Study of the Relations among Tumor Size and Axillary Lymph Nodes Involvement with the Prognosis of Patients with Breast Cancer Surgery in Shohada Hospital in Tehran, Tajrish

Facts and evidence hold out a steadily increasing prevalence of breast cancer in the mid-1940s. In most cases, the disease is discovered when the disease has reached an advanced stage, therefore, early diagnosis can significantly reduce the burden of disease. Breast cancer has some risk factors, such as tumor size and lymph node involvement. The aim of this study was to evaluate the correlation between tumor size and axillary lymph node involvement and the prognosis for patients with breast cancer has been surgery. The study population consisted of 100 patients with breast cancer surgery at Shohada Hospital of Tajrish during the last 10 years. The results suggest that lymph node involvement was significantly associated with prognosis in patients with breast cancer and in cases where the tumor size was less than 1 cm, it has no impact on the prognosis of breast cancer. Also, a family history of the disease among close relatives is an independent risk factor for poor prognosis, in patients with breast cancer in general it can be said that involvement of lymph nodes in patients with breast cancer is due to an unfavorable prognosis; but the number of lymph nodes involved and the size of the tumor did not have any effect on the prognosis.

Clinical Study of Double Contrast-Enhanced Ultrasound Combined with Dye Method and Marker Placement to Identify and Locate Sentinel Lymph Nodes in Patients with Breast Cancer

Objective: To explore the value of percutaneous ultrasonography combined with transvenous ultrasonography for accurate localization of sentinel lymph nodes and diagnosis of metastatic lymph nodes in patients with breast cancer. Methods: 18 cases of patients with breast cancer attending the Hainan General Hospital from May 2022 to June 2024 who were proposed to undergo axillary lymph node dissection were selected, and the ultrasonographic agent was injected subcutaneously through the areola on the 1st day before the operation, and the marker localization of the manifestation of the Sentinel lymph nodes and draw the lymphatic vessel alignment for drainage on the body surface, and record the manifestation of SLN by conventional ultrasound and dual ultrasonography. At the time of surgery, intraoperative melphalan localization was used to identify the SLN, the difference between the number of ultrasound and melphalan localization was observed, and resection was performed for pathological examination to determine whether they were metastatic or not. Results: There were 8 metastatic lymph nodes and 18 non-metastatic lymph nodes among 31 SLN. A total of 62 SLN were localized by intraoperative melphalan, of which 31 were consistent with ultrasound localization and 31 were not identified by ultrasound. The diagnostic sensitivity of SLN metastasis diagnosed by transcutaneous ultrasonography was 62.50%, specificity was 91.30%, positive predictive value was 71.43%, negative predictive value 87.50%, accuracy was 83.87%, and the AUC was 0.769;the diagnostic sensitivityof transvenous ultrasonography diagnosed was 75.00%, specificity was 75.00%, and the accuracy was 83.87%, 75.00%, specificity 91.30%, positive predictive value 75.00%, negative predictive value 91.30%, accuracy 87.10%, AUC 0.832;dual ultrasonography diagnostic sensitivity 87.50%, specificity 91.30%, positive predictive value 77.78%, negative predictive value 95.45%, accuracy 90.32%. The AUC was 0.894. Conclusion: Transcutaneous ultrasonography combined with transvenous ultrasonography can accurately localize sentinel lymph nodes and improve the sensitivity and accuracy of the diagnosis of metastatic SLN.

The Risk Factors of Lymphedema in Breast Cancer Patients Post Axillary Clearance

Introduction: Breast cancer is the number one malignancy affecting females in Saudi Arabia with a prevalence of 22.4%. Breast cancer incidence increases annually due to the aid of established screening programs, leading to the discovery of breast cancer in its early stages. Surgical treatment is an integral part of early breast cancer management to achieve local control. Axillary surgical interventions such sentinel lymph node biopsy (SLNB) and axillary lymph node clearance (ALND) aim to stage the axilla as an adjunct to the management of the primary breast tumor. In this paper, we reviewed female breast cancer patients aged 30 - 60 who underwent surgical treatment of SLNB and/or ALND with reporting the prevalence of lymphedema and other associated complications and risk factors. Methodology: A cross-sectional non-interventional study, with a sample size of 250 including breast cancer cases from 2016 to 2019 at National Guard Hospital (NGH) in Jeddah, Saudi Arabia. Results: A total of 253 breast cancer cases were included in this study, with a mean age of 53 years, 52.7% were postmenopausal and positive family history was present among 21% of cases. Further, 90.9% of the cases had unilateral disease. Staging was as follows: stage I 14.5%, stage II 45.2%, stage III 37.1%, and stage IV 3.2%. Mastectomy was done in 73.4% cases and lumpectomy was performed in 34.1% of cases. In addition, 93.3% of patients had SLNB and 49% of them were positive. Axillary dissection was performed in 69.6% of our patients. Radiotherapy and chemotherapy were given to 71.8% and 80.4% of cases respectively. Among the chemotherapy (chemo) recipients, 40.2% received adjuvant chemo, 54.5% received neoadjuvant chemo, and the remaining 5.3% received both. Further, the most prevalent complication was pain accounting for 42.1% of total complications, and the least prevalent was cellulitis 4%. Also, seroma developed in 18.3% cases, paresthesia noted in 5.6% of cases, winged scapula was reported as 2%, weakness and necrosis were seen in 6% and 13.1% of cases respectively. Axillary vein thrombosis and lymphangiosarcoma were reported in none of the patients (0%). Lymphoedema accounted for 16.1% of overall complications, 85% of the patients who developed lymphedema had undergone ALND, and 12.9% and 14.4% received radiotherapy and chemotherapy respectively. Lymphedema was observed in breast cancer stages as follows: stage I 1.2%, stage II 7.2%, and stage III 5.2%. Patients with body mass index (BMI) of 30 - 39 kg/m2 had 7.2% prevalence of lymphedema compared to other BMI groups. Overall mortality was 8.3%. Conclusion: The findings of our study suggest that the prevalence of lymphedema was higher in ALND patients with locally advanced tumors, and higher BMI, compared to patients with stage I breast cancer and low BMI. Further, the prevalence of lymphedema in patients who underwent ALND was significantly lower than those who were treated by lumpectomy 10.3% (p-value = 0.034) in comparison to mastectomy 19.3%.

THE PROGNOSIS SIGNIFICANCE OF CATHEPSIN-D EXPRESSIONIN THE DIFFERENT LOCATIONS IN AXILLARY NODES NEGATIVE CARCINOMA

Objective: The aim of this study was to investigate Cathepsin-D (Cath-D) expression in different location and its relationship with prognosis in the axillary lymph nodes negative (ANN) breast cancer patients. Methods: Cath-D expression in 192 cases of breast carcinoma were examined by immunohistochemistry. Depending on different parts of expression, three evaluating methods were used, compared and analysed. Results: The positive rate of Cath-D expression in ANN breast cancer with poor prognosis group and axillary nodes positive (ANP) group were significantly higher than that in ANN breast cancer with good prognosis group (x 2=23.20,P<0.01), while there was no significant difference between ANP group and ANN with poor prognosis group (x 2=0.19,P>0.05). Cath-D expression in stromal cells had no statistical difference among the three groups (x}2=1.56,P>0.05). When the Cath-D expression in cancer and stromal cells were counted into the positive rate, it was near the same (u 1=0.47,u 2=1.41,P>0.05). Conclusion: These results suggest that Cath-D expression is one of the powerful prognostic markers in ANN breast cancer. It’s a reliable, practical, and convenient method to observe and evaluate Cath-D expression in cancer cells.

Efficacy and prognosis of mastoscopic axillary lymph node dissection for breast cancer:a systematic evaluation and meta-analysis

Objective:To systematically evaluate the efficacy and prognosis of breast lumpectomy axillary lymphatic dissection for the treatment of breast cancer.Methods:We use computer to search PubMed,The Cochrane Library,EMBASE,Web of Science,China Knowledge Network,Wanfang database,VIP database and CBM for randomized controlled trials(RCTs)of breast lumpectomy in axillary lymphatic dissection for breast cancer.The search time frame was from the database establishment to July 2021.Meta-analysis was performed using Revman 5.4.1 software after 2 investigators independently screened the literature,extracted information,and evaluated the risk of bias of the included studies.Results:A total of 20 RCTs including 2672 patients were included.Mastoscopic axillary lymph node dissection(MALND)was used in the trial group and conventional axillary lymph node dissection(CALND)was used in the control group.The results showed that the trial group was more effective in controlling bleeding volume[MD=-54.72,95%CI(-79.73,-29.71),P<0.00001],postoperative drainage[MD=-98.99,95%CI(-128.83,-69.15),P<0.00001],length of hospital stay[MD=-2.75,95%CI(-4.67,-0.83),P=0.005],and incidence rate of adverse reaction[RR=0.30,95%CI(0.19,0.45),P<0.00001]were superior to the control group,and the differences were statistically significant.Conclusions:Current evidence suggests that MALND can achieve better outcomes compared with CALND.It is more advantageous in controlling the bleeding volume,postoperative drainage,length of hospital stays,and incidence rate of adverse events.

Clinicopathological features,psychological status,and prognosis of 33 patients with occult breast cancer

BACKGROUND Occult breast cancer(OBC)has traditionally been considered to be a carcinoma of unknown primary origin with a favorable prognosis and can be treated as stage II-III breast cancer.Due to the small number of cases and limited clinical experience,treatments vary greatly around the world and no standardized treatment has yet been established.AIM To investigate the clinicopathological features,psychological status and prognostic features of patients with OBC.METHODS The clinicopathological data of 33 OBC patients diagnosed and treated in the Affiliated Hospital of Xuzhou Medical University and Xuzhou Central Hospital from November 2015 to November 2022 were retrospectively analyzed.The psychological status of OBC patients was evaluated by the Self-rating Anxiety Scale and Self-rating Depression Scale.Patients’emotions,stress perception and psychological resilience were evaluated by the Positive and Negative Affect Schedule,the Chinese Perceived Stress Scale,and the Connor-Davidson Resilience Scale(CD-RISC),respectively.Patient survival was calculated using the Kaplan-Meier method,and survival curves were plotted for analysis with the log-rank test.Univariate and multivariate survival analyses were performed using the Cox regression model.RESULTS The 33 OBC patients included 32 females and 1 male.Of the 33 patients,30(91%)had axillary tumors,3(9%)had a neck mass as the primary symptom;18(54.5%)had estrogen receptor-positive tumors,17(51.5%)had progesterone receptor-positive tumors,and 18(54.5%)had Her-2-positive tumors;24(72.7%)received surgical treatment,including 18 patients who underwent modified radical mastectomy,1 patient who underwent breast-conserving surgery plus axillary lymph node dissection(ALND),and 5 patients who underwent ALND alone;12 patients received preoperative neoadjuvant therapy.All 30 patients developed anxiety and depression,with low positive affect scores and high negative affect scores,accompanied by a high stress level and poor psychological resilience.There were no differences in the psychological status of patients according to age,body mass index,or menopausal status.The overall survival and disease-free survival(DFS)of all the patients were 83.3%and 55.7%,respectively.Univariate analysis demonstrated that the initial tumor site(P=0.021)and node stage(P=0.020)were factors that may affect patient prognosis.The 5-year DFS rate of OBC patients who received radiotherapy was greater(P<0.001),while the use of different surgical methods(P=0.687)had no statistically significant effect on patient outcomes.Multivariate analysis revealed that radiotherapy(P=0.031)was an independent prognostic factor.Receiving radiotherapy had a significant effect on the CD-RISC score(P=0.02).CONCLUSION OBC is a rare breast disease whose diagnosis and treatment are currently controversial.There was no significant difference in the efficacy of other less invasive surgical procedures compared to those of modified radical mastectomy.In addition,radiotherapy can significantly improve patient outcomes.We should pay attention to the psychological state of patients while they receive antitumor therapy.

Analysis of factors related to non-sentinel lymph node metastasis in 296 sentinel lymph node-positive Chinese breast cancer patients

Objective: Axillary lymph node dissection(ALND) may be unnecessary in 20%–60% of breast cancer patients with sentinel lymph node(NSLN) metastasis. The aim of the present study was to review the medical records of Chinese patients with early-stage breast cancer and positive NSLN metastasis to identify clinicopathological characteristics as risk factors for non-NSLN metastasis.Methods: The medical records of 2008 early-stage breast cancer patients who received intraoperative sentinel lymph node biopsy(SLNB) between 2006 and 2016 were retrospectively reviewed. These patients were clinically and radiologically lymph nodenegative and had no prior history of receiving neoadjuvant chemotherapy or endocrinotherapy. The clinicopathological characteristics of patients with positive NSLN metastasis who underwent ALND were investigated.Results: In the present study, 296 patients with positive NSLN metastases underwent ALND. Positive non-NSLN metastases were confirmed in 95 patients(32.1%). On univariate analysis, ≥ 3 positive NSLN metastases(P <0.01), NSLN macrometastases(P =0.023), and lymphovascular invasion(P = 0.04) were associated with non-NSLN metastasis(P <0.05). In multivariate analysis, the number of positive SLNs was the most significant predictor of non-SLN metastasis. For patients with 0, 1, 2, or 3 associated risk factors, the non-SLN metastatic rates were 11.5%, 22.5%, 35.2%, and 73.1%, respectively.Conclusions: The number of positive NSLNs, NSLN macrometastases, and lymphovascular invasion were correlated with nonSLN metastasis. The number of positive SLNs was an independent predictor for non-NSLN metastasis. When 2 or 3 risk factors were present in one patient, the probability of non-NSLN was higher than that in the American College of Surgeons Oncology Group Z0011 trial(27.3%); thus, avoiding ALND should be considered carefully.

Macrometastasis at selective lymph node biopsy:A practical goingfor-the-one clinical scoring system to personalize decision making

BACKGROUND Axillary sentinel lymph node biopsy(SLNB)is standard treatment for patients with clinically and pathological negative lymph nodes.However,the role of completion axillary lymph node dissection(cALND)following positive sentinel lymph node biopsy(SLNB)is debated.AIM To identify a subgroup of women with high axillary tumor burden undergoing SLNB in whom cALND can be safely omitted in order to reduce the risk of longterm complications and create a Preoperative Clinical Risk Index(PCRI)that helps us in our clinical practice to optimize the selection of these patients.METHODS Patients with positive SLNB who underwent a cALND were included in this study.Univariate and multivariate analysis of prognostic and predictive factors were used to create a PCRI for safely omitting cALND.RESULTS From May 2007 to April 2014,we performed 1140 SLN biopsies,of which 125 were positive for tumor and justified to practice a posterior cALND.Pathologic findings at SLNB were micrometastases(mic)in 29 cases(23.4%)and macrometastasis(MAC)in 95 cases(76.6%).On univariate analysis of the 95 patients with MAC,statistically significant factors included:age,grade,phenotype,histology,lymphovascular invasion,lymph-node tumor size,and number of positive SLN.On multivariate analysis,only lymph-node tumor size(≤20 mm)and number of positive SLN(>1)retained significance.A numerical tool was created giving each of the parameters a value to predict preoperatively which patients would not benefit from cALND.Patients with a PCRI≤15 has low probability(<10%)of having additional lymph node involvement,a PRCI between 15-17.6 has a probability of 43%,and the probability increases to 69%in patients with a PCRI>17.6.CONCLUSION The PCRI seems to be a useful tool to prospectively estimate the risk of nodal involvement after positive SLN and to identify those patients who could omit cALND.Further prospective studies are necessary to validate PCRI clinical generalization.

Axillary lymph node dissection plus radiotherapy may be an optimal strategy for patients with occult breast cancer

Background:Because of the rarity of occult breast cancer(OBC)and limited experience in OBC treatment,the optimal treatment strategy is unknown.This study aimed to compare the efficacy of axillary lymph node dissection(ALND)plus radiotherapy with that of mastectomy plus ALND in patients with OBC.Methods:Relevant clinical data between January 2004 and December 2015 were retrospectively collected from the Surveillance,Epidemiology,and End Results database.The clinical characteristics and prognoses of patients who underwent ALND plus radiotherapy or mastectomy plus ALND were compared before and after propensity score matching.Results:Overall,569 eligible patients with OBC were included in this study.Of these,247 patients underwent ALND plus radiotherapy and 322 underwent mastectomy plus ALND.The 5-year overall survival(OS)rates in the ALND plus radiotherapy group and the mastectomy plus ALND group were 89.2%and 80.6%,respectively;and the corresponding 5-year breast cancer-specific survival(BCSS)rates were 95.2%and 93.0%,respectively.After propensity score matching,the OS in the ALND plus radiotherapy group was significantly better than that in the mastectomy plus ALND group.In addition,further subgroup analyses revealed that ALND plus radiotherapy prolonged OS in the pN3 subgroup.Among patients receiving adjuvant chemotherapy,those who underwent ALND plus radiotherapy had better BCSS and OS than those who underwent mastectomy plus ALND.Conclusions:ALND plus radiotherapy could improve the OS of patients with OBC,especially those with pN3 disease and those receiving chemotherapy.ALND combined with radiotherapy is the optimal treatment strategy for patients with imaging-negative OBC.

Diagnosis and Treatment of Axillary Web Syndrome:An Overview

Axillary web syndrome(AWS)is a self-limiting disease that can occur as an early or possibly late postoperative complication post-axillary surgery.This syndrome is characterized by the spread of the cords of subcutaneous tissue extending from the axilla into the arm and is clinically associated with pain and limited movement of the shoulder in the affected limb.Although its pathophysiology is not well established,the most common cause is surgery-related axillary lymphatic injury.Both the echography and magnetic resonance imaging results support the lymphatic hypothesis.The diagnosis of AWS is based on physical examination.Risk factors may include extensiveness of surgery,younger age,hypertension,lower body mass index,ethnicity,and healing complications.Effective clinical intervention shortens the natural course of AWS and improves the quality of life of patients with AWS.Treatments may include physical therapy,drug therapy,manual drainage,instrument-assisted soft tissue mobilization(IASTM),thoracic manipulation and stretching,manual axial distraction,percutaneous needle cord disruption with fat grafting and Xiaflex injection,and surgical intervention.Routine surgical treatment for AWS may not be recommended.Further research is needed to provide more comprehensive improvements in the diagnosis and treatment of AWS.

Can axillary radiotherapy replace axillary dissection for patients with positive sentinel nodes? A systematic review and meta-analysis

Objective: To compare the efficacy of axillary radiotherapy (ART) with that of completion axillary lymph node dissection (cALND) in clinically node-negative breast cancer patients with a positive sentinel lymph node. Methods: A literature search was performed in PubMed, EMBASE and Cochrane Library by using the search terms 'breast cancer', 'sentinel lymph node biopsy', 'axillary radiotherapy' or 'regional node irradiation' for articles published between 2004 and 2016. Only randomized controlled trials that included patients with positive sentinel nodes were included in the meta-analysis. Results: Two randomized controlled trials and three retrospective studies were identified. The reported overall survival rate (hazard ratio [HR] = 1.09, 95% confidence interval [CI]: 0.75-1.43, P = 0.365), disease-free survival rate (HR = 1.01, 95% CI:0.58-1.45, P = 0.144), and axillary recurrence rate (1.2% and 0.4%, and 1.3% and 0.8%, respectively) were similar in both groups. The absence of knowledge on the extent of nodal involvement in the ART group appeared to have no major impact on the administration of adjuvant systemic therapy. Conclusions: ART is not inferior to cALND in the patients with clinically node-negative breast cancer who had a positive sentinel lymph node. Information obtained by using cALND after SLNB may have no major impact on the administration of adjuvant systemic therapy.

Factors predicting upstaging from clinical N0 to pN2a/N3a in breast cancer patients

BACKGROUND With sentinel node metastasis in breast cancer(BC)patients,axillary lymph node(ALN)dissection is often omitted from cases with breast-conserving surgery.Omission of lymph node dissection reduces the invasiveness of surgery to the patient,but it also obscures the number of metastases to non-sentinel nodes.The possibility of finding≥4 lymph nodes(pN2a/pN3a)preoperatively is important given the ramifications for postoperative treatment.AIM To search for clinicopathological factors that predicts upstaging from N0 to pN2a/pN3a.METHODS Patients who were sentinel lymph node(SLN)-positive and underwent ALN dissection between September 2007 and August 2018 were selected by retrospective chart review.All patients had BC diagnosed preoperatively as N0 with axillary evaluation by fluorodeoxyglucose(FDG) positron emission tomography/computed tomography and ultrasound (US)examination. When suspicious FDG accumulation was found in ALN, the presence of metastasiswas reevaluated by second US. We examined predictors of upstaging from N0 to pN2a/pN3a.RESULTSAmong 135 patients, we identified 1-3 ALNs (pN1) in 113 patients and ³4 ALNs (pN2a/pN3a) in22 patients. Multivariate analysis identified the total number of SLN metastasis, the maximaldiameter of metastasis in the SLN (SLNDmax), and FDG accumulation of ALN as predictors ofupstaging to pN2a/pN3a.CONCLUSIONWe identified factors involved in upstaging from N0 to pN2a/pN3a. The SLNDmax and numberof SLN metastasis are predictors of ≥ 4 ALNs (pN2a/pN3a) and predictors of metastasis to nonsentinelnodes, which have been reported in the past. Attention should be given to axillaryaccumulations of FDG, even when faint.

SENTINEL NODE BIOPSY BY TWO KINDS OF BLUE DYES IN PATIENTS WITH BREAST CANCER

Objective To evaluate the identification successful rate of sentinel lymph node with breast cancer and the accuracy to predict axillary lymph node status in different vital blue dyes.Methods 94 patients with breast cancer were recruited for the study between Oct. 1999 and Apr. 2001, of whom 32 and 62, respectively, were injected 0.028mmol·L -1 Methylene blue and 0.018mmol·L -1 Patent blue violet in breast parenchyma surrounding the primary tumor to identify SLN.All 94 patients underwent the axillary lymph node dissection.Results For Methylene blue group and Patent blue violet group, SLN identification successful rates were 65.6% and 88.7% and accuracy rate to predict axillary lymph node status were 90.5% and 98.2% , respectively.Conclusion In identifying SLN,Patent blue violet is more ideal vital blue dye than Methylene blue, whereas the accuracy rate to predict axillary lymph node status had no significant difference.