A logistic regression model predicting high axillary tumour burden in early breast cancer patients

Purpose. As elective axillary dissection is loosing ground for early breast cancer (BC) patients both in terms of prognostic and therapeutic power, there is a growing interest in predicting patients with (nodal) high tumour burden (HTB), especially after a positive sentinel node biopsy (SNB) because they would really benefit from further axillary intervention either by complete lymph-node dissection or axillary radiation therapy. Methods/patients. Based on an analysis of 1254 BC patients in whom complete axillary clearance was performed, we devised a logistic regression (LR) model to predict those with HTB, as defined by the presence of three or more involved nodes with macrometastasis. This was accomplished through prior selection of every variable associated with HTB at univariate analysis. Results. Only those variables shown as significant at the multivariate analysis were finally considered, namely tumour size, lymphovascular invasion and histological grade. A probability table was then built to calculate the chances of HTB from a cross-correlation of those three variables. As a suggestion, if we were to follow the rationale previously used in the micrometastasis trials, a threshold of about 10% risk of HTB could be considered under which no further axillary treatment is warranted. Conclusions. Our LR model with its probability table can be used to define a subgroup of early BC patients suitable for axillary conservative procedures, either sparing completion lymph-node dissection or even SNB altogether (AU)

No disponible

A logistic regression model predicting high axillary tumour burden in early breast cancer patients.

PURPOSE: As elective axillary dissection is loosing ground for early breast cancer (BC) patients both in terms of prognostic and therapeutic power, there is a growing interest in predicting patients with (nodal) high tumour burden (HTB), especially after a positive sentinel node biopsy (SNB) because they would really benefit from further axillary intervention either by complete lymph-node dissection or axillary radiation therapy. METHODS/PATIENTS: Based on an analysis of 1254 BC patients in whom complete axillary clearance was performed, we devised a logistic regression (LR) model to predict those with HTB, as defined by the presence of three or more involved nodes with macrometastasis. This was accomplished through prior selection of every variable associated with HTB at univariate analysis. RESULTS: Only those variables shown as significant at the multivariate analysis were finally considered, namely tumour size, lymphovascular invasion and histological grade. A probability table was then built to calculate the chances of HTB from a cross-correlation of those three variables. As a suggestion, if we were to follow the rationale previously used in the micrometastasis trials, a threshold of about 10% risk of HTB could be considered under which no further axillary treatment is warranted. CONCLUSIONS: Our LR model with its probability table can be used to define a subgroup of early BC patients suitable for axillary conservative procedures, either sparing completion lymph-node dissection or even SNB altogether.

Role of axillary ultrasound, magnetic resonance imaging, and ultrasound-guided fine-needle aspiration biopsy in the preoperative triage of breast cancer patients

Purpose. Roughly two-thirds of early breast cancer cases are associated with negative axillary nodes and do not benefit from axillary surgery at all. Accordingly, there is an ongoing search for non-surgical staging procedures to avoid lymph-node dissection or sentinel node biopsy (SNB). Non-invasive imaging techniques with very high sensitivity (Se) and negative predictive value (NPV) could eventually replace SNB. We aimed to establish the role of axillary US and MRI, alone or in combination, associated with ultrasound-guided fine-needle aspiration biopsy (US-FNAB) in the prediction of axillary node involvement. Methods/patients. Between January 2003 and September 2015, we included 1505 of the 1538 breast cancer patients attending our centres. All patients had been referred from a single geographical area. Axillary US, magnetic resonance imaging and ultrasound-guided fine-needle aspiration biopsy (US-FNAB) were performed if required. Results. 1533 axillary US examinations and 1351 axillary MRI studies were analyzed. For axillary US, Se, Specificity (Sp), Positive Predictive Value (PPV), and NPV were 47.5, 93.6, 82.5, and 73.8%, respectively. For axillary MRI, corresponding values were 29.8, 96.6, 84.9, and 68.4%. When both tests were combined, Sp and PPV slightly improved over individual tests alone. US-FNAB showed a 100% Sp and PPV, with a Se of 80%. Conclusion. We may confidently state that axillary US and US-FNAB have to be included in the preoperative work-up of breast cancer patients (AU)

No disponible

Role of axillary ultrasound, magnetic resonance imaging, and ultrasound-guided fine-needle aspiration biopsy in the preoperative triage of breast cancer patients.

PURPOSE: Roughly two-thirds of early breast cancer cases are associated with negative axillary nodes and do not benefit from axillary surgery at all. Accordingly, there is an ongoing search for non-surgical staging procedures to avoid lymph-node dissection or sentinel node biopsy (SNB). Non-invasive imaging techniques with very high sensitivity (Se) and negative predictive value (NPV) could eventually replace SNB. We aimed to establish the role of axillary US and MRI, alone or in combination, associated with ultrasound-guided fine-needle aspiration biopsy (US-FNAB) in the prediction of axillary node involvement. METHODS/PATIENTS: Between January 2003 and September 2015, we included 1505 of the 1538 breast cancer patients attending our centres. All patients had been referred from a single geographical area. Axillary US, magnetic resonance imaging and ultrasound-guided fine-needle aspiration biopsy (US-FNAB) were performed if required. RESULTS: 1533 axillary US examinations and 1351 axillary MRI studies were analyzed. For axillary US, Se, Specificity (Sp), Positive Predictive Value (PPV), and NPV were 47.5, 93.6, 82.5, and 73.8%, respectively. For axillary MRI, corresponding values were 29.8, 96.6, 84.9, and 68.4%. When both tests were combined, Sp and PPV slightly improved over individual tests alone. US-FNAB showed a 100% Sp and PPV, with a Se of 80%. CONCLUSION: We may confidently state that axillary US and US-FNAB have to be included in the preoperative work-up of breast cancer patients.

The appropriate axillary procedure after a positive sentinel node in breast cancer patients: the 'Hôpital Tenon' score revisited. A two-institution study

Introduction. Until recently, completion ALND has been considered the standard of care after a positive SN in breast cancer patients. However, most patients will not display further axillary involvement. The Tenon score is a simple nomogram that can be used intraoperatively to avoid completion ALND in low-risk patients. We aimed at validating the Tenon score on a SN-positive patient sample that had been preoperatively selected using axillary US examination. Patients and method. We used a retrospective analysis of our bicentric database that included 246 breast cancer patients with a positive SN. We calculated sensitivity, specificity, as well as positive and negative predictive values for each cut-off point. ROCs were constructed and corresponding AUC values were calculated as a measure of discriminative capacity. Results. At least one non-SN was positive in 52 patients (21.1 %). 118 patients (48 %) had a score up to 5. Among them, three had at least one positive non-SN. NPV was 97.5 %. Using that threshold, the ROCs analysis showed an AUC of 0.822 (95 % CI 0.764-0.880). Conclusion. Use of preoperative axillary US examination led to a modification of the proposed Tenon cut-off value from 3.5 to 5 to attain good predictive power for non-SN status. Straightforward intraoperative use of the Tenon score may be considered an advantage over other available nomograms (AU)

No disponible

The appropriate axillary procedure after a positive sentinel node in breast cancer patients: the "Hôpital Tenon" score revisited. A two-institution study.

INTRODUCTION: Until recently, completion ALND has been considered the standard of care after a positive SN in breast cancer patients. However, most patients will not display further axillary involvement. The Tenon score is a simple nomogram that can be used intraoperatively to avoid completion ALND in low-risk patients. We aimed at validating the Tenon score on a SN-positive patient sample that had been preoperatively selected using axillary US examination. PATIENTS AND METHOD: We used a retrospective analysis of our bicentric database that included 246 breast cancer patients with a positive SN. We calculated sensitivity, specificity, as well as positive and negative predictive values for each cut-off point. ROCs were constructed and corresponding AUC values were calculated as a measure of discriminative capacity. RESULTS: At least one non-SN was positive in 52 patients (21.1 %). 118 patients (48 %) had a score up to 5. Among them, three had at least one positive non-SN. NPV was 97.5 %. Using that threshold, the ROCs analysis showed an AUC of 0.822 (95 % CI 0.764-0.880). CONCLUSION: Use of preoperative axillary US examination led to a modification of the proposed Tenon cut-off value from 3.5 to 5 to attain good predictive power for non-SN status. Straightforward intraoperative use of the Tenon score may be considered an advantage over other available nomograms.

A study comparing two consecutive historical periods in breast cancer with a focus on surgical treatment, loco-regional recurrence, distant metastases and mortality

Background and aim: Recent introduction of breast units, mass-screening programmes (SP) and sentinel node biopsy (SNB) has impacted on the clinical care of breast cancer patients (BC), resulting in a significant increase of breast-conserving surgery with the goal of achieving completely free margins and good cosmetic outcome, along with significantly less axillary morbidity. In order to ascertain the combined impact of SP and SNB on BC patients, we have reviewed the primary therapeutic approach of patients diagnosed with invasive breast carcinoma in our centre, both before and after implementation of the two new procedures. Methods: 1,942 patients operated for BC between 1997 and 2013 in two clinical centres. Two historical periods were considered: before and after the advent of the Breast Unit in our institutions and the concurrent implementation of SP and SNB (September 2002). Results: Rates of breast-conserving surgery and re-operations improved in the second period. Intraoperative margin re-excision increased in the second period. Breast-conserving surgery decreased in parallel to stage: from 79 % for stage I to 31 % for stage III. The Cox analysis, including stage as adjusted for all significant variables, showed statistically significant differences in favour of the initial stages but only for specific mortality, not overall mortality. Conclusions: Combined implementation of breast units, SP, and SNB have resulted in a significant improvement of BC treatment leading to increased rates of breast-conserving surgery and decreased disease recurrence and mortality (AU)

No disponible

Differential patterns of recurrence and specific survival between luminal A and luminal B breast cancer according to recent changes in the 2013 St Gallen immunohistochemical classification

Introduction. In 2011, the St Gallen panel introduced several changes in breast cancer classification, thereby creating the luminal B Her2− subtype. In 2013, the panel also included Ki67 overexpression and PR <20 % as risk factors, while excluding GH3 in the absence of increased Ki67. We compared the classification of 2011 modified with the new 2013 St Gallen classification. Patients and method. Consecutive breast cancer patients referred to the Breast Unit of the University Hospital Mútua Terrassa and Hospital of Terrassa for surgical treatment of either primary or recurrent tumors were prospectively included between 1997 and 2014. Eventually, 1,874 cases were included for the four-subtype analysis. The median follow-up was of 66 months. Results. Using the 2013 St Gallen classification no significant differences were found in specific mortality rates between luminal A and B subtypes. There were significant differences at 5, 10, and, 15 years if we excluded luminal A GH3 patients in the absence of increased Ki67 (p = 0.004, 0.005, and 0.007). Luminal A sub-type patients showed significantly less distant metastases than the rest, including luminal B Her2− patients (p < 0.001). Also, luminal B patients showed significantly less distant metastases than pure Her2 (0.05) and triple negative (TN) (p < 0.001). There were no differences between pure Her2 and TN patients (0.055), neither among the different luminal B sub-types. Conclusion. GH3, PR, and Ki67 may all be discriminatory factors for metastasis and specific mortality. Therefore, we suggest including GH3 in the luminal B subtype in the absence of Ki67 (AU)

No disponible

Differential patterns of recurrence and specific survival between luminal A and luminal B breast cancer according to recent changes in the 2013 St Gallen immunohistochemical classification.

INTRODUCTION: In 2011, the St Gallen panel introduced several changes in breast cancer classification, thereby creating the luminal B Her2- subtype. In 2013, the panel also included Ki67 overexpression and PR <20 % as risk factors, while excluding GH3 in the absence of increased Ki67. We compared the classification of 2011 modified with the new 2013 St Gallen classification. PATIENTS AND METHOD: Consecutive breast cancer patients referred to the Breast Unit of the University Hospital Mútua Terrassa and Hospital of Terrassa for surgical treatment of either primary or recurrent tumors were prospectively included between 1997 and 2014. Eventually, 1,874 cases were included for the four-subtype analysis. The median follow-up was of 66 months. RESULTS: Using the 2013 St Gallen classification no significant differences were found in specific mortality rates between luminal A and B subtypes. There were significant differences at 5, 10, and, 15 years if we excluded luminal A GH3 patients in the absence of increased Ki67 (p = 0.004, 0.005, and 0.007). Luminal A sub-type patients showed significantly less distant metastases than the rest, including luminal B Her2- patients (p < 0.001). Also, luminal B patients showed significantly less distant metastases than pure Her2 (0.05) and triple negative (TN) (p < 0.001). There were no differences between pure Her2 and TN patients (0.055), neither among the different luminal B sub-types. CONCLUSION: GH3, PR, and Ki67 may all be discriminatory factors for metastasis and specific mortality. Therefore, we suggest including GH3 in the luminal B subtype in the absence of Ki67.

A study comparing two consecutive historical periods in breast cancer with a focus on surgical treatment, loco-regional recurrence, distant metastases and mortality.

BACKGROUND AND AIM: Recent introduction of breast units, mass-screening programmes (SP) and sentinel node biopsy (SNB) has impacted on the clinical care of breast cancer patients (BC), resulting in a significant increase of breast-conserving surgery with the goal of achieving completely free margins and good cosmetic outcome, along with significantly less axillary morbidity. In order to ascertain the combined impact of SP and SNB on BC patients, we have reviewed the primary therapeutic approach of patients diagnosed with invasive breast carcinoma in our centre, both before and after implementation of the two new procedures. METHODS: 1,942 patients operated for BC between 1997 and 2013 in two clinical centres. Two historical periods were considered: before and after the advent of the Breast Unit in our institutions and the concurrent implementation of SP and SNB (September 2002). RESULTS: Rates of breast-conserving surgery and re-operations improved in the second period. Intraoperative margin re-excision increased in the second period. Breast-conserving surgery decreased in parallel to stage: from 79 % for stage I to 31 % for stage III. The Cox analysis, including stage as adjusted for all significant variables, showed statistically significant differences in favour of the initial stages but only for specific mortality, not overall mortality. CONCLUSIONS: Combined implementation of breast units, SP, and SNB have resulted in a significant improvement of BC treatment leading to increased rates of breast-conserving surgery and decreased disease recurrence and mortality.

Mortality and recurrence patterns of breast cancer patients diagnosed under a screening programme versus comparable non-screened breast cancer patients from the same population: analytical survey from 2002 to 2012.

Breast cancer screening programmes seem to bring about significant benefits, including decreased mortality, although they may also have some drawbacks such as false-negative and false-positive results. This study aims to compare the clinical outcome of a group of patients undergoing a breast cancer screening programme with that of a synchronous non-screened group of patients matched for age and follow-up period. We studied basic characteristics of epidemiology, immunohistochemistry, loco-regional relapse, distant metastases, disease-free interval and overall and specific mortality. We compared 510 patients in the screened group with 394 non-screened patients, along the period of 2002-2012. Screening was applied on a target population of 49,847 and was based on double-projection, double-read mammograms. Two years were allowed per round. Overall participation for the five rounds considered was 75.2%, with 86.5% coverage, and a total cumulative population of 123,445. The non-participant women amounted 40,794. Tumour detection rate for the screened women was 3.8 per thousand (475/123,445), while the corresponding rate for non-participants was 9.4 per thousand (382/40,797). Incidence of luminal A subtype was 15% higher in screened than that in non-screened patients (95% confidence interval (CI) 8-22%). Conversely, the triple-negative subtype was 6% higher in the non-screened group (95% CI 2-10%). Incidence of breast conservative treatments and sentinel node biopsies was significantly higher in the screened group. Overall mortality was 2.6 times higher in non-screened than that in screened group (95% CI 1.2-5.6) After 10 years of experience with our own screening programme, we believe that included patients receive a benefit versus comparable non-screened breast cancer patients, with acceptable benefit-risk relation.

Positive versus negative sentinel nodes in early breast cancer patients: axillary or loco-regional relapse and survival. A study spanning 2000-2012.

Sentinel Node Biopsy (SNB) is a minimally invasive alternative to elective axillary lymph node dissection (ALND) for nodal staging in early breast cancer. The present study was conducted to evaluate prognostic implications of a negative sentinel node (SN) versus a positive SN (followed by completion ALND) in a closely followed-up sample of early breast cancer patients. We studied 889 consecutive breast cancer patients operated for 908 primaries. Patients received adjuvant therapy with chemotherapy, hormone therapy and eventually trastuzumab. Radiation therapy was based on tangential radiation fields that usually included axillary level I. Median follow-up was 47 months. Axillary recurrence was seen in 1.2% (2/162) of positive SN patients, and 0.8% (5/625) of negative SN patients (p = n.s.). There was an overall 3.2% loco-regional failure rate (29/908). Incidence of distant recurrence was 3.3% (23/693) for negative SN patients, and 4.6% (9/196) for positive SN patients (p = n.s.). Overall mortality rate was 4% (8/198) for positive SN patients, while the corresponding specific mortality rate was 2.5% (5/198). For patients with negative SNs, overall mortality was 4.9% (34/693), and the specific mortality was 1.4% (19/693) (p = n.s.). We did not find significant differences in axillary/loco-regional relapse, distant metastases, disease-free interval or mortality between SN negative and SN positive patients, with a follow-up over 4 years.

Survival and clinicopathological characteristics of breast cancer patient according to different tumour subtypes as determined by hormone receptor and Her2 immunohistochemistry. a single institution survey spanning 1998 to 2010.

As far as recent breast cancer molecular subtype classification is concerned, much work has dealt with clinical outcomes for triple negative and Her2 patients. Less is known about the course of patients in the remaining subtypes. Molecular classification based on immunohistochemistry is widely available and correlates well with genetic microarray assessment, but at a lower cost. The aim of our investigation was to correlate immunohistochemical subtypes of breast cancer with clinical characteristics and patient outcomes. Since 1998, 1167 patients operated for 1191 invasive breast tumours were included in our database. Patients were regularly followed up until March 2010. Disease-free survival, overall mortality, and breast cancer-specific mortality at 5 years were calculated for the cohort. 72% of tumours were ER+PR±HER2- group, 13% triple negative (ER-PR-HER2-), 10% ER+PR±HER2+ group, and 5% Her2 (ER-PR-HER2+). Cancer-specific survival was 94.2% for the ER+PR+HER2- subtype, 84.8% for the Her2 subtype, 83.3% for the ER+PR-HER2- subtype, and 78.6% for triple negatives. Distant metastases prevalence ranged from 7% to 22% across subtypes, increasing stepwise from ER+PR+HER2-, ER+PR+HER2+, ER+PR-HER2-, ER+PR-HER2+, ER-PR-HER2+ through triple negative. Small, low-grade tumours with low axillary burden were more likely to belong to the ER+PR±HER2- group. Conversely, larger high-grade tumours with significant axillary burden were more likely to belong to Her2 or triple negative groups. ER+PR±HER2- group patients with negative PR receptors performed more like Her2 or triple negative than like the rest of ER+PR±HER2± groups patients. Molecular classification of breast tumours based only on immunohistochemistry is quite useful on practical clinical grounds, as expected. ER+PR±HER2- group patients with negative PR receptors seem to be at high risk and deserve further consideration.