Tan LK, Giri D, Hummer AJ, Panageas KS, Brogi E, Norton L, Hudis C, Borgen PI, Cody III HSOccult axillary node metastases in breast cancer are prognostically significant: results in 368 node-negative patients with 20-year follow-up. J Clin Oncol 26(11): 1803-1809
In breast cancer, sentinel lymph node (SLN) biopsy allows the routine performance of serial sections and/or immunohistochemical (IHC) staining to detect occult metastases missed by conventional techniques. However, there is no consensus regarding the optimal method for pathologic examination of SLN, or the prognostic significance of SLN micrometastases.
In 368 patients with axillary node-negative invasive breast cancer, treated between 1976 and 1978 by mastectomy, axillary dissection, and no systemic therapy, we reexamined the axillary tissue blocks following our current pathologic protocol for SLN. Occult lymph node metastases were categorized by pattern of staining (immunohistochemically positive or negative [IHC+/-], hematoxylin-eosin staining positive or negative [H & E +/-]), number of positive nodes (0, 1, > 1), number of metastatic cells (0, 1 to 20, 21 to 100, > 100), and largest cluster size (<or= 0.2 mm [pN0(i+)], 0.3 to 2.0 mm [pN1(mi)], > 2.0 mm [pN1a]). We report 20-year results as overall survival (OS), disease-free survival (DFS), and disease-specific death (DSD).
A total of 23% of patients (83 of 368) were converted to node-positive. Of these, 73% were <or= 0.2 mm in size (pN0(i+)), 20% were 0.3 to 2.0 mm (pN1(mi)), and 6% were more than 2 mm (pN1a). On univariate and multivariate analysis, pattern of staining, number of positive nodes, number of metastatic cells, and cluster size were all significantly related to both DFS and DSD. On multivariate analysis, each of these measures had significance comparable to, or greater than, tumor size, grade or lymphovascular invasion.
In breast cancer patients staged node-negative by conventional single-section pathology, occult axillary node metastases detected by our current pathologic protocol for SLN are prognostically significant.
"However, for evaluation of non-SNs, a more approximate procedure than that for SNs, such as single-section histology without immunohistochemical staining, has been adopted. Although the false-negative rate and underestimation of the metastasis volume can be reduced by serial sectioning and immunohistochemistry (Umekita et al, 2002; Reed et al, 2004; Tan et al, 2008), this procedure forces a heavy workload and cost on technicians and pathologists. The one-step nucleic acid amplification (OSNA) assay (Sysmex Corporation) is a rapid molecular detection procedure that "
[Show abstract][Hide abstract] ABSTRACT: The one-step nucleic acid amplification (OSNA) assay is a molecular-based lymph-node metastasis detection procedure that can assess a whole node and yields semi-quantitative results for the detection of clinically relevant nodal metastases. We aimed to determine the performance of the OSNA assay as an accurate nodal staging tool in comparison with routine histological examination.
Subjects comprised 183 consecutive patients with pT1-2 breast cancer who underwent axillary dissection after positive sentinel-node (SN) biopsy with the OSNA assay. Of these, for non-SN evaluation, 119 patients underwent OSNA assay evaluation, whereas 64 had single-section histology. We compared the detection rates of non-SN metastasis and upstaging rates from the SN stage according to the American Joint Committee on Cancer staging between the OSNA and histology cohorts.
OSNA detected more cases of non-SN metastases than histology (OSNA 66/119, 55.5% vs histology 13/64, 20.3%; P<0.001), particularly micrometastases (36/119, 30.3% vs 1/64, 1.6%; P<0.001). Total upstaging rates were similar in both cohorts (20/119, 16.8% vs 9/64, 14.1%, P=0.79).
OSNA detects a far greater proportion of non-SN micrometastases than routine histological examination. However, upstaging rates after axillary dissection were not significantly different between both cohorts. Follow-up of the OSNA cohort is required to determine its clinical relevance.
British Journal of Cancer 08/2011; 105(8):1197-202. DOI:10.1038/bjc.2011.350 · 4.84 Impact Factor
"Additional macrometastases were found in 15% and 4%, respectively, resulting in altered treatment in 7% of patients. In a recently published study involving 2408 patients detection of micrometastatic carcinoma was a major indicator of poorer survival  . In addition, 9.3% of these patients had additional axillary nodal disease on axillary dissection and decreased survival when axillary dissection was omitted. "
[Show abstract][Hide abstract] ABSTRACT: Biopsy of the sentinel lymph node now forms part of routine management in many centres dealing with early stage breast cancer. This article seeks to discuss developments over the past number of years and to summarise current practice.
Cancer Imaging 02/2008; 8 Spec No A(Spec Iss A):S10-8. DOI:10.1102/1470-7330.2008.9003 · 2.07 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Le statut ganglionnaire axillaire est le facteur pronostique le plus important dans les cancers du sein. L’atteinte du ganglion
sentinelle (GS) comprend deux entités: les atteintes métastatiques pN1 et les atteintes lymphatiques minimes: pN1mi et pN0i+.
La prise en charge thérapeutique postopératoire des patientes pN1 ayant eu la technique du GS est identique à la population
des patientes pN1 ayant eu un curage axillaire (CA). Par contre, la prise en charge des patientes pN1mi ou pN0i+ fait l’objet
de discussion avec une tendance à les réopérer (CA complèmentaire), car le risque d’atteinte métastatique est de l’ordre de
10 à 15% (les reclassant pN1), cela permet ainsi de décider des champs d’irradiation et des traitements systémiques adjuvants.
Les études concernant le pronostic des patientes avec atteinte lymphatique minime font l’objet de publications très récentes
depuis 2008. Ainsi, la taille métastatique semble être corrélée au pronostic de ces patientes tant en survie sans métastase
à cinq ans qu’en survie globale à dix ans et pourrait être un facteur décisionnel de traitement systémique adjuvant. L’étude
de l’atteinte ganglionnaire axillaire reste donc une nécessitè absolue dans la prise en charge des cancers du sein. L’étude
des atteintes lymphatiques minimes ouvre ainsi un nouveau champ d’exploration où les chirurgiens jouent leur rôle comme les
autres acteurs de la cancérologie.
The status of the axillary lymph nodes is the most important prognostic factor in breast cancer. Positive sentinel lymph node
may be divided into two categories: metastatic, that is, pN1, and minimal lymph node involvement, that is, pN1mi and pN0i+.
Postoperative management of pN1 patients following SNB (sentinel node biopsy) is same as pN1 patients following axillary lymph
node dissection, whereas postoperative management of pN1mi and pN0i+ patients is still debated, with a trend to do a complementary
axillary lymph node dissection because of the risk of positive-non-SNB. This risk is evaluated approximately 1015% (reclassifying
in pN1) and can modify irradiation fields and adjuvant systemic therapy. Recent papers concerning the prognosis of these patients
are published since 2008. The size of node metastasis seems to be correlated with 5-year distant free metastasis survival
as well as the 10-year overall survival and has been described as a decisive factor for adjuvant systemic therapy. Analysis
of lymphatic dissemination remains necessary in the management of breast cancer, and analysis of minimal lymph node involvement
gives the surgeons an opportunity to play a role in optimizing the postoperative treatment and the prognosis of our patients.
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