Lymph Node Ratio as an Alternative to pN Staging in Node-Positive Breast Cancer

Vinh-Hung, Vincent; Verkooijen, Helena M.; Fioretta, G; Neyroud-Caspar, Isabelle; Rapiti, Elisabetta; Vlastos, Georges; Déglise, Carole; Usel, M.; Lutz, Jean-Michel; Bouchardy, Christine

doi:10.1200/jco.2008.18.6965

Cited by 202 publications

(227 citation statements)

References 45 publications

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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%

“…29 Our data support studies that suggest that ALNR is a stronger prognostic factor for OS than the absolute number of pALN. 13,[16][17][18] In our multivariate model, when ALNR was included in the Cox analysis, the number of pALN lost its significance as an independent predictor of BC survival. Our data also show that among the initially assigned ALNR groups, statistically significant survival difference is only found when comparison was made with the\.25 subgroup, thus advocating the use of an ALNR of .25 as a cutoff.…”

Section: Discussionmentioning

confidence: 93%

“…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%

“…However, heterogeneity of lymph node examination is commonly encountered in daily practice; thus, the ALNR can be useful to address that heterogeneity. 18 It is generally accepted that C10 nodes are needed for accurate assessment and staging of BC. 30 The recovery of too few ALN in an ALND may lead clinicians to understage patients, which in turn would lead to undertreatment.…”

Section: Discussionmentioning

confidence: 99%

“…[12][13][14][15][16][17][18] Some studies included a heterogeneous group of patients recruited from different centers, which implies that patients were treated by different surgeons and different medical oncology teams. 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: 93%

Section: Discussionmentioning

confidence: 99%

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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Meta-analysis of ultrasound-guided biopsy of suspicious axillary lymph nodes in the selection of patients with extensive axillary tumour burden in breast cancer

Wely

Wilt

Francissen

et al. 2015

Journal of British Surgery

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Restratification of survival prognosis of N1b papillary thyroid cancer by lateral lymph node ratio and largest lymph node size

Kim

Choe

et al. 2017

Cancer Medicine

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The current 7th TNM staging stratifies N1b papillary thyroid cancer (PTC) patients without distant metastasis into either stage I or stage IV merely by an age threshold (45 years). To date, no studies have adequately quantified the mortality risk of PTC patients with N1b disease. We hypothesized that incorporating lymph node (LN) factors into the staging system would better predict cancer‐specific mortality (CSM). A total of 745 nonmetastatic PTC patients with N1b disease were enrolled. We identified factors related to LNs and cut‐points using Cox regression and time‐dependent ROC analysis. New prognostic groupings were derived based on minimal hazard differences for CSM among the groups stratified by LN risk and age, and prediction of CSM was assessed. Lateral lymph node ratio (LNR) and largest LN size were significant prognostic LN factors at cut‐points of 0.3 and 3 cm. Without LN risk (lateral LNR >0.3 or largest LN size >3 cm), stage IV patients had prognosis [adjusted HR 1.10 (98% CI 0.19–6.20); P = 0.906] similar to stage I patients with LN risk. Patients were restratified into three prognostic groups: Group 1, <45 years without LN risk; Group 2, <45 years with LN risk or ≥45 years without LN risk; and Group 3, ≥45 with LN risk. This system had a lower log‐rank P‐value (<0.001 vs. 0.002) and higher C‐statistics (0.80 vs. 0.71) than the 7th TNM. New prognostic grouping using lateral LNR and largest LN size predicts CSM accurately and distinguishes N1b patients with different prognosis.

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Lymph Node Ratio as an Alternative to pN Staging in Node-Positive Breast Cancer

Abstract: LNR predicts survival after breast cancer more accurately than pN classification and should be considered as an alternative to pN staging.

Cited by 202 publications

References 45 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

Meta-analysis of ultrasound-guided biopsy of suspicious axillary lymph nodes in the selection of patients with extensive axillary tumour burden in breast cancer

Restratification of survival prognosis of N1b papillary thyroid cancer by lateral lymph node ratio and largest lymph node size

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