Value of Memorial Sloan-Kettering Cancer Center nomogram in clinical decision making for sentinel lymph node-positive breast cancer.

BACKGROUND: The aim of this study was to determine the value of the Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram for individual decision making in a Dutch cohort of women with breast cancer with a positive sentinel lymph node (SLN) but at low risk of additional nodal metastases. METHODS: Data were collected on 168 patients with a positive SLN who underwent completion axillary lymph node dissection. The predicted probability of non-SLN metastases was calculated for each patient, using the MSKCC nomogram. Specificity and false-negative rates were calculated for subgroups with a predicted risk of no more than 5, 10 or 15 per cent. A receiver operating characteristic (ROC) curve was constructed and the area under the curve (AUC) calculated. RESULTS: The discrimination of the MSKCC nomogram, measured by the AUC, was 0.68. For low predicted probability cut-off values of no more than 5, 10 and 15 per cent, the false-negative rates were 20, 14 and 19 per cent, and the specificities were 4, 27 and 32 per cent, respectively. The low-risk category (5 per cent or less) consisted of only 3.0 per cent of the study population. CONCLUSION: The performance of the MSKCC nomogram was insufficient to make it a useful tool for individual decision making in this cohort of women with SLN-positive breast cancer.

[Acute abdominal pain and fever in a young woman as the first symptoms of lymphangioleiomyomatosis]. / Acute buikpijn en koorts bij een jonge vrouw als eerste verschijnselen van lymfangioleiomyomatose.

A previously healthy 28-year-old woman presented to the emergency clinic with acute severe abdominal pain and high fever. A diagnostic laparoscopy was performed, during which a large retroperitoneal tumour was found. A CT-scan of the abdomen and thorax confirmed the presence of a retroperitoneal mass but also revealed multiple renal angiomyolipomas and extensive cystic lesions in all lung fields. Based on these findings, the diagnosis lymphangioleiomyomatosis (LAM) was suspected, and later confirmed by histological examination of a biopsy specimen. The acute abdomen and fever appeared to have been caused by a Streptococcus agalactiae infection of the retroperitoneal lymphangiomyoma, which was treated with intravenous antibiotics. LAM is a very rare disease affecting mostly women of childbearing age and presenting almost exclusively with pulmonary symptoms. This is the first description of LAM presenting with an acute surgical abdomen and fever due to infection of a lymphangiomyoma.

Margin status and the risk of local recurrence after breast-conserving treatment of lobular breast cancer.

BACKGROUND: Invasive lobular breast carcinoma is known for its multicentricity and is associated with a higher incidence of incomplete excision after breast-conserving therapy. The aim of the study was to examine the influence of positive surgical margins on the local recurrence rate in patients diagnosed with invasive lobular cancer and treated with breast-conserving therapy. METHODS: All 416 women diagnosed with invasive lobular breast cancer and undergoing breast-conserving treatment between 1995 and 2002 were selected from the population-based Eindhoven Cancer Registry. Their medical charts were reviewed and detailed information was collected. RESULTS: The risk of margin involvement was 29% after the first operation and 17% when taking into account the final margin status of the patients undergoing re-excision. During follow-up, 18 patients developed a local recurrence. The 5 year actuarial risk of developing a local recurrence was 3.5% (95% confidence interval 2.5-4.5) and the 8 year risk was 6.4% (95% confidence interval 4.7-8.0). There was no influence of positive surgical margins on the risk of local recurrence, neither in the univariate analysis nor after adjustment for age, tumour size, nodal status and adjuvant systemic treatment. CONCLUSION: Patients with invasive lobular cancer, treated with breast-conservation, have a low risk of local recurrence, despite their high risk of having a microscopically incomplete excision of the tumour.

The significance of one positive axillary node.

AIMS: The aim of this study was to identify a subgroup of patients with breast cancer that can safely avoid axillary dissection. METHODS: Using data collected by the Eindhoven Cancer Registry, we compared the clinico-pathological features of 489 patients with only one positive lymph node to those of 817 patients with more than one positive lymph node in the axilla. All patients underwent complete axillary dissection, not preceded by a sentinel node biopsy. RESULTS: Tumour size greater than 1cm, harvesting more than 15 axillary lymph nodes at histopathological examination, metastasis size larger than 2mm, extranodal extension, and nodal involvement of the axillary apex are independently associated with the occurrence of more than one metastatic axillary lymph node. CONCLUSION: No subgroup could be identified in which axillary dissection can always be omitted. However, tumour size<1cm, finding a micrometastasis rather than a macrometastasis, and especially not finding extranodal extension were independently associated with finding only one positive axillary lymph node.

Long-term survival of T1 and T2 lymph node-negative breast cancer patients according to Mitotic Activity Index: a population-based study.

Node-negative breast cancer patients have a relatively good prognosis, but eventually one-third will die of the disease. Thus, prognostic factors to identify the high-risk group among these patients are needed. We retrospectively determined the Mitotic Activity Index (MAI) for a large series of node-negative breast cancer patients (n = 468) with tumours smaller than 5 cm, who only received locoregional treatment. Patients were followed for up to 29 years; crude and relative survival were calculated, both univariate and multivariate. Relative survival differed significantly according to MAI (p = 0.05), the difference occurred in the first 5 years after diagnosis and remained constant thereafter. After adjustment, MAI still significantly affected relative survival (RER, 1.9; 95% CI, 1.1-3.5). Tumour size also increased the risk, but this was not statistically significant (RER, 1.5; 95% CI, 0.8-2.7). Survival of patients with a T1 tumour and MAI < 10 was similar to that for the general population in the first 5 years after diagnosis. In conclusion, MAI significantly predicted long-term survival for T1/T2N0 breast cancer. Adjuvant systemic therapy appears to have little benefit for node-negative breast cancer patients with a T1 tumour, regardless of the MAI. For those with a T2 tumour and a MAI > or = 10 systemic therapy might have reduced mortality. The need for close surveillance of node-negative breast cancer patients with a T1 tumour and MAI < 10 seems limited.

The prognostic significance of axillary lymph-node micrometastases in breast cancer patients.

AIMS: We analysed the results of regional community practice to determine the prognosis of axillary lymph-node micrometastases in women with breast cancer. METHODS: Patient data were retrieved from the population-based Eindhoven Cancer Registry in The Netherlands. Between 1975 and 1997, 10,111 patients were diagnosed as having invasive breast cancer. We compared three subgroups: patients without axillary involvement (the pN0 group), patients with axillary micrometastasis (< or = 2 mm, the pN1a group), and patients with a macro metastasis in only one lymph node (> 2 mm, the pN1 group). Follow-up was completed until April 2002. RESULTS: The relative risk (RR) of dying comparing the pN1a group and the pN1 group to the pN0 group was 1.32 and 1.34, respectively. Excluding the adjuvantly treated patients, the RR of dying was 1.51 and 1.91, respectively for the pN1a group and the pN1 group vs. the pN0 group. CONCLUSION: This outcome data of nearly 25 years of community practice show that breast cancer patients with axillary lymph node micrometastasis have a significantly worse survival rate than those without independent of age or tumour size. Adjuvant systemic therapy should be contemplated when treating these patients.

Trends in breast cancer aggressiveness before the introduction of mass screening in southeastern Netherlands 1975-1989.

OBJECTIVE: The increased incidence of breast cancer in the southeastern Netherlands was accompanied by markedly improved relative survival and stable mortality. We investigated whether the average aggressiveness of tumors changed over time in a population-based study, before the introduction of mass screening. METHODS: The mitotic activity index (MAI) was determined retrospectively for 1051 consecutive patients diagnosed with invasive, non-metastatic breast cancer in 1975, 1981, 1988, and 1989. Trends over time, and effects of age, tumor size and lymph node status were examined by univariate and multivariate regressions. RESULTS: Age-adjusted incidence of low MAI tumors changed from 35/100,000 in 1975 to 45/100,000 in 1988-89, an increase of 30% (P = 0.01), the incidence of tumors with a high MAI increased about 20% (P = 0.28), from 25 to 29/100,000. For small tumors (T1) the odds for a high MAI was lower in 1981 (OR: 0.80; 95% CI: 0.37-1.73) and 1988-89 (OR: 0.66; 95% CI: 0.35-1.23) compared to 1975. Among T3 and T4 tumors the odds increased to 2.03 (95% Cl: 0.71-5.86) in 1981 and 2.16 (0.76-6.18) in 1988-89. CONCLUSION: Although the incidence of tumors with low aggressive potential increased, the incidence of high MAI tumors also increased. Stable breast cancer mortality rates in the face of increasing incidence rates during the period 1975-89 cannot be attributed solely to changes in tumor aggressiveness; early diagnosis and better treatment may also have contributed.