Meta-analysis has shown that postmastectomy radiotherapy (PMRT) improves the survival of patients of patients with node-positive breast cancer (1). PatientsThe records of patients with breast cancer who were treated at the Sun Yat-sen University Cancer Center (SYSUCC) from January 1998 to December 2007 were retrospectively analyzed. Number of NLNs in breast cancer patientsA total of 1,260 patients were included for analysis, and their characteristics are summarized in Table 1. TreatmentA total of 444 patients (35.2%) underwent PMRT, and the target volume included the ipsilateral chest wall and supra- and infra-clavicular lymph node areas. Survival and disease progressionThe median follow-up time for all patients was 58 months (range, 6-138months). Correlation between number of negative lymph nodes and clinicopathological characteristics. Effect of the number of NLNs on the LRFS of patients who did not receive PMRTThe subgroup analysis of 816 patients who did not receive PMRT showed that the effect of the number of NLNs on LRFS was significantly different among groups.
Effect of the number of NLNs on the efficacy of PMRT according to different BCSSubgroup analysis showed that PMRT improved the LRFS, DFS, and OS of luminal A subtype with ≤ 8 NLNs (Figure 3A-3C).
Effect of the number of negative lymph nodes on survival after radiotherapy in patients with different breast cancer subtypes. Impact of the number of negative lymph nodes on locoregional recurrence-free survival (A), disease-free survival (B) and overall survival (C).
Impact of the number of negative lymph nodes on locoregional recurrence-free survival (A, 0-8 NLNs; B, 9-40 NLNs) of patients with and without PMRT.
Impact of PMRT on locoregional recurrence-free survival (A), disease-free survival (B) and overall survival (C) of patients with 0-8 NLNs in luminal A subtype.
The present study assessed the prognostic value of NLN count in patients with node-positive breast cancer after mastectomy, and the effects of the number of NLNs on the efficacy of PMRT for different BCS. Although the value of the number of NLNs in patients with breast cancer requires further study, the current results suggest that the number of NLNs is an important prognostic indicator for patients with node-positive breast cancer, and it can predict the efficacy of PMRT of different BCS.
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Xiamen Cancer Center, Department of Radiation Oncology, the First Affiliated Hospital of Xiamen University, Xiamen 361000, China2. Number of Negative Lymph Nodes Can Predict Survival after Postmastectomy Radiotherapy According to Different Breast Cancer Subtypes. However, locoregional recurrence (LRR) varies in patients with the same lymph node status, and radiosensitivity may be different due to the heterogeneity of breast cancer (2), which affects the efficacy of PMRT. Locoregional recurrence-free survival (LRFS), disease-free survival (DFS), and overall survival (OS) were the primary endpoints.
The χ2 and Fisher's exact probability tests were used to analyze the differences between qualitative data. To the date of last follow-up in present study, 979 patients were still alive and the follow-up time was over 5 years in 553 patients (56.5%). The results showed that the number of NLNs is an independent prognostic factor in breast cancer survival, and NLN count can be used to predict the efficacy of PMRT in patients with different BCS.Survival after sentinel lymph node biopsy and axillary lymph node dissection is similar in specific populations with breast cancer (7, 8), and sentinel lymph node biopsy has an advantage in that it is associated with reduced postoperative lymphedema (9, 10).
2013B021800157), Medical Scientific Research Foundation of Guangdong Province (A2010192), the Youth Foundation of the First Affiliated Hospital of Xiamen University (No.
Both of which will support, guide, and inspire you toward the best possible health outcomes for you and your family.


Department of Radiation Oncology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510060, China3.
Univariate and multivariate Cox survival analysis indicated the number of NLNs was an independent prognostic factor of LRFS, DFS, and OS. Previous studies have indicated that the breast cancer molecular subtype can predict the efficacy of PMRT (3-6).While there is a growing number of studies on the replacement of axillary lymph node dissection by sentinel lymph node biopsy (7-10), axillary lymph node status remains an important factor in determining the use of PMRT. Patients were defined as positive for HER2 when immunohistochemistry for HER2 showed 3+ or 2+ with confirmation by fluorescence in situ hybridization (FISH). LRR was defined as pathologically confirmed recurrence at the ipsilateral chest wall, supraclavicular and subclavian lymph nodes, axillary lymph nodes, or internal mammary lymph nodes.
Recognizing that the total number of NLNs may be subject to incomplete counting or natural inter-individual variation in nodal distribution, the number of NLNs was examined as a categorical variable based on quartiles.
The number of NLNs was examined as a categorical variable based on quartiles: Group 1 (0-8, n = 377), Group 2 (9-11, n = 277), Group 3 (12-15, n = 325), and Group 4 (16-40, n = 281). The median number of chemotherapy cycles was 6 (range, 4-8), and 1,189 patients (94.4%) received anthracycline- or taxane-based chemotherapy. PMRT improved the LRFS of luminal B subtype with ≤ 8 NLNs, but did not affect the DFS and OS. However, axillary lymph node status is still one of the most important prognostic indicators in breast cancer, especially in patients with positive axillary lymph nodes. More studies are required to confirm our findings and to investigate the related mechanisms. XYY2012005) and the Education Scientific Research Project of Young Teachers in Fujian Province (No. Xiamen Cancer Center, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xiamen University, Xiamen 361000, China4. The exact assessment of axillary lymph node status is of great relevance to the extent of axillary lymph node dissection, in particular the number of axillary lymph nodes removed (11, 12).In breast cancer patients, the appropriate number of lymph nodes should be removed may be affected by the number of positive lymph nodes. All patients provided written consent for storage of their medical information in the hospital database and for research use of this information.
Distant metastasis was defined as recurrence at a site distant from the primary cancer, confirmed by two imaging methods or by pathological assessment. Survival rates were determined and plotted by the Kaplan-Meier method, and compared using the log rank test. A cyclophosphamide (CTX), methotrexate (MTX), and 5-fluorouracil (5-FU) (CMF) regimen was administered in 71 patients (5.6%). The number of NLNs did not affect the efficacy of PMRT in Her2+ and triple-negative subtypes.
As the dissection of more NLN count may reduce the number of occult lesions and improve the prognosis, the number of NLNs may better reflect the extent of axillary lymph node dissection.The prognostic value of NLN count has been confirmed in esophageal, rectal, and cervical cancer (17-19). The number of negative lymph nodes (NLNs) is defined as the number of removed lymph nodes minus the number of positive lymph nodes. All patients with positive hormone receptors underwent endocrine therapy; premenopausal patients received tamoxifen (TAM), and postmenopausal patients received TAM or an aromatase inhibitor (AI).
In patients without PMRT, the LRR occurred in 112 patients and the 8-year LRFS rate was 81.5%. Differences in number of NLNs may be associated with a different in number of occult lesions.
A cut-off point of 25% was used to distinguish between the categories of low and high proliferative tumors. For patients with luminal B subtype, PMRT only improved the LRFS of patients with ≤ 8 NLNs. Theoretically, removal of more NLNs reduces the number of occult lesions, thereby improving the survival of patients.
OS was calculated as a period of time from the date of diagnosis to the date of death from any cause or the date of last follow-up.
If a small number of NLNs are removed, the incidence of LRR may increase due to the presence of occult lesions.The purpose of PMRT is to reduce the occurrence of LRR, and thus improve survival.


Gallen International Breast Cancer Conference because some patients did not have Ki-67 immunohistochemistry results (3).
A total of 281 patients died among whom 274 died because of breast cancer and 7 died of other diseases.
The incidence of LRR varies greatly in patients with different breast cancer subtypes (BCS) (13), partly due to different treatment strategies (14) and partly due to the presence of residual lesions (15). Nevertheless, it would not affect the prognosis of patients with node-negative disease (20).
Therefore, we hypothesized that patients with different numbers of NLNs have different prognosis, and the number of NLNs may influence the efficacy of PMRT for patients with different BCS. Thus, the categorization of BCS was as follows: luminal A (ER+ or PR+, and HER2-), luminal B (ER+ or PR+, and HER2+), HER-2 + (ER-, PR-, and HER2+), and triple negative (TN) (ER-, PR-, and HER2-). In a study in which 68% of patients received PMRT, patients with >15 NLNs had better OS (12). The purpose of this study was to explore the prognostic value of the number of NLNs in patients with node-positive breast cancer after mastectomy, and to evaluate its effects on the efficacy of PMRT in patients with different BCS. However, the above studies were limited because adjuvant chemotherapy and endocrine therapy were either insufficient or not clearly stated.
In present study, we found that the number of NLNs was an important prognostic factor, but PMRT did not benefit patients with higher number of NLNs.
This may be because patients with fewer NLNs have more occult lesions, and the primary objective of PMRT is to eliminate locoregional residue lesions and improve locoregional control. Therefore, radiotherapy may be benefits in patients with fewer NLNs.Individualized treatment is the goal of comprehensive treatment of breast cancer. It suggests that hormone receptor status and the number of positive lymph nodes can be used to determine prognosis and thus influence the selection of adjuvant treatment.There are different therapeutic strategies for different BCS (3). In addition, studies have shown that different BCS have different radiosensitivities (4-6).
For this reason, we further conducted BCS analysis and the results showed that the number of NLNs could predict the efficacy of PMRT for different BCS, especially in luminal A subtype patients. This result suggests that for luminal A subtype patients with a better prognosis, an adequate number of NLNs can further reduce the number of occult lesions and achieve a better locoregional control, thereby making it possible to avoid radiation therapy. In this study, PMRT did not benefit patients with HER2+ and TN breast cancer regardless of the number of NLNs. However, the survival of patients with a higher number of NLNs was superior to that of patients with a fewer number of NLNs.
This also suggests that when the number of NLNs is higher, the number of occult lesions is reduced, thereby improving survival.We need to recognize the limitations of the present study.
First, this was a single center retrospective study, and thus cannot represent the population at large.
Patients with HER2+ breast cancer did not routine undergo trastuzumab treatment, which may affect the results. In addition, the optimal cut-off point of number of NLNs is not consistent with the previously findings (12, 20).
This might be ascribed to differences in the clinicopathological characteristics, surgical modalities, and methods used for statistical analysis.
In future prospective multicenter studies, it will be necessary to confirm the specific value of the number of NLNs in breast cancer patients and to explore the optimal cut-off point. Frequently, surgeons resect fragments of a lymph node for which pathologists assign duplicate or multiple counts for the same node.




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