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Scoring systems for the prediction of non–sentinel node metastasis in breast cancer patients
Letters to the Editor
799
Superior herniation of mediastinal thymus as a neck mass in children during valsalva maneuver To the Editor: We read with great interest the article written by Jianhong et al1 in the September 2006 issue of American Journal of Surgery describing the surgical treatment of jugular vein phlebectasia in children. In the article, jugular vein phlebectasia and laryngocele are mentioned as the two conditions in which neck mass is apparent or aggravated during valsalva maneuver and disappeared or decreased at rest. We would like to take this opportunity to recall an unusual clinical entity called “superior herniation of mediastinal thymus,” which presents as an anterior neck mass during valsalva maneuver and disappears during rest or normal breathing. This entity was defined by Mandell et al2 as intermittent migration of the broadest part of the “normal” thymus out of the thorax into the suprasternal region during valsalva maneuver along with increased intrathoracic pressure. It is important for surgeons and radiologists to be aware of this entity, in addition to the conditions mentioned in the article, especially to avoid unnecessary biopsy or surgery and their potential risk of altering immune function because the tissue present may be the only normal thymic tissue.
Saliha Senel, M.D. Nilgun Erkek, M.D. Candemir Karacan, M.D. Department of Pediatrics Dr Sami Ulus Children’s Hospital Ankara, Turkey Emrah Senel, M.D. Department of Pediatric Surgery Diskapi Children’s Hospital Ankara, Turkey doi:10.1016/j.amjsurg.2007.12.029
References 1. Jianhong Li, Xuewu J, Tingze H. Surgical treatment of jugular vein phlebectasia in children. Am J Surg 2206;192:286 –90. 2. Mandell GA, Bellah RD, Boulden MEC, et al. Cervical trachea: dynamics in response to herniation of the normal thymus. Radiology 1993;186:383– 6.
Scoring systems for the prediction of non–sentinel node metastasis in breast cancer patients To the Editor: In a recent issue of American Journal of Surgery, Ponzone et al1 contributed to the debate concerning the validation of two scoring systems predicting non–sentinel node (non-SN) metastasis in breast cancer patients having a metastatic sentinel node (SN). We read this article with interest; however, it invites several comments. SN biopsy is now accepted as the standard of care for axillary-node staging in patients with early-stage, clinically node-negative breast cancer. If the SN contains metastasis, it is currently recommended to perform axillary lymph node dissection (ALND). However, in 40% to 70% of patients, the SLN is the only involved axillary node, implying that these patients undergo unnecessary ALND. The future stake for our daily practice is to be able to select from patients having SN involvement those who have the weak risk of non-SLN involvement to avoid subjecting them to unnecessary ALND. A scoring system algorithm seems to be the best tool to select the patients for whom ALND would be pointless. Score or nomogram should be simple to use and have excellent negative predictive value.
Several studies have attempted to identify predictors of non-SN metastases in patients having a tumor-involved SN. Histologic primary tumor size, size of the SN metastasis, number of tumor-involved SNs, proportion of involved SNs among all removed SNs, and extracapsular extension of the SN metastasis have each been identified as independent predictors of non-SN tumor involvement in breast cancer patients having SN metastasis. Unfortunately, neither of these characteristics has been demonstrated to be a strong enough predictor of non-SN tumor involvement to identify a subset of patient who can safely forgo ALND. Several scoring system algorithms, including our scoring system (Tenon score),2 have been described to identify the individual patient’s risk of having non-SN metastases to predict non-SN status in breast cancer patients with SN metastasis. In the study by Ponzone et al,1 the authors concluded that the Memorial Sloan-Kettering nomogram3 was more accurate than the M. D. Anderson score,4 with the Memorial Sloan-Kettering nomogram having an ROC curve of 0.71. We are not totally in agreement with the explanation of Ponzole et al.1 The authors argued that the M. D. Anderson
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The American Journal of Surgery, Vol 196, No 5, November 2008
score was less accurate than the Memorial Sloan-Kettering nomogram because only four parameters were considered in the first scoring system. Recently, Dauphine et al5 compared the Memorial Sloan-Kettering nomogram with Tenon score2 and MD Anderson score,4 which included only three and fours characteristics, respectively, to predict the likelihood of non-SN metastases in patients with metastatic SN. The authors found that each scoring system analysed was a fair predictor of non-SN metastasis in patients with breast cancer and positive SN, with areas under the ROC curves approaching 0.70. We compared Memorial Sloan-Kettering nomogram,3 Tenon score,2 and M. D. Anderson score4 to also evaluate the likelihood of non-SN metastases in 119 patients with invasive breast carcinoma (unpublished data, 2007). With areas under the receiver operating characteristic curves ⬎0.85 for Tenon and Memorial Sloan-Kettering scores and 0.78 for the M. D. Anderson score, we found that these three scoring systems appear to provide a useful estimation of non-SN status in patients having metastatic SN. To date, two others scoring systems have been published. Saidi et al6 developed the latest score based on data for 34 patients with positive SN biopsy findings. The score (range 0 to 5) included tumor size, presence of a palpable mass, angiolymphatic invasion, and extracapsular extension. Patients with a score ⱕ2 had only a 5.8% risk of having non-SLN metastasis. Based on a study group of 574 patients with metastatic SN requiring ALND, Degnim et al7 developed a similar Memorial Sloan-Kettering nomogram for prediction of non-SN metastases. In this study, the area under the curve was 0.77. Further studies with larger numbers of patients should be published to validate these five axilla scoring systems, which seem to be promising.
Emmanuel Barranger, M.D. Olivier Morel, M.D. Department of Gynecology and Obstetrics Hôpital Lariboisiere Assistance Publique des Hôpitaux de Paris Paris, France Charles Coutant, M.D. Department of Gynecology and Obstetrics Hôpital Tenon Assistance Publique des Hôpitaux de Paris Paris, France doi:10.1016/j.amjsurg.2007.07.024
References 1. Ponzone R, Maggiorotto F, Mariani L, et al. Comparison of two models for the prediction of nonsentinel node metastases in breast cancer. Am J Surg 2007;193:686 –92. 2. Barranger E, Coutant C, Flahault A, et al. An axilla scoring system to predict non-sentinel lymph node status in breast cancer patients with sentinel lymph node involvement. Breast Cancer Res Treat 2005;91:113–9. 3. Van Zee KJ, Manasseh DME, Bevilacqua JL, et al. A nomogram for predictiong the likelihood of additional nodal metastases in breast cancer patients with a positive sentinel node biopsy. Ann Surg Oncol 2003;10:1140 –51. 4. Hwang RF, Krishnamurthy S, Hunt KK, et al. Clinicopathologic factors predicting involvement of nonsentinel axillary nodes in women with breast cancer. Ann Surg Oncol 2003;10:248 –54. 5. Dauphine CE, Haukoos JS, Vargas MP, et al. Evaluation of three scoring systems predicting non sentinel node metastasis in breast cancer patients with a positive sentinel node biopsy. Ann Surg Oncol 2007;14:1014 –9. 6. Saidi RF, Dubrick PS, Remine SG, et al. Nonsentinel lymph node status after positive sentinel lymph node biopsy in early breast cancer. Am Surg 2004;70:101–5. 7. Degnim AC, Reynolds C, Pantvaidya G, et al. Nonsentinel node metastasis in breast cancer patients: assessment of an existing and a new predictive nomogram. Am J Surg 2005;190:543–50.
799
Superior herniation of mediastinal thymus as a neck mass in children during valsalva maneuver To the Editor: We read with great interest the article written by Jianhong et al1 in the September 2006 issue of American Journal of Surgery describing the surgical treatment of jugular vein phlebectasia in children. In the article, jugular vein phlebectasia and laryngocele are mentioned as the two conditions in which neck mass is apparent or aggravated during valsalva maneuver and disappeared or decreased at rest. We would like to take this opportunity to recall an unusual clinical entity called “superior herniation of mediastinal thymus,” which presents as an anterior neck mass during valsalva maneuver and disappears during rest or normal breathing. This entity was defined by Mandell et al2 as intermittent migration of the broadest part of the “normal” thymus out of the thorax into the suprasternal region during valsalva maneuver along with increased intrathoracic pressure. It is important for surgeons and radiologists to be aware of this entity, in addition to the conditions mentioned in the article, especially to avoid unnecessary biopsy or surgery and their potential risk of altering immune function because the tissue present may be the only normal thymic tissue.
Saliha Senel, M.D. Nilgun Erkek, M.D. Candemir Karacan, M.D. Department of Pediatrics Dr Sami Ulus Children’s Hospital Ankara, Turkey Emrah Senel, M.D. Department of Pediatric Surgery Diskapi Children’s Hospital Ankara, Turkey doi:10.1016/j.amjsurg.2007.12.029
References 1. Jianhong Li, Xuewu J, Tingze H. Surgical treatment of jugular vein phlebectasia in children. Am J Surg 2206;192:286 –90. 2. Mandell GA, Bellah RD, Boulden MEC, et al. Cervical trachea: dynamics in response to herniation of the normal thymus. Radiology 1993;186:383– 6.
Scoring systems for the prediction of non–sentinel node metastasis in breast cancer patients To the Editor: In a recent issue of American Journal of Surgery, Ponzone et al1 contributed to the debate concerning the validation of two scoring systems predicting non–sentinel node (non-SN) metastasis in breast cancer patients having a metastatic sentinel node (SN). We read this article with interest; however, it invites several comments. SN biopsy is now accepted as the standard of care for axillary-node staging in patients with early-stage, clinically node-negative breast cancer. If the SN contains metastasis, it is currently recommended to perform axillary lymph node dissection (ALND). However, in 40% to 70% of patients, the SLN is the only involved axillary node, implying that these patients undergo unnecessary ALND. The future stake for our daily practice is to be able to select from patients having SN involvement those who have the weak risk of non-SLN involvement to avoid subjecting them to unnecessary ALND. A scoring system algorithm seems to be the best tool to select the patients for whom ALND would be pointless. Score or nomogram should be simple to use and have excellent negative predictive value.
Several studies have attempted to identify predictors of non-SN metastases in patients having a tumor-involved SN. Histologic primary tumor size, size of the SN metastasis, number of tumor-involved SNs, proportion of involved SNs among all removed SNs, and extracapsular extension of the SN metastasis have each been identified as independent predictors of non-SN tumor involvement in breast cancer patients having SN metastasis. Unfortunately, neither of these characteristics has been demonstrated to be a strong enough predictor of non-SN tumor involvement to identify a subset of patient who can safely forgo ALND. Several scoring system algorithms, including our scoring system (Tenon score),2 have been described to identify the individual patient’s risk of having non-SN metastases to predict non-SN status in breast cancer patients with SN metastasis. In the study by Ponzone et al,1 the authors concluded that the Memorial Sloan-Kettering nomogram3 was more accurate than the M. D. Anderson score,4 with the Memorial Sloan-Kettering nomogram having an ROC curve of 0.71. We are not totally in agreement with the explanation of Ponzole et al.1 The authors argued that the M. D. Anderson
800
The American Journal of Surgery, Vol 196, No 5, November 2008
score was less accurate than the Memorial Sloan-Kettering nomogram because only four parameters were considered in the first scoring system. Recently, Dauphine et al5 compared the Memorial Sloan-Kettering nomogram with Tenon score2 and MD Anderson score,4 which included only three and fours characteristics, respectively, to predict the likelihood of non-SN metastases in patients with metastatic SN. The authors found that each scoring system analysed was a fair predictor of non-SN metastasis in patients with breast cancer and positive SN, with areas under the ROC curves approaching 0.70. We compared Memorial Sloan-Kettering nomogram,3 Tenon score,2 and M. D. Anderson score4 to also evaluate the likelihood of non-SN metastases in 119 patients with invasive breast carcinoma (unpublished data, 2007). With areas under the receiver operating characteristic curves ⬎0.85 for Tenon and Memorial Sloan-Kettering scores and 0.78 for the M. D. Anderson score, we found that these three scoring systems appear to provide a useful estimation of non-SN status in patients having metastatic SN. To date, two others scoring systems have been published. Saidi et al6 developed the latest score based on data for 34 patients with positive SN biopsy findings. The score (range 0 to 5) included tumor size, presence of a palpable mass, angiolymphatic invasion, and extracapsular extension. Patients with a score ⱕ2 had only a 5.8% risk of having non-SLN metastasis. Based on a study group of 574 patients with metastatic SN requiring ALND, Degnim et al7 developed a similar Memorial Sloan-Kettering nomogram for prediction of non-SN metastases. In this study, the area under the curve was 0.77. Further studies with larger numbers of patients should be published to validate these five axilla scoring systems, which seem to be promising.
Emmanuel Barranger, M.D. Olivier Morel, M.D. Department of Gynecology and Obstetrics Hôpital Lariboisiere Assistance Publique des Hôpitaux de Paris Paris, France Charles Coutant, M.D. Department of Gynecology and Obstetrics Hôpital Tenon Assistance Publique des Hôpitaux de Paris Paris, France doi:10.1016/j.amjsurg.2007.07.024
References 1. Ponzone R, Maggiorotto F, Mariani L, et al. Comparison of two models for the prediction of nonsentinel node metastases in breast cancer. Am J Surg 2007;193:686 –92. 2. Barranger E, Coutant C, Flahault A, et al. An axilla scoring system to predict non-sentinel lymph node status in breast cancer patients with sentinel lymph node involvement. Breast Cancer Res Treat 2005;91:113–9. 3. Van Zee KJ, Manasseh DME, Bevilacqua JL, et al. A nomogram for predictiong the likelihood of additional nodal metastases in breast cancer patients with a positive sentinel node biopsy. Ann Surg Oncol 2003;10:1140 –51. 4. Hwang RF, Krishnamurthy S, Hunt KK, et al. Clinicopathologic factors predicting involvement of nonsentinel axillary nodes in women with breast cancer. Ann Surg Oncol 2003;10:248 –54. 5. Dauphine CE, Haukoos JS, Vargas MP, et al. Evaluation of three scoring systems predicting non sentinel node metastasis in breast cancer patients with a positive sentinel node biopsy. Ann Surg Oncol 2007;14:1014 –9. 6. Saidi RF, Dubrick PS, Remine SG, et al. Nonsentinel lymph node status after positive sentinel lymph node biopsy in early breast cancer. Am Surg 2004;70:101–5. 7. Degnim AC, Reynolds C, Pantvaidya G, et al. Nonsentinel node metastasis in breast cancer patients: assessment of an existing and a new predictive nomogram. Am J Surg 2005;190:543–50.