Annals of Surgical Oncology

, Volume 16, Issue 5, pp 1128–1135 | Cite as

Validation of a Nomogram to Predict the Risk of Nonsentinel Lymph Node Metastases in Breast Cancer Patients with a Positive Sentinel Node Biopsy: Validation of the MSKCC Breast Nomogram

  • R. F. D. van la Parra
  • M. F. Ernst
  • J. L. B. Bevilacqua
  • S. J. J. Mol
  • K. J. Van Zee
  • J. M. Broekman
  • K. Bosscha
Breast Oncology

Abstract

Background

Completion axillary lymph node dissection (ALND) remains the standard of care for patients with disease-positive sentinel lymph nodes (SLN). However, approximately two-thirds will have no additional disease-positive nodes. To identify the patient’s individual risk for non-SLN metastases, the Memorial Sloan-Kettering Cancer Center (MSKCC) developed a nomogram.

Methods

The records of 182 breast cancer patients who underwent SLN and ALND were selected. Serial hematoxylin and eosin (HE) analysis and immunohistochemistry were routinely performed on each sentinel node. For application of the nomogram, the detection method was assigned in two ways: for all metastases visible by serial HE, the method of detection was scored as “serial HE” (method 1), independent of the tumor size, and by a combination of size and staining method (method 2); so macrometastasis were scored as detected by routine HE, micrometastasis by serial HE, and isolated tumor cells by immunohistochemistry. A receiver operating characteristic curve (ROC) was drawn, and the area under the curve was calculated to assess the discriminative power of the nomogram.

Results

The area under the ROC was .71 (range, .64–.79) according to method 1 and .75 (range, .67–.88) according to method 2.

Conclusions

Because the variable “method of detection” in the MSKCC nomogram is a surrogate for SLN metastasis size, the size category of the SLN metastasis can be used in applying the nomogram to patients in whom the SLN histologic analysis is performed by a much different procedure than that used to develop the MSKCC nomogram. This results in an improved predictive accuracy.

References

  1. 1.
    CBO. Richtlijn behandeling van het mammacarcinoom. Amsterdam, The Netherlands: Van Zuiden Communications BV; 2005.Google Scholar
  2. 2.
    Bolster MJ, Peer PG, Bult P, et al. Risk factors for non-sentinel lymph node metastases in patients with breast cancer. The outcome of a multi-institutional study. Ann Surg Oncol. 2007;14:181–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Changsri C, Prakash S, Sandweiss L, Bose S. Prediction of additional axillary metastasis of breast cancer following sentinel lymph node surgery. Breast J. 2004;10:392–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Chu KU, Turner RR, Hansen NM, Brennan MB, Bilchik A, Giuliano AE. Do all patients with sentinel node metastasis from breast carcinoma need complete axillary node dissection? Ann Surg. 1999;229:536–41.PubMedCrossRefGoogle Scholar
  5. 5.
    Cserni G. Sentinel lymph-node biopsy-based prediction of further breast cancer metastases in the axilla. Eur J Surg Oncol. 2001;27:532–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Cserni G, Burzykowski T, Vinh-Hung V, et al. Axillary sentinel node and tumour-related factors associated with non-sentinel node involvement in breast cancer. Jpn J Clin Oncol. 2004;34:519–24.PubMedCrossRefGoogle Scholar
  7. 7.
    Farshid G, Pradhan M, Kollias J, Gill PG. A decision aid for predicting non-sentinel node involvement in women with breast cancer and at least one positive sentinel node. Breast. 2004;13:494–501.PubMedCrossRefGoogle Scholar
  8. 8.
    Fleming FJ, Kavanagh D, Crotty TB, et al. Factors affecting metastases to non-sentinel lymph nodes in breast cancer. J Clin Pathol. 2004;57:73–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Fournier K, Schiller A, Perry RR, Laronga C. Micrometastasis in the sentinel lymph node of breast cancer does not mandate completion axillary dissection. Ann Surg. 2004;239:859–63.PubMedCrossRefGoogle Scholar
  10. 10.
    Goyal A, Douglas-Jones A, Newcombe RG, Mansel RE. Predictors of non-sentinel lymph node metastasis in breast cancer patients. Eur J Cancer. 2004;40:1731–7.PubMedCrossRefGoogle Scholar
  11. 11.
    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.PubMedCrossRefGoogle Scholar
  12. 12.
    Menes TS, Tartter PI, Mizrachi H. Breast cancer patients with pN0(i+) and pN1(mi) sentinel nodes have high rate of nonsentinel node metastases. J Am Coll Surg. 2005;200:323–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Ozmen V, Karanlik H, Cabioglu N, et al. Factors predicting the sentinel and non-sentinel lymph node metastases in breast cancer. Breast Cancer Res Treat. 2006;95:1–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Reynolds C, Mick R, Donohue JH, et al. Sentinel lymph node biopsy with metastasis: can axillary dissection be avoided in some patients with breast cancer? J Clin Oncol. 1999;17:1720–6.PubMedGoogle Scholar
  15. 15.
    Saidi RF, Dudrick PS, Remine SG, Mittal VK. Nonsentinel lymph node status after positive sentinel lymph node biopsy in early breast cancer. Am Surg. 2004;70:101–5.PubMedGoogle Scholar
  16. 16.
    Stitzenberg KB, Meyer AA, Stern SL, et al. Extracapsular extension of the sentinel lymph node metastasis: a predictor of nonsentinel node tumor burden. Ann Surg. 2003;237:607–12.PubMedCrossRefGoogle Scholar
  17. 17.
    Travagli JP, Atallah D, Mathieu MC, et al. Sentinel lymphadenectomy without systematic axillary dissection in breast cancer patients: predictors of non-sentinel lymph node metastasis. Eur J Surg Oncol. 2003;29:403–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Turner RR, Chu KU, Qi K, et al. Pathologic features associated with nonsentinel lymph node metastases in patients with metastatic breast carcinoma in a sentinel lymph node. Cancer. 2000;89:574–81.PubMedCrossRefGoogle Scholar
  19. 19.
    van der Loo EM, Hop WC, Tervoort MA, de Graaf PW. [Very slight chance of other metastases in axillary nodes of breast cancer patients with a small sentinel node metastasis without extranodal tumor growth]. Ned Tijdschr Geneeskd. 2004;148:938–43.PubMedGoogle Scholar
  20. 20.
    van Iterson V, Leidenius M, Krogerus L, von SK. Predictive factors for the status of non-sentinel nodes in breast cancer patients with tumor positive sentinel nodes. Breast Cancer Res Treat. 2003;82:39–45.PubMedCrossRefGoogle Scholar
  21. 21.
    Viale G, Maiorano E, Pruneri G, et al. Predicting the risk for additional axillary metastases in patients with breast carcinoma and positive sentinel lymph node biopsy. Ann Surg. 2005;241:319–25.PubMedCrossRefGoogle Scholar
  22. 22.
    Wada N, Imoto S, Yamauchi C, Hasebe T, Ochiai A. Predictors of tumour involvement in remaining axillary lymph nodes of breast cancer patients with positive sentinel lymph node. Eur J Surg Oncol. 2006;32:29–33.PubMedCrossRefGoogle Scholar
  23. 23.
    Weiser MR, Montgomery LL, Tan LK, et al. Lymphovascular invasion enhances the prediction of non-sentinel node metastases in breast cancer patients with positive sentinel nodes. Ann Surg Oncol. 2001;8:145–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Wong SL, Edwards MJ, Chao C, et al. Predicting the status of the nonsentinel axillary nodes: a multicenter study. Arch Surg. 2001;136:563–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Zavagno G, De Salvo GL, Bozza F, et al. Number of metastatic sentinel nodes as predictor of axillary involvement in patients with breast cancer. Breast Cancer Res Treat. 2004;86:171–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Van Zee KJ, Manasseh DM, Bevilacqua JL, et al. A nomogram for predicting the likelihood of additional nodal metastases in breast cancer patients with a positive sentinel node biopsy. Ann Surg Oncol. 2003;10:1140–51.PubMedCrossRefGoogle Scholar
  27. 27.
    van la Parra RF, Ernst MF, Barneveld PC, broekman JM, Rutten MJ, Bosscha K. The value of sentinel lymph node biopsy in ductal carcinoma in situ (DCIS) and DCIS with microinvasion of the breast. Eur J Surg Oncol. 2007.Google Scholar
  28. 28.
    Barranger E, Coutant C, Flahault A, Delpech Y, Darai E, Uzan S. 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.PubMedCrossRefGoogle Scholar
  29. 29.
    Cripe MH, Beran LC, Liang WC, Sickle-Santanello BJ. The likelihood of additional nodal disease following a positive sentinel lymph node biopsy in breast cancer patients: validation of a nomogram. Am J Surg. 2006;192:484–7.PubMedCrossRefGoogle Scholar
  30. 30.
    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.PubMedCrossRefGoogle Scholar
  31. 31.
    Houvenaeghel G, Nos C, Mignotte H, et al. Micrometastases in sentinel lymph node in a multicentric study: predictive factors of nonsentinel lymph node involvement. Groupe des Chirurgiens de la Federation des Centres de Lutte Contre le Cancer. J Clin Oncol. 2006;24:1814–22.PubMedCrossRefGoogle Scholar
  32. 32.
    Nos C, Harding-MacKean C, Freneaux P, et al. Prediction of tumour involvement in remaining axillary lymph nodes when the sentinel node in a woman with breast cancer contains metastases. Br J Surg. 2003;90:1354–60.PubMedCrossRefGoogle Scholar
  33. 33.
    Rivers AK, Griffith KA, Hunt KK, et al. Clinicopathologic features associated with having four or more metastatic axillary nodes in breast cancer patients with a positive sentinel lymph node. Ann Surg Oncol. 2006;13:36–44.PubMedCrossRefGoogle Scholar
  34. 34.
    Sachdev U, Murphy K, Derzie A, Jaffer S, Bleiweiss IJ, Brower S. Predictors of nonsentinel lymph node metastasis in breast cancer patients. Am J Surg. 2002;183:213–7.PubMedCrossRefGoogle Scholar
  35. 35.
    Schrenk P, Konstantiniuk P, Wolfl S, et al. Prediction of non-sentinel lymph node status in breast cancer with a micrometastatic sentinel node. Br J Surg. 2005;92:707–13.PubMedCrossRefGoogle Scholar
  36. 36.
    Alran S, De RY, Fourchotte V, et al. Validation and limitations of use of a breast cancer nomogram predicting the likelihood of non-sentinel node involvement after positive sentinel node biopsy. Ann Surg Oncol. 2007;14:2195–201.PubMedCrossRefGoogle Scholar
  37. 37.
    Cripe MH, Beran LC, Liang WC, Sickle-Santanello BJ. The likelihood of additional nodal disease following a positive sentinel lymph node biopsy in breast cancer patients: validation of a nomogram. Am J Surg. 2006;192:484–7.PubMedCrossRefGoogle Scholar
  38. 38.
    Dauphine CE, Haukoos JS, Vargas MP, Isaac NM, Khalkhali I, Vargas HI. 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.PubMedCrossRefGoogle Scholar
  39. 39.
    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.PubMedCrossRefGoogle Scholar
  40. 40.
    Klar M, Jochmann A, Foeldi M, et al. The MSKCC nomogram for prediction the likelihood of non-sentinel node involvement in a German breast cancer population. Breast Cancer Res Treat. 2008;112(3):523–31.PubMedCrossRefGoogle Scholar
  41. 41.
    Kocsis L, Svebis M, Boross G, et al. Use and limitations of a nomogram predicting the likelihood of non-sentinel node involvement after a positive sentinel node biopsy in breast cancer patients. Am Surg. 2004;70:1019–24.PubMedGoogle Scholar
  42. 42.
    Kohrt HE, Olshen RA, Bermas HR, et al. New models and online calculator for predicting non-sentinel lymph node status in sentinel lymph node positive breast cancer patients. BMC Cancer. 2008;8:66.PubMedCrossRefGoogle Scholar
  43. 43.
    Lambert LA, Ayers GD, Hwang RF, et al. Validation of a breast cancer nomogram for predicting nonsentinel lymph node metastases after a positive sentinel node biopsy. Ann Surg Oncol. 2006;13:310–20.PubMedCrossRefGoogle Scholar
  44. 44.
    Pal A, Provenzano E, Duffy SW, Pinder SE, Purushotham AD. A model for predicting non-sentinel lymph node metastatic disease when the sentinel lymph node is positive. Br J Surg. 2008;95:302–9.PubMedCrossRefGoogle Scholar
  45. 45.
    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.PubMedCrossRefGoogle Scholar
  46. 46.
    Smidt ML, Kuster DM, van der Wilt GJ, Thunnissen FB, Van Zee KJ, Strobbe LJ. Can the Memorial Sloan-Kettering Cancer Center nomogram predict the likelihood of nonsentinel lymph node metastases in breast cancer patients in the Netherlands? Ann Surg Oncol. 2005;12:1066–72.PubMedCrossRefGoogle Scholar
  47. 47.
    Soni NK, Carmalt HL, Gillett DJ, Spillane AJ. Evaluation of a breast cancer nomogram for prediction of non-sentinel lymph node positivity. Eur J Surg Oncol. 2005;31:958–64.PubMedCrossRefGoogle Scholar
  48. 48.
    Specht MC, Kattan MW, Gonen M, Fey J, Van Zee KJ. Predicting nonsentinel node status after positive sentinel lymph biopsy for breast cancer: clinicians versus nomogram. Ann Surg Oncol. 2005;12:654–9.PubMedCrossRefGoogle Scholar
  49. 49.
    Zgajnar J, Perhavec A, Hocevar M, et al. Low performance of the MSKCC nomogram in preoperatively ultrasonically negative axillary lymph node in breast cancer patients. J Surg Oncol. 2007;96:547–53.PubMedCrossRefGoogle Scholar
  50. 50.
    Hosmer DW, Lemeshow S. Applied logistic regression. 2nd ed. New York: Wiley; 2000.Google Scholar
  51. 51.
    Goyal A, Newcombe RG, Chhabra A, Mansel RE. Factors affecting failed localisation and false-negative rates of sentinel node biopsy in breast cancer—results of the ALMANAC validation phase. Breast Cancer Res Treat. 2006;99:203–8.PubMedCrossRefGoogle Scholar
  52. 52.
    Martin RC, Chagpar A, Scoggins CR, et al. Clinicopathologic factors associated with false-negative sentinel lymph-node biopsy in breast cancer. Ann Surg. 2005;241:1005–12.PubMedCrossRefGoogle Scholar
  53. 53.
    Wong SL, Edwards MJ, Chao C, et al. Sentinel lymph node biopsy for breast cancer: impact of the number of sentinel nodes removed on the false-negative rate. J Am Coll Surg. 2001;192:684–9.PubMedCrossRefGoogle Scholar
  54. 54.
    Truong PT, Bernstein V, Wai E, Chua B, Speers C, Olivotto IA. Age-related variations in the use of axillary dissection: a survival analysis of 8038 women with T1–ST2 breast cancer. Int J Radiat Oncol Biol Phys. 2002;54:794–803.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2009

Authors and Affiliations

  • R. F. D. van la Parra
    • 1
  • M. F. Ernst
    • 1
  • J. L. B. Bevilacqua
    • 2
  • S. J. J. Mol
    • 3
  • K. J. Van Zee
    • 4
  • J. M. Broekman
    • 3
  • K. Bosscha
    • 1
  1. 1.Department of SurgeryJeroen Bosch Hospital‘s-HertogenboschThe Netherlands
  2. 2.Department of Breast SurgeryHospital Sirio LibanesSão PauloBrazil
  3. 3.Department of PathologyJeroen Bosch Ziekenhuis ‘s-HertogenboschThe Netherlands
  4. 4.Department of SurgeryMemorial Sloan-Kettering Cancer CenterNew YorkUSA

Personalised recommendations