Predictive Factors for Non-Sentinel Lymph Node Metastasis in the Case of Positive Sentinel Lymph Node Metastasis in Two or Fewer Nodes in Breast Cancer

Selective Avoidance of Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy in Human Epidermal Growth Factor 2-Positive/Triple-Negative Breast Cancer Patients With Excellent Response

PURPOSE

The Avoid Axillary Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy (ASLAN) trial aims to demonstrate the oncologic safety of omitting axillary surgery in patients with excellent response after neoadjuvant chemotherapy (NACT) for early human epidermal growth factor 2 (HER2)-positive (+)/triple-negative breast cancer (TNBC) who have undergone breast-conserving surgery (BCS) and adjuvant radiotherapy. The ASLAN trial will provide crucial information that could change the procedure in highly selected patients undergoing axillary surgery after NACT.

METHODS

ASLAN is a prospective, multicenter, and single-arm surgical trial. The recruitment will be conducted among five tertiary care hospitals in the Republic of Korea. The total number of patients to be recruited will be 178, and we plan to complete patient enrollment by December 2023. The enrollment is considered among patients with HER2+ breast cancer (BC) or TNBC at clinical stage T1-3N0-1M0 who are expected to achieve breast pathological complete response (BpCR) based on a combination of radiologic imaging and physical examination after NACT. BCS was performed on eligible patients. After BCS, patients who showed BpCR were enrolled with the omission of sentinel lymph node biopsy (SLNB). The primary study endpoint upon completion of this trial is 5-year recurrence-free survival, and the secondary endpoints include the 5-year ipsilateral breast tumor recurrence interval, 5-year ipsilateral axillary recurrence interval, 5-year distant metastasis-free survival, 5-year BC-specific survival, 5-year overall survival, 5-year contralateral BC-free survival, re-operation rate according to breast biopsy after NACT, adverse events within 5 years, and quality of life.

DISCUSSION

Several clinical trials are currently underway to determine whether SLNB can be omitted after NACT in patients with HER2+ BC or TNBC that are expected to achieve pathologic complete response. The ASLAN trial is expected to provide valuable clues regarding the feasibility of omitting axillary surgery in highly selected patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04993625. Registered on August 6, 2021. Clinical Research Information Service Identifier: KCT0006371. Registered on July 22, 2021.

Non-sentinel lymph node metastases risk factors in patients with breast cancer with one or two sentinel lymph node macro-metastases

Approximately 59 % of patients with breast cancer with one or two sentinel lymph nodes (1-2 SLN) macrometastases do not benefit from axillary lymph node dissection (ALND), which may also incur morbidities. It is necessary to evaluate the association between various clinicopathological characteristics and non-sentinel lymph node metastases (non-SLNM) in patients with breast cancer with 1-2 SLN macrometastases, and determine whether they 1-2 should avoid ALND. Eight electronic literature databases (PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Chinese Scientific Journal, Wanfang, and Chinese Biomedical Literature) were searched from their inception to June 30, 2023, and two reviewers independently extracted the data and assessed the risk of bias. Association strength was summarized using odds ratios (OR) and 95 % confidence intervals (CI). Heterogeneity was accounted for using a subgroup analysis. Publication bias was evaluated using funnel plots and Egger's test. There were 25 studies with 8021 participants, and 27 potential risk factors were evaluated. The risk factors for non-SLNM in patients with 1-2 SLN macrometastatic breast cancer include the following: factors of primary tumor: multifocality (OR (95 % CI (2.63 (1.96, 3.54))), tumor size ≥ T2 (2.64 (2.22, 3.14)), tumor localization (upper outer quad) (2.06 (1.23, 3.43)), histopathological grade (G3) (2.45 (1.70, 3.52)), vascular invasion (VI) (2.60 (1.35, 4.98)), lymphovascular invasion (LVI) (2.87 (1.80, 4.56)), perineural invasion (PNI) (3.16 (1.18,8.43)). Factors of lymph nodes: method of SLNs detected (blue dye) (3.85 (1.54, 9.60)), SLN metastasis ratio ≥0.5 (2.79 (2.24, 3.48)), two positive SLNs (3.55, (2.08, 6.07)), zero negative SLN (3.72 (CI 2.50, 4.29)), extranodal extension (ENE) (4.69 (2.16, 10.18)). Molecular typing: Her-2 positive (2.08 (1.26, 3.43)), Her-2 over-expressing subtype (1.83 (1.22, 2.73)). Factors of examination/inspection: axillary lymph nodes (ALNs) positive on imaging (3.18 (1.68, 6.00)), cancer antigen 15-3 (CA15-3) (4.01 (2.33,6.89)), carcinoembryonic antigen (CEA) (2.13 (1.32-3.43)). This review identified the risk factors for non-SLNM in patients with 1-2 SLN macrometastatic breast cancer. However, additional studies are needed to confirm the above findings owing to the limited number and types of studies included.

Can We Avoid Axillary Lymph Node Dissection (ALND) in Patients with 1-2 Positive Sentinel/Low Axillary Lymph Nodes (SLN/LAS+) in the Indian Setting?

The ACOSOG Z0011 study, heralded as a "practice changing" trial, suggested that women with T1-2 breast cancer with 1-2 SLN+, undergoing breast conservation therapy, need not be offered further ALND. However, whether these results are applicable to all women in the Indian setting, it remains debatable. A retrospective audit of all cN0 operated from 2013 to 2018 was conducted. We analyzed the percentage of additional LN positive (LN+) in the ALND group and compared it to the ACOZOG Z11 trial. Of the 2350 cN0 with EBC who underwent LAS, 687 (29%) had positive lymph nodes on final histopathology. Five hundred ninety-seven (86.9%) patients had 1-2 LN+, 40 (5.8%) patients had 3 LN+, and 50 (7.3%) had 4 or more nodes positive. Demographic features in the ACOSOG Z11 are different from those in our study, looking at ACOZOG Z11 versus our cohort-median pT 1.7 cm versus 3 cm, 45% micrometastasis versus 99.16% macrometastasis, and 28-30% grade 3 tumors versus 73.7%. In our cohort 31.82% of the 1-2 LN positive had additional LN+ on ALND. Keeping in mind the difference in clinicopathological features between our cohort and that of ACOZOG Z0011 and that 31.82% of women had additional LN+ on ALND, it may not be appropriate to apply the results of the ACOSOG Z0011 trial directly to our general population. Possibly, only a select subset of patients who match the trial population of the ACOSOG Z11 could be offered observation of the axilla and validated nomograms can be used to identify high-risk patients.

The diameter of metastasis in positive sentinel lymph node biopsy affects axillary tumor load in early breast cancer

INTRODUCTION

Omission of axillary lymph node dissection (ALND) after positive sentinel lymph biopsy (SLNB) has become a standard procedure for breast cancer patients with one or two metastatic lymph nodes. Here the aim was model development for selection for ALND.

MATERIAL AND METHODS

We analyzed 323 positive SLNB breast cancer patients, who afterwards underwent ALND. In 126 (39%), there were positive additional axillary lymph nodes. Specimens of resected lymph nodes were scanned and the volumes of tumors (expressed as diameter in mm) were calculated. The maximal diameter of metastasis in the sentinel lymph nodes (SLN_Dmax ) and axillary lymph nodes (ALN_Dsum ) indicated tumor load in the resected lymph nodes. ALN_Dsum higher or equal to 5 mm was defined as high and present in 62 patients (21%).

RESULTS

Risk factors for high ALN_Dsum were primary tumor diameter (P = 0.0092), histopathological type (P = 0.0173), number of positive SLNs (P = 0.0012), type of metastasis (P = 0.0025), molecular type (P = 0.0037), SLN_Dmax (P = 0.0001), and Her-2 status (P = 0.0093). Independent variables for high ALN_Dsum were SLN_Dmax (P < 0.0001), number of positive SLNs (P = 0.0237) and primary tumor diameter (P = 0.0296).

CONCLUSIONS

Twenty-one percent patients with positive SLNB are at risk of high ALN_Dsum . SLN_Dmax is the strong predictive factor for high ALN_Dsum after positive ALND.

Positive non-sentinel axillary lymph nodes in breast cancer with 1-2 sentinel lymph node metastases

Recent clinical trials have shown that sentinel lymph node biopsy (SLNB) alone without axillary lymph node dissection (ALND) can offer excellent regional control if there is sentinel lymph nodes (SLN) metastases to 1-2 nodes. This study aimed to explore the predictive factors for non-sentinel lymph node (NSLN) metastasis in breast cancer patients with 1-2 positive SLNs.Patients with breast cancer and 1-2 positive SLN admitted between March 2009 and March 2017 and who underwent ALND after SLN biopsy (SLNB) at Beijing Chaoyang Hospital were analyzed retrospectively. Factors influencing the status of NSLN were studied by univariate and multivariate analysis.Of 1125 patients, 147 patients had SLN metastasis (13.1%) and 119 patients (81.0%) had 1-2 positive SLNs. Among them, 42 patients (35.3%) had NSLN metastasis. The invasive tumor size (P <.001), histological grade (P =.011), lymphovascular invasion (LVI) (P =.006), and over-expression of HER2 (P =.025) significantly correlated with non-SLN metastasis by univariate analysis. LVI (LVI) (P =.007; OR: 4.130; 95% confidence interval [CI]: 1.465-11.641), invasive tumor size (P <.001; OR: 7.176; 95% CI: 2.710-19.002), and HER2 over-expression (P =.006; OR: 5.489; 95% CI: 1.635-18.428) were independently associated with NSLN metastasis by the Logistic regression model. The ROC analysis identified a cut-off point of 26 mm of tumor size (area under the receiver operating characteristic [ROC] curve [AUC] 0.712, CI: 0.614-0.811) was useful for dividing patients with positive SLN (1-2 nodes) into non-SLN-positive and non-SLN-negative groups.For 1-2 positive SLNs of breast cancer, LVI, large invasive tumor size, and HER2 over-expression are independent factors affecting NSLN metastases.

Frequency and Predictors of Axillary Lymph Node Metastases in Iranian Women with Early Breast Cancer

Background:

Axillary lymph node metastasis is the most important predictive factor for recurrence risk and survival in patients with invasive breast carcinoma. The aim of this study was to determine factors associated with metastatic involvement of axillary lymph nodes in Iranian women with early breast cancer.

Methods:

This article reports a retrospective study of 774 patients with T1-T2 breast cancer who underwent resection of the primary tumor and axillary staging by SLNB and/or ALND between 2005 and 2015 at our institution.

Results:

Of the 774 patients included in this study, 35.5% (275 cases) had axillary lymph node involvement at the time of diagnosis. Factors associated with nodal involvement in univariate analyses were tumor size, lymphovascular invasion (LVI), tumor grade, ER/PR status and HER2 expression. All factors identified with univariate analyses were entered into a multivariate logistic regression model and tumor size (OR= 3.01, CI 2.01–4.49, P <0.001), ER/PR positivity (OR = 1.74, CI 1.1.16–2.62, P = 0.007) and presence of LVI (OR = 3.3.8, CI 2.31–4.95, P <0.001) remained as independent predictors of axillary lymph node involvement.

Conclusions:

In conclusion, the results of this study suggests that positive hormonal receptor status, LVI and tumor size are predictive factors for ALNM in Iranian women with early breast cancer.

Preoperative prediction of sentinel lymph node metastasis in breast cancer based on radiomics of T2-weighted fat-suppression and diffusion-weighted MRI

OBJECTIVES

To predict sentinel lymph node (SLN) metastasis in breast cancer patients using radiomics based on T₂-weighted fat suppression (T₂-FS) and diffusion-weighted MRI (DWI).

METHODS

We enrolled 146 patients with histologically proven breast cancer. All underwent pretreatment T₂-FS and DWI MRI scan. In all, 10,962 texture and four non-texture features were extracted for each patient. The 0.623 + bootstrap method and the area under the curve (AUC) were used to select the features. We constructed ten logistic regression models (orders of 1-10) based on different combination of image features using stepwise forward method.

RESULTS

For T₂-FS, model 10 with ten features yielded the highest AUC of 0.847 in the training set and 0.770 in the validation set. For DWI, model 8 with eight features reached the highest AUC of 0.847 in the training set and 0.787 in the validation set. For joint T₂-FS and DWI, model 10 with ten features yielded an AUC of 0.863 in the training set and 0.805 in the validation set.

CONCLUSIONS

Full utilisation of breast cancer-specific textural features extracted from anatomical and functional MRI images improves the performance of radiomics in predicting SLN metastasis, providing a non-invasive approach in clinical practice.

KEY POINTS

• SLN biopsy to access breast cancer metastasis has multiple complications. • Radiomics uses features extracted from medical images to characterise intratumour heterogeneity. • We combined T ₂ -FS and DWI textural features to predict SLN metastasis non-invasively.

Factors Influencing Non-sentinel Node Metastasis in Patients with Macrometastatic Sentinel Lymph Node Involvement and Validation of Three Commonly Used Nomograms

OBJECTIVE

Omitting axillary lymph node dissection (ALND) in a subgroup of patients with sentinel lymph node (SLN) metastasis is becoming a widely accepted practice. Avoiding the well-known complications of ALND is the sole aim without compromising the curative intention of surgery.

MATERIALS AND METHODS

The data were probed for breast cancer patients that were operated on between February 2014 and June 2016. SLN biopsies were performed in 507 patients and out of 157 patients who underwent ALND for a metastatic SLN, 151 were found eligible for the analyses as having macrometastatic (>2mm) SLN. MD Anderson, Memorial Sloan Kettering Cancer Center and Helsinki nomograms were also tested in our patient population.

RESULTS

Pathologic tumor size greater than 2 cm, the ratio of metastatic SLN to dissected SLN, metastatic tumor greater than 1 cm and tumors that extended outside the SLN's capsule were found to be associated with non-sentinel node metastasis in both univariate and multivariate tests. MD Anderson nomogram performed well with an area under the curve (AUC) value of 0.72.

CONCLUSION

Our results suggest that ALND should be considered in patients with macrometastatic SLN greater than 10 mm in size, have extracapsular extension, have metastatic SLNs at a rate of more than 50% and whose primary tumor is greater than 2 cm.

Prediction of nonsentinel lymph node metastasis in breast cancer patients with one or two positive sentinel lymph nodes

OBJECTIVE

The aim of the present study was to investigate the association between non sentinel lymph node metastasis (NSLNM) and clinicopathological factors, particularly in the case of sentinel lymph node (SLN) metastasis in one or two, in clinically node negative patients with breast cancer.

METHODS

Between 10/2010 and 10/2014, 350 sentinel lymph node biopsy (SLNB) were performed in patients with histologically proven primary breast cancer in our clinic. The data collection includes the following characteristics: age, pathological tumor size, histological type, histological grade, lymphovascular invasion (LVI), number of positive SLN, size of the SLN metastasis (macrometastasis, micrometastasis, isolated tumor cells), multifocality (MF), extracapsuler invasion (ECI) of the SLN, the estrogen receptor (ER) status, the progesterone receptor (PR) status and the Her 2 receptor status, Ki 67 reseptor status. Data were collected retrospectively and then analyzed.

RESULTS

A successful SLN biopsy were performed in 345 (98.5%) cases. SLN metastases were detected in 110 (31.8%) cases. These patients then underwent axillary dissection; among these patients, 101 (91.8%) had only one to two positive SLNs. Of the 101 patients with positive SLN biopsies, 32 (31.6%) had metastases in the NSLNs. Univariate and multivariate analysis showed that lymphovascular invasion, extracapsular invasion (ECI), Her-2 receptor positive, and Ki-67 > 14% were related to NSLNM (p<.0.05).

CONCLUSION

The predicting factors of NSLNM were LVI, ECI, Ki-67 level, Her-2 reseptor positive and but should be further validated in our institutions, different institutions and different patient groups prospectively.

Breast cancer subtypes can be determinant in the decision making process to avoid surgical axillary staging: A retrospective cohort study

INTRODUCTION

The need for performing axillary lymph-node dissection in early breast cancer when the sentinel lymph node (SLN) is positive has been questioned in recent years. The purpose of this study was to identify a low-risk subgroup of early breast cancer patients in whom surgical axillary staging could be avoided, and to assess the probability of having a positive lymph-node (LN).

METHODS

We evaluated the cohort of 612 consecutive women affected by early breast cancer. We considered age, tumor size, histological grade, vascular invasion, lymphatic invasion and cancer subtype (Luminal A, Luminal B HER-2+, Luminal B HER-2-, HER-2+, and Triple Negative) as variables for univariate and multivariate analyses to assess probability of there being a positive SLN o nonsentinel lymph node (NSLN). Chi-square, Fisher's Exact test and Student's t tests were used to investigate the relationship between variables; whereas logit models were used to estimate and quantify the strength of the relationship among some covariates and SLN or the number of metastases.

RESULTS

A significant positive effect of vascular invasion and lymphatic invasion (odds ratios are 4 and 6), and a negative effect of TN (odds ratios is 10) were noted. With respect to positive NSLN, size alone has a significant (positive) effect on tumor presence, but focusing on the number of metastases, also age has a (negative) significant effect.

CONCLUSION

This work shows correlation between subtypes and the probability of having positive SLN. Patients not expressing vascular invasion, lymphatic invasion and, moreover, a triple-negative tumor subtype may be good candidates for breast conservative surgery without axillary surgical staging.