Rationale and Objectives
To test the ability of quantitative measures from preoperative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to predict, independently and/or with the Katz pathologic nomogram, which breast cancer patients with a positive sentinel lymph node biopsy will have four or more positive axillary lymph nodes on completion axillary dissection.
Materials and Methods
A retrospective review was conducted to identify clinically node-negative invasive breast cancer patients who underwent preoperative DCE-MRI, followed by sentinel node biopsy with positive findings and complete axillary dissection (June 2005–January 2010). Clinical/pathologic factors, primary lesion size, and quantitative DCE-MRI kinetics were collected from clinical records and prospective databases. DCE-MRI parameters with univariate significance ( P < .05) to predict four or more positive axillary nodes were modeled with stepwise regression and compared to the Katz nomogram alone and to a combined MRI–Katz nomogram model.
Results
Ninety-eight patients with 99 positive sentinel biopsies met study criteria. Stepwise regression identified DCE-MRI total persistent enhancement and volume adjusted peak enhancement as significant predictors of four or more metastatic nodes. Receiver operating characteristic curves demonstrated an area under the curve of 0.78 for the Katz nomogram, 0.79 for the DCE-MRI multivariate model, and 0.87 for the combined MRI–Katz model. The combined model was significantly more predictive than the Katz nomogram alone ( P = .003).
Conclusions
Integration of DCE-MRI primary lesion kinetics significantly improved the Katz pathologic nomogram accuracy to predict the presence of metastases in four or more nodes. DCE-MRI may help identify sentinel node–positive patients requiring further local-regional therapy.
For breast cancer patients without clinical axillary lymph node involvement, sentinel lymph node biopsy has become the standard of care for assessing local-regional extent of the disease. It is well agreed on that patients with negative sentinel sampling need no further axillary surgery . However, which patients may avoid completion axillary dissection after positive sentinel sampling is an evolving consideration, especially in the setting of adjuvant radiotherapy. Furthermore, optimal design of radiotherapy fields with regard to regional lymphatic coverage is not known.
Very low rates of local-regional recurrence in select sentinel node–positive patients who forego axillary dissection in the setting of planned radiotherapy supports a movement away from completion axillary dissection in low-risk patients. However, low-risk criteria have not been precisely defined . The rationale behind the increasing tendency to avoid additional surgery is clear—completion axillary dissection carries a 10%–40% risk of lymphedema , and excellent local control of the axilla has been demonstrated in previous studies with radiation therapy alone .
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Materials and methods
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Pathology
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DCE-MRI Acquisition
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DCE-MRI Data Analysis
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Early-phase kinetics
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Delayed-phase kinetics
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Statistical Analysis
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Results
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Table 1
Patient and Breast Cancer Pathologic Characteristics
Characteristics Mean ± Standard Deviation Range Patient age (years) 55.5 ± 10.4 31.5–75.4 Pathologic primary cancer size at the time of lumpectomy (cm) 3.2 ± 2.1 0.0–10.0 Number of positive sentinel lymph nodes 1.7 ± 1.3 1–11 Number of positive lymph nodes at completion dissection in patients with positive completion dissections 6.1 ± 7.3 1–29
Proportion Lobular histology 33/99 = 33% Estrogen receptor positive 94/99 = 95% Progesterone receptor positive 87/99 = 88% Her-2 positive 8/99 = 8% Nottingham grade 1 24/99 = 24% 2 50/99 = 51% 3 25/99 = 25%
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Table 2
Univariate Analysis—Correlations with Presence of Four or More Positive Axillary Lymph Nodes
Parameter Metric OR (95% CI)P Value Primary lesion volume Per log increase 2.20 (1.1–4.2) .009 Initial peak enhancement 2.12 (0.4–11.3) .32 Volume × peak 2.02 (1.1–3.7) .01 Percent rapid enhancement Per 10% increase 0.87 (0.7–1.0) .10 Percent rapid persistent enhancement 1.24 (0.9–1.7) .19 Percent rapid plateau enhancement 0.78 (0.5–1.1) .19 Percent rapid washout 0.66 (0.5–0.9) .005 Percent medium enhancement 1.21 (1.0–1.4) .02 Percent medium persistent enhancement 1.39 (1.2–1.7) .0003 Percent medium plateau enhancement 0.82 (0.5–1.3) .35 Percent medium washout 0.59 (0.3–1.2) .09 Total percent persistent enhancement 1.49 (1.2–1.8) <.0001 Total percent plateau enhancement 0.77 (0.6–1.1) .09 Total percent washout 0.69 (0.5–0.9) .002
CI, confidence interval; OR, odds ratio.
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Discussion
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