Development and validation of a pre- and intra-operative scoring system that distinguishes between non-advanced and advanced axillary lymph node metastasis in breast cancer with positive sentinel lymph nodes: a retrospective study

Abstract

Background There are currently no scoring-type predictive models using only easily available pre- and intraoperative data developed for assessment of the risk of advanced axillary lymph node metastasis (ALNM) in patients with breast cancer with metastatic sentinel lymph nodes (SLNs). We aimed to develop and validate a scoring system using only pre- and intraoperative data to distinguish between non-advanced (≤ 3 lymph nodes) and advanced (> 3 lymph nodes) ALNM in patients with breast cancer with metastatic SLNs. Methods We retrospectively identified 804 patients with breast cancer (cT1-3cN0) who had metastatic SLNs and had undergone axillary lymph node dissection (ALND). We evaluated the risk factors for advanced ALNM using logistic regression analysis and developed and validated a scoring system for the prediction of ALNM using training (n = 501) and validation (n = 303) cohorts, respectively. The predictive performance was assessed using the receiver operating characteristic (ROC) curve, area under the curve (AUC), and calibration plots. Results Ultrasound findings of multiple suspicious lymph nodes, SLN macrometastasis, the ratio of metastatic SLNs to the total number of SLNs removed, and the number of metastatic SLNs were significant risk factors for advanced ALNM. Clinical tumor size and invasive lobular carcinoma were of borderline significance. The scoring system based on these six variables yielded high AUCs (0.90 [training] and 0.89 [validation]). The calibration plots of frequency compared to the predicted probability showed slopes of 1.00 (training) and 0.85 (validation), with goodness-of-fit for the model. When the cutoff score was set at 4, the negative predictive values (NPVs) of excluding patients with advanced ALNM were 96.8% (training) and 96.9% (validation). The AUC for predicting advanced ALNM using our scoring system was significantly higher than that predicted by a single independent predictor, such as the number of positive SLNs or the proportion of positive SLNs. Similarly, our scoring system also showed good discrimination and calibration ability when the analysis was restricted to patients with one or two SLN metastases. Conclusion Our easy-to-use scoring system can exclude advanced ALNM with high NPVs. It may contribute to reducing the risk of undertreatment with adjuvant therapies in patients with metastatic SLNs, even if ALND is omitted.

A nomogram for predicting pathologic node negativity after neoadjuvant chemotherapy in breast cancer patients: a nationwide, multicenter retrospective cohort study (CSBrS-012)

“…We developed a nomogram based on multivariate logistic regression results. In contrast to previous nomograms that predicted axillary pCR in initially cN+ patients (38)(39)(40) or in specific subtypes (41,42), the current nomogram predicted ypN0 in all patients with stage cT1-4N0-3 disease. The AUC of the nomogram in the ROC curve analysis was 0.80, 0.79, and 0.76 in the training, internal, and external validation cohorts, respectively, and showed good discrimination in the prediction of ypN0.…”

Multimodal ultrasound imaging: a method to improve the accuracy of sentinel lymph node diagnosis in breast cancer

“…Therefore, preoperative diagnosis may eliminate the need for biopsy and lymph node dissection, thereby providing valuable information for axillary treatment. Conventional preoperative imaging methods can provide diagnostic information about axillary lymph nodes; however, they are not ideal for the localization and qualitative assessment of the SLN ( 13 , 14 ). Two-dimensional ultrasound (2D US) primarily distinguishes between benign and malignant lymph nodes by observing the lymph node architecture, the boundary between the cortex and medulla of lymph nodes, and the boundary with surrounding normal tissues, and by calculating aspects such as the length-to-width ratio and cortical thickness.…”

Multimodal Ultrasound Imaging: A Method to Improve the Accuracy of Sentinel Lymph Node Diagnosis in Breast Cancer

“…Therefore, preoperative diagnosis may eliminate the need for biopsy and lymph node dissection, thereby providing valuable information for axillary treatment. Conventional preoperative imaging methods can provide diagnostic information about axillary lymph nodes, they are not ideal for the localization and qualitative assessment of the SLN [13,14]. Two-dimensional ultrasound (2D US) primarily distinguishes between benign and malignant lymph nodes by observing the lymph node architecture, the boundary between the cortex and medulla of lymph nodes, the boundary with surrounding normal tissues, and calculating aspects such as the length-to-width ratio and cortical thickness.…”