Retrospective Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Oncol. Aug 24, 2021; 12(8): 675-687
Published online Aug 24, 2021. doi: 10.5306/wjco.v12.i8.675
Macrometastasis at selective lymph node biopsy: A practical going-for-the-one clinical scoring system to personalize decision making
Mercedes Herrero, Raquel Ciérvide, Maria Elisa Calle-Purón, Javier Valero, Paula Buelga, Isabel Rodriguez-Bertos, Leticia Benassi, Angel Montero
Mercedes Herrero, Javier Valero, Paula Buelga, Isabel Rodriguez-Bertos, Leticia Benassi, Department of Gynecology and Obstetrics, HM Hospitales, Madrid 28050, Spain
Raquel Ciérvide, Angel Montero, Department of Radiation Oncology, HM Hospitales, Madrid 28050, Spain
Maria Elisa Calle-Purón, Department of Preventive Medicine and Public Health, Complutense University of Madrid, Madrid 28050, Spain
Author contributions: Herrero M, Ciérvide R, Calle-Purón ME, Valero J, Buelga P, Rodriguez-Bertos Isabel, Benassi L and Montero A conceived the clinical protocol; Herrero M, Buelga P, Rodriguez-Bertos I and Benassi L carried out the surgical procedures; Valero J encouraged Mercedes Herrero to investigate this topic and supervised the findings of this work; Herrero M analyzed data; Calle-Purón ME verified the analytical methods; Ciérvide R and Montero A wrote the manuscript, tables and figure; All the authors read, reviewed and accepted manuscript.
Institutional review board statement: This study was reviewed and approved by the Comité Ético de Investigación con medicamentos de HM Hospitales the April 27, 2016, Acta Nº90. CEIm HM hospitales Code: 16.04.0940-GHM. And having evaluated the project from an ethical and methodological point of view, it issues a FAVORABLE OPINION for the project to be carried out by the main researcher Dr. Mercedes Herrero Conde, from the Gynecology service of HM Hospitales.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Data sharing statement: The datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Raquel Ciérvide, MD, Attending Doctor, Staff Physician, Department of Radiation Oncology, HM Hospitales, Oña, 10, Madrid 28050, Spain. raquel.ciervide@gmail.com
Received: December 29, 2020
Peer-review started: December 30, 2020
First decision: May 4, 2021
Revised: May 5, 2021
Accepted: July 9, 2021
Article in press: July 9, 2021
Published online: August 24, 2021
Processing time: 236 Days and 7.9 Hours
Abstract
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 long-term 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.

Keywords: Sentinel lymph node biopsy, Complete axillary lymph node dissection, Preoperative clinical risk index, Macrometastasis

Core Tip: The role of completion axillary lymph node dissection (cALND) following a positive sentinel lymph node biopsy (SLNB) is being actively debated. Patients with a positive SLNB performed at our institution who also underwent a cALND were analyzed. Univariate and multivariate analysis of prognostic and predictive factors were used to create a Preoperative Clinical Risk Index (PCRI). The PCRI could help estimate the risk in removing extra positive nodes beyond the SLN in order to identify which patients could safely avoid cALND. Further prospective studies are necessary to validate clinical generalization for suggested tool.