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Is small tumour size alone enough for omitting axillary clearance?
European Journal o f Surgical Oncology 1997; "23:466-467
CORRESPONDENCE
Is small tumour size alone enough for omitting axillary clearance?
3. Haybittle JL, Blamey RW, Elston CW, et al. A prognostic index in primary breast cancer. Br J Cancer 1982; 45: 361-6.
Sir, Drs Shetty and Reiman previously reported their findings regarding axillary metastases of 1244 breast cancers, t The well-known fact that larger.tumours have a greater chance of being associated with regional metastases is clearly demonstrated by data shown in the article. The authors stratify their data related to small turnouts by 0.1 cm, and it is concluded that tumours smaller than 0.5 cm (or more precisely tumours measuring 014 cm or less) do not require axillary dissection. This .conclusion is made on the weak basis of eight patients .with turnout sizes falling in this range, since none of the eight patients had axillary metastasis in their series. However they did not consider than only two patients of 19 (or one of 9-10 patients and perhaps zero of eight) with tumour size 0.7 cm had involved axillary nodes. Taking into account that smaller tumours have a smaller chance of regional metastasis, the eight tumours are a very weak argument. Zeros must be interpreted with more caution in reaching such statistical conclusions, and a higher number of cases is required for a strong argument. This is why we can be more confident about the SEER results they refer to in their discussion or another earlier series,2 fitlding 15% or more Stage II diseases with primary turnouts smaller than or equal to 0.5 cm. It is completely true that smaller tumours are less frequently associated with axillary metastasis, and axillary surgery represents needless intervention and unwarranted morbidity for node-negative patients, but for the moment there is no more accurate quantitative method than axillary clearance to decide exactly who is axillary metastasis-free and who is not. The authors are right when they try to look for factors that could eliminate this unnecessary morbidity, but I believe they are wrong when they draw their conclusions on the basis of such a small number of patients in the relevant subgroups. Size alone is not predictive of nodal status for the individual patient, and this is not only true for the SEER studies but also for the cited one) Although no follow-up period is mentioned, data on mortality seem to match well with theoretical prognostication. Since tumour size, axillary node status and histological grade of tumours were shown to be independent prognostic factors,3 there is nothing surprising in finding patients with a good prognostic profile (small turnout size, (node negativity) and histological and nuclear grade I) to have a good prognosis, and that patients having small tumours with a less favourable prognostic profile (positive node(s) and higher grade) do worse. The prognosis of small tumours can be further stratified by grade and axillary status; but even adding the information of both histological and nuclear grading failed to predict one of 33 axillary metastasis in patients of the best prognostic subset (histological and nuclear grade I).
Sir, I would like to thank Dr Cserni for his comments about our paper, 'Tumour size and axillary metastasis, a correlative occurrence', published in the April 1997 issue of the Journal. In our study eight patients with turnouts 0.4 cm or less had negative nodes. I agree with Dr Cserni that the numbers are too small to draw conclusions about axillary dissection based on size alone. Furthermore, if these lymph nodes were evaluated by the technique used by the Ludwig ~ Breast Cancer Study Group, with nodes sectioned more thoroughly, nodes initially called negative on routine pathologic evaluation, may indeed be called positive later. In addition, if immunohistochemical staining, as performed by Wells et al., 2 were used to study the nodes, a higher yield of metastasis may occur. I also stated that in a larger Surveillance, Epidemiology and End Results (SEER) study,3 tumours of less than 0.5 cm had a 17.2% incidence of positive nodes. We do not know if most of these positive nodes belonged to tumours of 0.1 cm or 0.4 cm, or anywhere in between, and whether there was a cutoff point at 0.4cm, as in our study. Dr Cserni stated that the SEER data give us more confidence, because of their larger numbers to draw conclusions from. In order to answer the question posed by Dr Cserni in the title 'Is small tumour size alone enough for omitting axillary clearance?' l reviewed the published literature on tumours of I cm and less from 1935 to 1997; a total of 62 years (Table l). 4"H There were 14, 214 patients and 1967 of these had lymph node metastasis, i.e. 13.8%. There were 6169 cases of tumours of 0.Scm and less, of which 588 cases had positive nodes, i.e. 9.5%. These studies did not look at tumours at l mm intervals, as we did, and they did not have a single pathologist analyse the slides, as in our study. A more thorough study of lymph nodes, as carried out by the Ludwig group, may indeed result in a higher percentage of node positivity, thereby reducing our reasons to omit axillary dissection in these patients. This larger database therefore does not answer the question, at what tumour size, measured at 0.1 cm intervals, the lymph nodes are always negative in cancers of I cm and less. Prospective studies are needed to answer this question. M. R. Shetty, MD
Northwest Communi O, Hospital, Arlington Heights, Illinois, USA
G~ibor Cserni, MD
Dept of Pathology, Bdcs-Kiskun County Hospital, H-6000 Kecskem~t, Nyiri (it 38. Hungary
References 1. Shetty MR, Reiman Jr, HM. Tumor size and axillary metastasis, a correlative occurrence in 1244 cases of breast cancer between 1980 and 1995. Eur J Surg Oncol 1997; 23: 139-41. 2. Donegan WL. Staging and primary treatment. In: Donegan WL, Spratt JS (eds) Cancer of the Breast (3rd edn). Philadelphia, PA: W.B. Saunders, 1988: 350. 0748-7983/97/050466+02 $12.00/0
References 1." Bettelheim R, Price KN, Gelber RD, Davis BW, Castiglione M, Goldhirsch A, Neville AM. Prognostic importance of occult axillary lymph node micrometastasis from breast cancers. Int'l (Ludwig) Breast Cancer Study Group. Lancet 1990; 335: 1565-8. 2. Wells CA, Heryet A, Brochier J, Gatter KC, Mason DY. The immunocytochemical detection of axillary micrometastasis in breast cancer. Br J Cancer 1984; 50.' 193-7. 3. Frykberg ER, Ames PC, Bland KI. Current concepts and management of early breast cancer. In: Bland KI, Copeland EM (eds) The Breast, A Comprehensive Management of Benign and Malignant Diseases. Philadelphia, PA: W.B. Saunders, 1991 : 737. © 1997 W.B. Saunders Company Limited
CORRESPONDENCE
Is small tumour size alone enough for omitting axillary clearance?
3. Haybittle JL, Blamey RW, Elston CW, et al. A prognostic index in primary breast cancer. Br J Cancer 1982; 45: 361-6.
Sir, Drs Shetty and Reiman previously reported their findings regarding axillary metastases of 1244 breast cancers, t The well-known fact that larger.tumours have a greater chance of being associated with regional metastases is clearly demonstrated by data shown in the article. The authors stratify their data related to small turnouts by 0.1 cm, and it is concluded that tumours smaller than 0.5 cm (or more precisely tumours measuring 014 cm or less) do not require axillary dissection. This .conclusion is made on the weak basis of eight patients .with turnout sizes falling in this range, since none of the eight patients had axillary metastasis in their series. However they did not consider than only two patients of 19 (or one of 9-10 patients and perhaps zero of eight) with tumour size 0.7 cm had involved axillary nodes. Taking into account that smaller tumours have a smaller chance of regional metastasis, the eight tumours are a very weak argument. Zeros must be interpreted with more caution in reaching such statistical conclusions, and a higher number of cases is required for a strong argument. This is why we can be more confident about the SEER results they refer to in their discussion or another earlier series,2 fitlding 15% or more Stage II diseases with primary turnouts smaller than or equal to 0.5 cm. It is completely true that smaller tumours are less frequently associated with axillary metastasis, and axillary surgery represents needless intervention and unwarranted morbidity for node-negative patients, but for the moment there is no more accurate quantitative method than axillary clearance to decide exactly who is axillary metastasis-free and who is not. The authors are right when they try to look for factors that could eliminate this unnecessary morbidity, but I believe they are wrong when they draw their conclusions on the basis of such a small number of patients in the relevant subgroups. Size alone is not predictive of nodal status for the individual patient, and this is not only true for the SEER studies but also for the cited one) Although no follow-up period is mentioned, data on mortality seem to match well with theoretical prognostication. Since tumour size, axillary node status and histological grade of tumours were shown to be independent prognostic factors,3 there is nothing surprising in finding patients with a good prognostic profile (small turnout size, (node negativity) and histological and nuclear grade I) to have a good prognosis, and that patients having small tumours with a less favourable prognostic profile (positive node(s) and higher grade) do worse. The prognosis of small tumours can be further stratified by grade and axillary status; but even adding the information of both histological and nuclear grading failed to predict one of 33 axillary metastasis in patients of the best prognostic subset (histological and nuclear grade I).
Sir, I would like to thank Dr Cserni for his comments about our paper, 'Tumour size and axillary metastasis, a correlative occurrence', published in the April 1997 issue of the Journal. In our study eight patients with turnouts 0.4 cm or less had negative nodes. I agree with Dr Cserni that the numbers are too small to draw conclusions about axillary dissection based on size alone. Furthermore, if these lymph nodes were evaluated by the technique used by the Ludwig ~ Breast Cancer Study Group, with nodes sectioned more thoroughly, nodes initially called negative on routine pathologic evaluation, may indeed be called positive later. In addition, if immunohistochemical staining, as performed by Wells et al., 2 were used to study the nodes, a higher yield of metastasis may occur. I also stated that in a larger Surveillance, Epidemiology and End Results (SEER) study,3 tumours of less than 0.5 cm had a 17.2% incidence of positive nodes. We do not know if most of these positive nodes belonged to tumours of 0.1 cm or 0.4 cm, or anywhere in between, and whether there was a cutoff point at 0.4cm, as in our study. Dr Cserni stated that the SEER data give us more confidence, because of their larger numbers to draw conclusions from. In order to answer the question posed by Dr Cserni in the title 'Is small tumour size alone enough for omitting axillary clearance?' l reviewed the published literature on tumours of I cm and less from 1935 to 1997; a total of 62 years (Table l). 4"H There were 14, 214 patients and 1967 of these had lymph node metastasis, i.e. 13.8%. There were 6169 cases of tumours of 0.Scm and less, of which 588 cases had positive nodes, i.e. 9.5%. These studies did not look at tumours at l mm intervals, as we did, and they did not have a single pathologist analyse the slides, as in our study. A more thorough study of lymph nodes, as carried out by the Ludwig group, may indeed result in a higher percentage of node positivity, thereby reducing our reasons to omit axillary dissection in these patients. This larger database therefore does not answer the question, at what tumour size, measured at 0.1 cm intervals, the lymph nodes are always negative in cancers of I cm and less. Prospective studies are needed to answer this question. M. R. Shetty, MD
Northwest Communi O, Hospital, Arlington Heights, Illinois, USA
G~ibor Cserni, MD
Dept of Pathology, Bdcs-Kiskun County Hospital, H-6000 Kecskem~t, Nyiri (it 38. Hungary
References 1. Shetty MR, Reiman Jr, HM. Tumor size and axillary metastasis, a correlative occurrence in 1244 cases of breast cancer between 1980 and 1995. Eur J Surg Oncol 1997; 23: 139-41. 2. Donegan WL. Staging and primary treatment. In: Donegan WL, Spratt JS (eds) Cancer of the Breast (3rd edn). Philadelphia, PA: W.B. Saunders, 1988: 350. 0748-7983/97/050466+02 $12.00/0
References 1." Bettelheim R, Price KN, Gelber RD, Davis BW, Castiglione M, Goldhirsch A, Neville AM. Prognostic importance of occult axillary lymph node micrometastasis from breast cancers. Int'l (Ludwig) Breast Cancer Study Group. Lancet 1990; 335: 1565-8. 2. Wells CA, Heryet A, Brochier J, Gatter KC, Mason DY. The immunocytochemical detection of axillary micrometastasis in breast cancer. Br J Cancer 1984; 50.' 193-7. 3. Frykberg ER, Ames PC, Bland KI. Current concepts and management of early breast cancer. In: Bland KI, Copeland EM (eds) The Breast, A Comprehensive Management of Benign and Malignant Diseases. Philadelphia, PA: W.B. Saunders, 1991 : 737. © 1997 W.B. Saunders Company Limited