Long-term breast cancer survival in relation to the metastatic tumor burden in axillary lymph nodes

A nomogram to predict the benefit of postmastectomy radiotherapy in breast cancer with nodal micrometastases

BACKGROUND

The role of postmastectomy radiotherapy (PMRT) in breast cancer (BC) with nodal micrometastases (N1mic) remains unclear. This study aimed to evaluate the efficacy of PMRT in T1-2N1mic BC patients who have undergone mastectomy.

METHODS

Female patients with T1-2N1mic BC who underwent mastectomy and were registered in the Surveillance, Epidemiology, and End Results database between 2010 and 2017. The chi-square test, logistic regression analysis, Kaplan-Meier methods, and multivariate Cox proportional hazards analysis were used for statistical analyses. Nomograms for predicting breast cancer-specific survival (BCSS) and overall survival (OS) were created by integrating the independent prognostic factors.

RESULTS

A total of 5948 eligible patients were included in this study. A total of 1207 patients (20.3%) received PMRT, while 4741 patients (79.7%) did not. The use of PMRT increased over the study period, from 15.7% in 2010 to 23.8% in 2017 (P < 0.001). The multivariate Cox proportional hazards analysis showed that PMRT did not improve BCSS and OS. Nomograms were established based on the independent prognostic factors to predict the BCSS and CSS of patients. Regarding BCSS, there were 3627 patients (61.0%) classified as low-risk and 2321 patients (39.0%) classified as high-risk using a cutoff point of 125, PMRT did not improve BCSS in patients with low-risk (P = 0.697) and high-risk (P = 0.149) groups. Regarding OS, there were 4791 patients (80.5%) classified as low-risk and 1157 patients (19.5%) classified as high-risk using a cutoff point of 130, patients who received PMRT had significantly better 5-year OS than those who did not receive PMRT (P = 0.047), while similar outcomes were found between the treatment arms in the low-risk group (P = 0.575).

CONCLUSIONS

While our findings suggest that PMRT does not enhance survival outcomes in T1-T2N1mic BC patients, it may offer a survival advantage in high-risk subgroups.

Utility of Multiparametric Breast MRI Radiomics to Predict Cyclin D1 and TGF-β1 Expression

OBJECTIVE

To develop a machine learning model that integrates clinical features and multisequence MRI radiomics for noninvasively predicting the expression status of prognostic-related factors cyclin D1 and TGF-β1 in breast cancer, providing additional information for the clinical development of personalized treatment plans.

METHODS

A total of 123 breast cancer patients confirmed by surgical pathology were retrospectively enrolled in our Hospital from January 2016 to July 2022. The patients were randomly divided into a training group (87 cases) and a validation group (36 cases). Preoperative routine and dynamic contrast-enhanced magnetic resonance imaging scans of the breast were performed for treatment subjects. The region of interest was manually outlined, and texture features were extracted using AK software. Subsequently, the LASSO algorithm was employed for dimensionality reduction and feature selection to establish the MRI radiomics labels. The diagnostic efficacy and clinical value were assessed through receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA).

RESULTS

In the cyclin D1 cohort, the area under the receiver operating characteristic (ROC) curve in the clinical prediction model training and validation groups was 0.738 and 0.656, respectively. The multisequence MRI radiomics prediction model achieved an AUC of 0.874 and 0.753 in these respective groups, while the combined prediction model yielded an AUC of 0.892 and 0.785. In the TGF-β1 cohort, the ROC AUC for the clinical prediction model was found to be 0.693 and 0.645 in the training and validation groups, respectively. For the multiseries MRI radiomics prediction model, it achieved an AUC of 0.875 and 0.760 in these respective groups; whereas for the combined prediction model, it reached an AUC of 0.904 and 0.833. Decision curve analysis (DCA) demonstrated that both cohorts indicated a higher clinical application value for the combined prediction model compared with both individual models-clinical prediction model alone or radiomics model.

CONCLUSION

The integration of clinical features and multisequence MRI radiomics in a combined modeling approach holds significant predictive value for the expression status of cyclin D1 and TGF-β1. The model provides a noninvasive, dynamic evaluation method that provides effective guidance for clinical treatment.

Diagnostic performance of DCE-MRI radiomics in predicting axillary lymph node metastasis in breast cancer patients: A meta-analysis

Radiomics offers a novel strategy for the differential diagnosis, prognosis evaluation, and prediction of treatment responses in breast cancer. Studies have explored radiomic signatures from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for predicting axillary lymph node metastasis (ALNM) and sentinel lymph node metastasis (SLNM), but the diagnostic accuracy varies widely. To evaluate this performance, we conducted a meta-analysis performing a comprehensive literature search across databases including PubMed, EMBASE, SCOPUS, Web of Science (WOS), Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Data, and the Chinese BioMedical Literature Database (CBM) until March 31, 2024. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and the area under the receiver operating characteristic curve (AUC) were calculated. Twenty-four eligible studies encompassing 5588 breast cancer patients were included in the meta-analysis. The meta-analysis yielded a pooled sensitivity of 0.81 (95% confidence interval [CI]: 0.77-0.84), specificity of 0.85 (95%CI: 0.81-0.87), PLR of 5.24 (95%CI: 4.32-6.34), NLR of 0.23 (95%CI: 0.19-0.27), DOR of 23.16 (95%CI: 17.20-31.19), and AUC of 0.90 (95%CI: 0.87-0.92), indicating good diagnostic performance. Significant heterogeneity was observed in analyses of sensitivity (I2 = 74.64%) and specificity (I2 = 83.18%). Spearman's correlation coefficient suggested no significant threshold effect (P = 0.538). Meta-regression and subgroup analyses identified several potential heterogeneity sources, including data source, integration of clinical factors and peritumor features, MRI equipment, magnetic field strength, lesion segmentation, and modeling methods. In conclusion, DCE-MRI radiomic models exhibit good diagnostic performance in predicting ALNM and SLNM in breast cancer. This non-invasive and effective tool holds potential for the preoperative diagnosis of lymph node metastasis in breast cancer patients.

A nomogram model for predicting the risk of axillary lymph node metastasis in patients with early breast cancer and cN0 status

Axillary staging is commonly performed via sentinel lymph node biopsy for patients with early breast cancer (EBC) presenting with clinically negative axillary lymph nodes (cN0). The present study aimed to investigate the association between axillary lymph node metastasis (ALNM), clinicopathological characteristics of tumors and results from axillary ultrasound (US) scanning. Moreover, a nomogram model was developed to predict the risk for ALNM based on relevant factors. Data from 998 patients who met the inclusion criteria were retrospectively reviewed. These patients were then randomly divided into a training and validation group in a 7:3 ratio. In the training group, receiver operating characteristic curve analysis was used to identify the cutoff values for continuous measurement data. R software was used to identify independent ALNM risk variables in the training group using univariate and multivariate logistic regression analysis. The selected independent risk factors were incorporated into a nomogram. The model differentiation was assessed using the area under the curve (AUC), while calibration was evaluated through calibration charts and the Hosmer-Lemeshow test. To assess clinical applicability, a decision curve analysis (DCA) was conducted. Internal verification was performed via 1000 rounds of bootstrap resampling. Among the 998 patients with EBC, 228 (22.84%) developed ALNM. Multivariate logistic analysis identified lymphovascular invasion, axillary US findings, maximum diameter and molecular subtype as independent risk factors for ALNM. The Akaike Information Criterion served as the basis for both nomogram development and model selection. Robust differentiation was shown by the AUC values of 0.855 (95% CI, 0.817-0.892) and 0.793 (95% CI, 0.725-0.857) for the training and validation groups, respectively. The Hosmer-Lemeshow test yielded P-values of 0.869 and 0.847 for the training and validation groups, respectively, and the calibration chart aligned closely with the ideal curve, affirming excellent calibration. DCA showed that the net benefit from the nomogram significantly outweighed both the 'no intervention' and the 'full intervention' approaches, falling within the threshold probability interval of 12-97% for the training group and 17-82% for the validation group. This underscores the robust clinical utility of the model. A nomogram model was successfully constructed and validated to predict the risk of ALNM in patients with EBC and cN0 status. The model demonstrated favorable differentiation, calibration and clinical applicability, offering valuable guidance for assessing axillary lymph node status in this population.

Predicting axillary lymph node metastasis in breast cancer patients: A radiomics-based multicenter approach with interpretability analysis

PURPOSE

To develop a MRI-based radiomics model, integrating the intratumoral and peritumoral imaging information to predict axillary lymph node metastasis (ALNM) in patients with breast cancer and to elucidate the model's decision-making process via interpretable algorithms.

METHODS

This study included 376 patients from three institutions who underwent contrast-enhanced breast MRI between 2021 and 2023. We used multiple machine learning algorithms to combine peritumoral, intratumoral, and radiological characteristics with the building of radiological, radiomics, and combined models. The model's performance was compared based on the area under the curve (AUC) obtained from the receiver operating characteristic analysis and interpretable machine learning techniques to analyze the operating mechanism of the model.

RESULTS

The radiomics model, incorporating features from both intratumoral tissue and the 3 mm peritumoral region and utilizing the backpropagation neural network (BPNN) algorithm, demonstrated superior diagnostic efficacy, achieving an AUC of 0.820. The AUC of the combination of the RAD score, clinical T stage, and spiculated margin was as high as 0.855. Furthermore, we conducted SHapley Additive exPlanations (SHAP) analysis to evaluate the contributions of RAD score, clinical T stage, and spiculated margin in ALNM status prediction.

CONCLUSIONS

The interpretable radiomics model we propose can better predict the ALNM status of breast cancer and help inform clinical treatment decisions.

Meta-analysis on axillary lymph node metastasis rate in ductal carcinoma in situ with microinvasion

OBJECTIVE

To address the question of axillary lymph node staging in ductal carcinoma in situ with microinvasion (DCIS-MI), we retrospectively evaluated axillary lymph nodes metastasis (ALNM) rate in a cohort of postsurgical DCIS-MI patients. By analyzing these data, we aimed to generate clinically relevant insights to inform treatment decision-making for this patient population.

METHODS

A systematic search was conducted on PubMed, Web of Science, Embase, The Cochrane Library, CNKI, Wanfang Database, Wipe, and China Biomedical Literature Database to identify relevant publications in any language. All the analyses were performed using Stata 16.0 software.

RESULTS

Among the 28 studies involving 8279 patients, the pooled analysis revealed an ALNM rate of 8% (95% CI, 7% to 10%) in patients with DCIS-MI. Furthermore, the rates of axillary lymph node macrometastasis, micrometastasis, and ITC in patients with DCIS-MI were 2% (95% CI, 2% to 3%), 3% (95% CI, 2% to 4%), and 2% (95% CI, 1% to 3%), respectively. Moreover, 13 studies investigated the non-sentinel lymph node (Non-SLN) metastasis rate, encompassing a total of 1236 DCIS-MI cases. The pooled analysis identified a Non-SLN metastasis rate of 33% (95% CI, 14% to 55%) in patients with DCIS-MI.

CONCLUSION

The SLNB for patients with DCIS-MI is justifiable and could provide a novel therapeutic basis for systemic treatment decisions.

Evaluating the utility of robotic axillary lymph node dissection in patients with invasive breast cancer: a systematic review

Robot-assisted axillary lymph node dissection (RALND) has been proposed to improve surgical and oncological outcomes for patients with breast cancer. To perform a systematic review of current literature evaluating RALND in patients with invasive breast cancer. A systematic search was performed in accordance with the PRISMA guidelines. Studies outlining outcomes following RALND were included. Two studies involving 92 patients were included in this review. Of these, 41 underwent RALND using the da Vinci© robotic system (44.57%), and 51 underwent conventional axillary lymph node dissection (CALND) (55.43%). There was no significant difference observed with respect to intra-operative blood loss or duration of procedure in those undergoing CALND and RALND (P > 0.050). One study reported a significant difference in lymphoedema rates in support of RALND (6.67% vs 26.67%, P = 0.038). Overall, data in relation to postoperative fat necrosis (10.00% vs 33.33%, P = 0.028), wound infection rates (3.33% vs. 20.00%, P = 0.044), and wound ≤ 40 mm in length (63.63% vs. 19.05%, P = 0.020) supported RALND. Oncological outcomes were only reported in one of the studies, which concluded that there was no local or metastatic recurrence in either group at 3-month follow-up. These provisional results support RALND as a safe alternative to CALND. Notwithstanding, the paucity of data limits the robustness of conclusions which may be drawn surrounding the adoption of RALND as the standard of care. Further high-quality studies are required to ratify these findings.

Investigation of synthetic MRI with quantitative parameters for discriminating axillary lymph nodes status in invasive breast cancer

OBJECTIVE

To investigate the potential value of quantitative parameters derived from synthetic magnetic resonance imaging (syMRI) for discriminating axillary lymph nodes metastasis (ALNM) in breast cancer patients.

MATERIALS AND METHODS

A total of 56 females with histopathologically proven invasive breast cancer who underwent both conventional breast MRI and additional syMRI examinations were enrolled in this study, including 30 patients with ALNM and 26 with non-ALNM. SyMRI has enabled quantification of T1 relaxation time (T1), T2 relaxation time (T2) and proton density (PD). The syMRI quantitative parameters of breast primary tumors before (T1tumor, T2tumor, PDtumor) and after (T1+tumor, T2+tumor, PD+tumor) contrast agent injection were obtained. Similarly, measurements were taken for axillary lymph nodes before (T1LN, T2LN, PDLN) and after (T1+LN, T2+LN, PD+LN) the injection, then theΔT1 (T1-T1+), ΔT2 (T2-T2+), ΔPD (PD-PD+), T1/T2 and T1+/T2+ were calculated. All parameters were compared between ANLM and non-ALNM group. Intraclass correlation coefficient for assessing interobserver agreement. The independent Student's t test or Mann-Whitney U test to determine the relationship between the mean quantitative values and the ALNM. Multivariate logistic regression analyses followed by receiver operating characteristics (ROC) analysis for discriminating ALN status. A P value < 0.05 was considered statistically significant.

RESULTS

The short-diameter of lymph nodes (DLN) in ALNM group was significantly longer than that in the non-ALNM group (10.22 ± 3.58 mm vs. 5.28 ± 1.39 mm, P < 0.001). The optimal cutoff value was determined to be 5.78 mm, with an AUC of 0.894 (95 % CI: 0.838-0.939), a sensitivity of 86.7 %, and a specificity of 90.2 %. In syMRI quantitative parameters of breast tumors, T2tumor, ΔT2tumor and ΔPDtumor values showed statistically significant differences between the two groups (P < 0.05). T2tumor value had the best performance in discriminating ALN status (AUC = 0.712), and the optimal cutoff was 90.12 ms, the sensitivity and specificity were 65.0 % and 83.6 % respectively. In terms of syMRI quantitative parameters of lymph nodes, T1LN, T2LN, T1LN/T2LN, T2+LN and ΔT1LN values were significantly different between the two groups (P < 0.05), and their AUCs were 0.785, 0.840, 0.886, 0.702 and 0.754, respectively. Multivariate analyses indicated that the T1LN value was the only independent predictor of ALNM (OR=1.426, 95 % CI: 1.130-1.798, P = 0.039). The diagnostic sensitivity and specificity of T1LN was 86.7 % and 69.4 % respectively at the best cutoff point of 1371.00 ms. The combination of T1LN, T2LN, T1LN/T2LN, ΔT1LN and DLN had better performance for differentiating ALNM and non-ALNM, with AUCs of 0.905, 0.957, 0.964 and 0.897, respectively.

CONCLUSION

The quantitative parameters derived from syMRI have certain value for discriminating ALN status in invasive breast cancer, with T2tumor showing the highest diagnostic efficiency among breast lesions parameters. Moreover, T1LN acted as an independent predictor of ALNM.

The prognostic value of lymphatic metastatic size in head and neck squamous cell carcinoma

BACKGROUND

Lymphatic metastatic size was proved to predict prognosis in different types of carcinomas, except in head and neck squamous cell carcinoma (HNSCC) located in hypopharynx, oropharynx and supraglottic region et al. The aim of this study is to evaluate the prognostic value of lymphatic metastatic size in HNSCC, which may guide clinical decision-making in practice.

METHODS

From 2008 to 2022, 171 patients, who were diagnosed as HNSCC in our center, were included. The demographic data, clinicopathological characteristics and lymphatic metastatic size were recorded and analyzed using the Kaplan-Meier method and Cox regression analysis.

RESULTS

Among 171 patients, 107 cases were hypopharyngeal cancer, 38 cases supraglottic cancer and 26 cases oropharyngeal cancer. The median of lymphatic metastatic size was 8 mm (range 0-46). According to lymphatic metastatic size, the patients were assigned to three subgroups: Group I (0 mm), Group II ( ≤ 10 mm) and Group III (> 10 mm). Kaplan-Meier analysis with log rank test revealed that Group I and Group II had similar locoregional control rate, distant metastasis free probability, disease-free survival and overall survival (all p > 0.05), whereas Group III had significant worse prognosis. Adjusted for demographic and other clinicopathological characteristics, lymphatic metastatic size was an independent predictor of disease-free survival and overall survival in HNSCC.

CONCLUSIONS

Lymphatic metastatic size was an independently prognostic factor in HNSCC, which may assist in postoperative adjuvant treatment decisions.

Ductal Carcinoma Arising in a Squamous Epithelial Inclusion Cyst within an Axillary Lymph Node: A Challenging Nodal Metastasis

Introduction. Assessment of axillary lymph nodes in breast carcinoma is an important part of staging to guide appropriate clinical management. Lymph node inclusions of different types, including nevoid, squamous, and glandular, are rare but have been reported in multiple different anatomic locations including the axilla. These can result in diagnostic challenges and pose risks of misdiagnoses. Rarely, malignancies may arise intrinsic to otherwise incidental benign nodal inclusions. Case Presentation. We report a case of ductal carcinoma diagnosed within a squamous epithelial inclusion cyst within an axillary lymph node in a patient with pure ductal carcinoma in situ (DCIS) of the ipsilateral right breast. To our knowledge, this is the fifth report in the literature of breast carcinoma confirmed within an axillary inclusion in a patient with pure DCIS. Evaluation of the primary DCIS and lymph node inclusions, by routine and immunohistochemical stains, was performed for assessment. Discussion. The presence of lymph node inclusions can pose a challenge in assessment of benignity and malignancy, on frozen and permanent histologic sections. Pathologists should carefully evaluate lymph node inclusions to ensure that intrinsic malignancies are not missed within rare otherwise benign appearing incidental epithelial rests.

Negative Survival Impact of Occult Lymph Node Involvement in Small HER2-Positive Early Breast Cancer Treated by Up-Front Surgery

(1) Background: The independent negative prognostic value of isolated tumor cells or micro-metastases in axillary lymph nodes has been established in triple-negative breast cancers (BC). However, the prognostic significance of pN0(i+) or pN1mi in HER2-positive BCs treated by primary surgery remains unexplored. Therefore, our objective was to investigate the impact of pN0(i+) or pN1mi in HER2-positive BC patients undergoing up-front surgery on their outcomes. (2) Methods: We retrospectively analyzed 23,650 patients treated in 13 French cancer centers from 1991 to 2013. pN status was categorized as pN0, pN0(i+), pN1mi, and pNmacro. The effect of pN0(i+) or pN1mi on outcomes was investigated both in the entire cohort of patients and in pT1a-b tumors. (3) Results: Of 1771 HER2-positive BC patients included, pN status distributed as follows: 1047 pN0 (59.1%), 60 pN0(i+) (3.4%), 118 pN1mi (6.7%), and 546 pN1 macro-metastases (30.8%). pN status was significantly associated with sentinel lymph node biopsy, axillary lymph node dissection, age, ER status, tumor grade, and size, lymphovascular invasion, adjuvant systemic therapy (ACt), and radiation therapy. With 61 months median follow-up (mean 63.2; CI 95% 61.5-64.9), only pN1 with macro-metastases was independently associated with a negative impact on overall, disease-free, recurrence-free, and metastasis-free survivals in multivariate analysis. In the pT1a-b subgroup including 474 patients, RFS was significantly decreased in multivariate analysis for pT1b BC without ACt (HR 2.365, 1.04-5.36, p = 0.039) and for pN0(i+)/pN1mi patients (HR 2.518, 1.03-6.14, p = 0.042). (4) Conclusions: Survival outcomes were not adversely affected by pN0(i+) and pN1mi in patients with HER2-positive BC. However, in the case of pT1a-b HER2-positive BC, a negative impact on RFS was observed specifically for patients with pN0(i+) and pN1mi diseases, particularly among those with pT1b tumors without ACt. Our findings highlight the importance of considering the pN0(i+) and pN1mi status in the decision-making process when discussing trastuzumab-based ACt for these patients.

Effectiveness of post-mastectomy adjuvant chemotherapy for the treatment of patients with prognostic stage IB breast cancer: A SEER-based study

BACKGROUND

Adjuvant chemotherapy (AC) is an important, effective treatment for breast cancer. This study evaluates the effectiveness of post-mastectomy AC in treating patients with prognostic stage IB breast cancer.

METHOD

We conducted a retrospective cohort-based study using Surveillance, Epidemiology, and End-Results database. Overall survival (OS) and breast cancer-specific survival (BCSS) were calculated using the Kaplan-Meier method. Multivariate Cox risk models were used to identify the impact of AC. Stratified analysis was performed according to molecular subtypes, anatomic stages, and other risk factors to evaluate the effect of AC on survival.

RESULTS

28,825 women diagnosed with prognostic stage IB breast cancer were included. The 5-year OS was significantly higher in AC group than in non-adjuvant chemotherapy (NAC) group (P < 0.0001); however, the 5-year BCSS in AC group was significantly lower than in NAC group (P = 0.039). Multivariate analysis revealed that AC was a favorable prognostic factor for OS (P < 0.001), but not BCSS (P = 0.407). AC was not an independent prognostic factor for BCSS in patients with hormone receptor-positive, human epidermal growth factor receptor 2-negative (HR[+]/HER2[-]) subtype or pT1a-1b/N0-1 stage with HER2 overexpression (HER2[+]) subtype, regardless of whether HR was positive or negative (P > 0.05). Meanwhile, AC is not an independent prognostic factor for OS and BCSS in patients with lymph node micrometastases.

CONCLUSION

Our study demonstrates that patients with prognostic stage IB do not fully benefit from AC. Individualized treatment management is required for patients with pT1a-1b/N0-1 tumors, lymph node micrometastases, or HR(+)/HER2(-) subtypes.

Nomogram for predicting axillary upstaging in clinical node-negative breast cancer patients receiving neoadjuvant chemotherapy

PURPOSE

The prediction of axillary lymph node status after neoadjuvant chemotherapy (NAC) becoming critical because of the advocation of the de-escalation of axillary management. We investigate associated factors of axillary upstaging in clinical node-negative (cN0) breast cancer patients receiving NAC to develop and validate an accurate prediction nomogram.

METHODS

We retrospectively analyzed 1892 breast cancer patients with stage of cT1-3N0 treated by NAC and subsequent surgery between 2010 and 2020 in twenty hospitals across China. Patients randomly divided into a training set and validation set (3:1). Univariate and multivariate logistic regression analysis were performed, after which a nomogram was constructed and validated.

RESULTS

In total, pathologic node negativity (ypN0) achieved in 1406 (74.3%) patients and another 486 (25.7%) patients upstaged to pathologic node positive (ypN+). Breast pathologic complete response (bpCR) was achieved in 445 (23.5%) patients and non-bpCR in 1447 (76.5%) patients. A nomogram was established by ER, tumor histology, HER2 status, cycle of NAC treatment, and the bpCR, which were confirmed by multivariate logistic analysis as independent predictors of nodal upstaging in the training cohort (n = 1419). The area under the receiver operating characteristic curve (AUC) of the training cohort and validation cohort (n = 473) were 0.73 (95% CI 0.693-0.751) and 0.77 (95% CI 0.723-0.812) respectively.

CONCLUSION

We present a nomogram with a nationwide large sample data which can effectively predict axillary upstaging after neoadjuvant chemotherapy to give better advice for individualized axillary lymph node management of breast cancer.

Prognosis and local treatment strategies of breast cancer patients with different numbers of micrometastatic lymph nodes

BACKGROUND

Lymph node micrometastasis is an important prognostic factor in breast cancer, but patients with different numbers of involved lymph nodes are all divided into the same N1mi stage without distinction. We designed this study to compare the prognosis and local treatment recommendations of N1mi breast cancer patients with different numbers of micrometastatic lymph nodes.

PATIENTS AND METHODS

A total of 27,032 breast cancer patients with T1-2N1miM0 stage from the Surveillance, Epidemiology, and End Results (SEER) database (2004-2019) who underwent breast surgery were included in this retrospective study. Patients were divided into three groups for prognosis comparison according to the number of micrometastatic lymph nodes: N1mi with 1 (Nmi = 1), 2 (Nmi = 2), or more (Nmi ≥ 3) involved lymph nodes. We explored the characteristics and survival outcomes of the population receiving different local treatments, including different axillary surgery types and whether receiving radiotherapy or not. Univariate and multivariate Cox proportional hazards regression analysis were used to compare the overall survival (OS) and breast cancer-specific survival (BCSS) in different groups. Stratified analyses and interaction analyses were also applied to explore the predictive significance of different involved lymph nodes numbers. Propensity score matching (PSM) method was utilized to balance the differences between groups.

RESULTS

Univariate and multivariate Cox regression analysis indicated that nodal status was an independent prognostic factor. After adjustment for other prognostic factors, there was a significant difference in prognosis between Nmi = 1 group and Nmi = 2 group [adjusted hazard ratio (HR) 1.145, 95% confidence interval (CI): 1.047-1.251, P = 0.003], and patients with Nmi ≥ 3 group had a significantly poorer prognosis (adjusted HR 1.679, 95% CI 1.589-2.407; P < 0.001). The proportion of N1mi patients only underwent sentinel lymph nodes biopsy (SLNB) gradually increased from 2010 (P_trend < 0.001). After adjusting for other factors, N1mi patients who underwent axillary lymph nodes dissection (ALND) was associated with significant survival benefit than SLNB (adjusted HR 0.932, 95%CI 0.874-0.994; P = 0.033), the same goes for receiving radiotherapy (adjusted HR 1.107, 95%CI 1.030-1.190; P = 0.006). Further stratified analysis showed that in the SLNB subgroup, radiotherapy was associated with a significant survival benefit (HR 1.695, 95%CI 1.534-1.874; P < 0.001), whereas in the ALND subgroup, there was no significant prognostic difference with or without radiotherapy (HR 1.029, 95%CI 0.933-1.136; P = 0.564).

CONCLUSION

Our study indicates that the increasing number of lymph node micrometastases was associated a worse prognosis of N1mi breast cancer patients. In addition, ALND does provide a significant survival benefit for these patients, while the benefit from local radiotherapy may be of even greater importance.

Evaluating the Necessity for Routine Sentinel Lymph Node Biopsy in Postmenopausal Patients Being Treated for Clinically Node Negative Breast Cancer the Era of RxPONDER

INTRODUCTION

Traditionally, sentinel lymph node biopsy (SLNB) was performed to inform adjuvant chemotherapy prescription and prognosis in breast cancer. Following RxPONDER, the OncotypeDX Recurrence Score (RS) guides adjuvant chemotherapy prescription for all postmenopausal patients with estrogen receptor positive, human epidermal growth factor receptor-2 negative (ER+/HER2-) breast cancer with 0 to 3 positive lymph nodes (0-3 + LN).

AIMS

To establish the oncological safety of omitting SLNB in postmenopausal patients with ER+/HER2- breast cancer indicated to undergo SLNB and to evaluate the primary determinants of chemotherapy prescription for these patients.

PATIENTS AND METHODS

A retrospective cohort study was undertaken. Cox regression and Kaplan-Meier analyses were performed. Data analytics was performed using SPSS v26.0.

RESULTS

Five hundred and seventy five consecutive patients were included (mean age: 66.5 years, range: 45-96). The median follow-up was 97.2 months (range: 3.0-181.6). Of the 575 patients, just 12 patients had positive SLNB (SLNB+) (2.1%). Using Kaplan-Meier analyses, SLNB+ failed to impact recurrence (P = .766) or mortality (P = .310). However, using Cox regression analyses, SLNB+ independently predicted poorer disease-free survival (hazard ratio: 1.001, 95% confidence interval (95% CI): 1.000-1.001, P = .029). Logistic regression analysis identified RS as the sole predictor of chemotherapy prescription (odds ratio: 1.171, 95% CI: 1.097-1.250, P < .001).

CONCLUSION

Omitting SLNB may be safe and justifiable in postmenopausal patients with ER+/HER2- breast cancer with clinically negative axillae. Following RxPONDER, RS is the most important guide of chemotherapy use in these patients and SLNB may be less important than previously perceived. Prospective, randomized clinical trials are required to fully establish the oncological safety of omitting SLNB in this setting.

Anatomical site and size of sentinel lymph node metastasis predicted additional axillary tumour burden and breast cancer survival

AIMS

Sentinel lymph node (SLN) biopsy is the current standard assessment for tumour burden in axillary lymph node (ALN). However, not all SLN+ patients have ALN metastasis. The prognostic implication of SLN features is not clear. We aimed to evaluate predictive factors for ALN metastasis and the clinical value of SLN features.

METHODS AND RESULTS

A total of 228 SLN+ and 228 SLN- (with matched year and grade) cases were included. Clinicopathological features in SLN, ALN and primary tumours, treatment data and survival data were analysed according to ALN status and outcome. Except for larger tumour size and the presence of LVI (both P < 0.001), no significant differences were found in SLN- and SLN+ cases. Only 31.8% of SLN+ cases with ALN dissection had ALN metastasis. The presence of macrometastases (MaM), extranodal extension (ENE), deeper level of tumour invasion in SLN and more SLN+ nodes were associated with ALN metastasis (P ≤ 0.025). Moreover, isolated tumour cells (ITC) and level of tumour invasion in SLN were independent adverse prognostic features for disease-free survival and breast cancer-specific survival, respectively. Interestingly, cases with ITC located in the subcapsular region have better survival than those in cortex (OS: χ²  = 4.046, P = 0.044).

CONCLUSIONS

Our study identified features in SLN, i.e. the level of tumour invasion at SLN and tumour size in SLN as useful predictors for both ALN metastasis and breast cancer outcome. The presence of ITC, particularly those with a deeper invasion in SLN, portended a worse prognosis. Proper attention should be taken for their management.

Evaluation of adjuvant therapy for T1-2N1miM0 breast cancer without further axillary lymph node dissection

Background

For breast cancer (BC) with sentinel lymph node micrometastases (SLNMs), there are limited data to guide the selection of postoperative adjuvant therapy. This study aimed to identify target populations who might benefit most from adjuvant therapy and examine prognostic factors among patients with T1-2N1miM0 BC with one or two SLNMs who underwent sentinel lymph node biopsy (SLNB) alone.

Methods

There were 7,423 patients diagnosed with T1-2N1miM0 BC between 2010 and 2015, and patients with one or two SLNMs were extracted from the Surveillance, Epidemiology, and End Results database. All the patients underwent SLNB alone without further axillary lymph node dissection, and they were stratified according to adjuvant therapy. The statistical significance of categorical variables was analyzed using the χ ² test. Univariable and multivariable Cox analyses were used to analyze characteristics predictive of Breast-cancer-specific survival and overall survival (OS). Kaplan-Meier methods with the log-rank test was analyzed to compare survival difference between the different treatments.

Results

Adjuvant chemotherapy and radiotherapy improved 5-year OS rates. Multivariate analysis revealed that age ≥70 years, high grade, T2 stage, triple-negative subtype, and absence of radiotherapy were poor prognostic factors for OS. Patients who received breast-conserving surgery (BCS), and those with invasive ductal carcinoma (IDC), luminal A, luminal B, or basal-like subtype, and T1c or T2 stage benefited from adjuvant radiotherapy. Patients who received BCS, and those with IDC, luminal A subtype, and T1b, T1c, or T2 stage benefited from adjuvant chemotherapy.

Conclusion

Our findings provide a clinical evaluation of treatment choice after surgery, which may help clinicians make individualized clinical decisions.

Contrast-enhanced lymphatic US can improve the preoperative diagnostic performance for sentinel lymph nodes in early breast cancer

OBJECTIVES

To evaluate the preoperative diagnostic value of contrast-enhanced lymphatic ultrasound (CEUS) for the sentinel lymph node (SLN) status in early breast cancer.

MATERIALS AND METHODS

We prospectively recruited 102 consecutive patients with clinically node-negative early breast cancer from July 2021 to October 2021. All patients underwent conventional US and percutaneous CEUS examinations. The CEUS of SLNs were classified into four enhancement patterns: homogeneous (I), featured inhomogeneous (II), focal defect (III), and no enhancement (IV). The diagnostic performance of conventional US and CEUS for SLN metastasis was assessed by receiver operating characteristic (ROC) curves and decision curves.

RESULTS

A total of 78 women were enrolled in this study, including 55, 18, and 5 patients with negative axilla, 1-2, and ≥ 3 metastastic SLNs pathologically, respectively. The identification rate of SLNs by CEUS was 100%. Patterns I and II can select 91.7% (44/48) of patients with disease-free axilla, while patterns III and IV had higher percentages of metastasis (65.2%, p < 0.001 and 57.1%, p < 0.002, respectively). For the SLN metastatic burden, 100% (48/48) of patients with pattern I/II had ≤ 2 metastatic SLNs. Compared with conventional US, the CEUS enhancement patterns showed significant improvement in diagnosing metastatic SLNs (0.813 vs 0.601, p < 0.001). CEUS had greater clinical benefits and correctly reclassified 48% of metastatic SLNs (p < 0.001) without sacrificing the classification accuracy of negative SLNs (p = 0.25), and could improve prediction accuracy by 0.42 (p < 0.001).

CONCLUSIONS

CEUS demonstrated better diagnostic performance and greater clinical benefits than conventional US for the preoperative diagnosis of SLNs, showing its potential to select candidates for precluding axillary surgery in early breast cancer.

KEY POINTS

• The homogeneous and featured inhomogeneous enhancement of SLNs are highly suggestive of negative LNs, while focal defect (p < 0.001) and no enhancement (p < 0.002) patterns had higher percentages of metastasis. • The proportion of SLNs with highly suspicious signs on conventional US increases as the type of enhancement pattern increases (no suspicious signs in pattern I/II, 34.8% in pattern III, and 85.7% in pattern IV). • Compared with conventional US, CEUS improved the area under the receiver operating characteristic curve (0.813 vs. 0.601, p < 0.001) and had greater clinical benefits (IDI = 0.42, p < 0.001) for the diagnosis of axillary metastasis.

Radiomics model based on features of axillary lymphatic nodes to predict axillary lymphatic node metastasis in breast cancer

BACKGROUND

Breast cancer (BC) is among the most common cancers worldwide. Machine learning-based radiomics model could predict axillary lymph node metastasis (ALNM) of BC accurately.

PURPOSE

The purpose is to develop a machine learning model to predict ALNM of BC by focusing on the radiomics features of axillary lymphatic node (ALN).

METHODS

A group of 398 BC patients with 800 ALNs were retrospectively collected. A set of patient characteristics were obtained to form clinical factors. Three hundred and twenty-six radiomics features were extracted from each region of interest for ALN in contrast-enhanced computed tomography (CECT) image. A framework composed of four feature selection methods and 14 machine learning classification algorithms was systematically applied. A clinical model, a radiomics model, and a combined model were developed using a cross-validation approach and compared. Metrics of the area under the curve (AUC), accuracy, sensitivity, and specificity were calculated to evaluate the performance of these models in the prediction of ALNM in BC.

RESULTS

Among the 800 cases of ALNs, there were 388 cases of positive metastasis (48.50%) and 412 cases of negative metastasis (51.50%). The baseline clinical model achieved the performance with an AUC = 0.8998 (95% CI [0.8540, 0.9457]). The radiomics model achieved an AUC = 0.9081 (95% CI [0.8640, 0.9523]). The combined model using the clinical factors and radiomics features achieved the best results with an AUC = 0.9305 (95% CI [0.8928, 0.9682]).

CONCLUSIONS

Combinations of feature selection methods and machine learning-based classification algorithms can develop promising predictive models to predict ALNM in BC using CECT features. The combined model of clinical factors and radiomics features outperforms both the clinical model and the radiomic model.

Comparison of the Nottingham Prognostic Index and OncotypeDX© recurrence score in predicting outcome in estrogen receptor positive breast cancer

INTRODUCTION

Traditionally, Nottingham prognostic index (NPI) informed prognosis in patients with estrogen receptor positive, human epidermal growth factor receptor-2 negative, node negative (ER+/HER2-/LN-) breast cancer. At present, OncotypeDX© Recurrence Score (RS) predicts prognosis and response to adjuvant chemotherapy (AC).

AIMS

To compare NPI and RS for estimating prognosis in ER + breast cancer.

METHODS

Consecutive patients with ER+/HER2-/LN- disease were included. Disease-free (DFS) and overall survival (OS) were determined using Kaplan-Meier and Cox regression analyses.

RESULTS

1471 patients met inclusion criteria. The mean follow-up was 110.7months. NPI was calculable for 1382 patients: 19.8% had NPI≤2.4 (291/1471), 33.0% had NPI 2.41-3.4 (486/1471), 30.0% had NPI 3.41-4.4 (441/1471), 10.9% had NPI 4.41-5.4 (160/1471), and 0.3% had NPI>5.4 (4/1471). In total, 329 patients underwent RS (mean RS: 18.7) and 82.1% had RS < 25 (270/329) and 17.9% had RS ≥ 25 (59/329). Using multivariable Cox regression analyses (n = 1382), NPI independently predicted DFS (Hazard ratio (HR): 1.357, 95% confidence interval (CI): 1.140-1.616, P < 0.001) and OS (HR: 1.003, 95% CI: 1.001-1.006, P = 0.024). When performing a focused analysis of those who underwent both NPI and RS (n = 329), neither biomarker predicted DFS or OS. Using Kaplan Meier analyses, NPI category predicted DFS (P = 0.008) and (P = 0.026) OS. Conversely, 21-gene RS group failed to predict DFS (P = 0.187) and OS (P = 0.296).

CONCLUSION

In our focused analysis, neither NPI nor RS predicted survival outcomes. However, in the entire series, NPI independently predicted both DFS and OS. On the 40th anniversary since its derivation, NPI continues to provide accurate prognostication in breast cancer, outperforming RS in the current study.

Role of Lymphatic Endothelium in Vascular Escape of Engineered Human Breast Microtumors

Introduction

Lymphatic vasculature provides a route for metastasis to secondary sites in the body. The role of the lymphatic endothelium in mediating the entry of breast cancer cells into the vasculature remains unclear.

Methods

In this study, we formed aggregates of MDA-MB-231 human breast carcinoma cells next to human microvascular lymphatic endothelial cell (LEC)-lined cavities in type I collagen gels to model breast microtumors and lymphatic vessels, respectively. We tracked invasion and escape of breast microtumors into engineered lymphatics or empty cavities under matched flow rates for up to sixteen days.

Results

After coming into contact with a lymphatic vessel, tumor cells escape by moving between the endothelium and the collagen wall, between endothelial cells, and/or into the endothelial lumen. Over time, tumor cells replace the LECs within the vessel wall and create regions devoid of endothelium. The presence of lymphatic endothelium slows breast tumor invasion and escape, and addition of LEC-conditioned medium to tumors is sufficient to reproduce nearly all of these inhibitory effects.

Conclusions

This work sheds light on the interactions between breast cancer cells and lymphatic endothelium during vascular escape and reveals an inhibitory role for the lymphatic endothelium in breast tumor invasion and escape.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12195-022-00745-9.

The Analysis of Relevant Gene Networks Based on Driver Genes in Breast Cancer

BACKGROUND

The occurrence and development of breast cancer has a strong correlation with a person's genetics. Therefore, it is important to analyze the genetic factors of breast cancer for future development of potential targeted therapies from the genetic level.

METHODS

In this study, we complete an analysis of the relevant protein-protein interaction network relating to breast cancer. This includes three steps, which are breast cancer-relevant genes selection using mutual information method, protein-protein interaction network reconstruction based on the STRING database, and vital genes calculating by nodes centrality analysis.

RESULTS

The 230 breast cancer-relevant genes were chosen in gene selection to reconstruct the protein-protein interaction network and some vital genes were calculated by node centrality analyses. Node centrality analyses conducted with the top 10 and top 20 values of each metric found 19 and 39 statistically vital genes, respectively. In order to prove the biological significance of these vital genes, we carried out the survival analysis and DNA methylation analysis, inquired about the prognosis in other cancer tissues and the RNA expression level in breast cancer. The results all proved the validity of the selected genes.

CONCLUSIONS

These genes could provide a valuable reference in clinical treatment among breast cancer patients.

Five-year survival rate and prognostic factors in women with breast cancer treated at a reference hospital in the Brazilian Amazon

Breast cancer is the most prevalent malignant neoplasm and the leading cause cancer of death among women globally. In Brazil, survival rates vary according to the region and few studies have been conducted on breast cancer survival in less developed areas, such as the Amazon region. The aim of this study was to analyze the five-year survival rate and prognostic factors in women treated for breast cancer in the city of Belém in northern Brazil. A retrospective hospital-based cohort study was conducted (2007-2013). Sociodemographic, clinical/tumor, and treatment variables were obtained from the records at the Ophir Loyola Hospital. Survival analysis involved the Kaplan-Meier statistical method and Cox regression analysis was performed. The significance level was 5% (p <0.05). A total of 1,430 cases were analyzed. Mean survival time was 51.71 (± 17.22) months, with an estimated overall survival of 79.4%. In the multivariate analysis, referral from the public health care system, advanced clinical stage, lymph node involvement and metastasis were associated with worse prognosis and lower survival rate. Radiotherapy and hormone therapy were associated with increased survival. These findings can contribute to the development of regional strategies for early detection of breast cancer, reducing the incidence and mortality rates and increasing survival time.

Preoperative Prediction of Axillary Lymph Node Metastasis in Breast Cancer Based on Intratumoral and Peritumoral DCE-MRI Radiomics Nomogram

Objective

To investigate the value of preoperative prediction of breast cancer axillary lymph node metastasis based on intratumoral and peritumoral dynamic contrast enhancement magnetic resonance imaging (DCE-MRI) radiomics nomogram. Material and Methods. In this study, a radiomics model was developed based on a training cohort involving 250 patients with breast cancer (BC) who had undergone axillary lymph node (ALN) dissection between June 2019 and January 2021. The intratumoral and peritumoral radiomics features were extracted from the second postcontrast images of DCE-MRI. Based on filtered radiomics features, the radiomics signature was built by using the least absolute shrinkage and selection operator method. The Support Vector Machines (SVM) learning algorithm was used to construct intratumoral, periatumoral, and intratumoral combined periatumoral models for predicting axillary lymph node metastasis (ALNM) in BC. Nomogram performance was determined by its discrimination, calibration, and clinical value. Multivariable logistic regression was adopted to establish a radiomics nomogram.

Results

The intratumoral combined peritumoral radiomics signature, which was composed of fifteen ALN status-related features, showed the best predictive performance and was associated with ALNM in both the training and validation cohorts (P < 0.001). The prediction efficiency of the intratumoral combined peritumoral radiomics model was higher than that of the intratumoral radiomics model and the peritumoral radiomics model. The AUCs of the training and verification cohorts were 0.867 and 0.785, respectively. The radiomics nomogram, which incorporated the radiomics signature, MR-reported ALN status, and MR-reported maximum diameter of the lesion, showed good calibration and discrimination in the training (AUC = 0.872) and validation cohorts (AUC = 0.863).

Conclusion

The intratumoral combined peritumoral radiomics model derived from DCE-MRI showed great predictive value for ALNM and may help to improve clinical decision-making for BC.

The implementation of a noninvasive lymph node staging (NILS) preoperative prediction model is cost effective in primary breast cancer

Purpose

The need for sentinel lymph node biopsy (SLNB) in clinically node-negative (cN0) patients is currently questioned. Our objective was to investigate the cost-effectiveness of a preoperative noninvasive lymph node staging (NILS) model (an artificial neural network model) for predicting pathological nodal status in patients with cN0 breast cancer (BC).

Methods

A health-economic decision-analytic model was developed to evaluate the utility of the NILS model in reducing the proportion of cN0 patients with low predicted risk undergoing SLNB. The model used information from a national registry and published studies, and three sensitivity/specificity scenarios of the NILS model were evaluated. Subgroup analysis explored the outcomes of breast-conserving surgery (BCS) or mastectomy. The results are presented as cost (€) and quality-adjusted life years (QALYs) per 1000 patients.

Results

All three scenarios of the NILS model reduced total costs (–€93,244 to –€398,941 per 1000 patients). The overall health benefit allowing for the impact of SLNB complications was a net health gain (7.0–26.9 QALYs per 1000 patients). Sensitivity analyses disregarding reduced quality of life from lymphedema showed a small loss in total health benefits (0.4–4.0 QALYs per 1000 patients) because of the reduction in total life years (0.6–6.5 life years per 1000 patients) after reduced adjuvant treatment. Subgroup analyses showed greater cost reductions and QALY gains in patients undergoing BCS.

Conclusion

Implementing the NILS model to identify patients with low risk for nodal metastases was associated with substantial cost reductions and likely overall health gains, especially in patients undergoing BCS.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-022-06636-x.

Thorny ground, rocky soil: Tissue-specific mechanisms of tumor dormancy and relapse

Disseminated tumor cells (DTCs) spread systemically yet distinct patterns of metastasis indicate a range of tissue susceptibility to metastatic colonization. Distinctions between permissive and suppressive tissues are still being elucidated at cellular and molecular levels. Although there is a growing appreciation for the role of the microenvironment in regulating metastatic success, we have a limited understanding of how diverse tissues regulate DTC dormancy, the state of reversible quiescence and subsequent awakening thought to contribute to delayed relapse. Several themes of microenvironmental regulation of dormancy are beginning to emerge, including vascular association, co-option of pre-existing niches, metabolic adaptation, and immune evasion, with tissue-specific nuances. Conversely, DTC awakening is often associated with injury or inflammation-induced activation of the stroma, promoting a proliferative environment with DTCs following suit. We review what is known about tissue-specific regulation of tumor dormancy on a tissue-by-tissue basis, profiling major metastatic organs including the bone, lung, brain, liver, and lymph node. An aerial view of the barriers to metastatic growth may reveal common targets and dependencies to inform the therapeutic prevention of relapse.

OUP accepted manuscript

Background

Axillary lymph node status remains the most powerful prognostic indicator in invasive breast cancer. Ductal carcinoma in situ (DCIS) is a non-invasive disease and does not spread to axillary lymph nodes. The presence of an invasive component to DCIS mandates nodal evaluation through sentinel lymph node biopsy (SLNB). Quantification of the necessity of upfront SLNB for DCIS requires investigation. The aim was to establish the likelihood of having a positive SLNB (SLNB+) for DCIS and to establish parameters predictive of SLNB+.

Methods

A systematic review was performed as per the PRISMA guidelines. Prospective studies only were included. Characteristics predictive of SLNB+ were expressed as dichotomous variables and pooled as odds ratios (o.r.) and associated 95 per cent confidence intervals (c.i.) using the Mantel–Haenszel method.

Results

Overall, 16 studies including 4388 patients were included (mean patient age 54.8 (range 24 to 92) years). Of these, 72.5 per cent of patients underwent SLNB (3156 of 4356 patients) and 4.9 per cent had SLNB+ (153 of 3153 patients). The likelihood of having SLNB+ for DCIS was less than 1 per cent (o.r. <0.01, 95 per cent c.i. 0.00 to 0.01; P < 0.001, I² = 93 per cent). Palpable DCIS (o.r. 2.01, 95 per cent c.i. 0.64 to 6.24; P = 0.230, I² = 0 per cent), tumour necrosis (o.r. 3.84, 95 per cent c.i. 0.85 to 17.44; P = 0.080, I² = 83 per cent), and grade 3 DCIS (o.r. 1.34, 95 per cent c.i. 0.80 to 2.23; P = 0.270, I² = 0 per cent) all trended towards significance in predicting SLNB+.

Conclusion

While aggressive clinicopathological parameters may guide SLNB for patients with DCIS, the absolute and relative risk of SLNB+ for DCIS is less than 5 per cent and 1 per cent, respectively. Well-designed randomized controlled trials are required to establish fully the necessity of SLNB for patients diagnosed with DCIS.

Registration number

CRD42021284194 (https://www.crd.york.ac.uk/prospero/)

Predictive value of chest computed tomography for axillary lymph node metastasis in patients with breast cancer: A retrospective cohort study

Purpose: This study aimed to evaluate the predictive value of preoperative chest computed tomography (CT) for axillary lymph node (ALN) metastasis in patients with breast cancer.Methods: CT features of ALNs were retrospectively reviewed in 212 patients with breast cancer who underwent preoperative chest CT examination and ALN dissection. Primary tumor size and CT characteristics of ALNs (cortical thickness, cortical shape, the presence or absence of contrast enhancement of ALNs, and the presence or absence of perinodal infiltration) were recorded and analyzed. A nomogram was developed to visualize the associations between the predictors and each ALN status endpoint.Results: Of 212 patients, 95 (44.8%) had ALN metastasis. Primary tumor size and CT characteristics of ALNs were identified as predictors of ALN metastasis. The nomogram comprising primary tumor size and cortical shape was a good validation model for predicting ALN metastasis. The sensitivity, specificity, and accuracy of the nomogram for predicting ALN metastasis were 88.4%, 79.5%, and 83.5%, respectively.Conclusion: Using preoperative chest CT scans, a nomogram combining the cortical shape of ALNs with the primary tumor size showed good performance in predicting ALN metastasis.

Breast-Conserving Therapy Has Better Prognosis for Tumors in the Central and Nipple Portion of Breast Cancer Compared with Mastectomy: A SEER Data-Based Study

BACKGROUND AND OBJECTIVES

Currently, the location of primary tumor was an independent prognostic factor of breast cancer. Tumors in the central and nipple portion (TCNP) had poor prognosis compared to other peripheral quadrants. The breast-conserving therapy (BCT) is becoming increasingly common worldwide in breast cancer operations. However, whether the availability of BCT was performed for TCNP remained a matter of debate. We sought to investigate whether BCT was suitable for TCNP with respect to survival outcomes, compared with mastectomy therapy.

METHODS

Utilizing the Surveillance, Epidemiology, and End Results (SEER) database, we obtained TCNP breast cancer patients diagnosed during the period of 2010-2015. One-to-one (1:1) propensity score matching (PSM) was applied to construct a matched sample consisting of pairs of BCT and mastectomy groups. Univariate and multivariate Cox proportional hazard models were applied to estimate the factors associated with breast cancer-specific survival (BCSS) and overall survival (OS). Survival analysis was performed with the Kaplan-Meier method.

RESULTS

In the overall cohort, a total of 9,900 patients were enrolled. We found that patients with BCT showed significantly better BCSS (log-rank, p < 0.001) and OS (log-rank, p < 0.001) than the mastectomy group before PSM. The same finding was also shown in 5,820 patients after PSM. Additionally, none of the subgroups, including age, sex, race, histological grade, AJCC stage, and molecular subtype undergoing mastectomy therapy, had better BCSS than BCT.

CONCLUSIONS

Our study was the first research to show that BCT exhibited superior prognosis in the cohort of TCNP from SEER databases than mastectomy therapy. This finding could provide a cue for treatment strategies for suitable TCNP patients, especially those with a strong willingness to conserve their breasts.

Characterizing Occult Nodal Disease Within a Clinically Node-Negative, Neoadjuvant Breast Cancer Population

BACKGROUND

Neoadjuvant therapy aims to preoperatively downstage breast cancer patients. We evaluated nodal upstaging in clinically node-negative (cN0) patients receiving neoadjuvant chemotherapy (NAC) and neoadjuvant endocrine therapy (NET).

METHODS

cN0 patients undergoing neoadjuvant therapy from 2009 to 2018 were reviewed. Univariate and multivariate analyses evaluated rates of nodal upstaging.

RESULTS

A total of 228 cN0 patients with a mean age of 55 years underwent neoadjuvant therapy for Stage I-III invasive carcinoma. Subtypes included ER+/HER2- = 93 (40%), HER2+ = 61 (27%), and triple negative (TNBC) = 74 (33%). Among ER+/HER2- patients, 65 (70%) underwent NET. Overall, 49 patients (21%) were upstaged due to occult nodal disease. Factors associated with higher rates of occult nodal disease included advanced stage on initial presentation (P = .008), larger presenting tumor size (P = .009), low/intermediate tumor grade (P = .025), and ER+/HER2- subtype (P < .001); incidence of occult nodal disease by subtype included: ER+/HER2- = 37%, HER2+ = 15%, TNBC = 8%. Patients experiencing a breast pCR had a significantly lower rate of nodal upstaging compared to those with residual tumor (4% vs. 96%, P < .001). On multivariate analysis, ER+/HER- patients exhibited higher risk of occult nodal disease when compared to patients with HER2+ (odds ratio [OR] = 3.4, 95% CI, 1.2-9.8, P = .003) and TNBC (OR = 5.7, 95% CI, 1.7-19.6, P = .003). Comparing NAC vs. NET in ER+/HER2- patients showed no difference in rates of occult nodal disease (39% vs. 35%, P = .13).

CONCLUSIONS

ER+/HER2- subtype carries higher risk for occult nodal disease after neoadjuvant therapy; NAC versus NET in these patients does not affect nodal upstaging.

The Multifaceted Effects of Breast Cancer on Tumor-Draining Lymph Nodes

Breast cancer (BC) accounts for significant morbidity and mortality among women worldwide. About one in three patients with breast cancer present with lymph node (LN) metastasis and LN status is one of the most important prognostic predictors in patients with BC. In addition to their prognostic value, LNs initiate adaptive immunity against BC. Yet, BC cells often avoid immune-mediated destruction in LNs. This review provides an overview of the ways by which BC cells modulate LN stromal and hematopoietic cells to promote metastasis and immune evasion.

Omitting completion axillary lymph node dissection after detection of sentinel node micrometastases in breast cancer: first results from the prospective SENOMIC trial

BACKGROUND

Completion axillary lymph node dissection has been abandoned widely among patients with breast cancer and sentinel lymph node micrometastases, based on evidence from prospective RCTs. Inclusion in these trials has been subject to selection bias, with patients undergoing mastectomy being under-represented. The aim of the SENOMIC (omission of axillary lymph node dissection in SENtinel NOde MICrometases) trial was to confirm the safety of omission of axillary lymph node dissection in patients with breast cancer and sentinel lymph node micrometastases, and including patients undergoing mastectomy.

METHODS

The prospective SENOMIC multicentre cohort trial enrolled patients with breast cancer and sentinel lymph node micrometastases who had breast-conserving surgery or mastectomy at one of 23 Swedish hospitals between October 2013 and March 2017. No completion axillary lymph node dissection was performed. The primary endpoint was event-free survival, with a trial accrual target of 452 patients. Survival proportions were based on Kaplan-Meier survival estimates.

RESULTS

The trial included 566 patients. Median follow-up was 38 (range 7-67) months. The 3-year event-free survival rate was 96.2 per cent, based on 26 reported breast cancer recurrences, including five isolated axillary recurrences. The unadjusted 3-year event-free survival rate was higher than anticipated, but differed between patients who had mastectomy and those who underwent breast-conserving surgery (93.8 versus 97.8 per cent respectively; P = 0.011). Patients who underwent mastectomy had significantly worse tumour characteristics. On univariable Cox proportional hazards regression analysis, patients who had mastectomy without adjuvant radiotherapy had a significantly higher risk of recurrence than those who underwent breast-conserving surgery (hazard ratio 2.91, 95 per cent c.i. 1.25 to 6.75).

CONCLUSION

After 3 years, event-free survival was excellent in patients with breast cancer and sentinel node micrometastases despite omission of axillary lymph node dissection. Long-term follow-up and continued enrolment of patients having mastectomy, especially those not receiving adjuvant radiotherapy, are of utmost importance.

Lack of prognostic impact of sentinel node micro-metastases in endocrine receptor-positive early breast cancer: results from a large multicenter cohort☆

Background

Prognostic impact of lymph node micro-metastases (pN1mi) has been discordantly reported in the literature. The need to clarify this point for decision-making regarding adjuvant therapy, particularly for patients with endocrine receptor (ER)-positive status and HER2-negative tumors, is further reinforced by the generalization of gene expression signatures using pN status in their recommendation algorithm.

Patients and methods

We retrospectively analyzed 13 773 patients treated for ER-positive breast cancer in 13 French cancer centers from 1999 to 2014. Five categories of axillary lymph node (LN) status were defined: negative LN (pN0i−), isolated tumor cells [pN0(i+)], pN1mi, and pN1 divided into single (pN1 = 1) and multiple (pN1 > 1) macro-metastases (>2 mm). The effect of LN micro-metastases on outcomes was investigated both in the entire cohort of patients and in clinically relevant subgroups according to tumor subtypes. Propensity-score-based matching was used to balance differences in known prognostic variables associated with pN status.

Results

As determined by sentinel LN biopsy, 9427 patients were pN0 (68.4%), 546 pN0(i+) (4.0%), 1446 pN1mi (10.5%) and 2354 pN1 with macro-metastases (17.1%). With a median follow-up of 61.25 months, pN1 status, but not pN1mi, significantly impacted overall survival (OS), disease-free survival (DFS), metastasis-free survival (MFS), and breast-cancer-specific survival. In the subgroup of patients with known tumor subtype, pN1 = 1, as pN1 > 1, but not pN1mi, had a significant prognostic impact on OS. DFS and MFS were only impacted by pN1 > 1. Similar results were observed in the subgroup of patients with luminal A-like tumors (n = 7101). In the matched population analysis, pN1macro, but not pN1mi, had a statistically significant negative impact on MFS and OS.

Conclusion

LN micro-metastases have no detectable prognostic impact and should not be considered as a determining factor in indicating adjuvant chemotherapy. The evaluation of the risk of recurrence using second-generation signatures should be calculated considering micro-metastases as pN0.

•

LN micro-metastases have no detectable prognostic impact.

•

pN1 status, but not pN1mi, significantly impacted overall survival, disease-free survival, metastasis-free survival.

•

In the subgroup of patients with known tumor subtype, pN1=1, as pN1>1, but not pN1mi, had a significant prognostic impact on OS.

•

LN micro-metastases should not be considered as a determining factor in indicating adjuvant chemotherapy.

Evaluation of Breast Edema Findings at T2-weighted Breast MRI Is Useful for Diagnosing Occult Inflammatory Breast Cancer and Can Predict Prognosis after Neoadjuvant Chemotherapy

Background Prediction of occult inflammatory breast cancer (IBC) and breast cancer prognosis based on breast edema findings on T2-weighted MRI scans, even for patients without clinical signs of IBC, would be useful in both pretreatment planning and prognosis and may elucidate the underlying biologic mechanisms. Purpose To evaluate whether classification of breast edema on T2-weighted MRI scans is useful for predicting the prognosis of patients with breast cancer treated with neoadjuvant chemotherapy (NAC). Materials and Methods A retrospective evaluation was performed of women with breast cancer who underwent breast MRI and were treated with NAC between January 2011 and December 2018. Breast edema on T2-weighted images was scored on a scale of 1 to 4, as follows: (a) breast edema score (BES) 1, no edema; (b) BES 2, peritumoral edema; (c) BES 3, prepectoral edema; and (d) BES 4, subcutaneous edema (suspicious for occult IBC). Clinically evident IBC was classified as BES 5 (without MRI). The log-rank test was performed, and hazard ratios were calculated using the Cox hazard model to evaluate associations between BES and progression-free survival (PFS) and overall survival (OS). PFS rate at 100 months after initiation of therapy was also evaluated. Results Of 408 patients (median age, 53 years; range, 28-80 years), 65 (16%) had a recurrence and 27 (7%) died. The log-rank test revealed differences in PFS for BES 4 versus 1, BES 5 versus 1, BES 5 versus 2, and BES 5 versus 3 (adjusted P < .05 for all). PFS rates for BES 1-5 were 0.92, 0.85, 0.80, 0.62, and 0.58, respectively, and the corresponding OS rates at 100 months were 0.98, 0.91, 0.92, 0.77, 0.86, respectively. Conclusion Classification of breast edema findings on T2-weighted MRI scans using a breast edema score was related to the prognosis of patients after neoadjuvant chemotherapy. © RSNA, 2021 Online supplemental material is available for this article.

Podoplanin expression in cancer-associated fibroblasts predicts unfavorable prognosis in node-negative breast cancer patients with hormone receptor-positive/HER2 - negative subtype

BACKGROUND

Podoplanin expression in cancer-associated fibroblasts (CAFs) has been proposed as an indicator for poor prognosis in patients with invasive breast carcinomas, but little is known about its clinical significance in node-negative breast cancer patients with hormone receptor (HR) + /HER2  - subtype, who are expected to have a favorable prognosis.

METHODS

Immunohistochemical analyses were performed on 169 resected specimens of node-negative invasive carcinoma of no special type with HR + /HER2 - subtype using antibodies for podoplanin. When more than 10% of CAFs showed immunoreactivity with podoplanin as strong as that of internal positive controls, the specimens were judged as podoplanin-positive.

RESULTS

Podoplanin-positive status in CAFs was observed in 16.0% (27 of 169 cases) and it associated with high Ki67 labeling index (LI) (> 30%) (p = 0.03), higher stromal tumor-infiltrating lymphocytes (p < 0.001) and progesterone receptor-negative status (p = 0.045). Log-rank test showed that podoplanin-positive status in CAFs correlated with shorter disease-free survival (DFS) (p = 0.007) and disease-specific survival (DSS) (p < 0.001). Univariate analysis showed a significant correlation between shorter DFS and podoplanin-positive status in CAFs (hazard ratio [HR] = 3.380; p = 0.012), the presence of lymphatic invasion (HR = 5.621; p < 0.001), high Ki67 LI (HR = 5.217; p < 0.001), and histological grade III (HR = 3.748; p = 0.008). According to Cox multivariate analysis, podoplanin-positive status in CAFs had the most significant effect on shorter DSS (HR = 37.759; p = 0.003) followed by high Ki67LI (HR = 27.664; p = 0.007).

CONCLUSION

Podoplanin expression in CAFs could be an independent predictor for poor prognosis in node-negative breast cancer patients with HR + /HER2 - subtype.

Adding contrast-enhanced ultrasound markers to conventional axillary ultrasound improves specificity for predicting axillary lymph node metastasis in patients with breast cancer

OBJECTIVE

To evaluate the diagnostic performance of contrast-enhanced ultrasound (CEUS) combined with conventional ultrasound of axillary lymph nodes (ALNs) in predicting metastatic ALNs in patients with breast cancer.

METHODS

This retrospective study included 259 patients with breast cancer who underwent conventional ultrasound and CEUS. The parameters and patterns evaluated on conventional ultrasound included short axis diameter (S), long axis/short axis (L/S) ratio, cortical thickness, resistive index (RI), lymph node (LN) morphology of greyscale ultrasound, hilum and vascular pattern. Meanwhile, enhancement pattern, wash-in time, time to peak (TP), maximum signal intensity, and duration of contrast enhancement were evaluated on CEUS. Univariate and multiple logistic regression analyses were performed to identify independent factors of ALN status. Three models (conventional ultrasound, CEUS, and combined parameters) were established. Receiver operating characteristic (ROC) curves were applied to evaluate the accuracy of the three predictive models.

RESULTS

On conventional axillary ultrasound, LN morphology and vascular pattern were independent factors in predicting metastatic ALNs. On CEUS, maximum signal intensity, duration of contrast enhancement, and TP were independent factors in predicting metastatic ALNs. When combining conventional ultrasound and CEUS features, five independent factors obtained from the conventional ultrasound and CEUS were associated with ALN status. ROC curve analysis showed that the use of CEUS markers combined with conventional ultrasound features (AUC = 0.965) was superior to the use of CEUS markers (AUC = 0.936) and conventional ultrasound features alone (AUC = 0.851).

CONCLUSION

Combining conventional ultrasound and CEUS features can enable discrimination of ALN status better than the use of CEUS and conventional ultrasound features alone.

ADVANCES IN KNOWLEDGE

The axillary lymph node status in breast cancer patients impacts the treatment decision. Our ultrasonic data demonstrated that CEUS features of ALNs in breast cancer patients could be image markers for predicting ALN status. Combining conventional ultrasound and CEUS features of ALNs can improve specificity discrimination of ALN status better than the use of CEUS and the conventional ultrasound features alone, which will help the treatment planning optimization.

Long-term standard sentinel node biopsy after neoadjuvant treatment in breast cancer: a single institution ten-year follow-up

INTRODUCTION

In patients with positive lymph nodes (cN+) prior to neoadjuvant treatment (NAT), which convert to a clinically negative axilla (cN0) after treatment, the use of sentinel node biopsy (SNB) is still debatable, since the false-negative rate (FNR) is significantly high (12.6-14.2%). The objective of this retrospective mono-institutional study, with a long follow-up, aimed to evaluate the outcome in patients undergoing NAT who remained or converted to cN0 and received SNB independent of target axillary dissection (TAD) or the removal of at least 3 sentinel nodes (SNs).

METHODS

This study analyzed 688 consecutive cT1-3, cN0/1/2 patients, operated at the European Institute of Oncology, Milan, from 2000 to 2015 who became or remained cN0 after NAT and underwent SNB with a least one SN found. Axillary dissection (AD) was not performed if the SN was negative. Nodal radiotherapy (RT) was not mandatory.

RESULTS

Axillary failure occurred in 1.8% of the initially cN1/2 patients and in 1.5% of the initially cN0 patients. After a median follow-up of 9.2 years (IQR 5.3-12.3), the 5- and 10-year overall survival (OS) were 91.3% (95% CI, 88.8-93.2) and 81.0% (95% CI, 77.2-84.2) in the whole cohort, 92.0% (95% CI, 89.0-94.2) and 81.5% (95% CI, 76.9-85.2) in those initially cN0, 89.8% (95% CI, 85.0-93.2) and 80.1% (95% CI, 72.8-85.7) in those initially cN1/2.

CONCLUSION

The 10-year follow-up confirmed our preliminary data that the use of standard SNB is acceptable in cN1/2 patients who become cN0 after NAT and will not translate into a worse outcome.

EMT related circular RNA expression profiles identify circSCYL2 as a novel molecule in breast tumor metastasis

Substantial evidence indicates that circular RNAs (circRNAs) play vital roles in several diseases, especially in cancer development. However, the functions of circRNAs in breast cancer metastasis remain to be investigated. This study aimed to identify the key circRNAs involved in epithelial mesenchymal transition (EMT) of breast cancer and evaluated their molecular function and roles in pathways that may be associated with tumor metastasis. An EMT model was constructed by treating breast cancer cells MCF‑7 and MDA‑MB‑231 with transforming growth factor‑β1. High‑throughput RNA sequencing was used to identify the differentially expressed circRNAs in EMT and blank groups of two cells, and reverse transcription‑quantitative PCR was used to validate the expression of circSCYL2 in human breast cancer tissues and cells. The effects of circSCYL2 on breast cancer cells were explored by transfecting with plasmids and the biological roles were assessed using transwell assays. EMT groups of breast cancer cells exhibited the characteristics of mesenchymal cells. Furthermore, the present study found that 7 circRNAs were significantly upregulated in both the MCF‑7 EMT and MDA‑MB‑231 EMT groups, while 16 circRNAs were significantly downregulated. The current study identified that circSCYL2 was downregulated in breast cancer tissues and cell lines, and that circSCYL2 overexpression inhibited cell migration and invasion. This study provides expression profiles of circRNAs in EMT groups of breast cancer cells. circSCYL2, which is downregulated in breast cancer tissues and cells, may play an important role in breast cancer EMT progression.

Biological Characteristics and Long-term Outcomes in Node-negative Breast Cancer

BACKGROUND

Because the risk of relapse of node-negative breast cancer (BC) is varying, we evaluated the prognosis of patients with this disease and the factors associated with increased risk of relapse.

PATIENTS AND METHODS

The clinical charts of patients with BC with evidence of negative nodes and with a potential ≥ 5-year follow-up were retrospectively reviewed.

RESULTS

We analyzed 1276 patients. Over a median follow-up of 71.6 months (range, 1-227.2 months), we observed 159 events of relapse or death. The median RFS was 170 months. The median overall survival (OS) was 192 months. At univariate analysis, older age, negative hormonal receptors, larger tumor size and higher proliferation index (Ki67) were associated with worse recurrence-free survival (RFS) and OS (P < .05); higher grading was associated with worse RFS (P = .01). At multivariate analysis for RFS, age, Ki67 and tumor size confirmed their independent prognostic role. At multivariate analysis for OS, age and positive hormonal receptors showed an independent prognostic role. We observed no differences in prognosis between human epidermal growth factor receptor 2 (HER2) positive and triple-negative (TN) BC, but TNBC showed a worse OS compared with luminal-like BC.

CONCLUSIONS

In node-negative BC, age, hormone receptor status, tumor size and Ki67 were prognostic factors. The TNBC subtype was not associated with poorer prognosis compared with the HER2-positive subtype, but showed a worse OS compared with luminal-like BC.

The effect of post mastectomy radiation therapy on survival in breast cancer patients with N1mic disease

Background

The role of post mastectomy radiation therapy (PMRT) in patients with N1mic breast cancer has not been well defined. A retrospective analysis was performed using the SEER database to evaluate the impact of PMRT on survival in patients with N1mic breast cancer.

Materials and methods

Women with T1-T2, N1mic, M0 breast cancer who had undergone mastectomy were analyzed. Descriptive statistics were calculated for all variables. Univariate analysis to assess for differences in survival with respect to covariates was performed using the log rank test while multivariate analysis was performed with Cox proportional hazards regression. Sub-cohort analysis with propensity score matching was used to assess differences in survival among patients undergoing PMRT vs no PMRT. Comparisons were considered statistically significant at P < 0.05.

Results

Among 5878 patients, 1202 (20%) underwent PMRT. On univariate analysis, PMRT was a significant predictor of CSS, but not OS. There was no difference in either OS or CSS between the PMRT vs no PMRT groups on multivariate Cox regression analysis and after propensity score matching.

Conclusions

Among patients with T1-T2, N1mic, M0 breast IDC from the SEER database, there was no difference in either OS or CSS among patients who underwent PMRT vs no PMRT. These results suggest that PMRT does not impact survival among breast cancer patients with N1mic disease. However, additional prospective studies with longer follow up are necessary for further evaluation.

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In women with N1mic breast cancer, there was no difference in overall survival with or without adjuvant radiation.

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CSS was worse among women undergoing adjuvant radiation on univariate analysis, but not on multivariate analysis.

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After propensity score matching, no significant difference was observed in survival between women undergoing PMRT vs no PMRT.

HOX genes function in Breast Cancer development

Breast cancer develops in the mammary glands during mammalian adulthood and is considered the second most common type of human carcinoma and the most incident and mortal in the female population. In contrast to other human structures, the female mammary glands continue to develop after birth, undergoing various modifications during pregnancy, lactation and involution under the regulation of hormones and transcription factors, including those encoded by the HOX clusters (A, B, C, and D). Interestingly, HOX gene deregulation is often associated to breast cancer development. Within the HOXB cluster, 8 out of the 10 genes present altered expression levels in breast cancer with an impact in its aggressiveness and resistance to hormone therapy, which highlights the importance of HOXB genes as potential therapeutic targets used to overcome the limitations of tamoxifen-resistant cancer treatments. Here, we review the current state of knowledge on the role of HOX genes in breast cancer, specially focus on HOXB, discussing the causes and consequences of HOXB gene deregulation and their relevance as prognostic factors and therapeutic targets.

Postmastectomy radiation therapy in early breast cancer: Utility or futility?

Postmastectomy radiation therapy (PMRT) has been shown to reduce the risk of locoregional recurrence (LRR), in patients with locally advanced breast cancer who are considered of high-risk because of large tumors (>5 cm) or presence of axillary lymph-node involvement, as well as to reduce breast cancer mortality. However, controversy still remains with respect to indication of PMRT in case of early-stages invasive tumors. This review aims to analyze the impact that PMRT has on final results in women with breast tumors in different scenarios that would otherwise be considered as early breast cancer, such as extensive DCIS, tumors without axillary lymph-node involvement or with minimal microscopic nodal-involvement. The existence of risk factors including young age, premenopausal status, and presence of lymphovascular invasion (LVI), high grade or tumor size >2 cm has been associated with an increased risk of LRR in these patients at early-stages and advises to consider PMRT in selected cases.

The generalisability of randomised clinical trials: an interim external validity analysis of the ongoing SENOMAC trial in sentinel lymph node-positive breast cancer

Purpose

None of the key randomised trials on the omission of axillary lymph node dissection (ALND) in sentinel lymph-positive breast cancer have reported external validity, even though results indicate selection bias. Our aim was to assess the external validity of the ongoing randomised SENOMAC trial by comparing characteristics of Swedish SENOMAC trial participants with non-included eligible patients registered in the Swedish National Breast Cancer Register (NKBC).

Methods

In the ongoing non-inferiority European SENOMAC trial, clinically node-negative cT1–T3 breast cancer patients with up to two sentinel lymph node macrometastases are randomised to undergo completion ALND or not. Both breast-conserving surgery and mastectomy are eligible interventions. Data from NKBC were extracted for the years 2016 and 2017, and patient and tumour characteristics compared with Swedish trial participants from the same years.

Results

Overall, 306 NKBC cases from non-participating and 847 NKBC cases from participating sites (excluding SENOMAC participants) were compared with 463 SENOMAC trial participants. Patients belonging to the middle age groups (p = 0.015), with smaller tumours (p = 0.013) treated by breast-conserving therapy (50.3 versus 47.1 versus 65.2%, p < 0.001) and less nodal tumour burden (only 1 macrometastasis in 78.8 versus 79.9 versus 87.3%, p = 0.001) were over-represented in the trial population. Time trends indicated, however, that differences may be mitigated over time.

Conclusions

This interim external validity analysis specifically addresses selection mechanisms during an ongoing trial, potentially increasing generalisability by the time full accrual is reached. Similar validity checks should be an integral part of prospective clinical trials.

Trial registration: NCT 02240472, retrospective registration date September 14, 2015 after trial initiation on January 31, 2015

The long-term impact of tumor burden in pT3N0M0 esophageal squamous cell carcinoma: A propensity score-matched analysis

The purpose of this study was to assess the impact of tumor burden on the survival of patients with pathologic T3N0M0 (pT3N0M0) esophageal squamous cell carcinoma (ESCC).A total of 84 patients with pathologic T3N0M0 ESCC treated with radical esophagectomy and 3-field lymphadenectomy (3-FL) from January 2008 to December 2009 in our center were analyzed. Receiver-operating characteristic (ROC) curve analysis was performed to calculate the optimal cutoff value. The Kaplan-Meier method and log-rank test were used to assess the overall survival (OS) differences between groups. A regression model was applied to identify prognostic factors for OS. Propensity score matching (PSM) was performed to adjust for the imbalance and indication biases in the 2 groups.The median follow-up time was 62 months (range, 1-84 months), and the 5-year OS rate was 62% (95% confidence interval, 52.2-71.8%). According to the ROC curve analysis, the optimal cutoff values for the maximal esophageal wall thickness, tumor length, and tumor volume were 1.3 cm, 5.9 cm, and 18.6 cc, respectively. Univariate analysis revealed that maximal esophageal wall thickness >1.3 cm (P = .014), tumor volume >18.6 cc (P < .001), and vascular invasion (P < .001) were significantly associated with OS. The multivariate Cox regression model identified tumor volume and vascular invasion as factors affecting OS. After propensity matching, patients with a tumor volume ≤18.6 cc had a better OS than those with a tumor volume >18.6 cc (5-year OS, 85% vs 50%, P = .008).Tumor volume may serve as a good prognostic factor for patients with pT3N0M0 ESCC treated with radical esophagectomy and 3-FL. Larger-scale studies are warranted to validate these findings.

The emerging role of circular RNAs in breast cancer

Breast cancer (BCa) is one of the most frequently diagnosed cancers and leading cause of cancer deaths among females worldwide. Circular RNAs (circRNAs) are a new class of endogenous regulatory RNAs characterized by circular shape resulting from covalently closed continuous loops that are capable of regulating gene expression at transcription or post-transcription levels. With the unique structures, circRNAs are resistant to exonuclease RNase R and maintain stability more easily than linear RNAs. Recently, an increasing number of circRNAs are discovered and reported to show different expression in BCa and these dysregulated circRNAs were correlated with patients’ clinical characteristics and grade in the progression of BCa. CircRNAs participate in the bioprocesses of carcinogenesis of BCa, including cell proliferation, apoptosis, cell cycle, tumorigenesis, vascularization, cell invasion, migration as well as metastasis. Here we concentrated on biogenesis and function of circRNAs, summarized their implications in BCa and discussed their potential as diagnostic and therapeutic targets for BCa.

Impact of 21-Gene Recurrence Score on Chemotherapy Decision in Invasive Ductal Carcinoma of Breast with Nodal Micrometastases

Purpose

The purpose of this study was to investigate the effect of 21-gene recurrence score (RS) on predicting prognosis and chemotherapy decision in node micrometastases (N1mi) breast invasive ductal carcinoma (IDC).

Methods

Patients with stage T1-2N1mi and estrogen receptor-positive IDC diagnosed between 2004 and 2015 were included. The associations of 21-gene RS with breast cancer-specific survival (BCSS), chemotherapy decision, and benefit of chemotherapy were analyzed.

Results

We identified 4,758 patients including 1,403 patients (29.5%) treated with adjuvant chemotherapy. In the traditional RS cutoffs, 2,831 (59.5%), 1,634 (34.3%), and 293 (6.2%) patients were in the low-, intermediate-, and high-risk RS groups, respectively. In 3,853 patients with human epidermal growth factor receptor-2 (HER2) status available, most patients were HER2-negative disease (98.3%). A higher RS was independently related to chemotherapy receipt, and 14.0%, 47.7%, and 77.8% of patients in the low-, intermediate-, and high-risk RS groups received chemotherapy, respectively. The multivariate analysis indicated that a higher RS was related to worse BCSS (p < 0.001). The 5-year BCSS rates were 99.3%, 97.4%, and 91.9% in patients with low-, intermediate-, and high-risk RS groups, respectively (p < 0.001). However, chemotherapy receipt did not correlate with better BCSS in low-, intermediate-, or high-risk RS groups. There were similar trends using Trial Assigning Individualized Options for Treatment RS cutoffs.

Conclusion

The 21-gene RS does predict outcome and impact on chemotherapy decision of N1mi breast IDC. Large cohort and long-term outcomes studies are needed to identify the effects of chemotherapy in N1mi patients by different 21-gene RS groups.

Detection of breast cancer lymph node metastases in frozen sections with a point-of-care low-cost microscope scanner

Background

Detection of lymph node metastases is essential in breast cancer diagnostics and staging, affecting treatment and prognosis. Intraoperative microscopy analysis of sentinel lymph node frozen sections is standard for detection of axillary metastases but requires access to a pathologist for sample analysis. Remote analysis of digitized samples is an alternative solution but is limited by the requirement for high-end slide scanning equipment.

Objective

To determine whether the image quality achievable with a low-cost, miniature digital microscope scanner is sufficient for detection of metastases in breast cancer lymph node frozen sections.

Methods

Lymph node frozen sections from 79 breast cancer patients were digitized using a prototype miniature microscope scanner and a high-end slide scanner. Images were independently reviewed by two pathologists and results compared between devices with conventional light microscopy analysis as ground truth.

Results

Detection of metastases in the images acquired with the miniature scanner yielded an overall sensitivity of 91% and specificity of 99% and showed strong agreement when compared to light microscopy (k = 0.91). Strong agreement was also observed when results were compared to results from the high-end slide scanner (k = 0.94). A majority of discrepant cases were micrometastases and sections of which no anticytokeratin staining was available.

Conclusion

Accuracy of detection of metastatic cells in breast cancer sentinel lymph node frozen sections by visual analysis of samples digitized using low-cost, point-of-care microscopy is comparable to analysis of digital samples scanned using a high-end, whole slide scanner. This technique could potentially provide a workflow for digital diagnostics in resource-limited settings, facilitate sample analysis at the point-of-care and reduce the need for trained experts on-site during surgical procedures.