Can We Skip Intraoperative Evaluation of Sentinel Lymph Nodes? Nomogram Predicting Involvement of Three or More Axillary Lymph Nodes before Breast Cancer Surgery.
OBJECTIVE
The American College of Surgeons Oncology Group Z0011 trial reported that complete dissection of axillary lymph nodes (ALNs) may not be warranted in women with clinical T1-T2 tumors and one or two involved ALNs who were undergoing lumpectomy plus radiation followed by systemic therapy. The present study was conducted to identify preoperative imaging predictors of ≥ 3 ALNs.


METHODS
The training set consisted of 1,917 patients with clinical T1-T2 and node negative invasive breast cancer. Factors associated with ≥ 3 involved ALNs were evaluated by logistic regression analysis. The validation set consisted of 378 independent patients. The nomogram was applied prospectively to 512 patients who met the Z0011 criteria.


RESULTS
Of the 1,917 patients, 204 (10.6%) had ≥ 3 positive nodes. Multivariate analysis showed that involvement of ≥ 3 nodes was significantly associated with ultrasonographic and chest computed tomography findings of suspicious ALNs (p < 0.001 each). These two imaging criteria, plus patient age, were used to develop a nomogram calculating the probability of involvement of ≥ 3 ALNs. The areas under the receiver operating characteristic curve of the nomogram were 0.852 (95% confidence interval [CI], 0.820 to 0.883) for the training set and 0.896 (95% CI, 0.836 to 0.957) for the validation set. Prospective application of the nomogram showed that 60 of 512 patients (11.7%) had scores above the cut-off. Application of the nomogram reduced operation time and cost, with a very low re-operation rate (1.6%).


CONCLUSIONS
Patients likely to have ≥ 3 positive ALNs could be identified by preoperative imaging. The nomogram was helpful in selective intraoperative examination of sentinel lymph nodes.
Department of Surgery, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea.
Soo Kyung
SK
Ahn
Department of Surgery, Chung-Ang University College of Medicine, Seoul, Korea.
Min Kyoon
MK
Kim
Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.
Jongjin
J
Kim
Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.
Eunshin
E
Lee
Department of Surgery, Seoul St. Mary's Hospital, Seoul, Korea.
Tae-Kyung
TK
Yoo
Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.
Han-Byoel
HB
Lee
Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.
Young Joon
YJ
Kang
Department of Surgery, Asan Medical Center, Seoul, Korea.
Jisun
J
Kim
Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.
Hyeong-Gon
HG
Moon
Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.
Jung Min
JM
Chang
Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.
Nariya
N
Cho
Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.
Woo Kyung
WK
Moon
Department of Pathology, Seoul National University College of Medicine, Seoul, Korea.
In Ae
IA
Park
Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.
Dong-Young
DY
Noh
Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.
Wonshik
W
Han
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001365:Axilla / Q000473:pathology*; D014408:Biomarkers, Tumor; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000401:mortality / Q000601:surgery*; D000066491:Clinical Decision-Making; D019468:Disease Management; D005260:Female; D006801:Humans; D007430:Intraoperative Care; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D008875:Middle Aged; D049451:Nomograms; D000072078:Positron Emission Tomography Computed Tomography; D011300:Preoperative Care; D012372:ROC Curve; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D000071036:Sentinel Lymph Node / Q000473:pathology*; D021701:Sentinel Lymph Node Biopsy; D014057:Tomography, X-Ray Computed; D047368:Tumor Burden; D055815:Young Adult
D014408:Biomarkers, Tumor
Axilla sonography; Breast neoplasms; Chest; Computed tomography; Nomograms; Sentinel lymph node; Z0011