title: Prognostic value of the lymph node ratio for lymph-node-positive breast cancer- is it just a denominator problem?
abstract: OBJECTIVE
  To 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).
  
  
  METHODS
  This 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.
  
  
  RESULTS
  The 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.
  
  
  CONCLUSIONS
  Although 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.
authors: Westmead Breast Cancer Institute, Westmead, New South Wales Australia ; Faculty of Medicine, University of New South Wales, Sydney, New South Wales Australia.
authors: Upali W
authors: UW
authors: Jayasinghe
authors: Westmead Breast Cancer Institute, Westmead, New South Wales Australia.
authors: Nirmala
authors: N
authors: Pathmanathan
authors: Westmead Breast Cancer Institute, Westmead, New South Wales Australia.
authors: Elisabeth
authors: E
authors: Elder
authors: Macquarie University Cancer Institute, Macquarie University, North Ryde, New South Wales Australia.
authors: John
authors: J
authors: Boyages
keywords: Breast cancer specific survival; Lymph node ratio; Number of nodes removed; pN stage