Neoadjuvant Chemotherapy for Breast Cancer: Revisiting the Lymph Node Ratio as a Prognostic Factor: NAC for BC

Nam P. Nguyen; Vincent Vinh-Hung

doi:10.32768/abc.2023103220-221

Nam P. Nguyen ⁽¹⁾, Vincent Vinh-Hung ⁽²⁾

(1) Department of Radiation Oncology, Howard University, Washington DC , USA, United States,

(2) Department of Radiotherapy, Institut Bergonié, Bordeaux, France, France

https://doi.org/10.32768/abc.2023103220-221

Issue
Volume 10, Issue 3, August 2023

Submitted
April 17, 2023

Published
June 16, 2023

Keywords:

neoadjuvant, chemotherapy, axillary lymph node, Lymph node ratio

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Mashoori N, Zand S, Nazemian R, Kaviani A. Effect of the Surgery Type, Mastectomy vs. Breast Conserving Surgery, on Outcomes of Patients With Locally Advanced Breast Cancer Receiving Neoadjuvant Therapy. Arch Breast Cancer. 2017;4(4):129-35. doi: 10.19187/abc.201744129-135.

Kuerer HM, Smith BD, Krishnamurthy S, Yang WT, Valero V, Shen Y, et al. Eliminating breast surgery for invasive breast cancer in exceptional responders to neoadjuvant systemic therapy: a multicentre, single-arm, phase 2 trial. Lancet Oncol. 2022 Dec;23(12):1517-1524. doi: 10.1016/S1470-2045(22)00613-1.

Rosenberger LH, Ren Y, Thomas SM, Greenup RA, Fayanju OM, Hwang ES, et al. Axillary lymph node dissection in node-positive breast cancer: are ten nodes adequate and when is enough, enough? Breast Cancer Res Treat. 2020 Feb;179(3):661-670. doi: 10.1007/s10549-019-05500-9.

Gangadaran S. Axillary Nodal Examination in Breast Cancer: How Much Is Enough? Evidence for a New Minimum. Arch Breast Cancer. 2016 12/03/2016;3(4):126-129. doi: 10.19187/abc.201634126-129

Erbes T, Orlowska-Volk M, Zur Hausen A, Rücker G, Mayer S, Voigt M, et al. Neoadjuvant chemotherapy in breast cancer significantly reduces number of yielded lymph nodes by axillary dissection. BMC Cancer. 2014 Jan 3;14. doi: 10.1186/1471-2407-14-4.

Safavi A, Kaviani A, Mohammadzadeh N, Zand S, Elahi A, Krag D. Breast Cancer Prognostication by Pathologic Node Staging (pN-staging) System Versus Lymph Node Ratio (LNR): A Critical Review of Conflicts With Number of Nodes, Z-0011 Trial , Staging Cut-points, Neo-adjuvant Therapy, and Survival Estimation. Arch Breast Cancer. 2017 Dec 10, 2017;4(4):110-123. doi: 10.19187/abc.201744110-123.

Vinh-Hung V, Verkooijen HM, Fioretta G, Neyroud-Caspar I, Rapiti E, Vlastos G, et al. Lymph node ratio as an alternative to pN staging in node-positive breast cancer. J Clin Oncol. 2009;27(7):1062-1068. doi: 10.1200/JCO.2008.18.6965.

Cho DH, Bae SY, You JY, Kim HK, Chang YW, Choi YJ, et al. Lymph node ratio as an alternative to pN staging for predicting prognosis after neoadjuvant chemotherapy in breast cancer. Kaohsiung J Med Sci. 2018 Jun;34(6):341-347. doi: 10.1016/j.kjms.2017.12.015.

Ai X, Liao X, Wang M, Hu Y, Li J, Zhang Y, et al. Prognostic Value of Lymph Node Ratio in Breast Cancer Patients with Adequate Pathologic Evidence After Neoadjuvant Chemotherapy. Med Sci Monit. 2020 Apr 29;26:e922420. doi: 10.12659/MSM.922420.

De la Cruz-Ku GA, Chambergo-Michilot D, Valcarcel B, Rebaza P, Möller M, Araujo JM, et al. Lymph node ratio as best prognostic factor in triple-negative breast cancer patients with residual disease after neoadjuvant chemotherapy. Breast J. 2020 Sep;26(9):1659-1666. doi: 10.1111/tbj.13988.

Jung SW, Lim SY, Na YM, et al. Lymph Node Ratio as a Good Prognostic Factor for Patients with Pathologic N3a Breast Cancer with 10 or More Metastatic Axillary Lymph Nodes. J Breast Dis. 2021 12;9(2):56-64.

Tsai J, Bertoni D, Hernandez-Boussard T, et al. Lymph Node Ratio Analysis After Neoadjuvant Chemotherapy is Prognostic in Hormone Receptor-Positive and Triple-Negative Breast Cancer. Ann Surg Oncol. 2016 Oct;23(10):3310-6.

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Authors

Nam P. Nguyen

Department of Radiation Oncology, Howard University, Washington DC , USA

https://orcid.org/0000-0001-5106-6665

Vincent Vinh-Hung

Department of Radiotherapy, Institut Bergonié, Bordeaux, France

https://orcid.org/0000-0002-6403-6120

anhxang@gmail.com (Primary Contact)

Author Biography

Nam P. Nguyen, Department of Radiation Oncology, Howard University, Washington DC , USA

Washington, DC 20060

Nguyen NP, Vinh-Hung V. Neoadjuvant Chemotherapy for Breast Cancer: Revisiting the Lymph Node Ratio as a Prognostic Factor: NAC for BC. Arch Breast Cancer [Internet]. 2023 Jun. 16 [cited 2024 Jul. 27];10(3):220-1. Available from: https://www.archbreastcancer.com/index.php/abc/article/view/709

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Neoadjuvant chemotherapy for locally advanced or early stage breast cancer is very popular due to its ability for disease downstaging and anatomic breast conservation. 1 In addition, this treatment modality may also provide prognostic information to the clinician as patients with pathologic complete response after surgery have excellent survival, prompting some institution to skip surgery if biopsy of the primary disease and lymph nodes shows no residual disease. 2 However, patients with pathologic lymph nodes involvement presents a dilemma as they experience a high rate of recurrence and a poor survival. There is a correlation between the number of metastatic lymph nodes and decreased survival. In principle, a minimum of 10 axillary lymph nodes or even more is recommended to avoid underestimation of the number of positive lymph nodes and false assessment of the risk of distant metastases. 3 4 However, following neoadjuvant chemotherapy, there was a significant decrease in the number of lymph nodes resected in addition to a change in morphology which clearly compromised the recommendation of axillary lymph node yield. 5 6 The question is whether the axillary lymph node ratio (LNR) touted as an effective method to predict survival after breast cancer surgery withstand the test of time. 7 Preliminary data suggests that the LNR is even more effective when the number of lymph nodes is reduced by chemotherapy.

Compared to the pathologic staging after neoadjuvant chemotherapy, the pathologic N stage was no longer associated with disease-free survival or overall survival. 8 In contrast, the LNR demonstrated an accurate prediction of those two parameters. Other studies also corroborated the superiority of the LNR over the traditional ypN stage regardless of histology, clinical T, and N stage at diagnosis. 9 10 Despite the paucity of lymph nodes resected after neoadjuvant chemotherapy, the LNR remained a reliable parameter to assess recurrence and survival. 11[12]12 A meta-analysis of 4,864 breast cancer patients who had neoadjuvant chemotherapy corroborated the LNR as an independent prognostic factor for survival. A high LNR correlated with a poor survival and disease-free survival. 13 Even though those studies are retrospective, we believe that LNR should be incorporated in future prospective studies of neoadjuvant therapy for breast cancer to validate its prognostic accuracy. As an international organization devoted to the care of older cancer patients, minorities, and women (http://www.igrg.org), we would like to conduct such prospective randomized studies with the LNR stratified to age and ethnicities as preliminary evidence indicated that women with African ancestry may have a worse prognosis following neoadjuvant therapy for breast cancer. 14 15 CONFLICT OF INTEREST Vincent Vinh-Hung is a section editor of the journal but was not involved in the blind review process or in the editorial decision.

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Neoadjuvant Chemotherapy for Breast Cancer: Revisiting the Lymph Node Ratio as a Prognostic Factor NAC for BC

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Nam P. Nguyen, Department of Radiation Oncology, Howard University, Washington DC , USA

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