Axillary lymph node ratio and total number of removed lymph nodes: predictors of survival in stage I and II breast cancer

Wal, Bart C. H. van der; Butzelaar, R. M. J. M.; Meij, Suzanne Van Der; Boermeester, Marja A.

doi:10.1053/ejso.2002.1239

Cited by 135 publications

(89 citation statements)

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“…11,25 In an attempt to address the above, several studies have focused on the utility of the ALNR as an independent prognostic indicator of OS. [12][13][14][15][16][17][18] Our study demonstrates a statistically significant negative correlation between ALNR and OS, thus supporting the findings of previous studies (Table 5). [12][13][14][15][16][17][18] The strength of the data in the present study draws on the following factors.…”

Section: Discussionsupporting

confidence: 91%

“…Interestingly, most studies had similar observations. 12,[15][16][17][18] Thus, it may be interpreted that ALN involvement in[25% of the excised nodes is associated with a poor outcome. The outcome greatly worsens with increasing ALNR.…”

Section: Discussionmentioning

confidence: 99%

“…14,18 Moreover, in many of these series, additional factors affecting OS, such as tumor receptor status (including HER2) and use of neoadjuvant or adjuvant treatment regimens, were not considered. [12][13][14][15][16][17][18] We thus report a single institutional experience with the prognostic significance of ALNR in nonmetastatic lymph node-positive BC patients treated by the same medical and surgical oncology team while attempting to address many of the shortcomings evident in some of the previous trials.…”

Section: Introductionmentioning

confidence: 99%

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Ratio Between Positive Lymph Nodes and Total Excised Axillary Lymph Nodes as an Independent Prognostic Factor for Overall Survival in Patients with Nonmetastatic Lymph Node-Positive Breast Cancer

Hatoum

Jamali

El-Saghir

et al. 2010

Indian J Surg Oncol

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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 (\.25, .25-.49, .50-.74, .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 C.25. Conclusions. Our study demonstrates that ALNR is a stronger factor in predicting OS than the absolute number of positive axillary lymph nodes.Breast cancer (BC) is the most common cancer in women and the second most common cause of female cancer death, with an estimated 182,460 new cases diagnosed and 40,480 deaths in the United States in 2008. 1 Despite the advent of sentinel node biopsy techniques and the dawning of the molecular era of BC staging, the status of the axillary lymph nodes (ALN) remains the single most important determinant of overall survival (OS). [2][3][4][5][6] For patients with pathologically proven ALN involvement, the number of positive axillary lymph nodes (pALN) correlates with the incidence of distant metastasis and OS, and more than three pALN is associated with a 13% to 24% locoregional recurrence rate. 7,8 The relationship between number of pALN and survival seems to be linear, with each additional pALN detected leading to a worsening of the prognosis. 9,10 The American Joint Committee on Cancer staging system was recently revised, grouping patients by the absolute number of pALN. This classification improved stratification in OS, but the confounding effect that the number of excised nodes may have on the yield of positive nodes and its effect on BC-specific survival prognostic accuracy and management decisions are problems that remain unresolved. 6,11 Thus, the ratio between the number of pALN and the total number of excised nodes, or the axillary lymph node ratio (ALNR), may be a more comprehensive approach to estimate prognosis because it takes into accou...

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Section: Discussionsupporting

confidence: 91%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Ratio Between Positive Lymph Nodes and Total Excised Axillary Lymph Nodes as an Independent Prognostic Factor for Overall Survival in Patients with Nonmetastatic Lymph Node-Positive Breast Cancer

Hatoum

Jamali

El-Saghir

et al. 2010

Indian J Surg Oncol

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“…[11][12][13] Few studies have focused on LRR outcomes. 9 The use of the percentage of positive lymph nodes in the context of appraising LRR risk and guiding adjuvant locoregional therapy decisions, thus, is unclear.…”

Section: Discussionmentioning

confidence: 99%

“…[11][12][13] However, relatively few data are available to define the effect of the percentage of positive lymph nodes on risks of LRR. Because postmastectomy radiotherapy has the potential to optimize locoregional control and improve survival, 4 -6,14 we were interested in evaluating whether the percentage of positive lymph nodes may be applied in patients with one to three positive lymph nodes to distinguish those at high risk who may benefit with adjuvant therapy from those at low risk who may be spared treatment-related toxicities.…”

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confidence: 99%

The prognostic significance of the percentage of positive/dissected axillary lymph nodes in breast cancer recurrence and survival in patients with one to three positive axillary lymph nodes

Truong

Berthelet

Lee

et al. 2005

Cancer

126

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BACKGROUNDAdjuvant therapy for women with T1–T2 breast carcinoma and 1–3 positive lymph nodes is controversial due to discrepancies in reported baseline locoregional recurrence (LRR) risks. This inconsistency has been attributed to variations in lymph node staging techniques, which have yielded different numbers of dissected lymph nodes. The current study evaluated the prognostic impact of the percentage of positive/dissected lymph nodes on recurrence and survival in women with one to three positive lymph nodes.METHODSThe study cohort was comprised of 542 women with pathologic T1–T2 breast carcinoma who had 1–3 positive lymph nodes and who had undergone mastectomy and received adjuvant systemic therapy without radiotherapy. Ten‐year Kaplan–Meier (KM) LRR, distant recurrence (DR), and overall survival (OS) rates stratified by the number of positive lymph nodes, the number of dissected lymph nodes, and the percentage of positive lymph nodes were examined using different cut‐off levels. Multivariate analysis was performed to evaluate the prognostic significance of the percentage of positive lymph nodes in disease recurrence and survival.RESULTSThe median follow‐up was 7.5 years. LRR, DR, and OS rates correlated significantly with the number of positive lymph nodes and the percentage of positive lymph nodes, but not with the number of dissected lymph nodes. The cut‐off level at which the most significant difference in LRR was observed was 25% positive lymph nodes (the 10‐year KM LRR rates were 13.9% and 36.7% in women with ≤ 25% and > 25% positive lymph nodes, respectively; P < 0.0001). Higher DR rates and lower OS rates were observed among patients who had > 25% positive lymph nodes compared with patients who had ≤ 25% positive lymph nodes (DR: 53.0% vs. 30.3%, respectively; P < 0.0001; OS: 43.4% vs. 62.6%, respectively; P < 0.0001). In the multivariate analysis, the percentage of positive lymph nodes and the histologic grade were significant, independent factors associated with LRR, DR, and OS.CONCLUSIONSThe presence of > 25% positive lymph nodes was an adverse prognostic factor in patients with 1–3 positive nodes and may be used to identify patients at high risks of postmastectomy locoregional and distant recurrence who may benefit with adjuvant radiotherapy and more aggressive systemic therapy regimens. Cancer 2005. © 2005 American Cancer Society.

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Site‐Specific Recommendations for p T and p N

2014

TNM Online

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This chapter is an expansion to the following general rules of the TNM system (TNM Classification 2002 [19], pp. 1, 3): 2b. Pathological assessment of the primary tumour (pT) entails a resection of the primary tumour or biopsy adequate to evaluate the highest pT category. The pathological assessment of the regional lymph nodes (pN) entails removal of nodes adequate to validate the absence of regional lymph node metastasis (pN0) and sufficient to evaluate the highest pN category. 4. If there is doubt concerning the correct T, N or M category to which a particular case should be allotted, then the lower (i.e., less advanced) category should be chosen. In the TNM Classification of 1997 and 2002 [18, 19] these general rules have been specified for breast cancer only. Analogous definitions for the pN0 category of other tumour sites are given in the 1997 and 2002 TNM Classification [18, 19], except for bone, soft tissues, urological, and ophthalmic tumours. The numbers of lymph nodes given in the different tumour sites are considered adequate for staging. If the examined lymph nodes are negative, but the number ordinarily resected is not met, classify as pN0 . The number of nodes examined and the number involved by tumour should be recorded in the pathology report [1, 6, 8, 9, 11, 13, 16]. This information may also be added in parentheses, e.g., for colorectal carcinoma pN0 (0/11) or pN1 (3/10). In many tumour sites, the number of involved regional lymph nodes indicates differences in prognosis. For details see [16]. A correlation exists between the number of examined lymph nodes and the pN classification. With increasing number of examined lymph nodes a higher frequency of lymph node‐positive cases is found and—in tumour sites where more than one positive pN category is provided—a greater proportion of higher pN categories can be observed [7, 16]. Therefore, the number of examined lymph nodes reflects the reliability of the pN classification.

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Axillary lymph node ratio and total number of removed lymph nodes: predictors of survival in stage I and II breast cancer

Cited by 135 publications

References 24 publications

Ratio Between Positive Lymph Nodes and Total Excised Axillary Lymph Nodes as an Independent Prognostic Factor for Overall Survival in Patients with Nonmetastatic Lymph Node-Positive Breast Cancer

Ratio Between Positive Lymph Nodes and Total Excised Axillary Lymph Nodes as an Independent Prognostic Factor for Overall Survival in Patients with Nonmetastatic Lymph Node-Positive Breast Cancer

The prognostic significance of the percentage of positive/dissected axillary lymph nodes in breast cancer recurrence and survival in patients with one to three positive axillary lymph nodes

Site‐Specific Recommendations for p T and p N

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