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

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.

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.

Partial omentectomy maybe practicable for T3 or shallower gastric cancer patients

BACKGROUND

Total omentectomy is often performed with gastrectomy as radical surgery for gastric cancer (GC) patients. However, it remains controversial whether GC patients can benefit from omentectomy. The aim of this study was to analyze the incidence and clinical significance of tumor deposits (TDs) in different anatomical subregions of perigastric omentum in GC patients undergoing gastrectomy with total omentectomy.

METHODS

From October 2011 to December 2013, 1253 patients who underwent gastrectomy with total omentectomy for GC were retrospective reviewed. The TDs in different anatomical subregions of perigastric omentum were examined.

RESULTS

Of 1253 patients, TDs positivity was 11.2%. Tumor deposits in the omentum of greater curvature and in the omentum of lesser curvature were associated with lymphovascular invasion, perineural invasion, advanced tumor node metastasis stages, and unfavorable survival. Besides, TDs in the proximal omentum of greater curvature and in the omentum of lesser curvature correlated with older patients and larger tumors. Kaplan-Meier curves showed that patients with TDs had worser overall survival (OS) than those without, regardless of TD positions. Patients with TDs in the omentum of greater curvature had the worst prognosis, followed by patients with TDs in the omentum of lesser curvature and patients with no TDs. Tumor deposits in the proximal omentum of greater curvature was an independent prognostic factor for OS. Moreover, only patients classified as pT4 had TDs in the distal omentum of greater curvature.

CONCLUSIONS

Patients with TDs in the omentum of greater curvature had the worst prognosis, followed by patients with TDs in the omentum of lesser curvature and patients with no TDs. In addition, partial omentectomy might be practicable for gastric cancer patients classified as T3 or shallower tumors.

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

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Electronic supplementary material

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

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.

Epidemiologic trends in head and neck cancer and aids in diagnosis

Head and neck squamous cell carcinoma is the sixth most common cancer worldwide predominately associated with tobacco use. Changing cause and increased incidence in oropharyngeal carcinomas is associated with high-risk types of human papilloma virus and has an improved survival. Optical devices may augment visual oral examination; however, their lack of specificity still warrants tissue evaluation/biopsy. Histologic factors of oral carcinomas are critical for patient management and prognostic determination. Clinical biomarkers are still needed to improve early detection, predict malignant transformation, and optimize therapies.

Node-extranodal soft tissue stage based on extranodal metastasis is associated with poor prognosis of patients with gastric cancer

BACKGROUND

The purpose of this study was to evaluate the effect of Node-Extranodal soft tissue (pNE) stage based on Extranodal Metastasis (EM) on recurrence and survival in patients with gastric cancer (GC).

MATERIALS AND METHODS

A total of 642 patients were divided into two groups according to statue of EM. Clinicopathologic features were compared among the two groups, the log-rank test was used to assess statistical differences between the groups. Independent prognostic factors were identified by the Cox proportional hazards regression model. According to the number of EMs, EM was incorporated into the pN stage of gastric carcinoma. The 5-y overall survival (OS) and disease free survival (DFS) rates were 48.1% and 17.4%, 44.5% and 14.3% between the two groups. Patients with EM had a deeper tumor invasion and more number of lymph node metastases. Peritoneal dissemination and distant metastasis were more frequent with EM. EM is an independent risk factor for distance recurrence (odds ratio = 1.605), and it is the highest risk factor for peritoneal recurrence (odds ratio = 2.448). Multivariate analysis showed that depth of tumor invasion (P = 0.025), lymph node metastasis (P <0.001), and EM (P = 0.006) were independent factors associated with OS. Furthermore, EM (P = 0.0039) was also an independent prognostic factor for DFS. The differences in prognostic prediction between the seventh edition of the pN classification and the pNE classification were directly compared. We found the pNE classification (hazard ratio = 1.730, P <0.001) was more appropriate for predicting the OS of GC patients after curative surgery, and the -2 loglikehood of the pNE staging (4533.991) is smaller than the value of pN.

CONCLUSIONS

EM was closely associated with cancer aggressiveness and the presence of EM was a significant independent predictor of reduced DFS and OS in GC patients. EM is an independent risk factor for distance recurrence, especially for peritoneal recurrence, the selection of postoperative adjuvant therapy in systemic (intravenous or intra-arterial) and regional (intraperitoneal) based on EM may be a reasonable approach. The lymph node imaging techniques such as injecting nanocarbon during surgery should be applied. As an important prognostic factor, EM should be incorporated into N stage according to its number retrieved in postoperative samples.

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Extranodal metastasis is a powerful prognostic factor in patients with adenocarcinoma of the esophagogastric junction

BACKGROUND AND OBJECTIVES

The purpose of this study is to estimate the effect of extranodal metastasis (EM) on recurrence and survival in patients with adenocarcinoma of the esophagogastric junction (AEG) after curative resection.

METHODS

Clinical data from 284 node-positive AEG patients who underwent curative resection were reviewed. Univariate and multivariate analyses were conducted to elucidate the effect of EM on recurrence-free survival (RFS) and overall survival (OS).

RESULTS

EM was detected in 70 (24.6%) of the 284 cases. It had a significant correlation with tumor size, Lauren type, histopathological grading, depth of tumor invasion, number of metastatic nodes, lymph node ratio, and TNM stage. The 5-year RFS and OS rates were 22.2% and 24.3%, respectively. Patients with EM had a significantly decreased RFS (16 vs. 36 months, P < 0.001) and OS (23 vs. 41 months, P < 0.001) compared with those without EM. Multivariate analyses identified EM as an independent prognostic factor (P = 0.003 and 0.001, respectively).

CONCLUSION

The presence of EM increases recurrence probability and reduces OS probability of AEG patients with lymph node metastasis. EM is a powerful prognostic factor reflecting a particularly aggressive biological behavior. Better understanding of EM status can help clinicians with regard to treatment decision and prognosis evaluation.

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.

Site-specific relapse pattern of the triple negative tumors in Chinese breast cancer patients

Background

It has been reported that triple negative phenotype is characterized by aggressive clinical history in Western breast cancer patients, however its pattern of metastatic spread had never been reported in the Chinese population. Considering racial disparities, we sought to analyze the spread pattern for different sites of first recurrence in Chinese triple negative breast cancers.

Methods

A retrospective study of 1662 patients was carried out from a large database of breast cancer patients undergoing surgery between January 1, 2000 and March 31, 2004 at the Cancer Hospital, Fudan University, Shanghai, China. Survival curves were generated using the Kaplan-Meier method and annual relapse hazards were estimated by the hazard function.

Results

We found a statistically significant difference in relapse-free survival (RFS) for locoregional and visceral recurrence (P = 0.007 and P = 0.025, respectively) among the triple negative, ERBB2+ and HR+/ERBB2- subgroups in univariate analysis. In the multivariate Cox proportional hazards regression analysis, RFS for either locoregional or visceral relapse in the triple negative category was inferior to that in HR+/ERBB2- patients (P = 0.027 and P = 0.005, respectively), but comparable to that in ERBB2+ women (both P >0.05). Furthermore, the early relapse peak appeared later in the triple negative group than that in the ERBB2+ counterpart for both locoregional and visceral relapse. On the other hand, when compared with triple negative breast cancers, a significantly lower risk of developing bone relapse was discerned for ERBB2+ women (P = 0.048; HR = 0.384, 95% CI 0.148-0.991), with the borderline significance for HR+/ERBB2- breast cancers (P = 0.058; HR = 0.479, 95% CI 0.224-1.025). In terms of bone metastasis, the hazard rate remained higher for the triple negative category than that for the ERBB2+ subtype.

Conclusion

Based on the site-specific spread pattern in different subgroups, the triple negative category of breast cancers in the Chinese population exhibits a different pattern of relapse, which indicates that different organotropism may be due to the different intrinsic subtypes. A better knowledge of the triple negative category is warranted for efficacious systemic regimens to decrease and/or delay the relapse hazard.

Sequencing chemotherapy and radiotherapy in locoregional advanced breast cancer patients after mastectomy - a retrospective analysis

BACKGROUND

Combined chemo- and radiotherapy are established in breast cancer treatment. Chemotherapy is recommended prior to radiotherapy but decisive data on the optimal sequence are rare. This retrospective analysis aimed to assess the role of sequencing in patients after mastectomy because of advanced locoregional disease.

METHODS

A total of 212 eligible patients had a stage III breast cancer and had adjuvant chemotherapy and radiotherapy after mastectomy and axillary dissection between 1996 and 2004. According to concerted multi-modality treatment strategies 86 patients were treated sequentially (chemotherapy followed by radiotherapy) (SEQgroup), 70 patients had a sandwich treatment (SW-group) and 56 patients had simultaneous chemoradiation (SIM-group) during that time period. Radiotherapy comprised the thoracic wall and/or regional lymph nodes. The total dose was 45-50.4 Gray. As simultaneous chemoradiation CMF was given in 95.4% of patients while in sequential or sandwich application in 86% and 87.1% of patients an anthracycline-based chemotherapy was given.

RESULTS

Concerning the parameters nodal involvement, lymphovascular invasion, extracapsular spread and extension of the irradiated region the three treatment groups were significantly imbalanced. The other parameters, e.g. age, pathological tumor stage, grading and receptor status were homogeneously distributed. Looking on those two groups with an equally effective chemotherapy (EC, FEC), the SEQ- and SW-group, the sole imbalance was the extension of LVI (57.1 vs. 25.6%, p < 0.0001).5-year overall- and disease free survival were 53.2%/56%, 38.1%/32% and 64.2%/50%, for the sequential, sandwich and simultaneous regime, respectively, which differed significantly in the univariate analysis (p = 0.04 and p = 0.03, log-rank test). Also the 5-year locoregional or distant recurrence free survival showed no significant differences according to the sequence of chemo- and radiotherapy. In the multivariate analyses the sequence had no independent impact on overall survival (p = 0.2) or disease free survival (p = 0.4). The toxicity, whether acute nor late, showed no significant differences in the three groups. The grade III/IV acute side effects were 3.6%, 0% and 3.5% for the SIM-, SW- and SEQ-group. By tendency the SIM regime had more late side effects.

CONCLUSION

No clear advantage can be stated for any radio- and chemotherapy sequence in breast cancer therapy so far. This could be confirmed in our retrospective analysis in high-risk patients after mastectomy. The sequential approach is recommended according to current guidelines considering a lower toxicity.

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 of pelvic lymph node metastases is of prognostic value in carcinoma of the cervix uteri

OBJECTIVES

Pelvic lymph node involvement is a well-recognized prognostic factor in cervical carcinoma (CX). Limited knowledge exists about extranodal extension of the tumor outside the lymph node capsule, i.e. extracapsular spread (ECS).

METHODS

Two hundred fifty-six cases of surgically treated CX (FIGO stage IB1 to IIB) with pelvic lymph node involvement were evaluated regarding the occurrence of extranodal spread of the metastatic deposits outside the lymph node capsule (ECS), determined on standardized handled lymphadenectomy specimens, regarding their impact of recurrent disease and overall survival during a median follow-up time of 62 months (95% CI 51-73 months).

RESULTS

ECS was seen in 30.9% (79/256) of the cases. The occurrence of ECS showed a significant correlation to advanced stage disease (p=0.02), the number of involved nodes (p<0.001) and the size of metastatic deposits (p<0.01). The 5-year recurrence-free survival rate in patients with ECS was significant lower compared to patients without ECS (59.7% [95% CI: 46.3%-73.2%] versus 67.2% [95% CI: 58.9%-75.5%]; (p=0.04). The 5-year overall survival rate was significant lower in patients with ECS (33.5% [95% CI: 20.6%-46.3%] vs. 60.5% [95% CI: 52.3%-68.6%]; p<0.001). In multivariate analysis, tumor stage, number of involved pelvic nodes, tumor differentiation and ECS were independent prognostic factors.

CONCLUSIONS

The results indicate that extracapsular spread (ECS) of pelvic lymph node metastases is of prognostic impact in cervical carcinomas. A revised FIGO/TNM classification system for pelvic lymph node disease is recommended: ECS 0 = lymph node involvement without extranodal spread of the metastatic deposits and ECS 1 = lymph node involvement with extranodal spread of the metastatic deposits.

Lymph Node Ratio is More Valuable than Level III Involvement for Prediction of Outcome in Node-Positive Breast Carcinoma Patients

BACKGROUND

We examined the relationship between different expressions of positive axillary lymph nodes (PN) and the outcomes of node-positive breast carcinoma patients to determine the best predictor(s) among these expressions and to assess whether anatomic high level involvement is an independent prognostic factor.

STUDY DESIGN

In this retrospective study, the primary endpoints were distant recurrence (DR), locoregional recurrences (LRR), and disease-free survival (DFS). Univariate and multivariate prognostic factor analyses were carried out using survival and regression methods in the data of 704 patients with PN.

RESULTS

In multivariate analysis, the number of PN, ratio of PN, log odds of PN, and level III (L-III) involvement, separately, were significant factors for DR in addition to age, tumor size, and lymphovascular invasion (LVI). In the final model including all expressions of nodal involvement, age (continuous P = 0.001; hazard ratio [HR]: 0.98; 95% confidence Interval [95% CI]: 0.96-0.99), tumor size (continuous: P < 0.0001; HR: 1.3; 95% CI, 1.2-1.5), LVI (yes vs. no: P = 0.005; HR: 1.6; 95% CI, 1.2-2.2), and ratio of PN (continuous: P = 0.02; HR: 1.03; 95% CI, 1.01-1.06) were the independent prognostic factors for DR. For LRR, ratio of PN (continuous: P = 0.001; HR: 1.02; 95% CI, 1.01-1.03) was the most important factor in addition to age (continuous: P = 0.02; HR: 0.98; 95% CI, 0.97-0.99) and tumor size (continuous: P = 0.04; HR: 1.3; 95% CI, 1.1-1.6). When patients were stratified by number categories of PN (1-3 vs. 4-9 vs. >/= 10), there was no difference between DFSs of patients with and without L-III involvement. In contrast, when patients were stratified by L-III involvement, DFSs according to the number categories were statistically different.

CONCLUSIONS

Ratio of PN was more valuable than number of PN for predicting outcome in node-positive breast carcinoma patients. Level III involvement was not an independent prognostic indicator either for locoregional or for distant recurrences.