- Email: [email protected]
The prevalence of axillary lymph-node metastases in patients with pure tubular carcinoma of the breast and sentinel node biopsy
EJSO 32 (2006) 488–491
www.ejso.com
The prevalence of axillary lymph-node metastases in patients with pure tubular carcinoma of the breast and sentinel node biopsy J. Leikolaa,*, P. Heikkila¨b, K. von Smittena, M. Leideniusa a
Breast Surgery Unit, Maria Hospital, Helsinki, Finland Department of Pathology, Helsinki University Central Hospital, Helsinki, Finland
b
Accepted 26 January 2006 Available online 29 March 2006
Abstract Aims: We aimed to evaluate the prevalence of and the risk factors for axillary lymph-node metastases in pure tubular carcinoma (PTC) of the breast. The role of axillary staging and treatment in PTC was also evaluated. Methods: Between March 2001 and August 2004, 33 PTC patients underwent sentinel node (SN) biopsy as a part of their surgical treatment. Level I/II axillary clearance was carried out in case of tumour positive SN findings. To confirm the correct histological diagnosis (PTC, O 90% tubular component), the breast tumours were reviewed by an expert breast pathologist. Results: The SN were successfully harvested in all patients. The median number of SN harvested in the axilla was 3 (range 1–10). Nine (27%) of the 33 patients had axillary nodal metastases. The median number of metastatic nodes was 1 (range1–3). The median size of the SN metastases was 0.5 mm (mean 1.7 mm, range 0.4–5 mm). In six patients, micrometastases were the only tumour positive SN findings. The median histological tumour size was similar, 9 vs 10 mm, in patients with or without axillary metastases. The median patient age was 54 (range 44–71) and 57 (range 39–80) years, respectively. After the histopathological review, six of the 27 patients with true PTC had axillary metastases. The review did not significantly change the risk factors for axillary metastases. Conclusions: Every fourth PTC patient has axillary lymph-node metastases, most often micrometastases. SN biopsy appears as a feasible method for axillary staging in PTC patients. q 2006 Elsevier Ltd. All rights reserved. Keywords: Lymph node metastasis; Sentinel node biopsy; Tubular carcinoma; Axillary staging
Introduction Pure tubular carcinoma (PTC) is a rare, well differentiated histologic subtype of invasive breast cancer. The definition of this histologic subtype varies according to the proportion of tubule formation. The commonly accepted definition is 90% or more of tubule formation,1,2 but even the recent studies have a cut-off point varying between 803 and 95%.4 In previous studies, the prevalence of lymph-node metastases in PTC has often been negligible in patients with a histological tumour size less than 1 cm.5–9 Due to the likely low risk of axillary metastases, it has been argued that the morbidity associated with axillary dissection may * Corresponding author. Address: Munkkiniemen Puistotie 8 B, FIN00330 Helsinki, Finland. Tel.: C358 40 589 1969; fax: C358 9 47163387. E-mail address: [email protected] (J. Leikola).
0748-7983/$ - see front matter q 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2006.01.021
outweigh any potential benefit of axillary staging.10 Due to its’ low morbidity and accuracy in staging, the use of sentinel node (SN) biopsy has been suggested as suitable for nodal staging in patients with favourable tumour subtypes, such as PTC.11 We aimed to evaluate the prevalence of and the risk factors for axillary lymph-node metastases in PTC. The role of axillary staging and treatment in PTC was also evaluated.
Methods Between March 2001 and August 2004 altogether 1324 breast cancer patients underwent SN biopsy in our unit. Thirty-three had PTC (over 90% tubular morphology).2 The median age of the patients was 56 (range 39–80) years. The median histological tumour size was 9
J. Leikola et al. / EJSO 32 (2006) 488–491
489
(range 3–26) mm. Fifteen patients had palpable tumours. The project plan was approved by the Ethical Committee of Helsinki City University Hospitals. Written informed consent was obtained from each patient.
considered as micrometastases and as isolated tumour cells, when 0.2 mm or less.13
SN biopsy
Proportional data was compared using chi-square or Fisher’s exact tests. The medians and means were compared using the Mann–Whitney U-test. Two-tailed P-values !0.05 were considered statistically significant.
Lymphoscintigraphy was performed the day before surgery, a median of 4 h after a single intratumoral injection of 99m Tc labelled human albumin colloid Nanocollw (Nycomed Amersham Sorin s.r.l. Saluggia, Italy), with particle size less than 80 nm in a volume of 0.2 ml as described in detail in our recent study.12 Pre-operative lymphatic mapping, a handheld gamma detector and blue dye were used to identify the sentinel nodes in the axilla. All focally radioactive and/or blue nodes in the axilla were harvested. Level I–II axillary clearance (AC) was performed during the primary operation in patients with SN metastases found on frozen section. Patients with false negative findings in the frozen section examination underwent level I–II AC as a second operation. In addition, AC was performed in one patient with tumour negative SN findings because of multifocality of primary tumour. Histology The breast specimens were assessed by experienced senior pathologists with special interest in breast pathology. To confirm the correct histological diagnosis (PTC, O90% tubular component), all breast specimens were reviewed by an expert breast pathologist (P.H.). The tumour re-classification was performed according to the classification of International Agency for Research on Cancer.1 The SN were histologically examined using serial sectioning and immunohistochemistry as described in detail in our previous study.12 Metastases of 2 mm or less were
Statistical methods
Results The SN were successfully harvested in all patients. The median number of SN harvested in the axilla was three (range 1–10). The median total number of retrieved axillary nodes was 16 (range15–24) in patients with AC. Prevalence of axillary metastases Nine of the 33 patients had axillary metastases. The median number of metastatic nodes was 1 (range 1–3). The median size of the SN metastases was 0.5 mm (mean 1.7 mm, range 0.4–5 mm). Micrometastases as the only tumour positive SN findings were observed in six patients. The SN metastases were detected in the intraoperative frozen section examination in seven patients. Both patients with false negative frozen section findings had SN micrometastases. Metastases in the non-sentinel nodes were detected in two patients. Both of them had 3 mm SN metastases. Risk factors for axillary metastases The median histological tumour size was similar, 9 vs 10 mm, in patients with or without axillary metastases. The histological tumour size was less than 1 cm in 17 patients. Five of them had axillary metastases. In these five patients, the median size of the SN metastasis was 0.5 mm (mean 1.3 mm, range 0.4–3 mm). The other evaluated risk factors
Table 1 The influence of patient and tumour characteristics on the prevalence of axillary metastases in 33 patients with pure tubular carcinoma (PTC) of the breast
a
Age (years) The histological size of the primary tumour (mm)a Histological tumour stage T1a–b T1c T2 Palpable tumours Tumour location Upper lateral Upper medial Lower lateral Lower medial Central a
Median (range).
Patients with SN metastases (NZ9)
Patients without SN metastases (NZ24)
P
54 (44–71) 9 (6–12)
57 (39–80) 10 (3–26)
0.808 0.700
5 4 0 4
15 8 1 11
0.795 0.944
3 3 2 1 0
15 7 1 1 0
0.739
490
J. Leikola et al. / EJSO 32 (2006) 488–491
Table 2 The influence of patient and tumour characteristics on the prevalence of axillary metastases in 27 patients with pure tubular carcinoma (PTC) following the histopathological tumour reclassification
Age (years)a The histological size of the primary tumour (mm)a Histological tumour stage T1a–b T1c T2 Palpable tumours Tumour location Upper lateral Upper medial Lower lateral Lower medial Central a
Patients with SN metastases (NZ6)
Patitents without SN metastases (NZ21)
P
55 (44–71) 7.5 (5–12)
57 (46–80) 10 (3–26)
0.661 0.333
5 1 0 3
13 7 1 9
0.322 0.761
2 3 0 1 0
13 7 0 1 0
0.290
Median (range).
did not influence significantly the prevalence of axillary nodal metastases. (Table 1). Influence of the histopathological review on the prevalence of and risk factors for axillary metastases The histopathological review of the tumour specimens revealed that five of the 33 tumours lacked sufficient tubularity to be classified as PTC. In one patient, the tumour specimens were not available for reclassification. Axillary metastases were detected in six of the remaining 27 patients with true PTC. The median number of metastatic nodes was 1 (range 1–3). The median size of the SN metastases was 0.5 mm (mean 1.1 mm, range 0.4–3 mm). Five patients had SN micrometastases only. Metastases in the non-sentinel nodes were detected in one patient. The histopathological review did not significantly influence the risk factors for axillary metastases (Table 2). Discussion Prevalence of nodal metastases in PTC The prevalence of axillary metastases in PTC in the present study was high, when compared with the 7% observed in a recent meta-analysis.7 When using SN biopsy in axillary staging, metastases have been detected in 17% of PTC patients.11 The meticulous histological examination of SN reveals metastases not detected in standard lymph node processing.14–16 Accordingly, the prevalence of metastases in the present study was only 9%, when excluding the micrometastases from the data.
PTC tumour less than 10 mm.5–9 In fact, tumour size did not influence the risk for metastases at all. The aggressiveness of the tumour17 as well as the risk for metastases7,18 increase with the decreasing proportion of tubular morphology. However, our results for axillary metastases were not altered after the histopathological reclassification of the tumour specimens. Role of axillary staging and treatment in PTC In PTC, the effect of nodal disease on survival has been controversial.3,4,8,9,19–22 However, axillary nodal metastases in PTC may be more common than assumed earlier.3,7,9 Therefore, SN biopsy appears as feasible axillary staging method in PTC, providing also valuable data for further evaluation of prognosis and natural history. In general, the risk for non-sentinel node metastases is substantial even in patients with SN micrometastases.12 The data concerning the size and the number of nodal metastases as well as the definite features of the primary tumour are available only in the post-operative phase. Therefore, we recommend AC, when the SN metastases are detected in the intraoperative diagnosis. Because none of our PTC patients with SN micrometastases had non-sentinel node metastases, AC as a second operation after false negative frozen section findings might be omitted in this patient group. Limitations of the study The number of the patients was small in the present study as well as in the vast majority of the previous ones3,4,7,9,11 addressing PTC. This renders the conclusions rather uncertain.
Risk factors for nodal metastases
Conclusions
Our findings did not support the assumption, that the risk of axillary nodal involvement is negligible in patients with a
Every fourth PTC patient has axillary lymph-node metastases, most often micrometastases. SN biopsy
J. Leikola et al. / EJSO 32 (2006) 488–491
appears as s feasible method for axillary staging in PTC patients.
References 1. Tavassoli FA, Devilee P, International Agency for Research on Cancer and World Health Organization. Pathology and genetics of tumours of the breast and female genital organs. Lyon; Oxford: International Agency for Research on Cancer; 2003. 2. Ellis IO, Galea M, Broughton N, Locker A, Blamey RW, Elston CW. Pathological prognostic factors in breast cancer. II. Histological type. Relationship with survival in a large study with long-term follow-up. Histopathology 1992;20(6):479–89. 3. Winchester DJ, Sahin AA, Tucker SL, Singletary SE. Tubular carcinoma of the breast. Predicting axillary nodal metastases and recurrence. Ann Surg 1996;223(3):342–7. 4. Cabral AH, Recine M, Paramo JC, McPhee MM, Poppiti R, Mesko TW. Tubular carcinoma of the breast: an institutional experience and review of the literature. Breast J 2003;9(4):298–301. 5. Rutgers EJ, EUSOMA Consensus Group. Quality control in the locoregional treatment of breast cancer. Eur J Cancer 2001;37(4): 447–53. 6. Fein DA, Fowble BL, Hanlon AL, Hooks MA, Hoffman JP, Sigurdson ER, et al. Identification of women with T1–T2 breast cancer at low risk of positive axillary nodes. J Surg Oncol 1997;65(1): 34–9. 7. Papadatos G, Rangan AM, Psarianos T, Ung O, Taylor R, Boyages J. Probability of axillary node involvement in patients with tubular carcinoma of the breast. Br J Surg 2001;88(6):860–4. 8. Maibenco DC, Weiss LK, Pawlish KS, Severson RK. Axillary lymph node metastases associated with small invasive breast carcinomas. Cancer 1999;85(7):1530–6. 9. McBoyle MF, Razek HA, Carter JL, Helmer SD. Tubular carcinoma of the breast: an institutional review. Am Surg 1997;63(7):639–44 [discusion 644–5]. 10. Kader HA, Jackson J, Mates D, Andersen S, Hayes M, Olivotto IA. Tubular carcinoma of the breast: a population-based study of nodal metastases at presentation and of patterns of relapse. Breast J 2001; 7(1):8–13.
491
11. Wong SL, Chao C, Edwards MJ, Carlson DJ, Laidley A, Noyes RD, et al. Frequency of sentinel lymph node metastases in patients with favorable breast cancer histologic subtypes. Am J Surg 2002;184(6): 492–8 [discussion 498]. 12. Leidenius MH, Vironen JH, Riihela MS, Krogerus LA, Toivonen TS, von Smitten KA, et al. The prevalence of non-sentinel node metastases in breast cancer patients with sentinel node micrometastases. Eur J Surg Oncol 2005;31(1):13–18. 13. International Union Against Cancer, UICC International Union Against Cancer. TNM classification of malignant tumours. New York: Wiley-Liss; 2002. 14. de Widt-Levert L, Tjan-Heijnen V, Bult P, Ruers T, Wobbes T. Stage migration in breast cancer: surgical decisions concerning isolated tumour cells and micro-metastases in the sentinel lymph node. Eur J Surg Oncol 2003;29(3):216–20. 15. McMasters KM, Giuliano AE, Ross MI, Reintgen DS, Hunt KK, Byrd DR, et al. Sentinel-lymph-node biopsy for breast cancer—not yet the standard of care. N Engl J Med 1998;339(14):990–5. 16. Leidenius M, Krogerus L, Tukiainen E, von Smitten K. Accuracy of axillary staging using sentinel node biopsy or diagnostic axillary lymph node dissection—a case–control study. APMIS 2004;112(4–5):264–70. 17. Peters GN, Wolff M, Haagensen CD. Tubular carcinoma of the breast. Clinical pathologic correlations based on 100 cases. Ann Surg 1981; 193(2):138–49. 18. Green I, McCormick B, Cranor M, Rosen PP. A comparative study of pure tubular and tubulolobular carcinoma of the breast. Am J Surg Pathol 1997;21(6):653–7. 19. Livi L, Paiar F, Meldolesi E, Talamonti C, Simontacchi G, Detti B, et al. Tubular carcinoma of the breast: outcome and loco-regional recurrence in 307 patients. Eur J Surg Oncol 2005;31(1):9–12. 20. Elson BC, Helvie MA, Frank TS, Wilson TE, Adler DD. Tubular carcinoma of the breast: mode of presentation, mammographic appearance, and frequency of nodal metastases. AJR Am J Roentgenol 1993;161(6):1173–6. 21. Diab SG, Clark GM, Osborne CK, Libby A, Allred DC, Elledge RM. Tumor characteristics and clinical outcome of tubular and mucinous breast carcinomas. J Clin Oncol 1999;17(5):1442–8. 22. Kitchen PR, Smith TH, Henderson MA, Goldhirsch A, CastiglioneGertsch M, Coates AS, et al. Tubular carcinoma of the breast: prognosis and response to adjuvant systemic therapy. Aust N Z J Surg 2001;71(1):27–31.
www.ejso.com
The prevalence of axillary lymph-node metastases in patients with pure tubular carcinoma of the breast and sentinel node biopsy J. Leikolaa,*, P. Heikkila¨b, K. von Smittena, M. Leideniusa a
Breast Surgery Unit, Maria Hospital, Helsinki, Finland Department of Pathology, Helsinki University Central Hospital, Helsinki, Finland
b
Accepted 26 January 2006 Available online 29 March 2006
Abstract Aims: We aimed to evaluate the prevalence of and the risk factors for axillary lymph-node metastases in pure tubular carcinoma (PTC) of the breast. The role of axillary staging and treatment in PTC was also evaluated. Methods: Between March 2001 and August 2004, 33 PTC patients underwent sentinel node (SN) biopsy as a part of their surgical treatment. Level I/II axillary clearance was carried out in case of tumour positive SN findings. To confirm the correct histological diagnosis (PTC, O 90% tubular component), the breast tumours were reviewed by an expert breast pathologist. Results: The SN were successfully harvested in all patients. The median number of SN harvested in the axilla was 3 (range 1–10). Nine (27%) of the 33 patients had axillary nodal metastases. The median number of metastatic nodes was 1 (range1–3). The median size of the SN metastases was 0.5 mm (mean 1.7 mm, range 0.4–5 mm). In six patients, micrometastases were the only tumour positive SN findings. The median histological tumour size was similar, 9 vs 10 mm, in patients with or without axillary metastases. The median patient age was 54 (range 44–71) and 57 (range 39–80) years, respectively. After the histopathological review, six of the 27 patients with true PTC had axillary metastases. The review did not significantly change the risk factors for axillary metastases. Conclusions: Every fourth PTC patient has axillary lymph-node metastases, most often micrometastases. SN biopsy appears as a feasible method for axillary staging in PTC patients. q 2006 Elsevier Ltd. All rights reserved. Keywords: Lymph node metastasis; Sentinel node biopsy; Tubular carcinoma; Axillary staging
Introduction Pure tubular carcinoma (PTC) is a rare, well differentiated histologic subtype of invasive breast cancer. The definition of this histologic subtype varies according to the proportion of tubule formation. The commonly accepted definition is 90% or more of tubule formation,1,2 but even the recent studies have a cut-off point varying between 803 and 95%.4 In previous studies, the prevalence of lymph-node metastases in PTC has often been negligible in patients with a histological tumour size less than 1 cm.5–9 Due to the likely low risk of axillary metastases, it has been argued that the morbidity associated with axillary dissection may * Corresponding author. Address: Munkkiniemen Puistotie 8 B, FIN00330 Helsinki, Finland. Tel.: C358 40 589 1969; fax: C358 9 47163387. E-mail address: [email protected] (J. Leikola).
0748-7983/$ - see front matter q 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2006.01.021
outweigh any potential benefit of axillary staging.10 Due to its’ low morbidity and accuracy in staging, the use of sentinel node (SN) biopsy has been suggested as suitable for nodal staging in patients with favourable tumour subtypes, such as PTC.11 We aimed to evaluate the prevalence of and the risk factors for axillary lymph-node metastases in PTC. The role of axillary staging and treatment in PTC was also evaluated.
Methods Between March 2001 and August 2004 altogether 1324 breast cancer patients underwent SN biopsy in our unit. Thirty-three had PTC (over 90% tubular morphology).2 The median age of the patients was 56 (range 39–80) years. The median histological tumour size was 9
J. Leikola et al. / EJSO 32 (2006) 488–491
489
(range 3–26) mm. Fifteen patients had palpable tumours. The project plan was approved by the Ethical Committee of Helsinki City University Hospitals. Written informed consent was obtained from each patient.
considered as micrometastases and as isolated tumour cells, when 0.2 mm or less.13
SN biopsy
Proportional data was compared using chi-square or Fisher’s exact tests. The medians and means were compared using the Mann–Whitney U-test. Two-tailed P-values !0.05 were considered statistically significant.
Lymphoscintigraphy was performed the day before surgery, a median of 4 h after a single intratumoral injection of 99m Tc labelled human albumin colloid Nanocollw (Nycomed Amersham Sorin s.r.l. Saluggia, Italy), with particle size less than 80 nm in a volume of 0.2 ml as described in detail in our recent study.12 Pre-operative lymphatic mapping, a handheld gamma detector and blue dye were used to identify the sentinel nodes in the axilla. All focally radioactive and/or blue nodes in the axilla were harvested. Level I–II axillary clearance (AC) was performed during the primary operation in patients with SN metastases found on frozen section. Patients with false negative findings in the frozen section examination underwent level I–II AC as a second operation. In addition, AC was performed in one patient with tumour negative SN findings because of multifocality of primary tumour. Histology The breast specimens were assessed by experienced senior pathologists with special interest in breast pathology. To confirm the correct histological diagnosis (PTC, O90% tubular component), all breast specimens were reviewed by an expert breast pathologist (P.H.). The tumour re-classification was performed according to the classification of International Agency for Research on Cancer.1 The SN were histologically examined using serial sectioning and immunohistochemistry as described in detail in our previous study.12 Metastases of 2 mm or less were
Statistical methods
Results The SN were successfully harvested in all patients. The median number of SN harvested in the axilla was three (range 1–10). The median total number of retrieved axillary nodes was 16 (range15–24) in patients with AC. Prevalence of axillary metastases Nine of the 33 patients had axillary metastases. The median number of metastatic nodes was 1 (range 1–3). The median size of the SN metastases was 0.5 mm (mean 1.7 mm, range 0.4–5 mm). Micrometastases as the only tumour positive SN findings were observed in six patients. The SN metastases were detected in the intraoperative frozen section examination in seven patients. Both patients with false negative frozen section findings had SN micrometastases. Metastases in the non-sentinel nodes were detected in two patients. Both of them had 3 mm SN metastases. Risk factors for axillary metastases The median histological tumour size was similar, 9 vs 10 mm, in patients with or without axillary metastases. The histological tumour size was less than 1 cm in 17 patients. Five of them had axillary metastases. In these five patients, the median size of the SN metastasis was 0.5 mm (mean 1.3 mm, range 0.4–3 mm). The other evaluated risk factors
Table 1 The influence of patient and tumour characteristics on the prevalence of axillary metastases in 33 patients with pure tubular carcinoma (PTC) of the breast
a
Age (years) The histological size of the primary tumour (mm)a Histological tumour stage T1a–b T1c T2 Palpable tumours Tumour location Upper lateral Upper medial Lower lateral Lower medial Central a
Median (range).
Patients with SN metastases (NZ9)
Patients without SN metastases (NZ24)
P
54 (44–71) 9 (6–12)
57 (39–80) 10 (3–26)
0.808 0.700
5 4 0 4
15 8 1 11
0.795 0.944
3 3 2 1 0
15 7 1 1 0
0.739
490
J. Leikola et al. / EJSO 32 (2006) 488–491
Table 2 The influence of patient and tumour characteristics on the prevalence of axillary metastases in 27 patients with pure tubular carcinoma (PTC) following the histopathological tumour reclassification
Age (years)a The histological size of the primary tumour (mm)a Histological tumour stage T1a–b T1c T2 Palpable tumours Tumour location Upper lateral Upper medial Lower lateral Lower medial Central a
Patients with SN metastases (NZ6)
Patitents without SN metastases (NZ21)
P
55 (44–71) 7.5 (5–12)
57 (46–80) 10 (3–26)
0.661 0.333
5 1 0 3
13 7 1 9
0.322 0.761
2 3 0 1 0
13 7 0 1 0
0.290
Median (range).
did not influence significantly the prevalence of axillary nodal metastases. (Table 1). Influence of the histopathological review on the prevalence of and risk factors for axillary metastases The histopathological review of the tumour specimens revealed that five of the 33 tumours lacked sufficient tubularity to be classified as PTC. In one patient, the tumour specimens were not available for reclassification. Axillary metastases were detected in six of the remaining 27 patients with true PTC. The median number of metastatic nodes was 1 (range 1–3). The median size of the SN metastases was 0.5 mm (mean 1.1 mm, range 0.4–3 mm). Five patients had SN micrometastases only. Metastases in the non-sentinel nodes were detected in one patient. The histopathological review did not significantly influence the risk factors for axillary metastases (Table 2). Discussion Prevalence of nodal metastases in PTC The prevalence of axillary metastases in PTC in the present study was high, when compared with the 7% observed in a recent meta-analysis.7 When using SN biopsy in axillary staging, metastases have been detected in 17% of PTC patients.11 The meticulous histological examination of SN reveals metastases not detected in standard lymph node processing.14–16 Accordingly, the prevalence of metastases in the present study was only 9%, when excluding the micrometastases from the data.
PTC tumour less than 10 mm.5–9 In fact, tumour size did not influence the risk for metastases at all. The aggressiveness of the tumour17 as well as the risk for metastases7,18 increase with the decreasing proportion of tubular morphology. However, our results for axillary metastases were not altered after the histopathological reclassification of the tumour specimens. Role of axillary staging and treatment in PTC In PTC, the effect of nodal disease on survival has been controversial.3,4,8,9,19–22 However, axillary nodal metastases in PTC may be more common than assumed earlier.3,7,9 Therefore, SN biopsy appears as feasible axillary staging method in PTC, providing also valuable data for further evaluation of prognosis and natural history. In general, the risk for non-sentinel node metastases is substantial even in patients with SN micrometastases.12 The data concerning the size and the number of nodal metastases as well as the definite features of the primary tumour are available only in the post-operative phase. Therefore, we recommend AC, when the SN metastases are detected in the intraoperative diagnosis. Because none of our PTC patients with SN micrometastases had non-sentinel node metastases, AC as a second operation after false negative frozen section findings might be omitted in this patient group. Limitations of the study The number of the patients was small in the present study as well as in the vast majority of the previous ones3,4,7,9,11 addressing PTC. This renders the conclusions rather uncertain.
Risk factors for nodal metastases
Conclusions
Our findings did not support the assumption, that the risk of axillary nodal involvement is negligible in patients with a
Every fourth PTC patient has axillary lymph-node metastases, most often micrometastases. SN biopsy
J. Leikola et al. / EJSO 32 (2006) 488–491
appears as s feasible method for axillary staging in PTC patients.
References 1. Tavassoli FA, Devilee P, International Agency for Research on Cancer and World Health Organization. Pathology and genetics of tumours of the breast and female genital organs. Lyon; Oxford: International Agency for Research on Cancer; 2003. 2. Ellis IO, Galea M, Broughton N, Locker A, Blamey RW, Elston CW. Pathological prognostic factors in breast cancer. II. Histological type. Relationship with survival in a large study with long-term follow-up. Histopathology 1992;20(6):479–89. 3. Winchester DJ, Sahin AA, Tucker SL, Singletary SE. Tubular carcinoma of the breast. Predicting axillary nodal metastases and recurrence. Ann Surg 1996;223(3):342–7. 4. Cabral AH, Recine M, Paramo JC, McPhee MM, Poppiti R, Mesko TW. Tubular carcinoma of the breast: an institutional experience and review of the literature. Breast J 2003;9(4):298–301. 5. Rutgers EJ, EUSOMA Consensus Group. Quality control in the locoregional treatment of breast cancer. Eur J Cancer 2001;37(4): 447–53. 6. Fein DA, Fowble BL, Hanlon AL, Hooks MA, Hoffman JP, Sigurdson ER, et al. Identification of women with T1–T2 breast cancer at low risk of positive axillary nodes. J Surg Oncol 1997;65(1): 34–9. 7. Papadatos G, Rangan AM, Psarianos T, Ung O, Taylor R, Boyages J. Probability of axillary node involvement in patients with tubular carcinoma of the breast. Br J Surg 2001;88(6):860–4. 8. Maibenco DC, Weiss LK, Pawlish KS, Severson RK. Axillary lymph node metastases associated with small invasive breast carcinomas. Cancer 1999;85(7):1530–6. 9. McBoyle MF, Razek HA, Carter JL, Helmer SD. Tubular carcinoma of the breast: an institutional review. Am Surg 1997;63(7):639–44 [discusion 644–5]. 10. Kader HA, Jackson J, Mates D, Andersen S, Hayes M, Olivotto IA. Tubular carcinoma of the breast: a population-based study of nodal metastases at presentation and of patterns of relapse. Breast J 2001; 7(1):8–13.
491
11. Wong SL, Chao C, Edwards MJ, Carlson DJ, Laidley A, Noyes RD, et al. Frequency of sentinel lymph node metastases in patients with favorable breast cancer histologic subtypes. Am J Surg 2002;184(6): 492–8 [discussion 498]. 12. Leidenius MH, Vironen JH, Riihela MS, Krogerus LA, Toivonen TS, von Smitten KA, et al. The prevalence of non-sentinel node metastases in breast cancer patients with sentinel node micrometastases. Eur J Surg Oncol 2005;31(1):13–18. 13. International Union Against Cancer, UICC International Union Against Cancer. TNM classification of malignant tumours. New York: Wiley-Liss; 2002. 14. de Widt-Levert L, Tjan-Heijnen V, Bult P, Ruers T, Wobbes T. Stage migration in breast cancer: surgical decisions concerning isolated tumour cells and micro-metastases in the sentinel lymph node. Eur J Surg Oncol 2003;29(3):216–20. 15. McMasters KM, Giuliano AE, Ross MI, Reintgen DS, Hunt KK, Byrd DR, et al. Sentinel-lymph-node biopsy for breast cancer—not yet the standard of care. N Engl J Med 1998;339(14):990–5. 16. Leidenius M, Krogerus L, Tukiainen E, von Smitten K. Accuracy of axillary staging using sentinel node biopsy or diagnostic axillary lymph node dissection—a case–control study. APMIS 2004;112(4–5):264–70. 17. Peters GN, Wolff M, Haagensen CD. Tubular carcinoma of the breast. Clinical pathologic correlations based on 100 cases. Ann Surg 1981; 193(2):138–49. 18. Green I, McCormick B, Cranor M, Rosen PP. A comparative study of pure tubular and tubulolobular carcinoma of the breast. Am J Surg Pathol 1997;21(6):653–7. 19. Livi L, Paiar F, Meldolesi E, Talamonti C, Simontacchi G, Detti B, et al. Tubular carcinoma of the breast: outcome and loco-regional recurrence in 307 patients. Eur J Surg Oncol 2005;31(1):9–12. 20. Elson BC, Helvie MA, Frank TS, Wilson TE, Adler DD. Tubular carcinoma of the breast: mode of presentation, mammographic appearance, and frequency of nodal metastases. AJR Am J Roentgenol 1993;161(6):1173–6. 21. Diab SG, Clark GM, Osborne CK, Libby A, Allred DC, Elledge RM. Tumor characteristics and clinical outcome of tubular and mucinous breast carcinomas. J Clin Oncol 1999;17(5):1442–8. 22. Kitchen PR, Smith TH, Henderson MA, Goldhirsch A, CastiglioneGertsch M, Coates AS, et al. Tubular carcinoma of the breast: prognosis and response to adjuvant systemic therapy. Aust N Z J Surg 2001;71(1):27–31.