Development of a novel scoring system to potentially avoid completion axillary lymph node clearance after breast cancer excision and positive sentinel lymph node biopsy.

Correspondence to: Charalampos Seretis, MBBS, MSc. Russells Hall Hospital, Dudley Group of Hospitals NHS Foundation Trust, Pensnett Road, DY1 2HQ, Dudley, West Midlands, United Kingdom. Tel: +44 1384 456111, Fax: +44 1384244051, E-mail: [email protected]. Received : 26/06/2016; Accepted : 04/07/2016 The advent of sentinel lymph node biopsy (SLNB), in conjunction with tissue-sparing surgery and the improvement of radiotherapy protocols have revolutionized the field of breast cancer surgery, reducing the cases where a mastectomy with axillary clearance would have been the indicated approach [1,2]. The latter has resulted in markedly improved cosmesis, better functional status and quality of life without impairing the final oncological outcome [3]. Therefore, in the absence of pre-operatively identified axillary nodal infiltration, SLNB is now standard practice to assess the need for axillary clearance in cases with operable breast cancer; upon presence of cancerous infiltration of the retrieved sentinel lymph nodes, usually the patients are undergoing further surgery to achieve axillary clearance and adjuvant treatment is considered. However, on many occasions where SLNB is positive and further surgery for axillary clearance is carried out, the axillary nodes which are removed at the axillary clearance procedure turn out not to be infiltrated. As a result, it would be of great importance to consider if a SLNB could be per se “curative” in these cases, since all the infiltrated lymph nodes are removed during the first procedure. Therefore, the development of scoring systems aiming to predict if a SLNB could be “curative” could result in change of clinical protocols, for instance with introduction of prophylactic/minimally therapeutic adjuvant therapy instead of a repeat surgical procedure to remove the remaining axillary lymph nodes. Under this notion, we performed a retrospective analysis of all patients that underwent either wide local excision (WLE) or mastectomy with SLNB for invasive ductal adenocarcinoma and we attempted to identify which factors related to tumor characteristics and systemic inflammatory response could be used in a combined system to predict the likelihood of further axillary lymphadenopathy after a positive SLNB. The concept of using in the same scoring system tumor-related parameters in conjunction with biomarkers of systemic inflammatory response lies on the evidence suggesting that cancer growth and progression depends on both more aggressive tumor-related features as well as an impaired immune response, enabling escape from immunosurveillance [4,5]. In order to standardize our patients’ characteristics, we included only patients with expression of hormonal receptors (any strength) and absence of HER-2/Neu expression. Also, we excluded patients where a further in situ cancerous component was incidentally found in the examined mastectomy or WLE specimen and we also did not include patients with histological type other than invasive ductal carcinoma, patients with neoadjuvant therapy and patients with previous breast cancer surgery. We used four parameters to construct our scoring system: the histological grade of the primary cancerous lesion (I-III), the maximal tumor diameter (mm), the sentinel lymph node ratio (number of infiltrated axillary sentinel lymph nodes divided by the absolute number of harvested axillary sentinel lymph nodes-SLNR) and neutrophil-to-lymphocyte ratio (NLR), a widely used marker of systemic inflammatory response and has been shown to be an independent factor JBUON 2016; 21(5): 1316-1319 ISSN: 1107-0625, online ISSN: 2241-6293 • www.jbuon.com E-mail: [email protected]