The significance of extracapsular extension of axillary lymph node metastases in early-stage breast cancer

Pathologic Exploration of the Axillary Soft Tissue Microenvironment and Its Impact on Axillary Management and Breast Cancer Outcomes

PURPOSE

Axillary soft tissue (AXT) involvement with tumor cells extending beyond the positive lymph node (LN+) and extracapsular extension (ECE) has been overlooked in breast pathology specimen analysis.

MATERIALS AND METHODS

We analyzed 2,162 LN+ patients, dividing them into four groups on the basis of axillary pathology: (1) LN+ only, (2) LN+ and ECE only, (3) LN+ and AXT without ECE, and (4) LN+ with both AXT and ECE. The primary end points were 10-year locoregional failure (LRF), the 10-year axillary failure, and 10-year distant metastasis rates. Multivariable Cox models, accounting for clinical factors, were fitted using the entire cohort, and subgroups analyses were conducted.

RESULTS

The median follow-up was 9.4 years. The 10-year distant metastasis incidence was 42% for LN + AXT + ECE, 23% for both LN + AXT and LN + ECE only, and 13% for LN+ only. The 10-year axillary failure rates were 4.5% for LN + AXT + ECE, 4.6% for LN + AXT, 0.8% for LN + ECE only, and 1.6% for LN+ only. The 10-year LRF rates were 14% for LN + AXT + ECE, 10% for LN + AXT, 5.7% for LN + ECE only, and 6.2% for LN+ only. Multivariable analysis revealed that AXT was significantly associated with distant metastasis (hazard ratio [HR], 1.6; P < .001), locoregional failure (HR, 2.3; P < .001), and axillary failure (HR, 3.3; P = .003). Subgroup analyses showed that regional LN radiation (RLNR) improved locoregional tumor outcomes with AXT, ECE, or both (HR, 0.5; P = .03). Delivering ≤50 Gy to the axilla in the presence of AXT/ECE increased axillary failure (HR, 3.0; P = .04). Moreover, when delivering RLNR, axillary LN dissection could be de-escalated to sentinel node biopsy even in the presence of features such as AXT or ECE without significantly increasing any failure outcome: (HR, 1.0; P = .92) for LRF, (HR, 1.1; P = .94) axillary failure, and (HR, 0.4; P = .01) distant metastasis.

CONCLUSION

Routine reporting of axillary tissue involvement, beyond LNs and ECE, is crucial in predicting breast cancer outcomes. Ruling out the presence of AXT is imperative before any form of axillary de-escalation, especially RLNR omission.

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.

Discordance in clinical versus pathological staging in breast cancer: Are we undermining the significance of accurate preoperative staging in the present era?

BACKGROUND

The present era of individualized treatment for breast cancer is influenced by the initial disease status including the anatomical extent, grade, and receptor status. An accurate preoperative staging is the basis of treatment planning and prognostication. Our study aims to determine the discordance between the preoperative clinical and the postoperative pathological stages of breast cancer patients.

METHODOLOGY

The medical records of all non-metastatic breast cancer patients from January 2017 to December 2018 who underwent upfront surgery were reviewed. They were staged as per the eighth AJCC and the concordance between the clinical (c) and pathological T (tumor), N (nodal), and final AJCC stage was studied. A Chi-square test was used to determine factors that significantly correlate with disease discordance.

RESULTS

A total of 307 breast cancer patients were analyzed. Among these, 43.3% were hormone receptor-positive, 30.6% were Her2 positive and 26% were triple-negative. Overall stage discordance was seen in 48.5% (n = 149) patients (upstaging in 22.1%, downstaging in 26.4%). The discordance rate was 48.9% for T stage (cT versus pT) and 57.4% for N stage (cN versus pN). Among patients with clinically node-negative disease, 53.4% were found to have positive nodes on histopathology, while 27.2% had vice versa. Overall, the factors associated with upstaging were ER-positive, Her2 positive and triple-negative status (all p < 0.05), while none of the factors showed significant association with downstaging.

CONCLUSIONS

About half of breast cancer patients had discordance between clinical and pathological staging with higher discordance in the nodal stage. This changes the disease prognosis, and may also affect the offered surgical treatment and radiotherapy. Thus highlighting the need for a precise pre-operative staging. Also, this information will aid clinicians in discussions with patients, keeping in mind the likelihood of change in disease staging and management.

Microscopic Extracapsular Extension in Sentinel Lymph Nodes Does Not Mandate Axillary Dissection in Z0011-Eligible Patients

BACKGROUND

In the ACOSOG (American College of Surgeons Oncology Group) Z0011 trial and the AMAROS (After Mapping of the Axilla: Radiotherapy or Surgery?) trial, matted nodes with gross extracapsular extension (ECE), a risk factor for locoregional recurrence, were an indication for axillary lymph node dissection (ALND), but the effect of microscopic ECE (mECE) in the sentinel lymph nodes (SLNs) on recurrence was not examined.

METHODS

Between 2010 and 2017, 811 patients with cT1-2N0 breast cancer and SLN metastasis were prospectively managed according to Z0011 criteria, with ALND for those with more than two positive SLNs or gross ECE. Management of mECE was not specified. In this study, we compare outcomes of patients with one to two positive SLNs with and without mECE, treated with SLN biopsy alone (n = 685).

RESULTS

Median patient age was 58 years, and median tumor size was 1.7 cm. mECE was identified in 210 (31%) patients. Patients with mECE were older, had larger tumors, and were more likely to be hormone receptor positive and HER2 negative, have two positive SLNs, and receive nodal radiation. At a median follow-up of 41 months, no isolated axillary failures were observed. There were 11 nodal recurrences; two supraclavicular ± axillary, four synchronous with breast, and five with distant failure. The five-year rate of any nodal recurrence was 1.6% and did not differ by mECE (2.3% vs. 1.3%; p = 0.84). No differences were observed in local (p = 0.08) or distant (p = 0.31) recurrence rates by mECE status.

CONCLUSIONS

In Z0011-eligible patients, nodal recurrence rates in patients with mECE are low after treatment with SLN biopsy alone, even in the absence of routine nodal radiation. The presence of mECE should not be considered a routine indication for ALND.

The Significance of Extent of Extracapsular Extension in Patients with T1-2 and N1 Breast Cancer

Objective

The prognostic importance of extracapsular extension (ECE) in breast cancer is not yet clear, especially in patients with pathological T1-2 and N1 (pT1-2N1) disease. We aimed to investigate whether the extent of ECE was an independent prognostic factor for survival outcomes in patients with pT1-2N1 breast cancer.

Materials and Methods

A total number of 131 patients with pT1-2N1 breast cancer treated between 2009 and 2015 were retrospectively evaluated. A single pathologist re-analyzed the histologic examples of all cases. The extent of ECE was graded from 0 to 4.

Results

There was a significant correlation between the number of lymph nodes involved and ECE grade (p=0.004). According to the univariate analysis, lymphovascular invasion (LVI) and ECE grade were the significant prognostic factors for overall survival (OS); age, number of metastatic lymph nodes, menopausal status, and ECE grade were the prognostic factors for disease-free survival (DFS). With a median follow-up of 46 months, grade 3-4 ECE seems to be notably associated with a shorter OS and DFS in multivariate analysis. The mean OS was 85 months for the patients with grade 0-2 ECE vs 75 months for the patients with grade 3-4 ECE (p=0.003). The mean DFS was 83 months for the patients with grade 0-3 ECE vs 68 months for the patients with grade 4 ECE (p=<0.0001).

Conclusion

This research has shown that the extent of ECE is an important prognostic factor for survival in pT1-2N1 breast cancer patients and grade 3-4 ECE seems to be notably associated with a shorter OS and DFS.

Extracapsular extension is not a significant prognostic indicator in non-squamous cancers of the major salivary glands

Background

Extracapsular extension (ECE) is a well-established prognostic feature in squamous cell cancers of the head and neck. Although some extrapolate data from mucosal head and neck cancer to include ECE as a high-risk feature in salivary gland cancers, data is lacking about ECE’s prognostic value for these malignancies. We investigate whether ECE is a significant prognostic indicator in pathologic node-positive cancers of the major salivary glands.

Methods

A retrospective study of adult salivary gland cancer cases diagnosed from 2004 to 2013 in the NCDB was conducted. Demographic, tumor, treatment, and survival variables were included in the study. Univariate Kaplan-Meier analyses, as well as multivariate Cox survival regressions were performed.

Results

Positive ECE status was associated with significantly worse survival in salivary SCC (HR 1.687; p = 0.002) but not non-squamous salivary cancers (HR 1.000; p = 0.998) on multivariate analysis. While post-operative radiotherapy was not associated with improved survival for patients without high-risk adverse features (high grade or positive surgical margins), its use was associated with better survival for ECE-positive salivary SCC patients without one of these additional adverse features (HR 0.064; p = 0.010).

Conclusions

Although ECE is a significant prognostic indicator in salivary SCC, its prognostic significance for non-squamous salivary cancers may be limited. Radiotherapy may improve survival in cases with at least one high-risk adverse feature: high grade; positive surgical margins; and for salivary SCC specifically, positive ECE status.

The Importance of Extracapsular Extension of Axillary Lymph Node Metastases in Breast Cancer

Purpose

To evaluate the prognostic value of extracapsular extension (ECE) of axillary lymph node metastases in 221 patients with axillary lymph node-positive, T1-T2 breast cancer treated at Dokuz Eylul University Hospital, Department of Radiation Oncology.

Patients and methods

The clinical records of patients with axillary node-positive, pathological stage II—III breast cancer examined at Dokuz Eylul University Hospital, Department of Radiation Oncology, between 1991–1999 were reviewed. All patients underwent modified radical mastectomy (MRM) or wide excision with axillary node dissection. Axillary surgery consisted of level l-ll dissection. The number of lymph nodes dissected from the axilla was equal to or more than 10 in 92% of the patients. All 221 patients had pathological T1–T2 tumors. The number of involved lymph nodes was four or more in 112 51% patients and less than four in the remaining 109 (49%). In 127 (57.5%) patients, extracapsular extension was detected in axillary lymph nodes. Tangential radiotherapy fields were used to treat the breast or chest wall. Lymphatic irradiation was performed in 215 (97%) patients with fields covering both the supraclavicular and axillary regions. Median radiotherapy dose for lymph nodes was 5000 cGy in 25 fractions. The following factors were evaluated: age, menopausal status, histological tumor type, pathological stage, number of involved axillary lymph nodes, and extracapsular extension. The chisquare test was used to compare proportions of categorical covariates between groups of patients with and without ECE. Survival analyses were estimated with the Kaplan-Meier method. The Cox regression model was used for the analysis of prognostic factors.

Results

The median follow-up for the survivors was 55 months (range, 19–23). The median age was 52 years (range, 28–75). In patients with extracapsular extension the percentages of pathological stage III (22% vs 4.3%, P <0.0001 and involvement of four or more axillary nodes (25.5% vs 69.3%, p<0.0000) were higher. Multivariate analysis revealed a significant correlation between the presence of ECE and disease-free survival (DFS) (P = 0.04) as well as distant metastases-free survival (DMFS) (P = 0.002), but there was no significant correlation between ECE and overall survival (OS). Only an elevated number of involved axillary lymph nodes significantly reduced the overall survival (P = 0.001).

Conclusion

The rate of extracapsular extension was found to be directly proportional to the number of axillary lymph nodes involved and the stage of disease. Extracapsular extension had significant prognostic value in both univariate and multivariate analysis for DFS and DMFS but not OS. The reason for ECE not affecting OS might be related to the much more dominant prognostic effect of the involvement of four or more axillary nodes on OS. Studies with more patients are needed to demonstrate that ECE is a likely independent prognostic factor for OS.

Rate of metastasis in examined lymph nodes as a predictor of extracapsular extension in patients with axillary node-positive breast cancer

BACKGROUND

The status of the axillary lymph nodes is an important factor in the prognosis and treatment of breast cancer. Extracapsular extension (ECE) is the spread of lymphatic tumor cells beyond the capsule of an axillary lymph node. Recent studies have demonstrated that ECE is a strongly unfavorable prognostic factor.

OBJECTIVE

In the present study, we investigated whether the rate of metastasis among examined lymph nodes can be used to predict ECE in patients with axillary node-positive breast cancer.

METHODS

The subjects were 95 women with axillary node-positive breast cancer. The numbers of lymph nodes removed (examined) and lymph nodes involved were recorded. The cut-off values, area under the curve, sensitivity, and specificity were calculated with the receiver operating characteristic curve technique for ability of the rate of metastasis to examined lymph nodes to predict ECE.

RESULTS

The rate of metastasis to examined lymph nodes was significantly greater in patients with ECE than in patients without ECE [0.57 (0.03-1.00) vs. 0.22 (0.04-1.00), respectively, p: 0.001]. Similarly, the presence of vascular infiltration was significantly higher in patients with ECE than in those without ECE [30 (73.2%) vs. 25 (47.2%) respectively, p: 0.010]. On the other hand, other variables did not differ between the groups (p>0.05). When the cut-off value was ≥0.23, the sensitivity and specificity of the rate of metastasis to examined lymph nodes were 80.49% and 55.56%, respectively. The area under the curve was 0.697 (95% confidence interval: 0.594-0.787, p: 0.004).

CONCLUSION

Our results suggest that rate of metastasis among examined lymph nodes is a predictor of ECE in patients with axillary node-positive breast cancer.

Effect of lymph node metastasis size on breast cancer-specific and overall survival in women with node-positive breast cancer

We investigated whether increasing size of lymph nodes (LN) metastases is associated with lower breast cancer-specific survival (BCSS) and overall survival (OS) independent of the number of positive LNs. Using Surveillance, Epidemiology, and End Results registry data, we identified 8791 women diagnosed between 1990 and 2003 with node-positive, non-metastatic invasive breast cancer treated with surgery and axillary LN dissection. Size of the largest involved LN metastasis was categorized as ≤2 mm, >2 mm to <2 cm, and ≥2 cm. BCSS and OS were estimated using the Kaplan-Meier method and compared using log-rank statistics. Adjusted hazard ratios (HR) were calculated using Cox proportional hazards models. Median follow-up was 109 months. Largest LN size was ≤2 mm, >2 mm to <2 cm, and ≥2 cm in 2219 (25.2 %), 5047 (57.4 %), and 1525 (17.3 %) women, respectively. The 10-year BCSS for women with LNs ≤2 mm, >2 mm to <2 cm, and ≥2 cm was 82.9, 75.5, 64.8 %, respectively (p < 0.001). On multivariable analysis, large (≥2 cm) LN size was significantly associated with worsened BCSS (HR: 1.169; p = 0.026) and OS (HR: 1.169; p = 0.006) in addition to age, race, grade, PR status, adjuvant radiation, T-stage, and number of positive LNs. Large (≥2 cm) LNs metastases were associated with lower BCSS and OS after controlling for other known prognostic factors including number of positive LNs. LN size could be useful to risk-stratify patients for adjuvant therapy if these results are validated in future prospective studies.

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.

The extent of extracapsular extension may influence the need for axillary lymph node dissection in patients with T1-T2 breast cancer

BACKGROUND

Whether extracapsular extension (ECE) of tumor in the sentinel lymph node (SLN) is an indication for axillary lymph node dissection (ALND) in patients managed by American College of Surgeons Oncology Group Z0011 criteria is controversial. Here we examine the correlation between ECE in the SLN and disease burden in the axilla.

METHODS

Patients meeting Z0011 clinicopathologic criteria (pT1-2, cN0 with <3 positive SLNs) were selected from a prospectively maintained database (2006-2013). Chart review documented the presence and extent of ECE. Neoadjuvant chemotherapy patients were excluded. Comparisons were made by presence and extent (≤2 vs. >2 mm) of ECE.

RESULTS

Of 11,730 patients, 778 were pT1-2, cN0 with <3 positive SLNs without ECE, and 331 (2.8 %) had ECE. Of these, 180 had ≤2 mm and 151 had >2 mm of ECE. Patients with ECE were older (57 vs. 54 years; p = 0.001) and had larger (2.0 vs. 1.7 cm; p < 0.0001), multifocal (p = 0.006), hormone receptor-positive tumors (p = 0.0164) with lymphovascular invasion (p < 0.0001). Presence and extent of ECE were associated with greater axillary disease burden; 20 and 3 % of patients with and without ECE, respectively, had ≥4 additional positive nodes at completion ALND (p < 0.0001), and 33 % of patients with >2 mm ECE had ≥4 additional positive nodes at completion ALND, compared with 9 % in the <2 mm group (p < 0.0001). On multivariate analysis, >2 mm of ECE was the strongest predictor of ≥4 positive nodes at completion ALND (odds ratio 14.2).

CONCLUSIONS

Presence and extent of ECE were significantly correlated with nodal tumor burden at completion ALND, thus suggesting that >2 mm of ECE may be an indication for ALND or radiotherapy when applying Z0011 criteria to patients with metastases in <3 SLNs. ECE reporting should be standardized to facilitate future studies.

The effects of ECE on the benefits of PMRT for breast cancer patients with positive axillary nodes

BACKGROUND

The purpose of the present study was to retrospectively evaluate the effects of extracapsular extension (ECE) on the benefits of post-mastectomy radiation therapy (PMRT) for groups of patients with varying numbers of positive axillary nodes (1-3, 4-9 and ≥10 positive axillary nodes).

METHODS

A total of 1220 axillary node-positive patients who had received mastectomy were involved in this study. Patients were grouped as 'Radio + /ECE + ', 'Radio-/ECE + ', 'Radio + /ECE-' or 'Radio-/ECE-' according to status of ECE and whether receiving PMRT or not, and were evaluated in terms of local region relapse (LRR) rate. The 5-year and 10-year Kaplan-Meier disease-free survival and overall survival (OS) rates were analyzed.

RESULTS

ECE-positive differed from ECE-negative groups with statistical significance for all comparisons in favor of the ECE-negative group: 5-year locoregional failure-free survival (LRFFS) (82.69% vs 91.83%, P < 0.001), 10-year LRFFS (75.39% vs 90.02%, P < 0.001); 5-year OS (52.12% vs 74.46%, P < 0.001), 10-year OS (35.17% vs 67.63%, P < 0.001). There were no significant effects of ECE on the benefits of PMRT for patients with 1-3 (P = 0.5720), ≥10(P = 0.0614) positive axillary nodes. However, for the group of patients with 4-9 positive axillary nodes, ECE status had a significant effect on the benefits of PMRT with respect to 5-year and 10-year LRFFS (P < 0.05).

CONCLUSION

In our study, regardless of the ECE status, PMRT didn't significantly improve the LRFFS for patients with 1-3 or ≥10 positive axillary nodes. However, for patients with 4-9 positive axillary nodes, ECE could be an important criterion to consider when deciding whether to receive PMRT.

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

BACKGROUND

This study searched for extra capsular tumour spread (ECS) as a prognostic factor for recurrence in terms of Disease Free Survival (DFS) and Overall Survival (OS).

PATIENTS AND METHODS

For this study, from a retrospective database of the Doubs cancer registry, 823 eligible women with node positive breast cancer treated from February 1984 to November 2000 were identified. The following factors were evaluated: ECS, numbers of involved nodes, histological tumour grade, tumour size, status of estrogen and progesterone receptors, and age of patient. A Cox proportional hazards method was used to search for significant factors related to OS and DFS length.

RESULTS

In the multivariate analysis, factors related to DFS length were found to be: tumour grade (aHR 0.76, 95 % CI 0.61-0.96, p = 0.02), ECS status (aHR 0.7, 95 % CI 0.49-0.96, p = 0.03), progesterone (PgR) status (aHR 0.63, 95 % CI 0.44-0.85 p = 0.008), number of nodes involved (aHR 0.75, 95 % CI 0.56-1, p = 0.05). The multivariate analysis for OS found as significant factors: tumour grade (aHR 0.76, 95 % CI 0.61-0.95; p = 0.02) and PgR status (aHR 0.8, 95 % CI 0.56-0.99, p = 0.02).

CONCLUSIONS

This study might suggest taking into account ECS status in the adjuvant decision-making process.

[Axillary lymph node irradiation in breast cancer: state of the art]

Place of axillary radiotherapy in the management of patients with breast cancer remains debated. While the prognostic value of axillary lymph node extension has been largely demonstrated, the benefit of axillary treatment is more uncertain. Large clinical trials having demonstrated the benefit of adjuvant radiotherapy in advanced breast cancer comprised large nodal irradiation, including axillary area. Analyzing the true benefit of axillary radiotherapy is rendered difficult by heterogeneity of series, particularly when focusing on the extent of lymph node dissection. Although adjuvant axillary radiotherapy is usually recommended in patients with insufficient lymph node dissection or with bulky axillary involvement, the prognosis in these patients remains poor by metastatic evolution and such strategy exposes to increased toxicity and functional sequels. Further assessments should better define the optimal indications and the true benefit of axillary radiotherapy.

Outcomes in women treated with MammoSite brachytherapy or whole breast irradiation stratified by ASTRO Accelerated Partial Breast Irradiation Consensus Statement Groups

PURPOSE

The American Society for Radiation Oncology published a Consensus Statement for accelerated partial breast irradiation identifying three groups: Suitable, Cautionary, and Unsuitable. The objective of this study was to compare oncologic outcomes in women treated with MammoSite brachytherapy (MB) vs. whole breast irradiation (WBI) after stratification into Statement groups.

METHODS

Eligible women had invasive carcinoma or ductal carcinoma in situ (DCIS) ≤ 3 cm, and ≤ 3 lymph nodes positive. Women were stratified by radiation modality and Statement groups. Survival analysis methods including Kaplan-Meier estimation, Cox regression, and competing risks analysis were used to assess overall survival (OS), disease-free survival (DFS), time to local failure (TTLF), and tumor bed failure (TBF).

RESULTS

A total of 459 (183 MB and 276 WBI) patients were treated from 2002 to 2009. After a median follow-up of 45 months, we found no statistical differences by stratification group or radiation modality with regard to OS and DFS. At 4 years TTLF or TBF were not statistically different between the cohorts. Univariate analysis in the MB cohort revealed that nodal positivity (pN1 vs. pN0) was related to TTLF (hazard ratio 6.39, p = 0.02). There was a suggestion that DCIS histology had an increased risk of failure when compared with invasive ductal carcinoma (hazard ratio 3.57, p = 0.06).

CONCLUSIONS

MB and WBI patients stratified by Statement groups seem to combine women who will have similar outcomes regardless of radiation modality. Although outcomes were similar, we remain guarded in overinterpretation of these preliminary results until further analysis and long-term follow-up data become available. Caution should be used in treating women with DCIS or pN1 disease with MB.

Radiotherapy of the regional lymph nodes: shooting at the sheriff?

The role of immune surveillance in controlling the spread of breast cancer to the regional nodes is poorly understood. In theory regional nodal irradiation (RNI) might compromise this host function. However the clinical evidence suggests that the risk of regional recurrence is lower in patients with early breast cancer whose axilla has been irradiated compared to no axillary treatment. The role of RNI after breast conserving surgery has not been well studied. A policy of level III clearance and only irradiating the axilla for residual disease and a selective policy of axillary irradiation in node positive patients after sentinel node biopsy or lower axillary node sample is recommended. Irradiation of the medial supraclavicular fossa after axillary dissection is suggested where there are four or more nodes involved on axillary dissection. There is little data to inform selection of patients for RNI after neoadjuvant systemic therapy. The role of postmastectomy radiotherapy (PMRT) was largely established on the basis of comprehensive RNI. It is unclear whether irradiating less than the chest wall and peripheral lymphatics confers the same level of benefit. The role of PMRT in women with 1-3 involved nodes remains controversial and investigational. Biological factors such as oestrogen and progesterone receptor status and HER-2 protein expression may play a role in determining benefits from PMRT. The role of internal mammary nodal irradiation is unclear. The individualisation of RNI based on molecular and genetic factors should be a priority for research. The benefits of RNI need to be carefully balanced against the risks of cardiotoxicity, pneumonitis, lymphoedema, brachial plexopathy and secondary malignancy.

The value of level III clearance in patients with axillary and sentinel node positive breast cancer

BACKGROUND

The value of level III axillary clearance is contentious, with great variance worldwide in the extent and levels of clearance performed.

OBJECTIVE

To determine rates of level III positivity in patients undergoing level I-III axillary clearance, and identify which patients are at highest risk of involved level III nodes.

METHODS

From a database of 2850 patients derived from symptomatic and population-based screening service, 1179 patients who underwent level I-III clearance between the years 1999-2007 were identified. The pathology, surgical details, and prior sentinel nodes biopsies of patients were recorded.

RESULTS

Eleven hundred seventy nine patients had level I-III axillary clearance. Of the patients, 63% (n = 747) were node positive. Of patients with node positive disease, 23% (n = 168) were level II positive and 19% (n = 141) were level III positive. Two hundred fifty patients had positive sentinel node biopsies prior to axillary clearance. Of these, 12% (n = 30) and 9% (n = 22) were level II and level III positive, respectively. On multivariate analysis, factors predictive of level III involvement in patients with node positive disease were tumor size (P < 0.001, OR = 1.36; 95% CI: 1.2-1.5), invasive lobular disease (P < 0.001, OR = 3.6; 95% CI: 1.9-6.95), extranodal extension (P < 0.001, OR = 0.27; 95% CI: 0.18-0.4), and lymphovascular invasion (P = 0.04, OR = 0.58; 95% CI: 0.35-1). Lobular invasive disease (P = 0.049, OR = 4.1; 95% CI: 1-16.8), extranodal spread (P = 0.003, OR = 0.18; 95% CI: 0.06-0.57), and having more than one positive sentinel node (P = 0.009, OR = 4.9; 95% CI: 1.5-16.1) were predictive of level III involvement in patients with sentinel node positive disease.

CONCLUSION

Level III clearance has a selective but definite role to play in patients who have node positive breast carcinoma. Pathological characteristics of the primary tumor are of particular use in identifying those who are at various risk of level III nodal involvement.

ACR appropriateness criteria on postmastectomy radiotherapy expert panel on radiation oncology-breast

This summary focuses on the role of postoperative radiation therapy in patients treated with modified radical mastectomy for invasive breast cancer, particularly in patients receiving systemic therapy.

Extracapsular tumor spread and the risk of local, axillary and supraclavicular recurrence in node-positive, premenopausal patients with breast cancer

BACKGROUND

Extracapsular tumor spread (ECS) has been identified as a possible risk factor for breast cancer recurrence, but controversy exists regarding its role in decision making for regional radiotherapy. This study evaluates ECS as a predictor of local, axillary, and supraclavicular recurrence.

PATIENTS AND METHODS

International Breast Cancer Study Group Trial VI accrued 1475 eligible pre- and perimenopausal women with node-positive breast cancer who were randomly assigned to receive three to nine courses of classical combination chemotherapy with cyclophosphamide, methotrexate, and fluorouracil. ECS status was determined retrospectively in 933 patients based on review of pathology reports. Cumulative incidence and hazard ratios (HRs) were estimated using methods for competing risks analysis. Adjustment factors included treatment group and baseline patient and tumor characteristics. The median follow-up was 14 years.

RESULTS

In univariable analysis, ECS was significantly associated with supraclavicular recurrence (HR = 1.96; 95% confidence interval 1.23-3.13; P = 0.005). HRs for local and axillary recurrence were 1.38 (P = 0.06) and 1.81 (P = 0.11), respectively. Following adjustment for number of lymph node metastases and other baseline prognostic factors, ECS was not significantly associated with any of the three recurrence types studied.

CONCLUSIONS

Our results indicate that the decision for additional regional radiotherapy should not be based solely on the presence of ECS.

Extracapsular extension is associated with increased ratio of metastatic to examined lymph nodes in axillary node-positive breast cancer

BACKGROUND

Extracapsular extension of nodal tumor cells, although it is not a parameter of staging, has recently been shown to be correlated with the high number of metastatic lymph nodes in patients with axillary-positive breast cancer. It is suggested that the use of involved/examined lymph node ratio instead of the number of metastatic lymph nodes in axillary evaluation would obtain standardized prognostic data for patient management. This study investigated the association of the extracapsular extension with the lymph node ratio in a node-positive group of patients.

PATIENTS AND METHODS

Medical records of 170 patients with positive axillary status were retrospectively reviewed. Of these, 54 were extracapsular extension positive, and the remaining were extracapsular extension negative. A comparison was made between extracapsular extension-positive and extracapsular extension-negative groups with respect to some potential prognostic indicators.

RESULTS

Number of metastatic lymph nodes, number of examined lymph nodes, and involved/examined lymph node ratio were found to be significantly higher in patients with a presence of extracapsular extension.

CONCLUSION

The results suggest that the presence of extracapsular extension might force physicians to perform more aggressive adjuvant therapies and that the extracapsular extension could be a valuable parameter in the management of breast cancer because it has a strong relationship with the proven prognostic factors.

The correlation of extranodal invasion with other prognostic parameters in lymph node positive breast cancer

BACKGROUND

The presence of extranodal invasion (ENI) in the metastatic lymph nodes is reported to increase the risk of locoregional recurrence while shortening disease-free and overall survival in patients with breast cancer. In this study the relationship between ENI and other prognostic parameters and survival is investigated.

METHODS

Of 650 patients with breast cancer who were treated in Ankara Oncology Teaching and Research Hospital from 1996 to 2003, 368 (56.6%) had lymph node metastasis. The patients with axillary metastasis were separated into two groups as with and without invasion to lymph node capsule and the surrounding adipose tissue. Clinicopathologic features were analyzed by univariate and multivariate logistic regression.

RESULTS

Of 368 patients with axillary metastasis, 135 (36.7%) had ENI. Based on multivariate analysis; the number of metastatic lymph nodes, lymphatic invasion, and tumor necrosis were found to be related with ENI. In the group with ENI, 5-year overall survival rate was 74.8%, compared to 82.3% for patients without ENI which was significantly lower (P = 0.04).

CONCLUSIONS

In lymph node positive breast cancer with presence of ENI, adverse prognostic parameters are more frequently encountered and has a worse overall survival compared to group without ENI.

Loco regional failure pattern after lumpectomy and breast irradiation in 4,185 patients with T1 and T2 breast cancer. Implications for nodal irradiation

The aim of this study is to determinate incidence and risk factors for loco regional failure (LRR) (breast, supraclavicular, axillary and internal mammary nodes) and indications for nodal irradiation. From January 1980 to December 2001, 4,185 patients with T1-T2 breast cancer were treated with conservative surgery and whole breast radiotherapy without nodal irradiation at the University of Florence. The median age was 55 years (range 19-86). All patients were followed for a median of eight years (range 3 months to 20 years). Multivariate analysis showed as independent prognostic factors for isolated nodal relapse (NR) the presence of more than three positive lymph nodes (PAN) (p = 0.001), angiolymphatic invasion (p = 0.002) and pT2 (p = 0.02). However, only 4.8% of patients with more than three PAN developed NR as the only site of recurrence. Having one to three PAN was not associated with an increased risk of NR. We believe that it is not necessary to prescribe nodal irradiation to patients with negative or one to three PAN. Regarding patients with more than three PAN, the number of isolated NR is also small to routinely justify a node irradiation.

The significance of one positive axillary node

AIMS

The aim of this study was to identify a subgroup of patients with breast cancer that can safely avoid axillary dissection.

METHODS

Using data collected by the Eindhoven Cancer Registry, we compared the clinico-pathological features of 489 patients with only one positive lymph node to those of 817 patients with more than one positive lymph node in the axilla. All patients underwent complete axillary dissection, not preceded by a sentinel node biopsy.

RESULTS

Tumour size greater than 1cm, harvesting more than 15 axillary lymph nodes at histopathological examination, metastasis size larger than 2mm, extranodal extension, and nodal involvement of the axillary apex are independently associated with the occurrence of more than one metastatic axillary lymph node.

CONCLUSION

No subgroup could be identified in which axillary dissection can always be omitted. However, tumour size<1cm, finding a micrometastasis rather than a macrometastasis, and especially not finding extranodal extension were independently associated with finding only one positive axillary lymph node.

Clinical investigation: Regional nodal failure patterns in breast cancer patients treated with mastectomy without radiotherapy

PURPOSE

The purpose of this study was to describe regional nodal failure patterns in patients who had undergone mastectomy with axillary dissection to define subgroups of patients who might benefit from supplemental regional nodal radiation to the axilla or supraclavicular fossa/axillary apex.

METHODS AND MATERIALS

The cohort consisted of 1031 patients treated with mastectomy (including a level I-II axillary dissection) and doxorubicin-based systemic therapy without radiation on five clinical trials at M.D. Anderson Cancer Center. Patient records, including pathology reports, were retrospectively reviewed. All regional recurrences (with or without distant metastasis) were recorded. Median follow-up was 116 months (range, 6-262 months).

RESULTS

Twenty-one patients recurred within the low-mid axilla (10-year actuarial rate 3%). Of these, 16 were isolated regional failures (no chest wall failure). The risk of failure in the low-mid axilla was not significantly higher for patients with increasing numbers of involved nodes, increasing percentage of involved nodes, larger nodal size or gross extranodal extension. Only 3 of 100 patients with <10 nodes examined recurred in the low-mid axilla. Seventy-seven patients had a recurrence in the supraclavicular fossa/axillary apex (10-year actuarial rate 8%). Forty-nine were isolated regional recurrences. Significant predictors of failures in this region included > or = 4 involved axillary lymph nodes, >20% involved axillary nodes, and the presence of gross extranodal extension (10-year actuarial rates 15%, 14%, and 19%, respectively, p < 0.0005). The extent of axillary dissection and the size of the largest involved node were not predictive of failure within the supraclavicular fossa/axillary apex.

CONCLUSIONS

These results suggest that failure in the level I-II axilla is an uncommon occurrence after modified radical mastectomy and chemotherapy. Therefore, supplemental radiotherapy to the dissected axilla is not warranted for most patients. However, patients with > or = 4 involved axillary lymph nodes, >20% involved axillary nodes, or gross extranodal extension are at increased risk of failure in the supraclavicular fossa/axillary apex and should receive radiation to undissected regions in addition to the chest wall.

Prognostic value of extracapsular tumor spread for locoregional control in premenopausal patients with node-positive breast cancer treated with classical cyclophosphamide, methotrexate, and fluorouracil: long-term observations from International Breast Cancer Study Group Trial VI

PURPOSE

We sought to determine retrospectively whether extracapsular spread (ECS) might identify a subgroup that could benefit from radiotherapy after mastectomy, especially patients with 1 to 3 positive lymph nodes (LN1-3+).

PATIENTS AND METHODS

We randomized 1,475 premenopausal women with node-positive breast cancer to three, six, or nine courses of "classical" CMF (cyclophosphamide, methotrexate, and fluorouracil). After a review of all pathology forms, 933 patients (63%) had information on the presence or absence of ECS. ECS was present in 49.5%. The median follow-up was 10 years.

RESULTS

In univariate analyses, ECS was associated with worse disease-free survival (DFS) and overall survival (OS). In multivariate analyses adjusting for tumor size, vessel invasion, surgery type, and age group, ECS remained significant (DFS: hazard ratio, 1.61; 95% CI, 1.34 to 1.93; P < .0001; OS: 1.67; 95% CI, 1.34 to 2.08; P < .0001). However, ECS was not significant when the number of positive nodes was added. The locoregional failure rate +/- distant failure (LRF +/- distant failure) within 10 years was estimated at 19% (+/- 2%) without ECS, versus 27% (+/- 2%) with ECS. The difference was statistically significant in univariate analyses, but not after adjusting for the number of positive nodes. No independent effect of ECS on DFS, OS, or LRF could be confirmed within the subgroup of 382 patients with LN1-3+ treated with mastectomy without radiotherapy.

CONCLUSION

Our results do not support an independent prognostic value of ECS, nor its use as an indication for irradiation in premenopausal patients with LN1-3+ treated with classical CMF. However, we could not examine whether extensive ECS is of prognostic importance.

Node-related factors and survival in node-positive breast carcinomas

The number of positive lymph nodes (+LNs) is the only node-related prognostic factor recognized by the American Joint Committee TNM system for breast cancer. In this study, we evaluated additional node-related prognostic factors in node-positive breast carcinomas. One hundred and thirty-four patients with infiltrating ductal carcinomas and axillary +LNs, who had been treated with modified radical mastectomy, were analyzed. Metastatic lymph nodes were evaluated for traditional prognostic factors, i.e., the number of involved nodes and the extranodal extension, but also for a variety of other node-related characteristics, such as nodal tumor burden and maximum size of tumor deposits, necrosis, stromatogenesis, extranodal vascular involvement, and nodal matting. The results reaffirmed the prognostic significance of metastasis in 1-3 vs. 4-7 axillary lymph nodes and, in addition, revealed the importance of 4 +LNs as a cut-off point for breast tumor aggressiveness, given that survival curves for 4-7 vs. >7 +LNs were indifferent. Interestingly, nodal tumor burden, when extensive, was statistically an adverse prognostic factor. Prognosis was equally poor if metastases to regional nodes showed extensive nodal necrosis or extensive nodal stromatogenesis, if there was extranodal spread, extranodal vascular involvement, or if the axillary +LNs were matted. In multivariate analysis, intranodal necrosis and extranodal vascular involvement were the only node-related features with a significant and independent prognostic function. Node-related pathological features in node-positive breast carcinomas are important in determining prognosis. Intranodal necrosis and extranodal tumor emboli should be considered, in parallel with the number of +LNs, in subsequent treatment design.

Prognostic Value of Extracapsular Extension of Axillary Lymph Node Metastases in T1 to T3 Breast Cancer

BACKGROUND

The importance of extracapsular extension (ECE) of axillary metastases as a risk factor for either local or distant recurrence and poorer survival in breast cancer has been suggested, but its prognostic value has not been uniformly confirmed.

METHODS

From a prospective database including 1142 breast cancer patients operated on at the Department of General Surgery and Surgical Oncology of the University of Siena, we selected 376 cases with pT1 to pT3 node-positive breast cancer. The prognostic significance of ECE of axillary metastases was evaluated with respect to disease-free survival, overall survival, and the patterns of disease recurrence. Such prognostic significance was then compared with that of other clinical and pathologic factors.

RESULTS

With a median follow-up of 103 months, factors with independent prognostic value for disease-free survival by multivariate analysis included absence of estrogen receptors (P < .0005), pN category (P < .01), presence of lymphovascular invasion (LVI; P < .005), and ECE (P < .0001). An independent negative prognostic effect on overall survival was observed for absence of estrogen and progesterone receptors (P < .05), pN category (P < .05), and presence of LVI (P < .005) and ECE (P < .0001). The presence of ECE was significantly related to an increased risk of regional (13.4% vs. 6.6%; P = .037) and distant (43% vs. 16.2%; P < .001) recurrences.

CONCLUSIONS

ECE demonstrated a stronger statistical significance in predicting prognosis than the pN category and was also related to an increased risk of distant recurrences. We suggest that the decision on adjuvant therapy should consider the presence of ECE of axillary metastases and peritumoral LVI as indicators of high biological aggressiveness.

Radiotherapy for invasive breast cancer in North America and Europe: Results of a survey

PURPOSE

To document and explain the current radiotherapeutic management of invasive breast cancer in North America and Europe. We also identified a number of areas of agreement, as well as controversy, toward which additional clinical research should be directed.

METHODS AND MATERIALS

An original survey questionnaire was developed to assess radiation oncologists' self-reported management of breast cancer. The questionnaire was administered to physician members of the American Society for Therapeutic Radiology and Oncology and the European Society for Therapeutic Radiology and Oncology. We present the results of the comparative analysis of 702 responses from North America and 435 responses from Europe.

RESULTS

Several areas of national and international controversy were identified, including the selection of appropriate candidates for postmastectomy radiation therapy (RT) and the appropriate management of the regional lymph nodes after mastectomy, as well as after lumpectomy. Only 40.7% and 36.1% of respondents would use postmastectomy RT in patients with 1-3 positive lymph nodes in North America and Europe, respectively. Sentinel lymph node biopsy was offered more frequently by North American than European respondents (p <0.0001) and more frequently by academic than nonacademic respondents in North America (p < 0.05). The average radiation fraction size was larger in Europe than in North America (p < 0.01). European respondents offered RT to the internal mammary chain more often than did the North American respondents (p < 0.001). North American respondents were more likely to offer RT to the supraclavicular fossa (p < 0.001) and axilla (p < 0.01).

CONCLUSION

Marked differences were found in physician opinions regarding the management of breast cancer, with statistically significant international differences in patterns of care. This survey highlighted areas of controversy, providing support for international randomized trials to optimize the RT management of invasive breast cancer.

Extra nodal growth as a prognostic factor in malignant melanoma

AIM

Extra nodal growth (ENG) in lymph-node metastases may be an additional indicator for poor prognosis and increased loco-regional recurrence in patients with a cutaneous malignant melanoma (CMM). Most studies analyzing prognostic factors lack a proper definition or description of the histological criteria for extra nodal growth. The objective of this study was to evaluate this factor.

METHODS

Retrospectively 94 patients with CMM and clinically lymph-node metastases were analysed. Metastatic lymph-nodes were evaluated for ENG and if present grouped in microscopic (<2 mm) or macroscopic (>2 mm) ENG. ENG was defined as metastatic tumour which clearly extends histologically through the nodal capsule into the perinodal fatty tissue or tumour involvement in the hilar region with interruption of the smooth outline of the (presumed) capsule.

RESULTS

Ninety-four patients, median age 52 (6-92) years with CMM, median Breslow thickness 2.8 (0.2-11.0) mm. In 50 patients ENG was present (macroscopic: 32, microscopic: 18). The median follow-up was 59 (range 5-325) months. The number of loco-regional recurrence was 10; 4 in the group with and 6 in the group without ENG (n.s.). Five years survival of patients with ENG was 42% and without ENG 50% (n.s.). There was no significant difference in survival or loco-regional recurrence between microscopic or macroscopic ENG.

CONCLUSION

ENG of lymph-node metastases of CMM is of no prognostic value and has no clinical impact.

Postmastectomy CT-based electron beam radiotherapy: Dosimetry, efficacy, and toxicity in 118 patients

PURPOSE

To evaluate the technique, dosimetry, acute and late toxicity, local control (LC), and overall survival (OS) with the use of computed tomography (CT)-based postmastectomy electron beam therapy (PMEBT) in high-risk patients.

METHODS AND MATERIALS

From 1990 to 2000, 118 patients with pathologic stage I-IIIB breast cancer underwent PMEBT of the chest wall (CW) (n = 3), CW and supraclavicular fossa (SCV) (n = 63), CW, SCV, and internal mammary lymph nodes (IMN) (n = 51), and SCV+IMN (n = 1). Radiation therapy was delivered with an en face electron beam with a custom cutout. Treatment plans were all CT-based. The plans of 16 patients were retrospectively reviewed to analyze dosimetry data. A retrospective chart review was conducted to assess acute and late complications, LC, and OS.

RESULTS

At a median follow-up of 43 months, 5-year LC and OS were 91% and 61%, respectively. Sixty-one patients developed acute grade 3-4 skin toxicity, necessitating treatment breaks in 33 patients. Fifteen patients experienced a worsening of lymphedema, and 2 patients developed cardiac injury thought to be unrelated to radiotherapy. No patients developed symptomatic pneumonitis. Dosimetric analysis revealed heart and lung normal tissue complication probabilities of zero. Analysis of other clinically relevant dosimetric parameters revealed PMEBT to be comparable to previously reported techniques.

CONCLUSION

Postmastectomy electron beam therapy is an effective way to deliver radiation to the postmastectomy chest wall and adjacent nodal sites. It offers acceptable acute and late toxicities and a high degree of local control given the high-risk population to which it is offered.

Implications of extranodal spread in node positive breast cancer: a review of survival and local recurrence

An evaluation of extra nodal spread (ENS) in predicting overall survival and locoregional relapse rates in 311 node positive breast cancer patients was undertaken: the study group comprised 71 patients with ENS and the control group comprised 240 patients with no ENS. A review of pathology reports that described ENS was performed and a scoring system to categorize focal involvement, extensive axillary fat involvement, and positive axillary surgical margins was devised. Median follow up time was 3.1 years. Overall survival, disease specific survival and disease-free survival rates were significantly worse in the study group in comparison with the control group. Poorer survival with more extensive pathological invasion of ENS was demonstrated. Multivariate analysis of disease specific survival in those patient with 1-3 involved lymph nodes demonstrated that ENS positivity was prognostically significant (P=0.013). Although locoregional relapse was increased in the presence of ENS, axillary relapses were uncommon and do not warrant axillary radiation.

Risk factors for regional nodal failure after breast-conserving therapy: regional nodal irradiation reduces rate of axillary failure in patients with four or more positive lymph nodes

PURPOSE

To determine the incidence of, and risk factors for, regional nodal failure (RNF) and to evaluate the effectiveness of, and indications for, regional nodal irradiation (RNI) in patients with Stage I-II breast cancer treated with breast-conserving therapy.

METHOD AND MATERIALS

A total of 1500 cases of Stage I-II breast cancer were treated with breast-conserving therapy between February 1980 and December 2000. All patients underwent excisional biopsy, and 925 (62%) underwent re-excision. Level I-II axillary lymph node dissection was done in 94% of patients. The lymph nodes were pathologically involved in 335 patients (22%); 255 with 1-3 nodes and 80 with >/=4 nodes involved. All patients received whole breast irradiation to a median dose of 45 Gy, and 97% received a tumor bed boost to a median dose of 61 Gy. Treatment included the breast only in 1309 patients (87%), and the breast and regional lymphatics in 191 (13%).

RESULTS

With a median follow-up of 8.1 years, 35 patients had failure within the regional nodes: 12 patients (6%) who received RNI and 23 patients (2%) who did not. The 5- and 10-year rate for any RNF was 1.9% and 2.8%, respectively. The 5 and 10-year rates of axillary failure and supraclavicular failure were 0.6% and 1.0% and 0.9% and 1.6%, respectively. In patients with >/=4 positive lymph nodes, RNI reduced the 10-year rate of any RNF from 11% to 2% (p = 0.024), the rate of axillary failure from 5% to 0% (p = 0.019), and the rate of supraclavicular failure from 11% to 2% (p = 0.114). RNI did not affect the rate of axillary failure or supraclavicular failure in patients with 1-3 positive nodes. In node-negative patients, the rate of RNF was significantly greater if <6 nodes were removed at the time of axillary dissection. Multiple clinical, pathologic, and treatment-related factors were analyzed for association with RNF. On univariate analysis, RNF was associated with the number of nodes excised, number of positive nodes, percentage of positive nodes, size of nodal metastasis, presence of angiolymphatic invasion, estrogen receptor status, age, systemic chemotherapy, and RNI. Three subsets of patients had unusually high rates of RNF, those with >/=67% nodes positive (16%), nodal metastasis >/=2.0 cm (44%), or age </=35 years (14%). On multivariate analysis, the only significant predictor of RNF was the maximal size of the nodal metastasis. RNI did not improve the overall survival for any subset of patients. The number of lymph nodes excised had an impact on overall survival, with a 10-year survival rate of 33%, 65%, and 69% in patients with <6, 6-10, and >10 nodes excised, respectively (p = 0.05).

CONCLUSION

Failure within the regional lymph nodes as an isolated site of first relapse is uncommon in patients with Stage I-II breast cancer treated with breast-conserving therapy. RNI can significantly reduce the rate of RNF (axillary failure) in patients with >/=4 positive lymph nodes. The maximal size of the lymph node metastasis was found to be the only significant independent predictor of RNF, with nodal metastases >/=2.0 cm associated with extremely high regional failure rates. Despite this, young age and the extent of axillary dissection (particularly as related to the number of positive nodes) also appear to be important and should be considered when evaluating patients for RNI. Inadequate axillary dissection was not only associated with increased regional failure, but also reduced survival.

Extracapsular extension of the sentinel lymph node metastasis: a predictor of nonsentinel node tumor burden

OBJECTIVE

To identify predictors of nonsentinel node (NSN) tumor involvement in patients with a tumor-involved sentinel node (SN).

SUMMARY BACKGROUND DATA

For many breast cancer patients who undergo intraoperative lymphatic mapping and sentinel lymphadenectomy (LM/SL), the SN is the only tumor-involved axillary node. Associations between NSN tumor involvement and several clinical and histopathologic factors have been identified. The authors hypothesize that extracapsular extension (ECE) of the SN metastasis is highly predictive of NSN tumor involvement.

METHODS

Between May 1998 and December 2001, 260 patients (263 cases) with clinical T1 or T2 (<5.0 cm) breast cancer underwent LM/SL at the University of North Carolina, using a combined blue dye and technetium sulfur colloid technique. In all cases with a tumor-involved SN, axillary lymph node dissection (ALND) was recommended. Statistical analysis, with Pearson chi-square tests, Fisher exact test, and multiple logistic regression, was performed.

RESULTS

The SN contained tumor in 74 (28.1%) cases. ALND was performed in 70 of the 74 cases. ECE of the SN metastasis was present in 18 (25.7%) of the 70 cases. Patients with ECE of the SN metastasis were more likely to have NSN tumor involvement and had a greater total number of tumor-involved nodes than patients without ECE of the SN metastasis. Increasing size of the SN metastasis and increasing size of the primary tumor, examined as continuous variables, were associated with an increased likelihood of NSN tumor involvement on univariate analysis. However, only ECE of the SN metastasis was associated with NSN tumor involvement on multivariate analysis.

CONCLUSIONS

ECE of the SN metastasis is a strong predictor of NSN tumor involvement. All patients with ECE of the SN metastasis should undergo mandatory completion ALND.

Pathobiology of preoperative chemotherapy: findings from the National Surgical Adjuvant Breast and Bowel (NSABP) protocol B-18

BACKGROUND

Examination was performed on pathologic material from patients enrolled in the National Surgical Adjuvant Breast Project (NSABP) protocol B-18, in which the clinical effects of preoperative (preop) and postoperative (postop) doxorubicin and cyclophosphamide (AC) were compared.

METHODS

Of the total number of 1523 patients, 1234 patients (81%) were in the pathologically evaluable cohort. Six hundred twenty-six patients had been randomized prospectively to receive AC postop and 608 had been randomized to receive AC preop. Preentry diagnosis was made by fine-needle aspiration (FNA) and/or Tru-cut biopsy (TC). AC-induced and other pathologic changes were identified, and their relation to pathologic response and overall survival (OS) and disease-free survival (DFS) was determined. Frequencies of the number of lymph node metastases, their size, stromal reaction, and extracapsular extension (ECE) were compared in the two treatment groups, as was their correlation with OS and DFS. Survival estimates were based on 9 years of follow-up.

RESULTS

Approximately 13% of primary breast carcinoma cases exhibited both a clinical complete response (cCR) and a pathologic complete response (absence of invasive tumor [pCR]) to preop AC. An additional 7% of patients exhibited a pCR in the absence of a cCR. A pCR occurred in 38% of those patients determined to have achieved a cCR. Poor nuclear grade of the tumor cells in the pre-entry FNA and/or TC specimens significantly predicted a pCR. Patients with the latter exhibited a better OS and DFS compared with those with a pathologic partial response (presence of sparse invasive tumor [pPR]) or no pathologic response (pNR). Epithelial alterations considered to be induced in tumors by preop AC were comprised of types 1 and 2 giant cells with meganuclei, apocrine metaplasia, and cytoplasmic vacuolation. They had a high degree of specificity (range, 86-99%) but a low sensitivity (range, 7-38%). All were predictive of a pPR and were found to be related adversely to OS and DFS. A fibrous stromal reaction noted in tumors or their putative sites in the preop group was found to have only modest degrees of specificity (63%) and sensitivity (74%). Moderate/marked sclerosis of basement membranes of the ductal and ductular elements of the terminal ductolobular unit (TDLU) was significantly more frequent in nontumor-bearing areas of breasts from patients in the preop treatment group compared with those in the postop treatment group (67% vs. 48%; P < 0.0001). The degrees of change in the TDLU in patients in the postop treatment group were found to be unrelated to age. Lymphatic tumor extension in the primary tumor, as well as a positive lymph node status, were less frequent in the preop treatment group compared with the postop treatment group. The OS and DFS were nearly identical in both treatment groups, being 69% and 55% and 70% and 53% in the preop and postop treatment groups, respectively, at 9 years. A fibrous stromal response to lymph node metastases was found to be significant for DFS but not OS. ECE was similar in both groups (55% vs. 48%; P = 0.12). Only 1% of ECE was found to be related to axillary failure in both treatment arms combined. There was no significant difference with regard to the parameters of survival for patients in the postop treatment group whose lymph nodes contained micrometastases (< 2.0 mm) or mini micrometastases (< 1.0 mm) (the latter detected immunohistochemically with anticytokeratin), and a true-negative lymph node status (not immunohistochemically converted to positive). Conversely, there was no apparent difference with regard to OS in preop treated patients with lymph node micrometastases, mini micrometastases, and macrometastases (P = 0.19). Those with mini micrometastases had a significantly worse OS compared with those with a true-negative lymph node status (P = 0.0007). DFS remained worse for patients in that treatment group with micrometastases and mini micrometastases compared with those with negative lymph nodes, although it was better than that for patients with macrometastases (P = 0.02).

CONCLUSIONS

Poor nuclear grade of tumor cells in the preentry FNA or TC specimens in the preop group was predictive of a pCR. AC-induced meganuclear giant cells and apocrine changes and nuclear and histologic grades of the primary tumors also were found to be prognostically significant in patients in the preop treatment group, and the latter two variables were found to be significant for those patients in the postop treatment group. No evidence was found to support the need for axillary lymph node radiation for ECE of lymph node metastases. Extended pathologic or immunohistochemical procedures also appear to be unnecessary for the detection of lymph node mini micrometastases, at least when traditional postop chemotherapy is used. The adverse relation between such small metastases and OS and DFS after preop AC appears to be related to the timing of the chemotherapy administration rather than any pathobiologic reasons.

Treatment guidelines and techniques in delivery of postmastectomy radiotherapy in management of operable breast cancer

Radiation therapy has been shown to statistically significantly reduce the risk of locoregional recurrence in high-risk patients with operable breast cancer following mastectomy and systemic therapy. Recent trials have also demonstrated a significant survival benefit following radiotherapy in high-risk patients. Therefore, it is important to identify the patients who could potentially derive that survival benefit and to not offer treatment to those patients who are not at increased risk for failure. Established risk factors that predict for increased rates of locoregional recurrence include axillary lymph node involvement and T3 (or T4) disease. While treatment-related factors, such as the extent of the axillary dissection and extent of lymph nodal positivity, also undoubtedly affect locoregional recurrence, additional studies are needed to define the magnitude of their risk. Locoregional patterns of failure have identified the chest wall and supraclavicular/infraclavicular regions to be the most common sites of locoregional failure following mastectomy, which justifies treatment to these regions. While long-term complications are uncommon following locoregional radiotherapy, careful treatment planning is critical to minimize cardiac (and pulmonary) toxicity.

Extranodal extension of axillary metastasis of invasive breast carcinoma as a possible predictor for the total number of positive lymph nodes

INTRODUCTION

By the implementation of the sentinel node procedure in the treatment of breast carcinoma routine axillary lymph node, dissection can be abandoned in patients with a tumour-negative sentinel node. When the sentinel node is positive there are two options; an axillary dissection or radiotherapy of the axilla. In the latter case one is not informed about the total number of positive lymph nodes which can be of importance for the choice of adjuvant chemotherapy. In this paper we analyse whether it is possible to use histological parameters of a lymph-node metastasis to predict the number of tumour-cell-containing nodes.

METHODS

Four hundred and ninety-eight patients treated for invasive breast cancer at our department from 1991 to 1996 were investigated to see whether extranodal extension of axillary metastases had a significant predictive value for the number of positive lymph nodes. Extranodal extension was scored as: no extranodal extension (NEE) and extranodal extension (EE); the latter was subdivided in minimal extranodal extension (MEE) or extensive extranodal extension (EEE).

RESULTS

Of 498 patients, 230 patients had axillary involvement. NEE was seen in 83 (36.1%) patients and 147 (63.9%) had EE. Subdivision of this latter group revealed 77 patients with MEE (52%), 65 patients with EEE (45%) and five patients not further specified (3%). The number of positive nodes for the EE-group (6.9+/-0.5) was significant higher compared with the NEE-group (2.1+/-0.2) (P<0.001). The number of positive nodes was also significantly higher for the EEE-group compared to the MEE-group, 10.6+/-0.8 vs 4.0+/-0.4 (P<0.001). The predictive value for > or =4 positive axillary lymph nodes was 84.6% for EEE, 58.5% for EE and only 14.5% for NEE. These differences were significant (P<0.001).

CONCLUSIONS

The presence of extranodal extension in axillary lymph-node metastases can be a good predictor for the expected number of positive nodes. This histological parameter could be of value to determine the kind of adjuvant chemotherapy after a positive sentinel-node biopsy with only radiotherapy of the axilla and no further axillary lymph-node dissection.