Axillary lymph node status and invasive lobular breast cancer

Background Invasive lobular carcinoma (ILC) represents the second most common type of invasive breast cancer (BC). Although ILC generally have good prognostic properties (positive estrogen receptor, ER, low tumor grade), they are generally diagnosed at a more advanced stage. The data on the axillary lymph node status in ILC compared to invasive ductal carcinoma (IDC) are considered controversial. Therefore, the aim of this study was to compare the pathological node stage (pN) between ILC and IDC in an Austria-wide register. Methods Data of the Clinical Tumor Register (Klinisches TumorRegister, KTR) of the Austrian Association for Gynecological Oncology (AGO) were retrospectively analyzed. Patients with primary early BC, invasive lobular or ductal, diagnosed between January 2014 and December 2018, and primary surgery were included. A total of 2127 tumors were evaluated and compared in 2 groups, ILC n = 303, IDC n = 1824. Results A total of 2095 patients were analyzed in the study. In the multivariate analysis, pN2 and pN3 were observed significantly more frequently in ILC compared with IDC (odds ratio, OR 1.93; 95% confidence interval, CI 1.19–3.14; p = 0.008 and OR 3.22; 95% CI: 1.47–7.03; p = 0.003; respectively). Other factors associated with ILC were tumor grades 2 and 3, positive ER, and pathological tumor stage (pT) 2 and pT3. In contrast, concomitant ductal carcinoma in situ, overexpression of the human epidermal growth factor receptor 2 (HER2), and a moderate and high proliferation rate (Ki67) were found less frequently in ILC. Conclusion The data show an increased risk of extensive axillary lymph node metastasis (pN2/3) in ILC.


Background
Invasive breast cancer (BC) is considered a heterogeneous disease. After invasive ductal carcinoma (IDC), invasive lobular carcinoma (ILC) represents the second most common type of invasive BC, comprising up to 15% of all cases [1][2][3].
The ILC is characterized by diffuse infiltration of the stroma with a single file pattern. The loss or lack of epithelial E-cadherin expression represents a characteristic feature of ILC. E-cadherin mediates cell-cell adhesion and dysregulation results in distinctive discohesive growth patterns observed in ILC. Thus, E-cadherin antibodies are used to differentiate between lobular and ductal lesions by immunohistochemistry [4,5].
The ILC distinctly differs from IDC in its clinicopathological characteristics and molecular alterations. Compared to IDC, ILC is more frequently multifocal, multicentric, and bilateral. Many studies show that ILC is associated with a good prognostic phenotype such as positive hormone receptors (HR) (both estrogen and progesterone receptors, ER, PR), human epidermal growth factor receptor 2 (HER2)-negativity, low tumor grade, and a low to moderate proliferation index. Despite these good prognostic properties, invasive lobular tumors are generally diagnosed at a more advanced stage. Furthermore, there is a tendency for late recurrences, and a higher rate of multiple metastases with a variable pattern of involvement of distant sites [3,[6][7][8][9][10][11][12][13][14][15][16][17][18].
The axillary lymph node (ALN) involvement represents one of the most important prognostic factors in early BC [19][20][21][22][23][24][25]; however, previous studies have shown controversial results regarding the ALN status between ILC and IDC. There are many studies demonstrating that the ALN involvement does not differ between both groups [10,26,27]; however, some studies showed an association between ILC and a higher incidence of positive ALN involvement [8,28,29]. In contrast, there are studies reporting less frequent ALN positivity in ILC [30,31]. Therefore, the aim of this study was to compare the pathological node stage (pN) between ILC and IDC in an Austria-wide register.

Study population
This was a retrospective study based on data from patients of the Clinical Tumor Register (Klinisches TumorRegister, KTR) of the Austrian Association for Gynecological Oncology (AGO). Women with primary early BC, invasive lobular or ductal, diagnosed between January 2014 and December 2018, and pri-464 Axillary lymph node status and invasive lobular breast cancer K original article mary surgery were enrolled in the study. Exclusion criteria were patients with both ductal and lobular carcinoma, patients who had neoadjuvant therapy, patients with recurrent disease, and patients with primary metastatic disease. In cases of bilateral BC, both sides were included as separate tumors. Altogether, the analysis was based on 2095 patients (bilateral cancer n = 32), all 2127 tumors were evaluated and compared in 2 groups, ILC n = 303 (14.2%), IDC n = 1824 (85.8%).
The KTR represents a computerized database and cancer register collecting data on breast, endometrial, ovarian, and cervical cancer from hospitals throughout Austria (https://ktr.iet.at). This register is maintained by the Department of Clinical Epidemiology, Tyrolean Federal Institute of Integrated Care, Innsbruck, Austria (https://www.iet.at).
In this study, the following clinicopathological parameters of BC patients were evaluated: age at diagnosis, menopausal status, bilateral cancer, tumor morphology, concomitant ductal carcinoma in situ (DCIS) component, tumor grade, immunohistochemical parameters (ER, PR, HER2, Ki67, ≤ 14% low, 15-40% intermediate, > 40% high), lymphovascular invasion (LVI), blood vessel invasion (BVI), and pathological tumor (pT) stage and pathological node (pN) stage. Additionally, we evaluated the axillary dissection rate, and the total number of lymph nodes removed. Comparisons were then made between patients/tumors divided into two separate histologic subgroups: IDC and ILC.

Statistical analysis
Descriptive statistics were performed to analyze the characteristics of the two histopathological groups (ILC and IDC). The χ 2 and Fisher's exact (for smaller sample sizes) tests were used to investigate the proportions of the clinical histopathological characteristics between ILC and IDC. Logistic regression was performed to identify independent parameters associated with ILC and IDC. Associations were summarized using the odds ratios (OR) and corresponding 95% CI derived from the model estimates. We excluded all unknown or undetermined values from the analysis. Statistical significance was considered at p < 0.05 (twotailed). We performed all statistical analyses using the statistical software package R version 3.4.1 [32].

Ethics approval
This study was approved by the ethics committee of the Medical University of Vienna (1589/2019). All procedures performed in the study were in accordance with the ethical standards of the institutional committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. According to the ethics committee of the Medical University of Vienna, written informed consent was not required owing to the retrospective design of the study.

Results
Altogether 2095 patients were evaluated in the study. The study population comprised 2 subgroups: 297 patients with ILC (14.2%) and 1798 patients with IDC (85.8%). The characteristics of the patients are summarized in Table 1. The mean age at diagnosis was 65.0 years (standard deviation (SD): 12.4) in patients with ILC compared to 63.0 years (SD: 12.9) in IDC patients (p = 0.01). We found no significant difference in the distributions of age at diagnosis between both groups (p = 0.27). Premenopausal patients were significantly more common in the IDC (n = 402, 22.4%) compared to the ILC group (n = 49, 16.5%) (p = 0.03). Bilateral BC was diagnosed in 32 (1.5%) patients; bilateral cancers did not differ between the groups (p = 0.62).
An axillary lymph node dissection was performed in 94 (31.0%) of invasive lobular versus 509 (27.9%) of invasive ductal carcinomas (p = 0.18). The mean total number of lymph nodes removed was 5.2 (SD: 5.6) in lobular versus 4.8 (SD: 5.1) in ductal tumors (p = 0.79) ( Table 2).  were found to be independent parameters; however, when these features were put into a multivariate regression model and adjusted for age, the following parameters were observed significantly more fre- In our study, mean age at diagnosis was significantly different (ILC: 65.0 years, IDC: 63.0 years, p = 0.01). Older age at diagnosis has been reported in several studies [6,10,11,13,17,26,31,33]. Otherwise, age at diagnosis did not differ significantly between ILC and IDC [34][35][36]. Compared to patients with IDC, patients with ILC were less frequently premenopausal in our analysis; however, there are reports about no difference regarding the menopausal status in the literature [17,33].
Patients with ILC presented more frequently with grade 2 tumors in comparison with IDC patients. This has been reported previously in several studies [13,17,29,31]. According to our findings, more frequent ER-positivity in ILC was observed in different studies comparing these tumors with IDC [7,9,10,16,17,29,36]. We found more HER2-negative tumors with ILC, and several similar reports exist in the literature [1,10,12,13,37]. Our findings show a slow or moderate proliferation rate (Ki67) more frequently in lobular Table 4 Published data on the ALN involvement in ILC compared with IDC

No difference in ALN involvement between ILC and IDC
Association between ILC and higher incidence of positive ALN involvement Association between ILC and lower incidence of positive ALN involvement ALN axillary lymph node, IDC invasive ductal carcinoma, ILC invasive lobular carcinoma tumors. Other studies revealed that ILC was more often slowly proliferative [10,12,37]. In our analysis, there were no significant differences found according to bilateral BC, PR, lymphovascular and blood vessel invasion. As in our study, ILC was associated with a larger tumor size in several trials [6-8, 10, 12, 13, 17, 29, 31, 38]; however, some studies found no difference in tumor size between ILC and IDC [16,26,35,36].
In the descriptive analysis, we found a significantly different pN distribution between ILC and IDC. The multivariate analysis identified pN2 and pN3 as associated with ILC; however, published data on the ALN status in ILC compared with IDC are controversial [8,10,[26][27][28][29][30][31]. Table 4 represents an overview of published data on the nodal status in association with the histological subtype.
Most studies showed that the ALN involvement did not differ between these histopathological groups [10-12, 16, 17, 26, 27, 33, 36, 39, 40]. Arpino et al. [10] compared 4140 patients with ILC with 45,169 patients with IDC; there was no difference in the frequency of ALN involvement. Furthermore, nodal status did not differ between ILC and IDC in an analysis of 13,220 patients [17]; however, several studies found an association between ILC and a higher incidence of ALN positivity [7,8,13,28,29,38]. Wasif et al. [7] demonstrated that ILC was more likely to be lymph node positive, when compared to IDC (36.8% versus 34.4%; p < 0.001). Evaluation of the Surveillance, Epidemiology and End Results Program (SEER) database showed a correlation between the ILC group and greater counts of positive lymph nodes [13]. In contrast, there are studies showing less frequent ALN involvement in ILC [9,30,31]. In a multivariate analysis, Vandorpe et al. [31] identified ILC as less likely to have ALN involvement (adjusted OR: 0.66; 95% CI: 0.53-0.82; p < 0.001). The authors retrospectively investigated 4292 tumors (ILC versus non-ILC). In contrast to our study, tumors with mixed ductal and lobular phenotypes were included. In conclu-sion, the lobular histology has been identified as an independent predictor of ALN involvement.
Limitations of this study are a moderate sample size and the retrospective design. Nevertheless, our results were similar to previously reported findings. In our analysis, we did not differentiate between the histological subtypes of ILC (e.g. classical, solid, alveolar); however, it is important to note that the patient collective of this investigation is quite homogeneous due to the inclusion and exclusion criteria: all patients underwent primary surgery, no patients with recurrent disease, or metastasis at the time of diagnosis.
In summary, this study was based on an Austrian cancer register. Our findings demonstrate an increased risk of extensive axillary lymph node metastasis (pN2/3) in ILC. Other factors associated with ILC were tumor grades 2 and 3, positive ER, and pT2 and pT3. In contrast, DCIS component, HER2+, and moderate or high Ki67 were found less frequently in ILC.
In the future, meta-analyses and pooling of data are required to make progress in research of ILC as a distinct histologic type of BC.

Conclusion
The findings support an increased risk of extensive axillary lymph node metastasis (pN2/3) in ILC.
Funding There is no funding of the study.
Author Contribution Sabine Danzinger, Karin Pöckl, Christian Pfeifer, Sandra Behrendt, Patricia Gscheidlinger, Lois Harrasser, Helmut Mühlböck, Irmgard Delmarko, and Christian F. Singer contributed to study conception and design. Sabine Danzinger, Karin Pöckl, Gerit Kronawetter, Walter Dirschlmayer, Christian Schauer, Roland Reitsamer, Heide-marieUher, KristinaSchönau, andChristian F. Singer provided the findings and contributed to the literature search. Sabine Danzinger, Sandra Behrendt, Patricia Gscheidlinger, Helmut Mühlböck, Irmgard Delmarko, and Christian F. Singer contributed to collection and assembly of data. All authors contributed to data analysis and interpretation. Sabine Danzinger, Karin Pöckl, Christian Pfeifer, and Christian F. Singer contributed to writing the manuscript. All authors contributed to the review and approval of the manuscript. Ethical standards The study was approved by the ethics committee of the Medical University of Vienna. All procedures performed in our study were in accordance with the ethical standards of the institutional committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. According to the ethics committee of the Medical University of Vienna, written informed consent was not required owing to the retrospective design of the study.
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