metastases. Patients were classified accordingly, and those at a higher risk underwent ultrasound of their axillae, followed by aspiration biopsy if needed. Sentinel node mapping was performed in all low-risk patients, and in high-risk patients with normal axillary ultrasounds or negative cytology. Final axillary status was compared in terms of nodal stage, number of positive nodes, and size of metastasis. 112 patients were at high risk for nodal disease (67%), with a statistically significant lower probability for remaining node-negative and a statistical significantly higher risk for having more than one positive node. All patients with more than three positive nodes were detected by ultrasound-guided cytology. High-risk patients with final positive axillae missed by ultrasound or ultrasound guided cytology had tumor deposits measuring </=5 mm. Extent of axillary dissections can be decided based on the risk for axillary metastases: sentinel node mapping for low-risk patients; less-aggressive axillary dissections for high-risk patients with negative ultrasound and/or negative cytology; and a standard dissection for high-risk patients with positive cytology.

Size of Sentinel Node Tumor Deposits and Extent of Axillary Lymph Node Involvement: Which Breast Cancer Patients May Benefit From Less Aggressive Axillary Dissections?

In most breast cancer series, nearly 30% to 40% of all patients are sentinel node positive; however, in a large proportion of these, the disease is limited to three or fewer positive nodes. On the basis of these observations, the object of this study is to identify a subset of patients who might benefit from a less aggressive axillary dissection, without compromising staging or local disease control. We reviewed known clinicopathologic variables associated with a higher risk for axillary metastasis in 467 patients who underwent sentinel node mapping at our institution. We then compared the incidence of these variables in patients with N1a versus N2-3 stage disease. Although the presence of lymphvascular invasion in the primary tumor and extracapsular extension of tumor in the sentinel node were statistically significantly different between N1a and N2-3 patients (P < .025 and P < .01, respectively), the variable that most reliably separated N1a from N2-3 patients was the size of the tumor deposits in the sentinel node (P < .001). All patients with sentinel node tumor deposits <or=5 mm had three or fewer positive nodes; 95% were sentinel node-positive only, and 91% had single-node involvement. Patients at low risk for extensive axillary nonsentinel node involvement may benefit from a more conservative surgical approach to their axillae, perhaps limited to sentinel node biopsy only or to axillary procedures restricted to the group of axillary nodes in close proximity to those designated as sentinel nodes.

Correlating primary breast cancer size, growth and treatment delay with the risk of axillary metastases

Correlating primary breast cancer size, growth and treatment delay with the risk of axillary metastases

Noninvasive Breast Carcinoma

One hundred twenty-nine biopsies from 121 patients with a frozen or paraffin section diagnosis of noninvasive breast carcinoma were studied. Eight women had bilateral noninvasive carcinoma. Seven biopsies reported as intraductal on frozen section contained invasive carcinoma on paraffin section. Of the remaining 122 biopsies proven to have noninvasive carcinoma on paraffin section, 39 (34%) were reported at frozen section and as noninvasive carcinoma, 24 (20%) as atypical and 59 (48%) as benign. Intraductal carcinoma (IDC) was identified more often at frozen section (45%) than was lobular carcinoma in situ (19%). Among 41 patients who had bilateral carcinoma with invasive disease in one breast, 76% of contralateral noninvasive carcinoma was LCIS. After excisional biopsy, carcinoma was found in 56% of 103 mastectomy specimens, including invasive carcinoma in 6% of breasts with IDC and 4% with LCIS. Residual noninvasive carcinoma was usually of the same type found at biopsy (90% IDC and 88% LCIS) and involved quadrants other than the biopsy site in 33% with IDC and in 80% with LCIS. When the frozen or paraffin section diagnosis of a generous excisional biopsy was noninvasive breast carcinoma, there was a substantial risk that foci of the same type of noninvasive carcinoma were also present in other quadrants. However, occult foci of invasive carcinoma were quite infrequent and the risk of axillary metastases was very low. Adequate treatment for noninvasive carcinoma requires elimination of all residual foci of noninvasive disease. At present this can best be accomplished by total mastectomy if the operation is properly performed. To insure removal of the axillary extension of the breast and for staging, in continuity dissection of the lowest axillary lymph nodes is also prudent.