Prognostic value of the lymph node ratio for lymph-node-positive breast cancer- is it just a denominator problem?

Abstract

PurposeTo examine the prognostic value of lymph node ratio (LNR) for patients with node-positive breast cancer with varying numbers of minimum nodes removed (>5, > 10 and > 15 total node count).MethodsThis study examined the original histopathological reports of 332 node-positive patients treated in the state of New South Wales (NSW), Australia between 1 April 1995 and 30 September 1995. The LNR was defined as the number of positive lymph nodes (LNs) over the total number of LNs removed. The LNR cutoffs were defined as low-risk, 0.01–0.20; intermediate-risk, 0.21– 0.65; and high-risk, LNR >0.65.ResultsThe median follow-up was 10.3 years. In multivariate analysis, LNR was an independent predictor of 10-year breast cancer specific survival when > 5 nodes were removed. However, LNR was not an independent predictor when > 15 nodes were removed. In a multivariate analysis the relative risk of death (RR) decreased from 2.20 to 1.05 for intermediate-risk LNR and from 3.07 to 2.64 for high-risk while P values increased from 0.027 to 0.957 for intermediate-risk LNR and 0.018 to 0.322 for high-risk with the number of nodes removed increasing from > 5 to > 15.ConclusionsAlthough LNR is important for patients with low node denominators, for patients with macroscopic nodal metastases in several nodes following an axillary dissection who have more than 15 nodes dissected, the oncologist can be satisfied that prognosis, selection of adjuvant chemotherapy and radiotherapy fields can be based on the numerator of the positive nodes.Electronic supplementary materialThe online version of this article (doi:10.1186/s40064-015-0865-2) contains supplementary material, which is available to authorized users.

Can axillary lymph node ratio (LNR) predict local recurrences or deaths in patients with breast cancer with nodal involvement?

“…They found that LNR lost its significance in patients with >10 and >15 nodes dissected, perhaps suggesting that LNR holds value only when axillary dissections are inadequate. They concluded that oncologist can be confident that prognosis and decisions on adjuvant therapies can be based on pN classification alone when adequate axillary dissections are performed (>15 nodes) but suggest that pN and LNR should be used on conjunction otherwise [2]. In our study, the mean number of axillary lymph nodes that were examined was [15], which could account for non-significance of our findings.…”

“…Current nodal staging systems solely use the number of positive axillary LNs, and although this parameter has been shown to be of value, recent literature queries whether additional information on the total number of LNs removed would be of prognostic benefit [13]. This is because data has shown that the chance of finding positive nodes increases with the number of LNs examined, and that under-staging of the axilla can be a result of inadequate dissections [2]. The concept of assessing LN status by ratios was first suggested years ago; a few parameters were developed but the lymph node ratio (LNR) was deemed the most clinically suitable [22].…”

“…Breast cancer is the most common cancer in the UK and one of the most significant prognostic markers for breast cancer is axillary lymph node (LN) status, as an increase in the positive lymph node number is independently associated with poor clinical outcomes and increased recurrence rate [1]. Clinical practice has now changed from full dissection of the axilla to the use of Sentinel Node Biopsy (SNB), which determines the patients at high risk of nodal involvement who then require Axillary Lymph Node Dissection (ALND) [2]. The American Joint Committee on Cancer (AJCC) stages patients based on number of positive nodes found on dissection (pN); stage pN1 if 1 to 3 nodes are involved, pN2 if 4-9 and pN3 if 10+ nodes are involved [3].…”

“…Recent studies explore the impact of the Lymph Node Ratio (LNR), defined as the number of positive LNs over the number of excised nodes [14][15][16][17]. There is evidence that LNR is a useful predictor of breast cancer recurrence and survival, and some studies found its prognostic superiority over absolute number of positive nodes [2,13,14,16,[18][19][20]. This poses the question whether LNR should be considered in combination with the pN staging to guide decisions for breast cancer management.…”

Expression of enhancer of zeste homolog 2 and cytokeratin 5/6 in triple negative versus non-triple negative breast cancer: An immunohistochemical study.

“…According to Jayasinghe et al (2015),no correlation between ER status and LNR was found. There are, however, some limitations for the value of lymph node ratio evaluation in the present study: data about axillary lymph node status show wide range of number of dissected lymph nodes (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20).…”