Observational Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Oncol. Sep 24, 2022; 13(9): 748-757
Published online Sep 24, 2022. doi: 10.5306/wjco.v13.i9.748
Factors predicting upstaging from clinical N0 to pN2a/N3a in breast cancer patients
Goshi Oda, Tsuyoshi Nakagawa, Hiroki Mori, Iichiro Onishi, Tomoyuki Fujioka, Mio Mori, Kazunori Kubota, Ryoichi Hanazawa, Akihiro Hirakawa, Toshiaki Ishikawa, Kentaro Okamoto, Hiroyuki Uetakesszsz
Goshi Oda, Tsuyoshi Nakagawa, Department of Breast Surgery, Tokyo Medical and Dental University, Tokyo 1138519, Japan
Hiroki Mori, Department of Plastic and Reconstructive Surgery, Tokyo Medical and Dental University, Tokyo 1138519, Japan
Iichiro Onishi, Department of Pathology, Tokyo Medical and Dental University, Tokyo 1138519, Japan
Tomoyuki Fujioka, Mio Mori, Kazunori Kubota, Department of Radiology, Tokyo Medical and Dental University, Tokyo 1138519, Japan
Ryoichi Hanazawa, Akihiro Hirakawa, Department of Clinical Biostatistics, Tokyo Medical and Dental University, Tokyo 1138519, Japan
Toshiaki Ishikawa, Kentaro Okamoto, Hiroyuki Uetakesszsz, Department of Specialized Surgeries, Tokyo Medical and Dental University, Tokyo 1138519, Japan
Author contributions: Oda G contributed to the conceptualization, methodology, software, validation, formal analysis, visualization and writing-original draft preparation; Hanazawa R, Hirakawa A contributed to the statistical checks; Oda G, Nakagawa T, Mori H, Onishi I, Fujioka T, Mori M, and Kubota K contributed to the investigation, resources; Oda G and Mori M contributed to the data curation; Nakagawa T contributed to the writing-review and editing; Okamoto K, Ishikawa T and Uetakesszsz H contributed to the supervision; All authors have read and agreed to the published version of the manuscript.
Institutional review board statement: The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of Tokyo Medical and Dental University, Tokyo, Japan (M2019-137, date of approval: 19 September 2019).
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The authors declare no conflict of interest.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at odasrg2@tmd.ac.jp.
STROBE statement: The authors have read the STROBE Statement checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
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: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Goshi Oda, MD, PhD, Assistant Lecturer, Doctor, Department of Breast Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 1138519, Japan. odasrg2@tmd.ac.jp
Received: May 25, 2022
Peer-review started: May 25, 2022
First decision: July 13, 2022
Revised: July 25, 2022
Accepted: September 6, 2022
Article in press: September 6, 2022
Published online: September 24, 2022
Research background

With sentinel node metastasis in breast cancer (BC) patients, axillary lymph node (ALN) dissection is often omitted from cases with breast-conserving surgery. Omission of lymph node dissection reduces the invasiveness of surgery to the patient, but it also obscures the number of metastases to non-sentinel nodes.

Research motivation

The possibility of finding ≥ 4 lymph nodes (pN2a/pN3a) preoperatively is important given the ramifications for postoperative treatment.

Research objectives

The purpose of this study is to search for clinicopathological factors that predict upstaging from N0 to pN2a/N3a.

Research methods

Patients who were SLN-positive and underwent ALN dissection between September 2007 and August 2018 were selected by retrospective chart review. All patients had BC diagnosed preoperatively as N0 with axillary evaluation by fluorodeoxyglucose (FDG) positron emission tomography/computed tomography and ultrasound (US) examination. When suspicious FDG accumulation was found in ALN, the presence of metastasis was reevaluated by second US. We examined predictors of upstaging from N0 to pN2a/pN3a.

Research results

Among 135 patients, we identified 1-3 ALNs (pN1) in 113 patients and ³4 ALNs (pN2a/pN3a) in 22 patients. Multivariate analysis identified the total number of SLN metastasis, the maximal diameter of metastasis in the SLN (SLNDmax), and FDG accumulation of ALN as predictors of upstaging to pN2a/pN3a.

Research conclusions

We identified factors involved in upstaging from N0 to pN2a/pN3a. The SLNDmax and number of SLN metastasis are predictors of ≥ 4 ALNs (pN2a/pN3a) and predictors of metastasis to non-sentinel nodes, which have been reported in the past. Attention should be given to axillary accumulations of FDG, even when faint.

Research perspectives

It is somewhat possible to predict upstaging to pN2a/pN3a by searching for clinicopathological factors