Impact of Axillary Lymph Nodes Ratio on Outcomes of Non Metastatic, Triple Negative Breast Cancer Patients Treated with Up Front Surgery (A Retrospective Study) (original) (raw)
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The Prognostic Value of Axillary Lymph Node Ratio for Non- Metastatic Node Positive Breast Cancers
IOSR Journals , 2019
Introduction: Breast cancer is the most common female cancer worldwide representing nearly a quarter (25%) of all cancers with an estimated 1.67 million new cancer cases diagnosed in 2012. Women from less developed regions (883 000 cases) have slightly more number of cases compared to more developed (794 000) regions. Materials and Methods: Our study is a retrospective case control study where we had analyzed the medical records of all the cases of breast cancers who had undergone surgery (Modified Radical Mastectomy, MRM; with axillary lymph node dissection, ALND) and post-operative adjuvant therapy (chemotherapy, radiotherapy or hormonal) during January, 2018 and December, 2018. From the information recorded and retrieved from the Hospital Information system (HIS) of the Mahatma Gandhi Institute of Medical Sciences and the District Cancer Registry, a total of 353 number of cases had met with the criteria for the study (n=353). The study was approved by the Ethics Committee of the institution where the study was held. Results: ata from 353 patients were evaluated and 213 met the inclusion criteria. The mean age was 46 years and most patientswere premenopausal (Table 1). The majority of patients (84.0%) had T1-2 stage cancer and received modified radical surgery (96.3%). The median number of axillary lymph nodes removed was 14 and the median LNR was 0.18. About half the patients' tumors were positive for estrogen or progesterone receptor expression and about a quarter expressed HER2 (Table 1). All patients received chemotherapy most of which included a regimen of cyclophosphamide, methotrexate, and 5-fluorouracil (CMF), or a taxane, anthracycline regimen (Table 1). Approximately one fourth of the patients had radiotherapy and over half received adjuvant endocrine therapy (Table 1). Conclusion: In conclusion, our findings support the use of LNR as a predictor of survival in patients with breast cancer, and that LNR is superior to pN staging in determining disease prognosis. These findings, as well as others, indicate that cancer staging should not be confined to the TNM staging system and should at least include LNR assessment.
The Prognostic Significance of the Lymph Node Ratio in Axillary Lymph Node Positive Breast Cancer
2010
This study evaluated the prognostic impact of the lymph node ratio (LNR; i.e., the ratio of positive to dissected lymph nodes) on recurrence and survival in breast cancer patients with positive axillary lymph nodes (LNs). Methods: The study cohort was comprised of 330 breast cancer patients with positive axillary nodes who received postoperative radiotherapy between 1987 and 2004. Ten-year Kaplan-Meier locoregional failure, distant metastasis, disease-free survival (DFS) and disease-specific survival (DSS) rates were compared using Kaplan-Meier curves. The prognostic significance of the LNR was evaluated by multivariate analysis. Results: Median follow-up was 7.5 years. By minimum p-value approach, 0.25 and 0.55 were the cutoff values of LNR at which most significant difference in DFS and DSS was observed. The DFS and DSS rates correlated significantly with tumor size, pN classification, LNR, histologic grade, lymphovascular invasion, the status of estrogen receptor and progesterone receptor. The LNR based classification yielded a statistically larger separation of the DFS curves than pN classification. In multivariate analysis, histologic grade and pN classification were significant prognostic factors for DFS and DSS. However, when the LNR was included as a covariate in the model, the LNR was highly significant (p< 0.0001), and pN classification was not statistically significant (p> 0.05). Conclusion: The LNR predicts recurrence and survival more accurately than pN classification in our study. The pN classification and LNR should be considered together in risk estimates for axillary LNs positive breast cancer patients.
Lymph Node Ratio: A Proposed Refinement of Current Axillary Staging in Breast Cancer Patients
Journal of the American College of Surgeons, 2011
BACKGROUND: The optimal method for classifying lymph node (LN) status in breast cancer patients is unknown. We sought to determine if LN ratio (LNR) improves axillary staging. STUDY DESIGN: Kentucky Cancer Registry data (1996 to 2007) were used to compare LN categorization schemas. Overall survival (OS) was evaluated using the Kaplan-Meier method and log rank tests. Schemas included: LN positive (ϩ) vs negative (Ϫ) disease, current American Joint Committee on Cancer (AJCC) staging (0 vs 1 to 3 vs 4 to 9 vs Ն10 LNϩ), and LNR 0 vs 0.01 to 0.20 vs 0.21 to 0.65 vs Ͼ0.65 (LNϪ vs low, intermediate, and high risk LNϩ groups). RESULTS: There were 1,436 patients who had complete LN evaluation data: 880 (61.3%) were LNϪ and 556 (39.6%) were LNϩ; 309 (21.5%) had 1 to 3 positive LNs, 138 (9.6%) had 4 to 9 positive LNs, and 109 (7.6%) had 10 or more positive LNs. For LNϩ patients, the median number of positive LNs was 3; median LNR was 0.23. The median follow-up was 65 months. LN status was associated with 5-year OS (91.3% and 73.3% for LNϪ and LNϩ groups, respectively, p Ͻ 0.001). Increasing AJCC pN stage was associated with worse OS (5-year OS 80.5%, 75.3%, and 49.8% for pN1 to N3, respectively, p Ͻ 0.001). LNR was also associated with OS (5-year OS of 83.1%, 72.7%, and 52.7% for the low, intermediate, and high risk LNϩ groups, respectively, p Ͻ 0.001). In subgroup analyses of patients in the 1 to 3 and 4 to 9 LNϩ groups, OS was statistically associated with LNR (p ϭ 0.021 and p ϭ 0.016, respectively). On multivariable survival analysis, LNR was associated with OS, independent of AJCC categorization, p ϭ 0.003. CONCLUSIONS: LNR was associated with OS, regardless of AJCC LN categories. (J Am Coll Surg 2011;213: 45-53.
Prognostic Value of Metastatic Axillary Lymph Node Ratio for Chinese Breast Cancer Patients
PLoS ONE, 2013
Objective: The prevalence of breast cancer varies among countries and regions. This retrospective study investigated the prognostic value of the lymph node ratio (LNR) compared with the number of positive lymph nodes (pN) in Chinese breast cancer patients. Methods: The medical records of female breast cancer patients (N = 2591) were retrospectively evaluated. The association of LNR and TMN staging system were compared with respect to overall, disease-free, and distant metastasis-free survival. Results: Out of 2591 patients, 2495 underwent modified radical surgery and 96 received breast conserving surgery. All patients had adjuvant chemotherapy following surgery. The median follow up period 66.9 months (range 5-168 months). The 5-year and 10-year overall survival rates were 89.3% and 78.8%, respectively, and 5-year disease-free survival and distant metastasis-free survival rates were 81.6% and 83.5%, respectively. Univariate analysis indicated that in general T, pN, LNR, as well as tumor expression of the estrogen receptor, progesterone receptor, and HER2 were associated with overall, diseasefree, and distant metastasis-free survival (all P-values ,0.05). Mutlivariate analysis found pN stage and LNR were independent predictors of overall, disease-free, and distant metastasis-free survival (all P-values ,0.001). If pN stage and LNR were both included in a multivariate analysis, LNR was still an independent prognostic factor for overall, disease-free, and distant metastasis-free survival (all P-values ,0.001). Conclusion: Our findings support the use of LNR as a predictor of survival in Chinese patients with breast cancer, and that LNR is superior to pN stage in determining disease prognosis.
Lymph Node Ratio Predicts Long-Term Survival in Lymph Node-Positive Breast Cancer
European Journal of Breast Health, 2020
Globally, breast cancer (BC) is the most commonly diagnosed cancer in women as well as being one of the most common cancer-related deaths, particularly in patients aged 40-49 years (1,2). Its treatment requires a multidisciplinary team approach which includes surgical oncology, medical oncology, and radiation oncology. The majority of BC patients are diagnosed at non-metastatic stage. Approximately 5% of patients have metastatic disease at the time of diagnosis (2, 3). For BC patients, the treatment decision depends on some factors including disease stage, hormone receptor status, and human epidermal growth factor receptor-2 (HER-2) status at presentation (1-3). It is well-known that locoregional radiotherapy to axillary lymph nodes (ALN) has decreased local recurrence and improved survival in node-positive BC. The ALN status has been considered a possible indication for post-surgical adjuvant radiotherapy. However, it may depend on the degree of ALN resected. Moreover, in some cases, the decision regarding whether radiotherapy is necessary depends on the physician (4-6). The lymph node ratio (LNR) is described as the ratio of number of positive ALN to total number of ALN resected. Truong et al. (7) included 80 BC patients with 1 to 3 ALN positive and reported that LNR was related to an increased locoregional recurrence and also a stronger prognostic factor than the number of positive ALN. Similarly, Han et al. (8) included 130 BC patients with N1 stage and reported that LNR was associated with an increased risk of recurrence, especially in younger BC patients. A study performed by Kuru (9) who analyzed 801 BC patients showed that the number of ALN resected >15 or number of negative ALN >15 improved survival. ALN status continues to be one of the main prognostic factors guiding the adjuvant radiotherapy decision. pN stage is based on the number of ALN resected. However, the accuracy of the approach is affected by the number of ALN resected, which
PLoS ONE, 2012
Introduction: Lymph node ratio (LNR, i.e. the ratio of the number of positive nodes to the total number of nodes excised) is reported to be superior to the absolute number of nodes involved (pN stage) in classifying patients at high versus low risk of death following breast cancer. The added prognostic value of LNR over pN in addition to other prognostic factors has never been assessed. Methods: All patients diagnosed with lymph node positive, non-metastatic invasive breast cancer at the National University Hospital (Singapore) and University of Malaya Medical Center (Kuala Lumpur) between 1990-2007 were included (n = 1589). Overall survival of the patients was estimated by the Kaplan Meier method for LNR [categorized as low (.0 and ,0.2), intermediate (0.2-0.65) and high (.0.65-1)] and pN staging [pN1, pN2 and pN3]. Adjusted overall relative mortality risks associated with LNR and pN were calculated by Cox regression. The added prognostic value of LNR over pN was evaluated by comparing the discriminating capacity (as indicated by the c statistic) of two multivariate models, one including pN and one including LNR. Results: LNR was superior to pN in categorizing mortality risks for women $60 years, those with ER negative or grade 3 tumors. In combination with other factors (i.e. age, treatment, grade, tumor size and receptor status), substituting pN by LNR did not result in better discrimination of women at high versus low risk of death, neither for the entire cohort (c statistic 0.72 [0.70-0.75] and 0.73 [0.71-0.76] respectively for pN versus LNR), nor for the subgroups mentioned above. Conclusion: In combination with other prognosticators, substitution of pN by LNR did not provide any added prognostic value for South East Asian breast cancer patients.
Journal of Clinical Oncology, 2009
Background. The status of the axillary lymph nodes in nonmetastatic lymph node-positive breast cancer (BC) patients remains the single most important determinant of overall survival (OS). Although the absolute number of nodes involved with cancer is important for prognosis, the role of the total number of excised nodes has received less emphasis. Thus, several studies have focused on the utility of the axillary lymph node ratio (ALNR) as an independent prognostic indicator of OS. However, most studies suffered from shortcomings, such as including patients who received neoadjuvant therapy or failing to consider the use of adjuvant therapy and tumor receptor status in their analysis. Methods. We conducted a single-center retrospective review of 669 patients with nonmetastatic lymph nodepositive BC. Data collected included patient demographics; breast cancer risk factors; tumor size, histopathological, receptor, and lymph node status; and treatment modalities used. Patients were subdivided into four groups according to ALNR value (<0.25, 0.25-0.49, 0.50-0.74, 0.75-1.00). Study parameters were compared at the univariate and multivariate levels for their effect on OS. Results. On univariate analysis, both the absolute number of positive lymph nodes and the ALNR were significant predictors of OS. On multivariate analysis, only the ALNR remained an independent predictor of OS, with a 2.5-fold increased risk of dying at an ALNR of ≥0.25. Conclusions. Our study demonstrates that ALNR is a stronger factor in predicting OS than the absolute number of positive axillary lymph nodes.
Annals of Surgical Oncology, 2009
Background The status of the axillary lymph nodes in nonmetastatic lymph node-positive breast cancer (BC) patients remains the single most important determinant of overall survival (OS). Although the absolute number of nodes involved with cancer is important for prognosis, the role of the total number of excised nodes has received less emphasis. Thus, several studies have focused on the utility of the axillary lymph node ratio (ALNR) as an independent prognostic indicator of OS. However, most studies suffered from shortcomings, such as including patients who received neoadjuvant therapy or failing to consider the use of adjuvant therapy and tumor receptor status in their analysis. Methods We conducted a single-center retrospective review of 669 patients with nonmetastatic lymph node-positive BC. Data collected included patient demographics; breast cancer risk factors; tumor size, histopathological, receptor, and lymph node status; and treatment modalities used. Patients were subdivided into four groups according to ALNR value (Results On univariate analysis, both the absolute number of positive lymph nodes and the ALNR were significant predictors of OS. On multivariate analysis, only the ALNR remained an independent predictor of OS, with a 2.5-fold increased risk of dying at an ALNR of ≥.25. Conclusions Our study demonstrates that ALNR is a stronger factor in predicting OS than the absolute number of positive axillary lymph nodes.
The lymph node ratio as prognostic factor in node-positive breast cancer
Radiotherapy and Oncology, 2004
The clinical records of the node-positive breast cancer patients treated at our department were reviewed, to evaluate if there is a correlation between the ratio of involved axillary lymph nodes and the overall and cause specific survival.From 1984 until July 2001, 2073 files from patients with an invasive breast carcinoma were submitted to retrospective analyses. In 810 cases, a node positive status was diagnosed. All pT-stages were included. The total number of dissected nodes (pNtot) and the number of involved nodes (pN+) were available for 741 patients. The ratio of nodal involvement (pN+%) was categorized into three groups, pN+%≤10% (n=212), between 11 and 50% (n=346) and between 51 and 100% (n=183).The actuarial overall survival (OS) at 5 and 10 years was, respectively, 78.2 and 59.1%. Cause specific survival (CSS) rates were, respectively, 83.6 and 69.1%. In univariate analyses, age (P=0.01), grade (P=0.02), pT-stage (P<0.0001), chemotherapy (P=0.0002), the number of involved nodes ≤3 versus >3 (pN+) (P<0.0001) and ratio pN+% (P<0.0001) were associated significantly with overall survival. A multivariate analysis using the Cox proportional hazards model found that pN+% was the most significant prognostic factor; pN+lost significance when pN+% was taken into account.The percentage of positive lymph nodes in an axillary lymph node dissection appears to be an important prognostic factor for survival. The nodes ratio improved on the absolute numbers of involved axillary lymph nodes for assessment of prognosis.