Small Invasive Breast Carcinomas in Taiwanese Women

Background: Female Taiwanese breast cancer patients are younger than their Western counterparts. This study examined the predictors of axillary lymph node metastases in Taiwanese women with T1 breast cancer.Methods: Data from 394 Taiwanese women with T1 invasive breast carcinoma were retrospectively reviewed.Results: The data contained 6 T1a, 51 T1b, and 337 T1c breast tumors. The patients ages ranged from 23 to 82 years (mean ± SD, 48.2 ± 11.4 years; median, 46.4 years). Axillary nodal metastases were present in 38.3% of the patients (16.7% in T1a, 35.3% in T1b, and 39.2% in T1c tumors). The patients with nodal metastases had significantly greater body weights and S-phase fractions than those without nodal metastases. Univariate analysis revealed that unfavorable pathology, lymphovascular invasion, S-phase fraction >7%, and nondiploid DNA ploidy were significantly associated with lymph node metastases. Lymphovascular invasion was the only significant variable as the independent predictor in the multiple logistic regression analysis. In the Cox proportional hazards regression analysis, axillary nodal status and lymphovascular invasion were significantly associated with survival.Conclusions: Taiwanese women with small breast cancer displayed a relatively higher incidence of axillary lymph node metastases than Western women. Axillary lymph node dissection or sentinel lymph node biopsy should be conducted on Taiwanese patients with small invasive breast carcinomas, particularly when risk factors exist.     

Axillary lymph node metastases in patients with small carcinomas of the breast: is accurate prediction possible?

OBJECTIVES: To find out whether macroscopic classification of the tumour margin is predictive of axillary lymph node metastases and to identify a combination of clinical and pathological findings by which axillary node status can be predicted accurately in small carcinomas (T1) of the breast. DESIGN: Retrospective study. SETTING: Municipal referral centre, Japan. SUBJECTS: All 1003 patients with T1 invasive carcinoma of the breast who had axillary lymph node dissection between January 1970 and December 1996 as part of their treatment. MAIN OUTCOME MEASURES: The association between the incidence of axillary lymph node metastases and 10 clinical and pathological factors (age, palpability and size of tumour, macroscopic classification of tumour margin, clinical axillary status, radiating spiculation on a mammogram, histological type, lymphatic invasion, oestrogen and progesterone receptor status) were analysed. RESULTS: Clinical axillary node status, macroscopic classification of tumour margin, lymphatic invasion, and age of the patient were significant predictors of axillary lymph node metastases (p < 0.01 in each case). Among 47 patients aged 65 or more whose tumours had well-defined margins and with a clinical N0 status in the axillae, the incidence of histological axillary lymph node metastasis was only 6% (n = 3) whereas it was 65% in 57 patients with tumours of ill-defined margins whose axillae were N1 or N2. CONCLUSIONS: Macroscopic classification of tumour margins is an independent predictor of axillary lymph node metastases for patients with small carcinomas of the breast. However, even with combinations of the examined predictors of axillary node metastases, the subgroup of patients at minimal risk of metastasis was less than 5% in T1 breast cancer, whereas three-quarters of the patients had clear axillary lymph nodes. Most patients with T1 breast cancer will need surgical staging of the axillae by methods such as sentinel node biopsy.     

Do all patients with sentinel node metastasis from breast carcinoma need complete axillary node dissection?

OBJECTIVE: To determine the likelihood of nonsentinel axillary metastasis in the presence of sentinel node metastasis from a primary breast carcinoma. SUMMARY BACKGROUND DATA: Sentinel lymphadenectomy is a highly accurate technique for identifying axillary metastasis from a primary breast carcinoma. Our group has shown that nonsentinel axillary lymph nodes are unlikely to contain tumor cells if the axillary sentinel node is tumor-free, but as yet no study has examined the risk of nonsentinel nodal involvement when the sentinel node contains tumor cells. METHODS: Between 1991 and 1997, axillary lymphadenectomy was performed in 157 women with a tumor-involved sentinel node. Fifty-three axillae (33.5%) had at least one tumor-involved nonsentinel node. The authors analyzed the incidence of nonsentinel node involvement according to clinical and tumor characteristics. RESULTS: Only two variables had a significant impact on the likelihood of nonsentinel node metastasis: the size of the sentinel node metastasis and the size of the primary tumor. The rate of nonsentinel node involvement was 7% when the sentinel node had a micrometastasis (< or =2 mm), compared with 55% when the sentinel node had a macrometastasis (>2 mm). In addition, the rate of nonsentinel node tumor involvement increased with the size of the primary tumor. CONCLUSIONS: If a primary breast tumor is small and if sentinel node involvement is micrometastatic, then tumor cells are unlikely to be found in other axillary lymph nodes. This suggests that axillary lymph node dissection may not be necessary in patients with sentinel node micrometastases from T1/T2 lesions, or in patients with sentinel node metastases from T1a lesions.     

Evaluation of Fluorodeoxyglucose Positron Emission Tomography in the Detection of Axillary Lymph Node Metastases in Patients With Early-Stage Breast Cancer

Background: The aim of this study was to assess the capacity of positron emission tomography (PET) with fluorodeoxyglucose (FDG) to determine axillary lymph node status in patients with breast cancer undergoing sentinel node (SN) biopsy.Methods: Thirty-two patients with breast cancer and clinically negative axillary nodes were recruited. All patients underwent FDG-PET before SN biopsy. After SN biopsy, all patients underwent complete axillary lymph node (ALN) dissection.Results: The SNs were identified in all patients. Fourteen patients (43.8%) had metastatic SNs (macrometastatic in seven, micrometastatic in six, and isolated tumor cells in one). The false-negative rate of SN biopsy was 6.6% (1 in 15). FDG-PET identified lymph node metastases in 3 of the 14 patients with positive SNs. The overall sensitivity, specificity, and positive and negative predictive values of FDG-PET in the diagnosis of axillary metastasis were 20%, 100%, 100%, and 58.6%, respectively. No false-positive findings were obtained with FDG-PET.Conclusions: This study demonstrates the limitations of FDG-PET in the detection of ALN metastases in patients with early breast cancer. In contrast, FDG-PET seems to be a specific method for staging the axilla in breast cancer. SN biopsy can be avoided in patients with positive FDG-PET, in whom complete ALN dissection should be the primary procedure.     

Feasibility of Breast Preservation in the Treatment of Occult Primary Carcinoma Presenting With Axillary Metastases

Background: The objective of the study was to compare the treatment outcomes in patients with occult primary carcinoma with axillary lymph node metastasis who were treated with mastectomy or with intent to preserve the breast.Methods: From 1951 to 1998, 479 female patients were registered with axillary lymph node metastasis from an unknown primary. After clinical workup, including mammography, 45 patients retained this diagnosis and received treatment for T0 N1–2 M0 carcinoma of the breast. Clinical and pathological data were collected retrospectively, and survival was calculated from the date of initial diagnosis using the Kaplan-Meier method. Median follow-up time was 7 years.Results: Median age was 54 years (range, 32–79). Clinical nodal status was N1 in 71% and N2 in 29% of the patients. Surgical treatment was mastectomy in 29% and an intent to preserve the breast in 71% of the patients. Locoregional radiotherapy was used in 71% and systemic chemoendocrine therapy was used in 73% of the patients. Of the 13 mastectomy patients, only one had a primary tumor discovered in the specimen. Two patients (4%) were ultimately diagnosed with lung cancer and neuroendocrine tumor. No significant difference was detected between mastectomy and breast preservation in locoregional recurrence (15% versus 13%), distant metastases (31% versus 22%), or 5-year survival (75% vs. 79%). Regardless of surgical therapy, the most important determinant of survival was the number of positive nodes. Five-year overall survival was 87% with 1–3 positive nodes compared with 42% with 4 positive nodes (P < .0001).Conclusions: Occult primary carcinoma with axillary metastases can be treated with preservation of the breast without a negative impact on local control or survival.     

Sentinel Lymph Node Metastases Detected by Immunohistochemistry Only Do Not Mandate Complete Axillary Lymph Node Dissection in Breast Cancer

Background: The significance of breast cancer sentinel lymph node (SLN) metastases detected only by immunohistochemistry staining (IHC) remains poorly understood. This study attempted to quantify the risk of non-SLN metastases.Methods: A prospectively collected database of 750 consecutive SLN biopsy procedures in breast cancer patients was reviewed. Medical records were reviewed to supplement the database.Results: SLNs were identified in 738 (98.4%) of these procedures in 723 patients. Of these, 151 patients (20.5%) had metastases detected by hematoxylin and eosin staining (H&E), and 33 (4.6%) of the 718 with known IHC staining results had metastases detected by IHC only. Twenty-eight (84.8%) of 33 patients with IHC-detected metastases underwent complete axillary lymph node dissection (CALND). The median primary tumor size was 2.0 cm among those undergoing CALND and 0.9 cm among the five patients treated without CALND (P = .10). Two of the 28 patients (7.1%) had additional metastases detected with CALND. These patients had a T3 or T4 invasive lobular primary tumor. Of 24 patients with T1 or T2 primary tumors and IHC-detected metastases who underwent CALND, none had additional metastases detected. Median follow-up was 14.5 months. All patients with IHC-detected SLN metastases were treated with adjuvant systemic therapy. None of the five patients with IHC-detected metastases not undergoing CALND has subsequently manifested clinical axillary disease.Conclusions: CALND could have been or was safely omitted in 29 of 29 patients with T1 or T2 primary tumors and metastases detected by IHC. Such patients should be counseled about this low risk before CALND is recommended.     

Factors Correlating With Lymph Node Metastases in Patients With T1 Breast Cancer

Background: Identification of reliable predictors of axillary metastases (ALNM) may be useful in selecting appropriate management for patients with T1-size breast cancer. This study was undertaken to determine the degree of correlation between ALNM and several variables, including age, race, menopausal status, palpability, tumor size, positive margin on initial excision, histology, grade, lymphatic invasion (LI), estrogen receptor status (ER), progesterone receptor status, S-phase, and ploidy.Methods: Data from 1416 patients with T1 breast cancers treated at Columbia-Presbyterian Medical Center between 1989 and 1998 was reviewed. Patients with multifocal tumors were excluded.Results: Mean patient age was 57.5 years (SD = 12.0); 65% of the patients were postmenopausal. One hundred thirty-one patients with T1a (0.5 cm), 435 with T1b (0.6–1.0 cm), and 850 patients with T1c (1.1–2.0 cm) lesions were studied. The overall rate of ALNM was 23%. AM was identified in 11% of T1a, 15% of T1b, and 29% of T1c patients. Statistically significant factors from univariate analysis were age, palpability, skin changes, tumor size, LI, histology, grade, ER status, and positive margin on initial excision.Conclusions: Axillary staging by either sentinel lymph node biopsy or level I/II axillary dissection is indicated for most T1 breast cancer patients. Omission of axillary staging can be considered for highly selected patients with T1a cancers.     

Sentinel Node Metastasis in Patients with Breast Carcinoma Accurately Predicts Immunohistochemically Detectable Nonsentinel Node Metastasis

Background: Sentinel lymphadenectomy is highly accurate for identifying axillary metastasis from a primary breast carcinoma. Nonsentinel axillary lymph nodes (NSNs) are unlikely to contain tumor cells if the axillary sentinel node (SN) is tumor free. We previously showed that the size of the primary tumor and the size of its SN metastasis predict the risk of NSN tumor involvement detected by hematoxylin and eosin staining. This study used immunohistochemical staining (IHC) to determine the likelihood of NSN axillary metastasis in the presence of SN metastasis.Methods: Between 1991 and 1997, axillary lymphadenectomy was performed in 156 women (157 axillary basins) who had primary breast carcinoma with SN metastasis. By hematoxylin and eosin staining, we identified NSN metastasis in 55 axillae (35%). IHC was then used to re-examine all NSNs (1827 lymph nodes) from the remaining 102 axillae. The incidence of IHC-detected NSN involvement was analyzed with respect to clinical and tumor characteristics.Results: By using IHC, we identified NSN metastasis in 15 (14.7%) of the 102 axillae. By multivariate analysis, the size of the SN metastasis (P = .0001) and the size of the primary tumor (P = .038) were the only independent variables predicting NSN metastasis determined by using either hematoxylin and eosin staining or IHC. Only the number of SN metastases (1 vs. >1) was a significant (P = .04) predictor of IHC-detected NSN metastasis.Conclusions: Use of IHC increases the likelihood of detection of NSN metastasis, and the risk of IHC-detected metastasis increases with the size of the SN metastasis and the size of the primary tumor. If SN involvement is micrometastatic (2 mm) or detected by using IHC, tumor cells are unlikely to be found in other axillary lymph nodes in patients with a small primary tumor. The clinical significance of micrometastatic disease in lymph nodes is controversial, and a prospective randomized study is necessary to resolve this important issue.Presented at the 52nd Annual Meeting of the Society of Surgical Oncology, Orlando, FL, March 4–7, 1999.     

Significance of intramammary lymph nodes in the staging of breast cancer: correlation with tumor characteristics and outcome

Intramammary lymph nodes (intraMLNs) have received little attention as potential prognostic indicators for patients with breast carcinoma. Patients with stage I breast carcinoma and positive intraMLN metastases have been reported to have a poorer prognosis compared to patients with similar stage and negative intraMLN metastases. However, the presence of intraMLN metastases does not appear to influence the survival of patients with stage II breast carcinoma. In the current retrospective analysis, we assessed the clinical significance of intraMLNs and evaluated their role in predicting outcome in patients with breast carcinoma. Between 1995 and 2005, 116 intraMLN specimens were identified. In all, 59 patients (50.8%) were found in association with benign breast conditions and the remaining 57 (49.2%) with primary breast carcinoma. Primary tumor characteristics and axillary lymph node (AxLN) status were recorded. Outcome data were documented. Statistical analysis was performed to detect correlation between intraMLN and tumor characteristics as well as outcome. IntraMLN metastases were found in 26% of all in-situ and invasive cancer cases (15/57), and 32% (15/47) of invasive cancer cases only. Most patients (80%) who had intraMLN metastases also had axillary metastases; however, an isolated intraMLN metastasis was documented in one patient (7%). Univariate analysis revealed that predictors of intraMLN metastases include: tumor size (p = 0.04), tumor grade (p = 0.04), tumor stage (p < 0.001), and AxLN status (p < 0.001). Furthermore patients with intraMLN positive for metastases have a poorer 4-year overall (40% versus 88%; p < 0.001) and disease-free survival (37% versus 83%; p < 0.001) than patients with negative intraMLN. On multivariate analysis, intraMLN metastasis is not an independent predictor of outcome (disease-free survival: p = 0.350; and overall survival p = 0.138). IntraMLN metastasis is a poor prognostic marker but not an independent predictor of poor outcome in patients with breast carcinoma.     

The Genomic Heritage of Lymph Node Metastases: Implications for Clinical Management of Patients with Breast Cancer

Background Metastatic breast cancer is an aggressive disease associated with recurrence and decreased survival. To improve outcomes and develop more effective treatment strategies for patients with breast cancer, it is important to understand the molecular mechanisms underlying metastasis. Methods We used allelic imbalance (AI) to determine the molecular heritage of primary breast tumors and corresponding metastases to the axillary lymph nodes. Paraffin-embedded samples from primary breast tumors and matched metastases (n = 146) were collected from 26 patients with node-positive breast cancer involving multiple axillary nodes. Hierarchical clustering was used to assess overall differences in the patterns of AI, and phylogenetic analysis inferred the molecular heritage of axillary lymph node metastases. Results Overall frequencies of AI were significantly higher (P < 0.01) in primary breast tumors (23%) than in lymph node metastases (15%), and there was a high degree of discordance in patterns of AI between primary breast carcinomas and the metastases. Metastatic tumors in the axillary nodes showed different patterns of chromosomal changes, suggesting that multiple molecular mechanisms may govern the process of metastasis in individual patients. Some metastases progressed with few genomic alterations, while others harbored many chromosomal alterations present in the primary tumor. Conclusions The extent of genomic heterogeneity in axillary lymph node metastases differs markedly among individual patients. Genomic diversity may be associated with response to adjuvant therapy, recurrence, and survival, and thus may be important in improving clinical management of breast cancer patients.     

Level III axillary lymph nodes involvement in node positive breast cancer received neoadjuvant chemotherapy

ObjectiveTo investigate the incidence, associated factors and prognosis of level III node involvement for breast cancer with positive axillary lymph nodes after neoadjuvant chemotherapy.MethodsA consecutive series of 521 node positive T_0–2 invasive breast cancer cases were included in this retrospective study. Axillary node metastases were proved by ultrasound guided needle biopsy (NB) if ultrasonographic abnormal node was detected or by sentinel node biopsy (SNB) if no abnormal node was detected. After 4 to 8 cycles of neoadjuvant chemotherapy (NCT）, axillary lymph nodes dissection included level III lymph nodes were completed for each case.ResultsThe pathologic complete response rate of axillary nodes was 31.1% (90/289) in NB positive subgroup. The incidence of residual positive level III lymph nodes were 9.0% (47/521). Multivariate analysis showed that node NB positivity (OR = 2.212, 95% CI: 1.022–4.787, P = 0.044), clinical tumor size >2 cm before NCT (OR = 2.672, 95% CI: 1.170–6.098, P = 0.020), and primary tumor non-response to neoadjuvant chemotherapy (OR = 1.718, 95% CI: 1.232–2.396, P = 0.001) were independent predictors of level III lymph nodes positivity. At median follow-up time of 30 months, the distant disease-free survival (DDFS) rate of level III node positive group was much lower than that of level III negative group (p = 0.011).ConclusionsAbout 9% of node positive T_0–2 breast cancer will have residual positive node in level III region after neoadjuvant chemotherapy. Node positivity proved by NB, large tumor size, and primary tumor non-response to neoadjuvant chemotherapy are independent predictors of level III lymph nodes positivity.     

Indications for axillary dissection in T1 breast cancer

Background: Debate regarding axillary dissection in the treatment of women with small invasive cancers of the breast has been increasing. Recently, omission of axillary dissection has been proposed because of the reported low incidence of nodal metastases in women with such cancers. Variation in the incidence of nodal metastases in T1 breast cancers is examined and discussed with regard to a selective approach to lymphadenectomy. Methods: The literature was reviewed, and cases of 2185 women with T1 breast cancers in Rhode Island and Massachusetts were analyzed. Results: The incidence of axillary nodal metastases in T1 breast cancer varies among series and ranges from 3% to 37%. The probability of nodal metastases depends on tumor grade and patient age as well as tumor size. Conclusions: T1 breast cancers are not equivalent in their risk of associated axillary metastases. A treatment algorithm for selective axillary node dissection in patients with T1 breast cancers is proposed. Future applications of this type of algorithm are discussed with respect to sentinel node biopsy.Annals of Surgical Oncology is pleased to present the first article in a new series. The Surgical Oncology Forum will feature state-of-the-art reviews on the diagnosis and multidsciplinary treatment of malignancies.     

Sentinel node biopsy in breast cancer

Background: Sentinel lymph node biopsy (SNB) in breast cancer may be used in place of axillary lymph node dissection (ALND) if SNB accurately stages the axilla. This study assessed the success and accuracy of axillary SNB with isosulfan blue (ISB) and technetium-99 sulfur colloid (TSC) compared to ALND. Methods: Forty-two women with T1 or T2 breast cancer underwent SNB and ALND. Sixty to 90 minutes before anesthetic induction, a mixture of 3 mL ISB and 1 mCi TSC was injected around the primary cancer or prior biopsy site. Intraoperatively, the SLN was identified using a gamma detector (Neoprobe 1000) or by visualization of the blue-stained lymph node and afferent lymphatics. The SLN was excised separately, and a level I/II ALND was completed. The histologic findings of the axillary contents and SLN were compared. Results: An axillary SLN was found in 38 of 42 (90%) cases. SLN localization rate and predictive value were the same for women who had and those who had not undergone excisional biopsy before the date of SNB. Fifteen of 42 (36%) patients had lymph node metastases. The SLN was positive in all women with axillary metastases (negative predictive value, 100%). Conclusions: If confirmed by larger series, a negative SNB may eliminate the need for ALND for select women with breast cancer. Presented at the 50th Annual Cancer Symposium of The Society of Surgical Oncology, Chicago, Illinois, March 20–23, 1997.     

Primary Tumor Response to Induction Chemotherapy as a Predictor of Histological Status of Axillary Nodes in Operable Breast Cancer Patients

Background: Routine use of axillary lymph node dissection is being questioned, especially in clinically N0 patients. The goal of this study was to determine whether primary tumor response to induction chemotherapy (IC) can predict the histological volume of residual axillary disease in patients who were candidates for breast conservation surgery after IC.Methods: Forty-seven patients with stage II or IIIA breast cancer who received breast conservation surgery were selected from a population of patients randomized to receive four cycles of IC. Largest clinical tumor size before and after IC was determined by physical examination, mammography, and breast ultrasound. Clinical nodal status was determined by physical examination and axillary ultrasound and compared with histological findings.Results: In patients with at least 50% reduction in primary tumor size after IC, 12 of 14 (86%) N0 patients and 11 of 17 (65%) N1 patients were histologically negative. In patients with a less than 50% reduction, 0 of 3 N0 patients and 2 of 13 (15%) N1 patients were histologically negative.Conclusions: There is significantly less axillary disease in responders than in nonresponders after IC. For N0 responders, axillary irradiation may be an acceptable alternative to axillary lymph node dissection, and could easily be incorporated into the postsurgical radiotherapy that is standard protocol for breast conservation therapy. The more aggressive disease in nonresponders is best treated by axillary lymph node dissection, pending further study.Presented at the 52nd Annual Meeting of the Society of Surgical Oncology, Orlando, Florida, March 4–7, 1999.     

Prognosis in stage II (T1N1M0) breast cancer.

As part of a detailed study of prognostic factors in breast cancer, we have analyzed the ten year survival rates of 524 patients with primary invasive carcinomas 2.0 cm or less in diameter (T1). This report describes the subset of 142 patients (27%) who had metastases only in axillary lymph nodes (T1N1M0). All the patients were treated initially by at least a modified radical mastectomy. Factors associated with a significantly poorer prognosis were: axillary lymph node metastases suspected on clinical examination; perimenopausal menstrual status at diagnosis; tumor larger than 1.0 cm; prominent lymphoid reaction; infiltrating duct or lobular rather than medullary, colloid and tubular carcinoma; and blood vessel invasion. When compared with those patients with negative nodes (T1N0M0), the patients with one or more lymph node metastases had a significantly poorer prognosis. Generally, survival rates tended to diminish as the number of involved lymph nodes increased. In this respect, comparison of patients with one-three and four or more nodal metastases provided a significant discrimination of prognostic groups in the entire series. However, for patients with disease limited to Level I, the same discrimination was obtained comparing those with one-two and three or more positive nodes. In the subset with a single lymph node metastasis, the size of the metastasis (micro or less than or equal to 2 mm vs macro or greater than 2 mm) was not significantly related to prognosis. Lymph node metastases were significantly less frequent among tumors smaller than 1 cm and special tumor types (medullary, colloid, lobular and tubular). However, no factor proved to be a reliable predictor of the presence of axillary metastases for the single largest group consisting of patients with infiltrating duct carcinoma 1-2 cm in diameter.     

Lymphatic Mapping and Sentinel Lymphadenectomy After Preoperative Therapy for Stage II and III Breast Cancer

Background: We evaluated the accuracy of sentinel lymph node dissection (SLND) in patients with stage II and III breast cancer who had received preoperative therapy.Methods: A prospective clinical trial evaluated 122 patients who had SLND followed by axillary lymph node dissection. Thirty-two women had stage II or III breast cancer and received preoperative doxorubicin-based chemotherapy or paclitaxel and radiotherapy.Results: A sentinel lymph node (SLN) was identified in 31 (97%) of 32 patients. The SLN predicted the status of the axillary nodes in 30 (97%) of 31 patients. Eighteen (58%) of 31 had metastases in the SLN. Eighteen of 19 patients with axillary metastases had a tumor-positive SLN (sensitivity, 95%; false-negative rate, 5%). Eight (44%) of 18 women with metastases in the SLN also had metastases in 1 or more nonsentinel nodes.Conclusions: In this relatively small study, the accuracy of SLND in women with stage II or III breast cancer treated with preoperative therapy was similar to that achieved in early-stage breast cancer. If these results are confirmed in a larger cohort, it may be feasible to substitute SLND for routine axillary lymph node dissection in this population. This approach could reduce the morbidity of surgical therapy while preserving the accuracy of axillary staging and maintaining regional control in this high-risk population.     

Impact of multicentricity on clinical outcome in patients with T1-2, N0-1, M0 breast cancer

Background: The objective was to determine the impact of multicentric breast cancer on recurrence and survival and to evaluate the current tumor, node, metastasis staging system recommendations for multicentricity in the breast. Methods: This study included 284 nonpregnant patients with T1-2, N0-1, M0 breast cancer, without previous cancer, who were treated by modified radical mastectomy followed by doxorubicin-based adjuvant chemotherapy. Clinical and pathological data were collected retrospectively and survival was calculated from the date of initial diagnosis using the Kaplan-Meier method. Results: The median follow-up time was 8 years (range, 0.3–24.0), and the median age was 47 years (range, 23–76). The median clinical size of the index tumor was 2.5 cm. In 17% of patients, the clinical nodal status was N1. In 84% of patients, pathology of the index lesion was invasive ductal ± in situ. Multicentric breast cancer was detected in 60 patients (21%): 30 patients with two lesions, 13 patients with three lesions, and 17 patients with four or more lesions. Locoregional recurrence, contralateral breast cancer, distant metastasis, and survival (disease-specific and disease-free) were similar in both groups of multicentric versus unicentric breast tumors. There was a significant difference between groups in estrogen receptor and axillary lymph node positivity, but these did not contribute significantly to outcome on multivariate analysis. Conclusions: Multicentricity does not increase the risk of poor outcomes in patients with early-stage breast cancer. This supports the current recommendations of the tumor, node, metastasis staging system that tumor size should be based on the diameter of the largest lesion in patients with multicentric breast cancer.     

PET/CT诊断乳腺癌及腋窝淋巴结状态的作用评价

目的：评价PET／CT诊断乳腺癌和腋窝淋巴结转移的临床价值。方法：对33例疑似乳腺癌病人进行PET／CT检查，定性分析肿瘤病灶、淋巴结摄取氟脱氧葡萄糖（FDG）的程度，半定量测量标准摄取值（SUV），根据乳腺和淋巴结的FDG摄取强度诊断乳腺癌和淋巴结转移，检验SUV与乳腺癌分化程度、有丝分裂计数的关联性。结果：PET／CT诊断乳腺癌和腋窝淋巴结转移的敏感度、特异度和精确度分别为92．6％、100％、93．9％和82．3％、90％、85．2％；SUV与乳腺癌分化程度、有丝分裂计数显著相关（P〈0．05）；诊断乳腺癌的Kappa指数=0．835，μ=8．48，（P〈0．01）。结论：PET／CT诊断乳腺癌和腋窝淋巴结转移的敏感度、特异度较高，作为一种非侵袭性检查方法，可提供乳腺癌在活体内的多方面生物学信息，为选择合理的手术方式及新辅助化疗提供参考，弥补传统检查方法的不足。     

Incidence of axillary lymph node metastases in T1a and T1b breast carcinoma

Background: We investigated the incidence of axillary lymph node metastases in patients with T1a (0.5 cm) and T1b (>0.5 cm and 1.0 cm) breast cancers. Methods: The charts of 2000 patients who underwent axillary lymph node dissection for breast cancer at our institution from 1989 to 1991 were reviewed. Of these, 81 patients had T1a and 166 had T1b primary breast cancers. Results: Among the 247 patients with T1a and T1b breast cancers, nodal metastases were present in 30 (12.1%), with a 7.4% positivity rate for patients with T1a and 14.5% positivity rate for T1b tumors. Of the 212 patients who had 10 nodes dissected, 29 (13.7%) had positive nodes. Of those, 6 of 60 (10.0%) patients with T1a and 23 of 152 (15.1%) with T1b tumors had positive nodes. The presence of lymphovascular invasion (LVI) predicted a significantly higher nodal positivity rate (27.8% vs. 10.9%,p=0.05). Conclusions: Of patients with adequately evaluated axillae, 10% with T1a and 15% with T1b cancers were found to have nodal metastases. Although LVI was significantly associated with a higher risk of lymph node metastases, we could not characterize any subgroup at acceptably low risk of nodal positivity. Until a more useful prognostic indicator is discovered, axillary dissection should continue to be part of the mainstay of management for small breast cancers.Presented at the 50th Annual Cancer Symposium of the Society of Surgical Oncology, Chicago, IL, March 1997.     

Clinicopathologic factors predicting involvement of nonsentinel axillary nodes in women with breast cancer

Background: It is unclear which breast cancer patients with positive sentinel lymph nodes (SLNs) require a completion axillary lymph node dissection. Our aim was to determine factors that predict involvement of nonsentinel axillary nodes (NSLNs) in patients with positive SLNs.Methods: We reviewed the records of all patients with invasive breast cancer who underwent SLN biopsy at our institution between 1993 and August 2001. Multivariate analysis was used to identify clinicopathologic features in SLN-positive patients that predict involvement of NSLNs.Results: A total of 131 patients had a positive SLN and underwent completion axillary lymph node dissection. Multivariate analysis revealed that primary tumor >2 cm (P = .009), SLN metastasis >2 mm (P = .024), and lymphovascular invasion (P = .028) were independent predictors of positive NSLNs. The number of SLNs harvested was a significant negative predictor (P = .04). In our model, based on the presence of these factors, the positive predictive value was 100% for a score of 4.Conclusions: The likelihood of positive NSLNs correlates with primary tumor size, size of the largest SLN metastasis, and presence of lymphovascular invasion. A scoring system incorporating these factors may help determine which patients would benefit from additional axillary surgery.Presented at the 55th Annual Cancer Symposium of the Society of Surgical Oncology, Denver, Colorado, March 13–17, 2002.