New Study Examines Correlation Of Node Status With 21
4/7/2022 12:32:11 PM
Positive lymph node status may not be a reliable indicator of the need for adjuvant chemotherapy, and sentinel node biopsy may be unnecessary in older women with certain low-risk cancers, according to a new study presented by Nicholson et al at the American Society of Breast Surgeons 23rd Annual Meeting. The study examined the correlation between nodal status and 21-gene recurrence score, which reflects a tumors individual biology and is considered among the most reliable tools for chemotherapy decision-making.
While 2016 Choosing Wisely guidelines advise against performing sentinel node biopsies on women aged 70 or older with hormone receptorpositive breast cancer, studies show physicians continue to do so for 65% to 85% of these patients. Lead study author Katharine Yao, MD, Vice Chair of Research, NorthShore University Health System and Clinical Professor of Surgery at the Pritzker School of Medicine, University of Chicago, hypothesized that one reason surgeons continue to perform sentinel node biopsy on this patient population is to obtain nodal status for adjuvant chemotherapy decisions. However, the new study found that regardless of their nodal status, a similar proportion of these women had 21-gene recurrence scores qualifying them for adjuvant chemotherapy.
More Study Information
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. and does not necessarily reflect the ideas and opinions of ASCO®.
A Young Woman With A Small Er
Anthony D. Elias, MDOncology
patient is a 39-year-old premenopausal woman who presents with a new diagnosis of breast cancer to our multidisciplinary second opinion clinic.
SECOND OPINION
Multidisciplinary Consultations on Challenging Cases
E. David Crawford, MD
University of Colorado Health Sciences CenterUniveristy of Colorado Cancer Center Denver, Colorado
The patient is a 39-year-old premenopausal woman who presents with a new diagnosis of breast cancer to our multidisciplinary second opinion clinic.
Stage Ii Breast Cancer
Stage II is one of the following:
- The tumor is no more than 2 centimeters across. The cancer has spread to the lymph nodes under the arm.
- The tumor is between 2 and 5 centimeters . The cancer has not spread to the lymph nodes under the arm.
- The tumor is between 2 and 5 centimeters . The cancer has spread to the lymph nodes under the arm.
- The tumor is larger than 5 centimeters . The cancer has not spread to the lymph nodes under the arm.
Stage IIA – T0, N1, M0 or T1, N1, M0 or T2, N0, M0
Stage IIB – T2, N1, M0 or T2, N0, M0
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What Happens When Breast Cancer Spreads
Breast cancer can spread to other parts of the body. This happens primarily through the lymph nodes, and a much smaller portion through the blood vessels. Here is a discussion of the role of the lymphatic system in breast cancer.
For a quick refresher, lymph nodes are kidney bean shaped organs that are scattered all over the body, but have 5 concentrated areas, one of which is the underarms. The lymph nodes in the underarms primarily take care of the breast and arm on the same side. They help to stimulate your immune system to fight off intruders. They also transport fighter cells to the bone marrow. When cancer cells are trapped in the lymph nodes, they may be destroyed by the immune system, or they may spread to other areas from there.
When there is breast cancer in your lymph nodes, you may not notice any symptoms at all. In fact, it is not until the lymph nodes are overloaded with cancer and swollen that you may notice a lump in the underarm or even swelling of the arm or breast on the same side.
Once breast cancer leaves the lymph nodes, it is considered metastatic, or stage IV.
There are times when breast cancer is metastatic, or spread to other organs, when it is first diagnosed. In these cases, breast cancer was not detected in the breast before it spread to other parts of the body.
Increasing Negative Lymph Node Count Predicts Favorable Os And Dss In Breast Cancer With Different Lymph Node
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Roles Data curation, Formal analysis, Investigation, Software, Validation, Writing original draft
Affiliation Department of General Surgery, Tianjin First Central Hospital,Tianjin,China
- Jing Wei,
Roles Formal analysis, Investigation, Methodology, Writing original draft
Affiliation Department of Thoracic Surgery, Xuzhou Central Hospital, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, China
- Xiaoxin Li,
Roles Software, Supervision, Validation
Affiliation Department of Pathology, Xuzhou Central Hospital, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, China
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Affiliation College of Clinical Medicine, Binzhou Medical University, Yantai, China
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Contributed equally to this work with: Pei Wang, Susheng Cao
Roles Conceptualization, Project administration, Supervision, Validation, Writing review & editing
* E-mail:
Affiliation Department of Breast Surgery, Xuzhou Central Hospital, The Affiliated Xuzhou Hospital of Medical College of Southeast University,Xuzhou, China
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Contributed equally to this work with: Pei Wang, Susheng Cao
Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Writing review & editing
* E-mail:
Affiliation Department of Breast Surgery, Xuzhou Central Hospital, The Affiliated Xuzhou Hospital of Medical College of Southeast University,Xuzhou, China
Read Also: How I Discovered I Had Breast Cancer
Are There Symptoms Of Breast Cancer In The Lymph Nodes
You probably wouldnt notice if a few cancer cells reached a lymph node. As the number of cancer cells grows, symptoms can include lumps or swelling in the armpits or around the collarbone.
Its possible to have enlarged lymph nodes even if you havent discovered a lump in your breast. There are also noncancerous conditions that cause enlarged lymph nodes in an area close to the breasts.
If you notice enlarged lymph nodes but no other symptoms or signs, schedule an appointment with a doctor.
- your genetics or inherited genes
The Korean Breast Cancer Registry
All data used in this study were retrieved from the Korean Breast Cancer Registry , which has prospectively maintained an online database to store information on each patients Korean personal identification number, age, type of surgery, primary tumour size, number of positive/dissected nodes, oestrogen receptor /progesterone receptor status, histologic grade, and details of adjuvant therapy. Nation-wide collaborative efforts from 102 general hospitals, including 41 university hospitals, have contributed to the KBCR database since 1996 . Exploiting the patients identification number as a unique identifier, we amalgamated the KBCR database with two population-based sources of information: the Korean Central Cancer Registry, which provides patients survival data, and the Korean National Statistical Office, which publishes complete death statistics.
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What Is Breast Cancer In Men
Breast Cancer in men is a type of cancer that occurs in the non-functional milk ducts, glands, and breast tissues. Mens breasts have fatty tissues, breast cells, and ducts. Breast tissues in men are similar to that of a pre-puberty girl. These tissues in men do not grow much because they have low levels of female hormones. Cancer develops when healthy cells grow out of control, forming a mass of cells called a tumor.
A tumor can be malignant or benign. The tumor is malignant if it grows and spreads to other parts of the body. On the other hand, a benign tumor can grow but doesnt spread to other body parts. When Breast Cancer spreads to the other body parts through the lymph or blood, it is called metastasis.
About The Lymph Nodes
The lymphatic system helps protect us from infection and disease. It also drains lymph fluid from the tissues of the body, before returning it to the blood.
The lymphatic system is made up of fine tubes called lymphatic vessels. They connect to groups of lymph nodes throughout the body.
Lymph nodes are small and bean-shaped. They filter bacteria and disease from the lymph fluid. When you have an infection, lymph nodes often swell as they fight the infection.
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What Difference Will This Project Make
Michael hopes that this project could lead to a widely used test that can identify the cases where breast cancer cells in the lymph nodes will not respond to hormone treatment, while the tumour in the breast will. Once these people can be identified the this gives the opportunity to add new treatments, to improve the survival of people with breast cancer.
Michael also hopes to improve the treatment of all hormone therapy resistant breast cancers. By studying how and why hormone therapy resistance happens, he hopes to be able to improve the treatment and overall outcomes for women with ER+ cancer.
What About High Risk Dcis
The prevailing consensus is that a sentinel lymph node biopsy is unnecessary with DCIS.
Critics might argue that high risk DCIS can potentially be understaged . However, the relative convenience of the SLNB warrants its application from the get-go.
There are two main reasons why breast cancer patients and researchers can be somewhat eager to have a sentinel node biopsy. Firstly, the sensitivity of the sentinel lymph node biopsy is a huge bonus. Secondly, the detection of the presence of micro-metastasis on the lymph nodes.
However, it is important to remember that up to 90% of all ductal carcinomas can be treated and cured locally.
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Where Does Breast Cancer Spread To
Breast cancer cells seem to prefer to settle into:-
- long bones in the arms and legs
- ribs
- skull
With an osteolytic metastasis, the cancer kind of eats away at the bone, creating holes.
With an osteoblastic bone metastasis, the bone mineral density actually increases, but this can cause the bones to fracture more easily. This requires a little more explanation. Breast cancer metastases tend to be lytic when they are untreated, and then they become densely sclerotic as they respond to treatment.
Even if no treatment is given yet, an osteoblastic metastasis from breast cancer generally indicates that the persons own body is trying to fight cancer with some success.
A CT scan may also be used to check for metastasis to the lungs or liver. A CT scan is essentially an X-ray linked to a computer. The breast cancer doctor injects a contrast dye agent into the bloodstream and this makes any cancer cells in the liver and chest easier to see.
Lymph Node Surgery For Breast Cancer
If breast cancer spreads, it typically goes first to nearby lymph nodes under the arm. It can also sometimes spread to lymph nodes near the collarbone or near the breastbone . Knowing if the cancer has spread to your lymph nodes helps doctors find the best way to treat your cancer.
If you have been diagnosed with breast cancer, its important to find out how far the cancer has spread. To help find out if the cancer has spread outside the breast, one or more of the lymph nodes under the arm are removed and checked in the lab. This is an important part of staging. If the lymph nodes have cancer cells, there is a higher chance that cancer cells have also spread to other parts of the body. More imaging tests might be done if this is the case.
Lymph node removal can be done in different ways, depending on whether any lymph nodes are enlarged, how big the breast tumor is, and other factors.
Read Also: How To Know If You Got Breast Cancer
How Does Cancer Spread To Lymph Nodes
Cancer can spread from where it started to other parts of the body.
When cancer cells break away from a tumor, they can travel to other areas through either the bloodstream or the lymph system. If they travel through the lymph system, the cancer cells may end up in lymph nodes. Most of the escaped cancer cells die or are killed before they can start growing somewhere else. But one or two might settle in a new area, begin to grow, and form new tumors. This spread of cancer to a new part of the body is called metastasis.
In order for cancer cells to spread to new parts of the body, they have to go through several changes. They must become able to break away from the original tumor and attach to the outside wall of a lymph or blood vessel. Then they must move through the vessel wall to flow with the blood or lymph to a new organ or lymph node.
When cancer does spread to lymph nodes, it usually spreads to nodes near the tumor itself. These are the nodes that have been doing most of the work to filter out or kill the cancer cells.
Overall The Sentinel Lymph Nodes In Breast Biopsy Is A Major Plus For Breast Cancer Treatment
Now that the SLNB is in widespread use, the challenge for researchers is to refine the groups of patients who will most benefit from the technique. The main benefit is in identifying patients with less aggressive cancers, who may not need complete lymph node dissection.
Additional benefits of bypassing axillary dissection, from a purely medical perspective, is that the normal flow of lymph fluid is relatively undisturbed. This adds to the benefit of preventative chemical and radiation therapies already underway.
For all breast cancers, between 70% to 80% of patients will not develop axillary lymph node metastasis. Therefore, for breast cancer patients undergoing multimodal therapiesand with histologically negative sentinel lymph nodes, the rate of recurrent disease is extremely low.
Some cancer treatment centers, particularly those in less affluent parts of the world, have gone so far as to replace all other diagnostic measures for axillary metastasis with the sentinel lymph node biopsy.
It is reliable and accurate and improves long term quality of life by avoiding axillary dissection. This is, of course, somewhat of a radical conclusion but does highlight the practical and ethical dilemmas women sometimes encounter during breast cancer treatment.
The best advice is to develop good relationships with an experienced multidisciplinary breast cancer treatment team and to trust their judgement.
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Limited Arm And Shoulder Movement
You might also have limited movement in your arm and shoulder after surgery. This is more common after ALND than SLNB. Your doctor may advise exercises to help keep you from having long-lasting problems .
Some women notice a rope-like structure that begins under the arm and can extend down toward the elbow. This is sometimes called axillary web syndrome or lymphatic cording. It is more common after ALND than SLNB. Symptoms may not appear for weeks or even months after surgery. It can cause pain and limit movement of the arm and shoulder. This often goes away without treatment, although some women may find physical therapy helpful.
What Does It Mean If Theres Cancer In My Lymph Node
If cancer is found in one or more lymph nodes, it could mean that more tests are needed to know how far the cancer has spread. This information is used to determine the stage of your cancer and the best treatment options.
For more information on staging, see Cancer Staging, or find your cancer type for more detailed information.
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Breast Cancer Staging And Lymph Nodes
After an initial cancer diagnosis, youll need to know if it has spread beyond the primary tumor. If you have enlarged lymph nodes, your doctor may be able to perform a needle biopsy. Otherwise, the lymph nodes can be checked when you have breast surgery.
Your doctor will assign a clinical stage based on:
- a physical exam
- imaging tests
- a biopsy of the tumor
After surgery, youll have more detailed information from the breast tissue and lymph nodes. This information helps provide the pathological stage.
Lymph node involvement is a key factor in staging breast cancer. In the TNM staging system:
- T is for tumor size
- N represents lymph node involvement
- M is for metastasis
Heres a closer look at what to know about cancer cells and lymph node involvement.
Breast Cancer Progression Tends To Be Consistent And Predictable
There are many ways that breast cancer can develop but most of the time it starts in the breast ducts.
While cancer is still confined to the breast ducts, specialists refer to it as ductal carcinoma in situ, or DCIS. The good news is that if breast screening detects cancer at this in-situ stage, the chance of survival is close to 100%.
As cancer moves into the breast duct wall and finally begins to affect the surrounding breast tissue, specialists call it infiltrative or invasive breast cancer.
If treatment does not occur, breast cancer will usually spread to other areas of the body . Very often the first area that cancer usually spreads to is the lymph nodes in the underarm area .
Once cancer enters the lymphatic system, it can and usually does spread to other areas of the body. Sometimes this is called distant metastasis.
Not all breast cancers spread first to the axillary lymph nodes and then to the rest of the body. If the breast tumor occurs near the nipple, cancer may spread first to the internal mammary nodes beneath the sternum. And in some cases, the breast cancer can spread via the bloodstream without involving the lymphatic system.
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What This Means For You
If youve been diagnosed with early-stage breast cancer, your doctor may recommend treatments after surgery to reduce your risk of recurrence.
If you were diagnosed with hormone receptor-positive, early-stage breast cancer, its likely that your doctor will recommend you take some type of hormonal therapy medicine either tamoxifen or an aromatase inhibitor depending on your menopausal status for five to 10 years after surgery.
Chemotherapy after surgery is usually completed in three to six months. If youre also receiving a targeted therapy, such as Herceptin , with chemotherapy, you may continue to receive the targeted therapy for up to a year after completing chemotherapy.
Radiation therapy after surgery can be completed in one to seven weeks.
So, hormonal therapy after surgery takes the longest to complete. Hormonal therapy medicines also can cause troubling side effects, such as hot flashes, night sweats, and joint pain. Less common but more severe side effects include heart problems and blood clots.
Research has shown that about 25% of women who are prescribed hormonal therapy to reduce the risk of recurrence after surgery either dont start taking the medicine or stop taking it early, in many cases because of side effects.
Learn more about Staying on Track With Treatment. You can read about why its so important to stick to your treatment plan, as well as ways to manage side effects after radiation, chemotherapy, and hormonal therapy.