title: Development and validation of a nomogram for predicting survival on the base of modified lymph node ratio in breast cancer patients.
abstract: BACKGROUND
  Axillary lymph node status is one of the most important prognostic factors in breast cancer and previous studies indicated that lymph node ratio (LNR) could better predict the outcome than the counting of positive lymph nodes. In the current study, we evaluated the prognostic effect of modified LNR in breast cancer patients.
  
  
  METHODS
  A total of 3339 breast cancer patients undergoing axillary lymph nodes dissection were enrolled and respectively analyzed. Seventy five percent of participants were randomly selected as training cohort and the remaining 25% were as validation cohort. Univariate and multivariate analyses were performed and the prognostic impact of mLNR was compared with pN staging. A prognostic nomogram was established and externally validated in the validation cohort.
  
  
  RESULTS
  In multivariate analysis, both the mLNR and pN staging were independent prognostic factors for breast cancer patients, and the mLNR manifested superior discrimination power than the pN stages regardless of the total number of lymph nodes retrieved and the lymph node status. The nomogram was built including the identified independent prognostic factors and the calibration curves indicated optimal agreement between nomogram prediction and actual observation. The Concordance index (C-index) of the nomogram was statistically higher than that of the TNM system (0.747 vs. 0.711 in training cohort, 0.789 vs. 0.760 in validation cohort, both p < 0.05).
  
  
  CONCLUSIONS
  Modified LNR is an important prognostic parameter and can predict survival more accurately than pN staging. The novel nomogram could provide individual prediction for breast cancer patients and help clinicians in treatment option making and prognosis evaluation.
authors.affiliation: Department of Breast Oncology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China.
authors.forename: Jiahuai
authors.initials: J
authors.lastname: Wen
authors.affiliation: Department of Obstetrics and Gynecology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China.
authors.forename: Yanning
authors.initials: Y
authors.lastname: Yang
authors.affiliation: Department of Breast Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.
authors.forename: Peng
authors.initials: P
authors.lastname: Liu
authors.affiliation: Department of Breast Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.
authors.forename: Feng
authors.initials: F
authors.lastname: Ye
authors.affiliation: Department of Breast Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.
authors.forename: Hailin
authors.initials: H
authors.lastname: Tang
authors.affiliation: Department of Breast Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.
authors.forename: Xiaojia
authors.initials: X
authors.lastname: Huang
authors.affiliation: Department of Breast Oncology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China.
authors.forename: Shaowen
authors.initials: S
authors.lastname: Zhong
authors.affiliation: Department of Breast Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China. Electronic address: xiexm@sysucc.org.cn.
authors.forename: Xiaoming
authors.initials: X
authors.lastname: Xie
mesh_terms: D000328:Adult; D001365:Axilla; D001943:Breast Neoplasms / Q000401:mortality* / Q000473:pathology*; D005260:Female; D006801:Humans; D008197:Lymph Node Excision / Q000401:mortality; D008198:Lymph Nodes / Q000473:pathology* / Q000601:surgery; D008875:Middle Aged; D015999:Multivariate Analysis; D009367:Neoplasm Staging; D049451:Nomograms; D015203:Reproducibility of Results; D012189:Retrospective Studies; D016019:Survival Analysis
keywords: Breast cancer; Modified lymph node ratio; Nomogram; Prognosis