Histopathological predictors of axillary lymph node metastases in patients with Breast Cancer

Background  A tumor 30 mm or less in diameter is a standard candidate for breast conserving surgery (BCS) in Japan. Axillary lymph node metastases (ALNM) is the most important prognostic factor for survival in patients with breast cancer, but the role of axillary node dissection has been controversial. Histopathological predictive factors of axillary lymph node involvement have not been established. The purpose of this study was to determine the association between the incidence of ALNM and histopathological factors by univariate and multivariate analysis. Methods  Sixty-five patients with noninvasive ductal carcinoma, and 993 patients with tumors 30 mm or less in diameter who underwent axillary dissection between 1988 and 1997 at our institute were reviewed. The association between ALNM and 13 histopathological factors (size, age, histological subtype, histological invasiveness, lymphatic invasion, vascular invasion, macroscopic classification, histological daughter mass, ductal spread, ER, PgR, p-53, and c-erbB-2) were analyzed by univariate and, when significant, by multivariate analysis. Results  Only one patient with noninvasive ductal carcinoma had ALNM, and 33.1% of 993 patients with a tumor 30 mm or less in size had ALNM. Multivariate analysis identified six factors as independent predictors for ALNM: lymphatic invasion, size, histological invasiveness, macroscopic classification, age and histological daughter mass. Conclusions  Axillary lymph node dissection can be omitted in patients with noninvasive ductal carcinoma. Histopathological features of tumors 30 mm or less in diameter can be used to estimate the risk of ALNM, and routine axillary node dissection might be spared in selected patients at minimal risk of ALNM, if the treatment decision is not influenced by lymph node status, such as in elderly patients.     

Axillary node metastasis from T1N0M0 breast cancer: possible avoidance of dissection in a subgroup

BACKGROUND: Axillary lymph node dissection is now no longer considered to be the standard treatment in all patients with invasive breast cancer. We have attempted to identify a sub-group of patients with invasive breast carcinoma who may not need to undergo axillary lymph node dissection. METHODS: Patients (n = 823) with T1 N0M0 invasive breast cancer treated at our hospital between 1970 and 1994 were studied. We investigated the relationship between positive axillary lymph nodes and the following clinico-pathological factors: patient age, menopausal status, contralateral breast cancer (synchronous or asynchronous), tumor location, tumor size (T:cm), histopathology, histological grade, presence or absence of malignant microcalcification or spiculation on mammography and estrogen receptor status. RESULTS: The incidence of axillary lymph node metastases in patients with T1N0M0 invasive breast cancer was 25% (208/823). The node-negative group was significantly older than the node-positive group. Premenopausal patients had a higher rate of lymph node metastases although this was not significant. The frequency of nodal metastases when related to the tumor size was as follows: T< or =1.0 cm, 17%; T< or =1.5 cm, 25%; T< or =2.0 cm, 29%. Mammography revealed that patients with malignant calcification or spiculation had a significantly higher rate of nodal metastases than those without these findings. Certain tumor types (medullary, mucinous and tubular carcinomas) had lower positive rates for lymph node involvement. With regard to the histological grade, lymph node positivity increased significantly with high-grade tumors. No correlation was observed between any other factors and the presence or absence of lymph node metastases. CONCLUSIONS: It may be possible to avoid axillary lymph node dissection in postmenopausal patients (50 years or older) where the histological type is favorable when the tumor diameter is < or =1.0 cm and when microcalcification or spiculation is absent on mammography.      

A clinicopathological study of resected non-small cell lung cancers 2 cm or less in diameter: a prognostic assessment

The detection and diagnosis of small-sized (2 cm or less) non-small cell lung cancer (NSCLC) has increased with the development of computed tomography (CT). Over 80% of 5-year survival rate has been reported in surgically treated peripheral lung cancer. There are systematic mediastinal and hilar lymph node involvement pleural invasion and intrapulmonary metastasis even with tumor diameter less than 2 cm. The appropriate surgical procedure for such kinds of lung cancer is lobectomy with mediastinal lymph node dissection. To evaluate the prognostic factors and establish the optimal surgical strategy, we analyzed the clinicopathologic features and survival benefit in different tumor size of peripheral small-sized NSCLC. Among the resected lung cancer cases between January 1999 and July 2001, 185 patients were retrospectively analyzed in surgical methods, lymph node involvement, CT scan findings and survival rates. Survival was analyzed by Kaplan–Meier method and log-rank test. Lymph node involvement was recognized in 26(14.05%) patients. There was no statistically significant difference in the incidence of lymph node involvement between tumors 1.6–2.0 cm (17.82%) in diameter than in those 1.0–1.5 cm (11.94%). There was no lymph node metastasis in tumors less than 1.0 cm in diameter. The 5-year survival rates with or without lymph node involvement were 89.98 and 46.15%, respectively, showing significant difference (P = 0.000). The overall 5-year survival rate was 83.78%. The 5-year survival rate in tumors 1.6–2.0 cm, 1.0–1.5 cm and less than 1.0 cm in diameter was 80.20, 85.07 and 100%, respectively, and showing significant difference(P = 0.035). The 5-year survival rate of 19 patients showing ground-glass opacity (GGO) on CT scan was 94.74% without any metastasis and recurrence after operation. There are systematic mediastinal and hilar lymph node involvement even with tumor diameter less than 2 cm. The results of the present study suggested that systematic lymph node dissection is necessary even for cases with tumor diameter less than 2 cm. However, if the tumor is within 1.0 cm in diameter with obvious GGO showing on chest CT scan, these are good candidates for partial resection without mediastinal lymph node dissection.     

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.     

T1 breast cancer: identification of patients at low risk of axillary lymph node metastases

Objective. The status of the axillary lymph nodes is one of the most important prognostic factors in patients with breast cancer. A panel of molecular markers of tumor aggressiveness in addition to conventional clinical and histopathologic features were analyzed in an attempt to identify a subgroup of patients with a low risk of axillary lymph node metastases. Material and methods. Data from 358 patients with T1 breast cancer who underwent level I/II axillary lymph node dissection (ALND) were investigated. Hormone receptor status, Ki-67, S-phase fraction, DNA ploidy, HER-2/neu, p53, epidermal growth factor receptor, urokinase type plasminogen activator, plasminogen activator inhibitor-1, bone marrow micrometastases as well as patient age, menopausal status, tumor site, tumor size, histologic type, tumor grade, carcinoma in situ, multifocality, and lymph vascular invasion (LVI) were studied to predict axillary lymph node status. Results. In a multivariate logistic regression analysis LVI (present v.s. not present), Ki-67 (18% v.s. <18%), tumor size (1.1–2 cm v.s. 1 cm), and histologic grade (G3 v.s. G1/2) were identified as independent predictive factors of axillary lymph node metastases. Approximately 13% of patients (n = 47) with well or moderately differentiated tumors less than or equal to 1 cm, no lymph vascular invasion, and a low Ki-67 staining were identified as having a low risk of axillary lymph node metastases of 4.3%. However, 20 patients with all four unfavorable predictive factors had a 75% incidence of axillary lymph node involvement. Conclusion. Primary tumor characteristics can be used to identify a subgroup of patients with a low risk of axillary lymph node metastases in T1 breast cancer. Preoperative risk assessment might be used to omit routine ALND in those patients at low risk of axillary lymph node metastases.     

Axillary lymph node staging in breast cancer by 2-fluoro-2-deoxy-D-glucose-positron emission tomography: clinical evaluation and alternative management

BACKGROUND: Surgical removal of axillary lymph node and histologic examination for metastases are used to determine whether adjuvant treatment is necessary for patients with breast cancer. Axillary lymph node dissection (ALND) is a costly procedure associated with various side effects, and 80% or more of patients with tumors of 20 mm or less are lymph node negative and might avoid ALND. In this study, we evaluated whether an alternative, noninvasive method--i.e., positron emission tomography (PET) with 2-[(18)F]fluoro-2-deoxy-D-glucose (FDG)-- could be used to determine axillary lymph node status in patients with breast cancer. METHODS: One hundred sixty-seven consecutive patients with breast cancers of 50 mm or less (range = 5-50 mm; mean = 21 mm) scheduled for complete ALND were studied preoperatively with FDG-PET, and then PET and pathology results from ALND were compared. All statistical tests were two-sided. RESULTS: The overall sensitivity, specificity, and accuracy of lymph node staging with PET were 94.4% (PET detected 68 of 72 patients with axillary involvement; 95% confidence interval [CI] = 86.0% to 98.2%), 86.3% (82 of 95 patients without axillary involvement; 95% CI = 77.8% to 91.9%), and 89.8% (150 of 167 patients with breast cancer; 95% CI = 84.2% to 93.6%), respectively. Positive- and negative-predictive values were 84.0% (68 patients with histologically positive lymph nodes of 81 patients with positive FDG-PET scan; 95% CI = 74.2% to 90.5%) and 95.3% (82 patients with histologically negative lymph nodes of 86 patients with negative FDG-PET scan; 95% CI = 88.2% to 98.5%), respectively. When PET results for axillary metastasis were analyzed by tumor size, the diagnostic accuracy was similar for all groups (86.0%-94.2%), with higher sensitivity for tumors of 21-50 mm (98.0%) and higher specificity for tumors of 10 mm or less (87.8%), and the range was 93.5%-97.3% for negative-predictive values and 54.5%-94.1% for positive-predictive values. Among the 72 patients with axillary involvement, PET detected three or fewer metastatic lymph nodes in 27 (37.5%) patients, about 80% of whom had no clinically palpable axillary lymph nodes. CONCLUSIONS: Noninvasive FDG-PET appears to be an accurate technique to predict axillary status in patients with breast cancer and thus to identify patients who might avoid ALND. These results should be confirmed in large multicenter studies.     

Is risk of axillary lymph node metastasis associated with proximity of breast cancer to the skin?

Introduction Risk of axillary lymph node metastasis, the most important predictor of disease-free and overall survival in breast cancer patients, is estimated primarily from histologic features of the primary cancer including tumor size, histologic type and grade, and hormone receptor expression. Based upon a clinical impression, and research showing that palpable cancers are more likely to be node positive, we hypothesized that primary breast cancers more proximal to the skin of the breast are more likely to be positive for axillary lymph node metastasis.Methods This is a retrospective medical record review of 209 women with stage T1 or T2 (≤5.0 cm) invasive breast cancer who received dedicated breast ultrasound at a single mammography clinic in Columbia, South Carolina, between 1997 and 2002.Results None of the 26 cancers more than 14 mm from the skin had metastasized to axillary lymph nodes. In logistic regression modeling only tumor size, histologic grade and tumor proximity to the skin (as a categorical variable) were significantly associated with odds of axillary metastasis. Among cancers within 14 mm of the skin, proximity was not an independent predictor.Conclusions Stage T1 and T2 breast cancers located less proximally to the skin may be less likely to spread to the axillary lymph nodes. We observed what appears to be a threshold at approximately 14 mm from the skin (based upon this group of patients): none of 26 cancers below this level had spread to axillary nodes. Further research is needed to confirm these provocative findings.     

乳腺癌患者胸肌间淋巴结转移的影响因素及手术清扫

  目的   分析乳腺癌患者胸肌间淋巴结（IPNs）的检出率、转移率及其影响因素,探讨胸肌间淋巴结清扫的意义和指征。   方法   回顾性分析1 673例接受乳腺癌改良根治术并且胸肌间淋巴结单独送病理检查患者的病理临床资料,记录IPNs的检出率和转移情况,分析IPNs转移与肿瘤大小、腋窝淋巴结、临床分期、新辅助化疗、激素受体、Her-2表达以及乳腺癌分子亚型的关系。   结果   本组病例IPNs检出率、IPNs总体转移率、腋窝淋巴结阳性者IPNs转移率分别为13.39%、4.3%和10.01%。IPNs转移率与腋窝淋巴结转移、肿瘤TNM分期之间具有显著相关性（P < 0.05）,但与激素受体状况、Her-2表达以及乳腺癌分子亚型之间未见相关（P>0.05）;新辅助化疗并未降低肿瘤局部偏晚患者的IPNs转移率;IPNs转移者表现为肿瘤较大、腋窝淋巴结转移多、TNM分期较晚。   结论   IPNs转移多见于肿瘤直径较大、腋窝淋巴结转移、TNM分期较晚、局部晚期以及适合新辅助化疗的乳腺癌患者,这些指征可能意味着需要常规进行IPNs的手术清扫和单独送检。      

Lymph node metastasis from ductal carcinoma in situ with microinvasion.

BACKGROUND: Widespread use of mammography has increased the detection of ductal carcinoma in situ with microinvasion (DCISM) in pathology specimens. Currently there is disagreement regarding the incidence of axillary metastasis from DCISM. The controversy centers on whether complete lymphadenectomy is indicated for axillary staging, given its morbidity and the reportedly minimal rate of axillary involvement in these patients. Intraoperative lymphatic mapping and sentinel lymphadenectomy (SLND) may obviate complete axillary lymph node dissection in selected breast carcinoma patients. In intraoperative lymphatic mapping, isosulfan blue dye is used to demonstrate the course of lymphatic flow from the breast tumor to the first draining or sentinel lymph node. This blue-stained lymph node is selectively excised for pathologic examination; its tumor status is used to predict the tumor status of the other axillary lymph nodes. The authors examined whether SLND would be suitable for staging DCISM. METHODS: From February 1992 to January 1997, 14 patients with DCISM underwent intraoperative lymphatic mapping and SLND at the John Wayne Cancer Institute in Santa Monica, California. Clinical and pathologic data were prospectively collected. RESULTS: Primary DCISM tumors ranged in size from 0.9 to 6.5 cm. Nine patients presented with mammographic abnormalities, two patients presented with Paget's disease and a palpable lesion, and three patients presented with palpable lesions. Two patients (14.3%) had tumor-involved sentinel lymph nodes. One of these patients had two sentinel lymph nodes, both of which contained single cancer cells identified by immunohistochemistry. The other patient had 1 sentinel lymph node, in which a 0.3-cm metastasis was revealed by light microscopy. Completion axillary dissection was performed on both patients and revealed no further tumor positive lymph node metastases. CONCLUSIONS: SLND can detect lymph node micrometastases (tumor deposits <2 mm) in patients with DCISM. The clinical relevance of these micrometastases is unknown, but their existence shows that DCISM can involve the lymph nodes.     

Tumor size as predictor of microinvasion, invasion, and axillary metastasis in ductal carcinoma in situ

Ductal carcinoma in situ (DCIS) represents a small number of cases in countries with inadequate breast cancer screening programs, and in the majority of cases is diagnosed as a palpable lump. It has been proposed that DCIS with palpable lump > or = 2.5 cm can be associated with microinvasion or invasive carcinoma and risk of axillary metastasis. The purpose of the present study is to evaluate incidence of microinvasion, invasion, and the role of lymphatic mapping and sentinel lymph node biopsy in DCIS > or = 2.5 cm.We conducted a retrospective analysis of patients with histologically proven incisional, excisional, or core biopsy of DCIS lump > or = 2.5 cm at a tertiary-care hospital. All patients underwent lymphatic mapping with sentinel lymph node biopsy.A total of 24 patients were included with average tumor size of 4 cm (range, 2.5-6 cm); 29% had microinvasive and 12.5% had invasive disease, three patients (12.5%) had positive sentinel lymph node, all had micrometastasis, and no metastasis were found in non-sentinel lymph nodes. Incidence of microinvasion and invasion were directly related with tumor size (10% for DCIS tumor size of 2.5-3.5 cm, 57% for 3.6-4.5 cm, and 71% for tumors between 4.5 and 6 cm). In addition, axillary metastasis incidence had a direct relationship with tumor size. (0% in 2.5-3.5-cm tumor size, 14% for 3.6-4.5 cm, and 28% in DCIS between 4.6 and 6.0 cm).The present study shows high incidence of microinvasion and invasion in DCIS diagnosed in tumors > or = 2.5 cm and supports the importance of axillary evaluation in patients with tumors >3.5 cm by means of lymphatic mapping and sentinel lymph node biopsy.     

Sentinel lymph node biopsy with metastasis: can axillary dissection be avoided in some patients with breast cancer?

PURPOSE: Recent studies have suggested that the sentinel lymph node (SLN) biopsy is an accurate alternative staging procedure for women with breast cancer. The goal of this study was to identify a subset of breast cancer patients in whom metastatic disease was confined only to the SLN. MATERIALS AND METHODS: From two institutions, we recruited 222 women with breast cancer for SLN biopsy. A SLN biopsy was performed in each patient, followed by an axillary dissection in 182 patients. Histologic and immunohistochemical cytokeratin stains were used on all SLNs. RESULTS: The SLN was identified in 220 (97. 8%) of the 225 biopsies. Evidence of metastatic breast cancer in the SLN was found in 60 (27.0%) of the 222 patients. Of these patients, 32 (53.3%) had evidence of tumor in the SLN only. By multivariate analysis, two factors were found to be significantly associated with a higher likelihood of tumor involvement in the non-SLNs: primary tumor size larger than 2.0 cm (P =.0004) and macrometastasis (> 2.0 mm) in the SLN (P =.002). Additional analysis revealed that none (0%; 95% confidence interval, 0% to 18.5%) of the 18 patients with primary tumors < or = 2.0 cm and micrometastasis to the SLN had remaining axillary lymph node involvement. CONCLUSION: The primary tumor size and metastasis size in the SLN are independent factors in predicting the incidence of tumor in the non-SLNs. Therefore, the SLN biopsy alone may be adequate for staging and/or therapy decision making in patients with primary breast tumors < or = 2.0 cm and micrometastasis in the SLN.     

前哨淋巴结阳性早期乳腺癌非前哨淋巴结的组织学检测及临床意义

目的：研究早期乳腺癌患者前哨淋巴结(SLN)阳性时非前哨淋巴结(NSN)转移的可能性及其临床意义。方法：对84例SLN阳性接受乳癌根治术的早期乳腺癌患者的NSN及HER-2免疫组化等进行检测，分析NSN转移的发生率及相关临床因素。结果：SLN阳性患者NSN转移的检出率是48．8％(41／84)，NSN转移与原发肿瘤的大小、SLN转移灶的大小及HER-2的表达状况有关，原发肿瘤直径小于1cm及SLN转移灶小于1mm时NSN无转移，NSN的阳性率随原发肿瘤及SLN转移灶直径的增大而提高，HER-2蛋白阳性者NSN转移率高。结论：原发肿瘤直径小于1cm且SLN转移灶小于1mm时的早期乳腺癌患者可免于腋窝清扫，反之亦然；HER-2阳性患者NSN转移率较高，应考虑腋窝清扫。     

CD95、CD44V6与乳腺癌淋巴结微小转移的关系

目的探讨乳腺癌组织中CD95、CD44V6的表达与腋窝淋巴结转移的关系及其临床病理意义。方法筛选101例乳腺癌根治标本,癌组织免疫组织化学标记CD95与CD44V6其中40例腋窝淋巴结阴性者淋巴结全部标记MCKo并进行统计学分析。结果在常规病理诊断淋巴结未转移的病例中,免疫组化标记检出9例（22．5％,9／40）有微小转移。CD95与CD44V6的表达在转移组与微转移组相似。淋巴结转移组CD95的阳性率与未转移组之间差异具有统计学意义。当肿瘤〉2cm时,CD95的阳性率及CD44V6的高表达率具有统计学意义（P〈0．05）。结论通过检测乳腺癌组织中CD95与CD44V6的表达,有助于预测淋巴结微小转移情况,为临床判断预后和选择治疗方案提供更加可靠的依据。     

Malignant neoplasm in the axilla of a male: suspected primary carcinoma of an accessory mammary gland

A 58-year-old Japanese male patient visited our hospital for evaluation of an elastic hard mass, measuring 80 × 50 mm, in the right axillary area. Incisional biopsy for suspected malignancy was performed, and histopathologic examination by hematoxylin–eosin (H&E) staining yielded a diagnosis of poorly differentiated adenocarcinoma metastatic from an unknown primary. As the tumor was immunohistochemically positive for both ER and PgR, metastatic breast cancer was strongly suspected. Ultrasonography, CT, and MRI revealed no evidence of tumors in the bilateral mammary glands. Detailed examination of the head and neck region, lung, and upper and lower gastrointestinal tract also revealed no evidence of a primary tumor. After chemotherapy, the patient underwent tumor resection with axillary lymph node dissection. On the basis of the histological features of H&E-stained specimens and immunohistochemistry of the resected tumor, this case was diagnosed as breast cancer of unknown origin in a male. The tumor could have been an axillary lymph node metastasis from an occult breast carcinoma, or primary cancer arising in an accessory mammary gland.     

Two cases of occult breast cancer in which PET-CT was helpful in identifying primary tumors

We report two cases of occult breast cancer in which masses were completely nonpalpable and positron emission tomography-computed tomography (PET-CT) was extremely helpful in identifying the primary tumor. Case 1 involved a 56-year-old woman with enlarged lymph nodes 3 cm in size in the axilla. Based on excisional biopsy, axillary lymph node metastasis of breast cancer was suspected but an obvious primary tumor in the breast was not identifiable on mammography, contrast-enhanced CT, or ultrasonography. Faint accumulation of fluorodeoxyglucose (FDG) was noted only on PET-CT, so the site was considered to be the primary site, and operation was performed. As a result of postoperative pathological examination, ductal carcinoma in-situ (DCIS) was diagnosed. Case 2 involved a 55-year-old woman with enlarged lymph nodes 3 cm in size in the axilla. Based on the excisional biopsy, axillary lymph node metastasis of breast cancer was suspected. In this case as well, an obvious primary tumor was not identifiable with palpation or mammography. On PET-CT, faint accumulation of FDG was noted in the vicinity of the CD regions, or upper and lower outer quadrants. When contrast-enhanced CT and ultrasonography were performed, a faint nodular opacity less than 1 cm in size corresponding to this site was found and diagnosed as the primary site, operation was subsequently performed. Pathologic diagnosis indicated invasive cancer. PET-CT is a helpful option for the diagnosis of occult breast cancer with primary sites that conventional imaging studies have difficulty identifying.     

临床Ⅰ期和Ⅱ期乳腺癌腔镜腋窝淋巴结清扫术效果及预后分析

目的探讨临床Ⅰ、Ⅱ期乳腺癌腔镜腋窝淋巴结清扫术的可行性。方法本院2006年1月至2008年1月对临床Ⅰ、Ⅱ期乳腺癌患者行腔镜下腋窝淋巴结清扫术55例,同时选取传统腋窝淋巴结清扫术63例,对两组手术时间、出血量、淋巴结清扫数量、腋下引流液量及预后进行比较。定量资料的分析采用t检验;定性资料的比较用χ2检验。结果腔镜手术组手术时间平均121.0min,术中出血51.0ml,平均每例清扫淋巴结数量17.3枚,术后总引流量平均208.0ml,随访1～3年术后复发转移者2例;对照组手术时间平均70.0min,术中出血平均80.0ml,平均每例清扫淋巴结19.5枚,术后总引流量平均350.0ml,术后复发转移者2例。腔镜手术组手术时间较传统手术长,但术中出血及术后引流液明显低于传统手术(P0.05)。两组间近期复发转移率比较,差异无统计学意义(χ2=0.02,P=0.89)。结论腔镜手术可以达到传统手术的治疗效果。     

Sentinel lymphadenectomy without systematic axillary dissection in breast cancer patients: predictors of non-sentinel lymph node metastasis.

AIMS: To identify factors predicting metastatic involvement of non sentinel axillary lymph nodes in breast cancer patients who underwent sentinel lymph node (SLN) biopsy followed by complete axillary dissection only in case of metastatic sentinel lymph node. METHODS: A prospective database including 165 breast cancer patients who underwent SLN biopsy without further complete axillary dissection in case of non-metastatic SLN was reviewed. Primary tumor size, pathologic grade, lymphatic invasion in the primary tumor, estrogen receptor status, tumor size in the SLN and number of metastatic SLNs were tested as possible predictors of metastatic involvement of non-SLN. RESULTS: The sentinel lymph node detection rate was 97% (160/165 patients). The mean number of SLNs per patient was 1.8 (range: 1-5). Fifty patients (31.3%) had a metastatic axillary SLN: 10 of the 42 patients with T1a or T1b breast tumors and 40 of the 118 patients with T1c< or = 15mm tumors. Fifteen of the 50 patients with metastatic SLN had metastatic non-SLN. Primary tumor size, tumor size in the SLN, pathologic grade, estrogen receptor status and age were not significantly associated with metastatic involvement of non-SLN. Number of metastatic SLNs fell short of reaching statistical significance (P: NS). Lymphatic invasion in the primary tumor was the only factor significantly associated with the presence of tumor in the non SLN (P<0.01). CONCLUSION: In our series, only lymphatic invasion in the primary tumor was correlated with metastases detection in the non-SLN. We could not identify a subset of patients without metastatic non-SLN in patients with metastatic SLN.     

Role of ultrasound-guided fine-needle aspiration of indeterminate and suspicious axillary lymph nodes in the initial staging of breast carcinoma

BACKGROUND: Ultrasound (US) is more sensitive than physical examination alone in determining axillary lymph node involvement during preliminary staging of breast carcinoma. Due to occasional overlap of sonographic features of benign and indeterminate lymph nodes, fine-needle aspiration (FNA) of sonographically indeterminate/suspicious lymph nodes can provide a more definitive diagnosis than US alone. This study was undertaken to determine the diagnostic accuracy of US-guided FNA of indeterminate/suspicious/metastatic-appearing axillary lymph nodes during the initial staging of breast carcinoma. METHODS: The cytology of 103 cases of US-guided FNA of nonpalpable indeterminate/suspicious/metastatic-appearing lymph nodes was compared with the final histopathologic status of the entire axilla after axillary dissection. The final axillary lymph node status was categorized as either negative when all lymph nodes were negative for metastasis or positive when there was evidence of metastasis in one or more lymph nodes. The sensitivity, specificity, diagnostic accuracy, and false-negative rate of US-guided FNA of nonpalpable axillary lymph nodes in the preliminary staging process were calculated. RESULTS: In 51 of 103 cases (49.5%), the US-guided FNA and histopathology were both positive for metastasis. In 24 of 103 cases (23.3%), both were negative. The apparent false-positive FNA in 16 (15.5%) cases was explained by the complete response of the metastatic lymph nodes to neoadjuvant chemotherapy in the interval between FNA and axillary dissection. In 12 cases (11.6%), US-guided FNA was negative, but metastasis was seen in histologic sections. All cases with three or more lymph nodes with metastatic disease and 93% of those with metastatic deposit measuring more than 0.5 mm were detected by US-guided FNA. The probability of detecting lymph nodes with smaller metastatic deposit measuring less than 0.5 cm was 44%. The overall sensitivity of US-guided FNA was 86.4%, the specificity was 100%, the diagnostic accuracy was 79.0%, the positive predictive value was 100%, and the negative predictive value was 67%. CONCLUSIONS: US-guided FNA of nonpalpable indeterminate and suspicious axillary lymph nodes is a simple, minimally invasive, and reliable technique for the initial determination of axillary lymph node status in breast carcinoma. The common causes of discrepancy between the initial and final axillary lymph node status include failure to visualize all lymph nodes during US examination, small-sized metastases, and preoperative neoadjuvant chemotherapy.     

核素淋巴显像识别前哨淋巴结在乳腺癌治疗中的应用

目的评价核素淋巴显像和γ探针定位在乳腺癌中确定前哨淋巴结(SLN)的应用价值,验证前哨淋巴结活检替代腋窝淋巴结清除术用于乳腺癌治疗的安全性与价值。方法选择1999年6月至2009年11月本院住院的女性乳腺癌患者206例(体检时腋窝均未扪及肿块),应用99Tcm-DX37～74 MBq或99Tcm-SC74 MBq经皮下注射,行核素淋巴显像后,术中注射专利兰1 ml和(或)术中用γ探针定位并行前哨淋巴结活检,与术中冰冻病理检查结果对照。若术中冰冻发现有前哨淋巴结转移,则行腋窝淋巴结清除术,若前哨淋巴结阴性,则不做腋窝淋巴结清除,术后定期随访。结果 206例乳腺癌术中成功活检SLN204例,成功率为99.0%(204/206)。本组有64例仅行SLN切除,术后病理检查证实64例SLN均阴性,故未行腋窝淋巴结清除,其中仅1例于术后1年时出现腋窝淋巴结转移,其余63例患者在随访期间均未发现腋窝淋巴结转移,也未出现同侧上肢水肿、感觉及活动异常;另140例行腋窝淋巴结清除,其中6例经病理证实SLN阳性但腋窝淋巴结为阴性,134例经病理证实SLN阳性35例,阴性99例,腋窝淋巴结阳性37例,阴性97例。核素淋巴显像和γ探针定位法的灵敏度为94.6%(35/37例),准确率为98.5%(138/140),假阴性为5.4%(2/37)。结论核素淋巴显像和γ探针定位应用于乳腺癌是切实可行和可能的,对预测腋窝淋巴结转移有很大的临床实用价值。如技术方法规范,早期乳腺癌前哨淋巴结活检则能取代常规的腋窝淋巴结清除术,乳腺癌手术上肢并发症的发生率可大大降低。     

Clinicopathologic Features Predicting Involvement of Nonsentinel Axillary Lymph Nodes in Iranian Women with Breast Cancer

Background: Almost half of the breast cancer patients with positive sentinel lymph nodes have no additional disease in the remaining axillary lymph nodes. This group of patients do not benefit from complete axillary lymph node dissection. This study was designed to assess the clinicopathologic factors that predict non-sentinel lymph node metastasis in Iranian breast cancer patients with positive sentinel lymph nodes. Materials and Methods: The records of patients who underwent sentinel lymph node biopsy, between 2003 and 2012, were reviewed. Patients with at least one positive sentinel lymph node who underwent completion axillary lymph node dissection were enrolled in the present study. Demographic and clinicopathologic characteristics including age, primary tumor size, histological and nuclear grade, lymphovascular invasion, perineural invasion, extracapsular invasion, and number of harvested lymph nodes, were evaluated. Results: The data of 167 patients were analyzed. A total of 92 (55.1%) had non-sentinel lymph node metastasis. Univariate analysis of data revealed that age, primary tumor size, histological grade, lymphovascular invasion, perineural invasion, extracapsular invasion, and the number of positive sentinel lymph nodes to the total number of harvested sentinel lymph nodes ratio, wereassociated with non-sentinel lymph node metastasis. After logistic regression analysis, age (OR=0.13; 95% CI, 0.02-0.8), primary tumor size (OR=7.7; 95% CI, 1.4-42.2), lymphovascular invasion (OR=19.4; 95% CI, 1.4-268.6), extracapsular invasion (OR=13.3; 95% CI, 2.3-76), and the number of positive sentinel lymph nodes to the total number of harvested sentinel lymph nodes ratio (OR=20.2; 95% CI, 3.4-121.9), were significantly associated with non-sentinel lymph node metastasis. Conclusions: According to this study, age, primary tumor size, lymphovascular invasion, extracapsular invasion, and the ratio of positive sentinel lymph nodes to the total number of harvested sentinel lymph nodes, were found to be independent predictors of non-sentinel lymph node metastasis.