DOI QR코드

DOI QR Code

Metastatic Axillary Lymph Node Ratio (LNR) is Prognostically Superior to pN Staging in Patients with Breast Cancer -- Results for 804 Chinese Patients from a Single Institution

  • Xiao, Xiang-Sheng (Department of Breast Oncology, Sun Yat-Sen University Cancer Center) ;
  • Tang, Hai-Lin (Department of Breast Oncology, Sun Yat-Sen University Cancer Center) ;
  • Xie, Xin-Hua (Department of Breast Oncology, Sun Yat-Sen University Cancer Center) ;
  • Li, Lai-Sheng (Department of Laboratory Medicine, The First Affliated Hospital of Sun Yat-Sen University) ;
  • Kong, Ya-Nan (Department of Breast Oncology, Sun Yat-Sen University Cancer Center) ;
  • Wu, Min-Qing (Department of Breast Oncology, Sun Yat-Sen University Cancer Center) ;
  • Yang, Lu (Department of Breast Oncology, Sun Yat-Sen University Cancer Center) ;
  • Gao, Jie (Department of Breast Oncology, Sun Yat-Sen University Cancer Center) ;
  • Wei, Wei-Dong (Department of Breast Oncology, Sun Yat-Sen University Cancer Center) ;
  • Xie, Xiaoming (Department of Breast Oncology, Sun Yat-Sen University Cancer Center)
  • Published : 2013.09.30

Abstract

The number of axillary lymph nodes involved and retrieved are important prognostic factors in breast cancer. The purpose of our study was to investigate whether the lymph node ratio (LNR) is a better prognostic factor in predicting disease-free survival (DFS) for breast cancer patients as compared with pN staging. The analysis was based on 804 breast cancer patients who had underwent axillary lymph node dissection between 1999 and 2008 in Sun Yat-Sen University Cancer Center. Optimal cutoff points of LNR were calculated using X-tile software and validated by bootstrapping. Patients were then divided into three groups (low-, intermediate-, and high-risk) according to the cutoff points. Predicting risk factors for relapse were performed according to Cox proportional hazards analysis. DFS was estimated using the Kaplan-Meier method and compared by the log-rank test. The 5-year DFS rate decreased significantly with increasing LNRs and pN. Univariate analysis found that the pT, pN, LNR, molecule type, HER2, pTNM stage and radiotherapy well classified patients with significantly different prognosis. By multivariate analysis, only LNR classification was retained as an independent prognostic factor. Furthermore, there was a significant prognostic difference among different LNR categories for pN2 category, but no apparent prognostic difference was seen between different pN categories in any LNR category. Therefore, LNR rather than pN staging is preferable in predicting DFS in node positive breast cancer patients, and routine clinical decision-making should take the LNR into consideration.

Keywords

Breast cancer;LNR;prognostic factors;DFS

References

  1. Chagpar AB, Camp RL, Rimm DL (2011). Lymph node ratio should be considered for incorporation into staging for breast cancer. Ann Surg Oncol, 18, 3143-8. https://doi.org/10.1245/s10434-011-2012-9
  2. Yang T, Lapinski PE, Zhao H, et al (2005). A rare transporter associated with antigen processing polymorphism overpresented in HLAlow colon cancer reveals the functional significance of the signature domain in antigen processing. Clin Cancer Res, 11, 3614-3. https://doi.org/10.1158/1078-0432.CCR-04-1804
  3. Camp RL, Dolled-Filhart M, Rimm DL (2004). X-tile: a new bio-informatics tool for biomarker assessment and outcomebased cut-point optimization. Clin Cancer Res, 10, 7252-9. https://doi.org/10.1158/1078-0432.CCR-04-0713
  4. Chan JK, Kapp DS, Cheung MK, et al (2007). The impact of the absolute number and ratio of positive lymph nodes on survival of endometrioid uterine cancer patients. Br J Cancer, 97, 605-11. https://doi.org/10.1038/sj.bjc.6603898
  5. Chen SL, Steele SR, Eberhardt J, et al (2011). Lymph node ratio as a quality and prognostic indicator in stage III colon cancer. Ann Surg, 253, 82-7. https://doi.org/10.1097/SLA.0b013e3181ffa780
  6. Fitzgibbons PL, Page DL, Weaver D, et al (2000). Prognostic factors in breast cancer. College of American Pathologists Consensus Statement 1999. Arch Pathol Lab Med, 124, 966-78.
  7. Greenstein AJ, Litle VR, Swanson SJ, et al (2008). Prognostic significance of the number of lymph node metastases in esophageal cancer. J Am Coll Surg, 206, 239-46. https://doi.org/10.1016/j.jamcollsurg.2007.09.003
  8. Herr HW (2003). Superiority of ratio based lymph node staging for bladder cancer. J Urol, 169, 943-5. https://doi.org/10.1097/01.ju.0000032474.22093.06
  9. Pawlik TM, Gleisner AL, Cameron JL, et al (2007). Prognostic relevance of lymph node ratio following pancreaticoduodenectomy for pancreatic cancer. Surgery, 141, 610-8. https://doi.org/10.1016/j.surg.2006.12.013
  10. Keck T, Kusters S, Wellner UF, Hopt UT, Karcz KW (2012). Total laparoscopic partial pancreatoduodenectomy and reconstruction via laparoscopic pancreatogastrostomy. Langenbecks Arch Surg, 397, 1009-12. https://doi.org/10.1007/s00423-012-0964-2
  11. Kim JY, Ryu MR, Choi BO, et al (2011). The prognostic significance of the lymph node ratio in axillary lymph node positive breast cancer. J Breast Cancer, 14, 204-12. https://doi.org/10.4048/jbc.2011.14.3.204
  12. Li Y, Holmes E, Shah K, et al (2012). The prognostic value of lymph node cross-sectional cancer area in node-positive breast cancer: a comparison with N stage and lymph node ratio. Patholog Res Int, 2012, 161964.
  13. Peparini N, Chirletti P (2011). Lymph node ratio, number of excised nodes and sentinel-node concepts in breast cancer. Breast Cancer Res Treat, 126, 829-33. https://doi.org/10.1007/s10549-010-1296-y
  14. Singletary SE, Allred C, Ashley P, et al (2002). Revision of the American Joint Committee on Cancer staging system for breast cancer. J Clin Oncol, 20, 3628-36. https://doi.org/10.1200/JCO.2002.02.026
  15. Tausch C, Taucher S, Dubsky P, et al (2012). Prognostic value of number of removed lymph nodes, number of involved lymph nodes, and lymph node ratio in 7502 breast cancer patients enrolled onto trials of the Austrian Breast and Colorectal Cancer Study Group (ABCSG). Ann Surg Oncol, 19, 1808-17. https://doi.org/10.1245/s10434-011-2189-y
  16. Tsuchiya A, Kanno M, Abe R (1997). The impact of lymph node metastases on the survival of breast cancer patients with ten or more positive lymph nodes. Surg Today, 27, 902-6. https://doi.org/10.1007/BF02388136
  17. Vinh-Hung V, Burzykowski T, Cserni G, et al (2003). Functional form of the effect of the numbers of axillary nodes on survival in early breast cancer. Int J Oncol, 22, 697-704.
  18. Walker MJ, Osborne MD, Young DC, et al (1995). The natural history of breast cancer with more than 10 positive nodes. Am J Surg, 169, 575-9. https://doi.org/10.1016/S0002-9610(99)80224-4
  19. Vinh-Hung V, Verkooijen HM, Fioretta G, et al (2009). Lymph node ratio as an alternative to pN staging in node-positive breast cancer. J Clin Oncol, 27, 1062-8. https://doi.org/10.1200/JCO.2008.18.6965
  20. Vinh-Hung V, Verschraegen C, Promish DI, et al (2004). Ratios of involved nodes in early breast cancer. Breast Cancer Res, 6, R680-8. https://doi.org/10.1186/bcr934
  21. Voordeckers M, Vinh-Hung V, Van de Steene J, Lamote J, Storme G (2004). The lymph node ratio as prognostic factor in node-positive breast cancer. Radiother Oncol, 70, 225-30. https://doi.org/10.1016/j.radonc.2003.10.015
  22. Wang F, He W, Qiu H, et al (2012). Lymph node ratio and pN staging show different superiority as prognostic predictors depending on the number of lymph nodes dissected in Chinese patients with luminal A breast cancer. Clin Breast Cancer, 12, 404-11. https://doi.org/10.1016/j.clbc.2012.07.009
  23. Wang W, Xu DZ, Li YF, et al (2011). Tumor-ratio-metastasis staging system as an alternative to the 7th edition UICC TNM system in gastric cancer after D2 resection--results of a single-institution study of 1343 Chinese patients. Ann Oncol, 22, 2049-56. https://doi.org/10.1093/annonc/mdq716
  24. Wasserman S, Bockenholt U (1989). Bootstrapping: applications to psychophysiology. Psychophysiology, 26, 208-21. https://doi.org/10.1111/j.1469-8986.1989.tb03159.x
  25. Yildirim E, Berberoglu U (2007). Lymph node ratio is more valuable than level III involvement for prediction of outcome in node-positive breast carcinoma patients. World J Surg, 31, 276-89. https://doi.org/10.1007/s00268-006-0487-5
  26. Yu CJ, He WT, Shi W, Shu YQ, Liu P (2011). Prognostic value of metastatic lymph node ratio for patients with gastric cancer. Zhonghua Wei Chang Wai Ke Za Zhi, 14, 516-9.
  27. Zhu C, Wu XZ (2012). Proposal of new classification for stage III breast cancer on the number and ratio of metastatic lymph nodes. J Surg Oncol, 106, 696-702. https://doi.org/10.1002/jso.23118
  28. Zuo G, Xu Z, Yu H, Hao B (2010). Jackknife and bootstrap tests of the composition vector trees. Genomics Proteomics Bioinformatics, 8, 262-7. https://doi.org/10.1016/S1672-0229(10)60028-9