Is extracapsular tumour spread a prognostic factor in patients with early breast cancer?

Breast cancer in Switzerland: a comparison between organized-screening versus opportunistic-screening cantons

BACKGROUND

Switzerland is one of the few remaining European countries without a uniform national breast cancer screening program. Most Swiss cantons have initiated mammography screening programs, with the notable exceptions of the cantons of central Switzerland. The aim of this study is to compare the TNM (tumor-node-metastasis) status in woman diagnosed with screen- and non-screen-detected breast cancers. We compare TNM of breast cancers of cantonal screening cantons (Or-SC) with organized mammographic screening and opportunistic-screening cantons (Op-SC) without organized mammographic screening.

MATERIALS AND METHODS

We compared the TNM documented in cantons with organized screening (Or-SC) in the national cancer registry with those in the cantons of central Switzerland without organized screening (Op-SC) between 2014 and 2020. Since 2014, a total of 19 236 patients from Or-SC and 2282 from Op-SC with breast cancer were compared. Age groups were defined as younger than 50 years, between 50 and 69 years, and older than 70 years.

RESULTS

By comparison, women aged 50-69 years in the cantons of the Op-SC group exhibited significantly larger tumors T1-3 [point estimate of the difference with 95% confidence interval (CI) for T1: -7.7% (95% CI -11.0% to -4.4%); T2: 5.3% (95% CI 2.2% to 8.5%); T3: 2.5% (95% CI 0.8% to 4.2%)] and significantly fewer proportion of N0 [-5.7% (95% CI -9.0% to -2.5%)] without significant difference in the M status (P = 0.97).

CONCLUSION

Our study shows that patients aged 50-69 years from Op-SC have significantly larger tumors and higher incidence of lymph node metastases than women in the corresponding Or-SC group. This globally unique case within one single small country with very high living standards, but with different screening strategies, indicates the benefits of organized breast screening programs.

Extra-Capsular Spread of Lymph Node Metastasis in Oral, Oropharyngeal and Hypopharyngeal Cancer: A Comparative Subsite Analysis

BACKGROUND

The extra-capsular spread (ECS) of lymph node metastasis (LNM) is a hallmark of aggressive primary tumor phenotype in head and neck cancer (HNC); however, the factors influencing ECS are poorly understood.

PATIENTS AND METHODS

This was a retrospective study, including 190 cases of oral tongue cancer (OTC), 148 cases of oropharyngeal cancer (OPC) (118 HPV-positive and 30 HPV-negative), and 100 cases of hypopharyngeal cancer (HPC). Tumor dimension, tumor biological variables (lymphovascular/perineural invasion and histologic grade), and LNM variables (LNM number and size) were analyzed according to the presence of ECS using multivariable logistic regression and receiver operating characteristic (ROC) curve analyses.

RESULTS

LNM variables were significant factors for ECS in all subsites of HNC (p < 0.05), except HPV-positive OPC. In OTC, tumor dimensional variables were significantly related to ECS (p < 0.01). Meanwhile, in OPC and HPC, neither the primary tumor dimension nor the T status were significant factors for ECS occurrence. The predictability of ECS by ROC curve using multiple variables was 0.819 [95% confidence interval: 0.759-0.878] in OTC, 0.687 [0.559-0.815] in HPV-positive OPC, 0.823 [0.642-1.000] in HPV-negative OPC, and 0.907 [0.841-0.973] in HPC.

CONCLUSION

LNM variables were correlated with ECS occurrence for most HNC subsites, and site-dependent primary tumor characteristics might contribute differentially to the ECS development of LNM in HNC.

Extranodal extension, an international survey on its evaluation and reporting in breast cancer patients

Lymph node metastasis is the most important prognostic factor for breast cancer patients. In addition to the number of nodes involved and the largest metastatic focus, extranodal extension (ENE) is also used to subclassify breast cancer patients into different risk groups. More recently, pathologists are required to report the size/extent of ENE per the new CAP guideline, as it seems to be associated with more axillary nodal burden and/or a worse prognosis. Although the definition of ENE is largely understood and agreed upon among pathologists around the world, evaluation and reporting for the size of ENE are not. To understand current practice, we conducted an international survey among pathologists who are interested in breast pathology. A total of 70 pathologists responded. The results showed that (1) 98% of the participants reported the presence or absence of ENE and 61% also reported the size of ENE in millimeter (mm). (2) There was no uniform method of measuring the size of ENE; 47% measured the largest dimension regardless of orientation, while 30% measured the largest perpendicular distance from the capsule. (3) The most common factors affecting the accuracy in diagnosis of ENE are the presence of lymphovascular invasion (LVI), lack of capsule integrity, and the presence of fatty hilar or fatty replacement of a lymph node. (4) 71% felt that the H&E stain is adequate to evaluate ENE, deeper levels and IHC analysis for vascular and cytokeratin markers can be helpful if needed. (5) 75% agreed that there is an urgent need to standardize the measurement and reporting for ENE. Our survey highlights the variation in ENE evaluation and the need for its standardization in breast cancer patients with axillary node metastasis.

Prognostic value of extranodal extension in axillary lymph node-positive breast cancer

Several studies have demonstrated that extranodal extension (ENE) is associated with prognosis in breast cancer. Whether this association should be described in pathological reports warrants further investigation. In this research, we evaluated the predictive value of ENE in axillary lymph nodes (ALNs) in invasive breast cancer and explored the feasibility of employing ENE to predict clinicopathological features, nodal burden, disease recurrence-free survival (DRFS) and overall survival (OS) in clinical practice. In addition, the cutoff values of perpendicular diameter ENE (PD-ENE) and circumferential diameter ENE (CD-ENE) of ENE were investigated. A total of 402 cases of primary invasive breast cancer were extracted from Fudan University Shanghai Cancer Center; these patients underwent axillary lymph node dissection (ALND) between 2010 and 2015. ENE in the ALN was defined as the tumor cells breaking through the lymph node capsule into peripheral adipose tissue and causing connective tissue reactions. Relationships between ENE and clinicopathological features, nodal burden, disease recurrence-free survival (DRFS) and overall survival (OS) were analyzed. PD-ENE was defined by measuring from the point where tumor tissue broke the node capsule to the highest point of the tumor cells in the perinodal adipose tissue.K The average PD-ENE was 1.8 mm; therefore, we divided ENE-positive patients into two groups: PD-ENE no greater than 2 mm and PD-ENE greater than 2 mm. CD-ENE was defined as measuring along the nodal capsule as the distance between peripheral edges of the ENE area. According to the average circumferential diameter (CD-ENE), we classified ENE-positive patients into two groups: CD-ENE no greater than 3 mm and CD-ENE greater than 3 mm. Correlations between ENE cutoffs and prognosis were analyzed. In this cohort of patients, 158 (39.3%) cases were positive for ENE in ALN.98 (24.4%) cases had PD-ENE no larger than 2 mm, and 60 (14.9%) cases had PD-ENE larger than 2 mm. Also, 112 (27.9%) cases had CD-ENE no larger than 3 mm, and 46 (11.4%) cases had CD-ENE larger than 3 mm. Statistical analysis indicated that histological grade, N stage, and HER2 overexpression subtype were associated with ENE. The presence of ENE had significant statistical correlations with nodal burden, including N stage, median metastatic tumor diameter and peri-lymph node vascular invasion (p < 0.001, p < 0.001, p = 0.001, respectively). Cox regression analysis demonstrated that patients with ENE exhibited significantly reduced DRFS in both univariable analysis (HR 2.126, 95% CI 1.453–3.112, p < 0.001) and multivariable analysis (HR 1.745, 95% CI 1.152–2.642, p = 0.009) compared with patients without ENE. For overall survival (OS), patients with ENE were associated with OS in univariable analysis (HR 2.505, 95% CI 1.337–4.693, p = 0.004) but not in multivariable analysis (HR 1.639, 95% CI 0.824–3.260, p = 0.159). Kaplan–Meier curves and log-rank test showed that patients with ENE in ALN had lower DRFS and OS (for DRFS: p < 0.0001; and for OS: p = 0.002, respectively). However, neither the PD-ENE group (divided by 2 mm) nor the CD-ENE group (divided by 3 mm) exhibited significant differences regarding nodal burden and prognosis. Our study indicated that ENE in the ALN was a predictor of prognosis in breast cancer. ENE was an independent prognostic factor for DRFS and was associated with OS. ENE in the ALN was associated with a higher nodal burden. The size of ENE, which was classified by a 3-mm (CD-ENE) or 2-mm (PD-ENE) cutoff value, had no significant prognostic value in this study. Based on our findings, the presence of ENE should be included in routine pathological reports of breast cancers. However, the cutoff values of ENE warrant further investigation.

Clinical relevance of a degree of extracapsular extension in a sentinel lymph node in breast cancer patients: a single-centre study

In some breast cancer (BC) patients, an examination of lymph nodes dissected during sentinel lymph node biopsy (SLNB) demonstrates a presence of metastatic lesions and extracapsular extension (ECE) in a SLN. This study aimed to evaluate clinical relevance of ECE in BC patients. This is a retrospective analysis of 891 patients with cancer metastases to SLN, referred to supplementary axillary lymph node dissection (ALND), hospitalized between Jan 2007 and Dec 2017. Clinical and epidemiological data was evaluated. Long-term treatment outcomes were analysed. In 433 (48.6%) patients, cancer metastases were limited to the SLN (group I), in 61 (6.8%) patients the SLN capsule was exceeded focally (≤ 1 mm—group II). In 397 (44.6%) patients, a more extensive ECE was found (> 1 mm—group III). Metastases to non-sentinel lymph nodes (nSLNs) were diagnosed in 27.0% patients from group I, 44.3% patients from group II and in 49.6% patients from group III. No statistically significant differences were observed in long-term treatment outcomes for compared groups. The presence of ECE is accompanied by a higher stage of metastatic lesions in the lymphatic system. The differences in this respect were statistically significant, when compared to the group of ECE(−) patients. ECE, regardless of its extent, did not impact the long-term treatment results. ECE remains an indication for supplementary ALND and for other equivalent cancer treatment procedures, regardless of ECE size.

Breast Cancer Systemic Treatments and Upper Limb Lymphedema: A Risk-Assessment Platform Encompassing Tumor-Specific Pathological Features Reveals the Potential Role of Trastuzumab

Breast cancer related lymphedema (BCRL) is frequent but strategies for an individualized risk assessment are lacking. We aimed to define whether tumor-specific pathological features, coupled with clinical and therapeutic data, could help identify patients at risk. Data from 368 patients with node-positive breast cancers were retrospectively collected, including 75 patients with BCRL (0.4⁻25.6 years follow-up). BCRL was assessed during the standard follow-up oncology visits using the circumferential measurement. Clinicopathologic and therapeutic factors associated with BCRL were integrated into a Cox proportional hazards regression model. Lymphovascular invasion (LVI) was more common in BCRL patients (n = 33, 44% vs. n = 85, 29%, p = 0.01), akin extra nodal extension (ENE) of the metastasis (n = 57, 76% vs. n = 180, 61%, p = 0.02). Sentinel lymph node excision without axillary dissection and extra-axillary radiotherapy were BCRL-unrelated. A higher number of BCRL-positive patients were treated with taxane-based chemotherapy with or without trastuzumab, compared to BCRL-negative patients (p < 0.01). Treatment with trastuzumab and/or taxanes, adjusted for systemic infections, laterality, therapy, and pathological features (i.e., LVI and ENE), had a significant impact in BCRL-free survival (p < 0.01). This work offers new insights on BCRL risk stratification, where the integration of clinical, therapeutic, and tumor-specific pathological data suggests a possible role of anti-human epidermal growth factor receptor 2 (HER2) therapy in BCRL pathogenesis.

Lymphovascular invasion and extranodal tumour extension are risk indicators of breast cancer related lymphoedema: an observational retrospective study with long-term follow-up

Background

Breast cancer related lymphoedema (BCRL) occurs in a substantial proportion of breast cancer survivors and is a major contributor to patients’ disability. Regrettably, there are no validated predictive biomarkers, diagnostic tools, and strong evidence-supported therapeutic strategies for BCRL. Here, we provide an integrative characterization of a large series of women with node-positive breast cancers and identify new bona fide predictors of BCRL occurrence.

Methods

Three hundred thirty-two cases of surgically-treated node-positive breast cancers were retrospectively collected (2–10.2 years of follow-up). Among them, 62 patients developed BCRL. To identify demographic and clinicopathologic features related to BCRL, Fisher’s exact test or Chi-squared test were carried out for categorical variables; the Wilcoxon rank-sum was employed for continuous variables. Factors associated with BCRL occurrence were assessed using a Cox proportional hazards regression model.

Results

En-bloc dissection of the axillary lymph nodes but not the type of breast surgery impacted on BCRL development. Most of BCRL patients had a Luminal A-like neoplasm. The median number of lymph nodes involved by metastatic deposits was significantly higher in BCRL compared to the control group (p = 0.04). Both peritumoral lymphovascular invasion (LVI) and extranodal extension (ENE) of the metastasis had a negative impact on BCRL-free survival (p = 0.01). Specifically, patients with LVI and left side localization harboured 4-fold higher risk of developing BCRL, while right axillary nodes metastases with ENE increased the probability of BCRL compared to ENE-negative patients.

Conclusions

Assessment of LVI and ENE should be integrated with clinical and surgical data to improve BCRL risk stratification.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4851-2) contains supplementary material, which is available to authorized users.

Extra-nodal extension is a significant prognostic factor in lymph node positive breast cancer

Presence of lymph node (LN) metastasis is a strong prognostic factor in breast cancer, whereas the importance of extra-nodal extension and other nodal tumor features have not yet been fully recognized. Here, we examined microscopic features of lymph node metastases and their prognostic value in a population-based cohort of node positive breast cancer (n = 218), as part of the prospective Norwegian Breast Cancer Screening Program NBCSP (1996–2009). Sections were reviewed for the largest metastatic tumor diameter (TD-MET), nodal afferent and efferent vascular invasion (AVI and EVI), extra-nodal extension (ENE), number of ENE foci, as well as circumferential (CD-ENE) and perpendicular (PD-ENE) diameter of extra-nodal growth. Number of positive lymph nodes, EVI, and PD-ENE were significantly increased with larger primary tumor (PT) diameter. Univariate survival analysis showed that several features of nodal metastases were associated with disease-free (DFS) or breast cancer specific survival (BCSS). Multivariate analysis demonstrated an independent prognostic value of PD-ENE (with 3 mm as cut-off value) in predicting DFS and BCSS, along with number of positive nodes and histologic grade of the primary tumor (for DFS: P = 0.01, P = 0.02, P = 0.01, respectively; for BCSS: P = 0.02, P = 0.008, P = 0.02, respectively). To conclude, the extent of ENE by its perpendicular diameter was independently prognostic and should be considered in line with nodal tumor burden in treatment decisions of node positive breast cancer.

Metastatic Tumor Volume and Extranodal Tumor Extension: Clinical Significance in Patients With Stage II Breast Cancer

CONTEXT

Lymph node status and the number of lymph node (LN) positive for cancer cells are the most important prognostic factors in breast cancer. Extranodal tumor extension (ENTE) has been used as a histopathologic feature to classify patients into high risk versus low risk for local recurrence. However, in the current era of early detection and systemic therapy, the prognostic significance of ENTE is not as well defined in patients with 1 to 3 LNs positive for cancer.

OBJECTIVE

To determine whether the amount of tumor burden in an axillary dissection or the presence of ENTE provides any additional information regarding patient outcome in patents with 1 to 3 positive LN results.

DESIGN

Clinical and pathologic factors were identified for 456 patients with breast cancer at the University of Texas MD Anderson Cancer Center, Houston, who had pT1 tumors and 1 to 3 LNs positive for cancer and were treated by mastectomy, with or without postmastectomy radiotherapy, between 1978 and 2007.

RESULTS

Of the 456 patients, 257 (56.4%), 141 (31.6%), and 58 (12.7%) patients had 1, 2, or 3 positive LN results, respectively. Extranodal tumor extension was present in 99 patients (21.7%) and was absent in the remaining 357 cases (78.3%). Seventy-six patients (16.7%) received radiation therapy. Patients had both worse overall survival time and disease-free survival when ENTE was present, regardless of the amount, as long as the treatment era was not included in the multivariate analysis (pre-2000 versus post-2000). However, ENTE was no longer significant on multivariate analysis when the year of treatment was taken into account.

CONCLUSIONS

The number of positive LNs remains an important predictor of survival in patients with 1 to 3 positive LN results, but the prognostic significance of ENTE in this cohort of patients has diminished over time.

Prognostic significance of epithelial-mesenchymal transition of extracapsular spread tumors in lymph node metastases of head and neck cancer

BACKGROUND AND PURPOSE

The extracapsular spread (ECS) of lymph node metastasis (LNM) reflects tumor aggressiveness and is associated with poor survival and risk of distant metastasis. In this study, we aimed to explore the prognostic significance of epithelial-mesenchymal transition (EMT) of ECS tumors in LNM of head and neck cancers.

METHODS

We collected LNM samples from head and neck cancer patients (follow-up >2 years) and made 20 ECS(-): ECS(+) pairs (1:2) of LNM (N = 60), matched by the primary sites and by T and N classifications. Immunostaining of cytokeratin, E-cadherin, vimentin, and CD31 were performed and quantified to determine the epithelial-mesenchymal transition percent (EMT%), defined as vimentin(+)/cytokeratin(+) area of ECS. Univariate and multivariable analyses of clinic-pathologic factors, including EMT% of ECS, were conducted to identify the significant prognosticators. In addition, the anatomical relationship between CD31 vessels and ECS tumors was analyzed.

RESULTS

Rather than the presence of ECS in LNM, higher EMT% (>50 %) of ECS strongly correlated with the worse overall and disease-free survival and had more frequent recurrence and distant dissemination in their clinical courses. ECS tumors intermingled closely with Ki-67(-) CD31(+) non-proliferating perinodal blood vessels. Particularly, vimentin(+) ECS areas exhibited a higher density of CD31(+) perinodal vessels than did vimentin(-) ECS.

CONCLUSION

High EMT scores of ECS tumors in LNM predict an unfavorable prognosis and systemic dissemination more accurately than the simple presence of ECS in LNM in head and neck cancer patients.