title: The lymph node ratio as an independent prognostic factor for non-metastatic node-positive breast cancer recurrence and mortality.
abstract: OBJECTIVE
  To examine the prognostic value of lymph node ratio (LNR) in pathological nodal (pN) stage breast cancer patients. Also, to analyse additional clinical and pathologic prognostic factors and the impact of LNR among molecular subtypes.
  
  
  METHODS
  Among a total of 3088 patients, 1004 women with non-metastatic lymph node-positive breast cancer were analysed. The patients were classified into low (≤0.20), intermediate (0.20 to 0.65) and high-risk (>0.65) LNR groups. Univariate and multivariate Cox proportional hazards regression model for disease-free survival (DFS), and overall survival (OS) were performed to evaluate the prognostic value of LNR.
  
  
  RESULTS
  The median LNR was 0.17 (range 0.02-1.00). Of the patients, 55.7% were in low, 32.1% in intermediate, and 12.3% in high risk group. When compared with low risk group, high risk group had more often large tumor size and high grade tumor with lymphovascular invasion. The median follow-up period was 46.8 months. The 5-year breast cancer-specific OS and DFS rates for patients with low, intermediate, and high were 88%-67%, 65%-48% and 53%-24%, respectively (both plog-rank<0.0001). On multivariate analysis, pN stage and LNR were both independent predictors of survival, however, an overlapping between N1 (250 months, 95% confidence interval [CI] 88.15-413.21) and N2 (176 months, 95% CI 129.51-222.93) curves in pN staging was determined. We also observed clear prognostic separation for triple negative breast cancer with LNR survival over pN staging.
  
  
  CONCLUSIONS
  The LNR predicts survival more accurately than pN staging in node-positive breast cancer patients. The use of LNR may standardize the staging and guide decisions for adjuvant treatments.
authors.affiliation: Hacettepe University Cancer Institute, Department of Medical Oncology, Ankara, Turkey.
authors.forename: Mustafa
authors.initials: M
authors.lastname: Solak
authors.forename: Fatma P
authors.initials: FP
authors.lastname: Turkoz
authors.forename: Ozge
authors.initials: O
authors.lastname: Keskin
authors.forename: Sercan
authors.initials: S
authors.lastname: Aksoy
authors.forename: Taner
authors.initials: T
authors.lastname: Babacan
authors.forename: Furkan
authors.initials: F
authors.lastname: Sarici
authors.forename: Neyran
authors.initials: N
authors.lastname: Kertmen
authors.forename: Ali R
authors.initials: AR
authors.lastname: Sever
authors.forename: Kadri
authors.initials: K
authors.lastname: Altundag
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000401:mortality* / Q000473:pathology* / Q000628:therapy; D016009:Chi-Square Distribution; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000473:pathology* / Q000601:surgery; D008207:Lymphatic Metastasis; D008875:Middle Aged; D015999:Multivariate Analysis; D009364:Neoplasm Recurrence, Local; D009367:Neoplasm Staging; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D064726:Triple Negative Breast Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy; D047368:Tumor Burden; D055815:Young Adult