Novel factors to improve prediction of nodal positivity in patients with clinical T1/T2 breast cancers.

BACKGROUND: Memorial Sloan Kettering Cancer Center (MSKCC) and MD Anderson Cancer Center (MDACC) have established nomograms to predict sentinel node positivity. We propose the addition of two novel variables-distance of tumor from the nipple and from the skin-can improve their performance. METHODS: Ultrasounds of clinical T1/T2 tumors were reviewed. Distances of the tumor from the skin and from the nipple were measured. MSKCC and MDACC nomogram predictions and the AUC-ROC for each model were calculated. The added utility of the two variables was then examined using multiple logistic regression. RESULTS: Of 401 cancers studied, 79 (19.7 %) were node positive. The mean distance of tumors from the nipple in node-positive patients was 4.9 cm compared with 6.0 cm in node-negative patients (p = 0.0007). The mean distance of tumors from the skin was closer in node-positive cases (0.8 cm) versus node-negative cases (1.0 cm, p = 0.0007). The MSKCC and MDACC nomograms AUC-ROC values were 0.71 (95 % CI 0.64-0.77) and 0.74 (95 % CI 0.68-0.81). When adjusted for the MSKCC predicted probability, addition of both distance from nipple (p = 0.008) and distance from skin (p = 0.02) contributed significantly to prediction of nodal positivity and improved the AUC-ROC to 0.75 (95 % CI 0.70-0.81). Similarly, distance from nipple (p = 0.002), but not distance from skin (p = 0.09), added modestly to the MDACC nomogram performance (AUC 0.77; 95 % CI 0.71-0.83). CONCLUSIONS: Distance of tumor from the nipple and from the skin are important variables associated with nodal positivity. Adding these to established nomograms improves prediction of nodal positivity.

Should axillary ultrasound be used in patients with a preoperative diagnosis of ductal carcinoma in situ?

BACKGROUND: We evaluated the usefulness of axillary ultrasound (US) in patients with core biopsy-proven ductal carcinoma in situ (DCIS). METHODS: Preoperative axillary US, fine-needle aspiration (FNA), and sentinel lymph node (SLN) data from women with DCIS were reviewed. RESULTS: Eighty-two women with DCIS underwent axillary US. In 16 women (19.5%) US was abnormal; however, FNA was negative in all cases. Sixty-one women (74%) underwent SLN surgery; 2 were positive for macrometastasis (3%) and 1 had isolated tumor cells. None of them had an abnormal US. Axillary US did not change the management in any of the cases. CONCLUSIONS: Axillary US and FNA did not change the management in any of the 82 cases. In women with a core biopsy diagnosis of DCIS, positive nodes are uncommon and unlikely to be detected by axillary US. Routine preoperative axillary US is not recommended for pure DCIS on core biopsy.

Distance of breast cancer from the skin and nipple impacts axillary nodal metastases.

BACKGROUND: Lymphatic drainage of the breast is via subareolar and dermal lymphatics. The aim of this study was to determine whether distance of breast cancers from the skin and/or distance from the nipple impacts the likelihood of axillary nodal metastases. METHODS: A retrospective review was performed of sonographically visible T1 and T2 breast cancers with breast and axillary surgery performed at Mayo Clinic, Rochester, MN. Distance of tumor from the nipple was reviewed. Ultrasounds were reviewed to measure the distance of tumor from the skin. RESULTS: Data were collected on 233 eligible T1 or T2 breast cancers, of which 177 (76%) were node negative and 56 (24%) were node positive. On multivariable analysis, tumor stage and lymphovascular invasion, as well as decreasing distance of the tumor from the nipple and decreasing distance of the tumor from the skin, were significantly associated with axillary lymph node positivity. Each 1-cm decrease in the distance of the tumor from the nipple was associated with a 23% increased likelihood of positive lymph nodes (odds ratio 1.23; P = .003). Each 1-mm decrease in the distance of the tumor from the skin was associated with a 15% increased likelihood of positive lymph nodes (odds ratio 1.15; P = .003). CONCLUSION: T1 and T2 breast cancers located closer to the skin and those located closer to the nipple have a higher incidence of metastases to axillary lymph nodes. Distance from the skin and distance from the nipple should be considered when estimating a patient's likelihood of axillary nodal positivity.