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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 7  |  Issue : 1  |  Page : 1-6

Clinical study of co-relation between positive axillary lymph node status and size of the tumor in breast malignancies


Department of Surgery, Great Eastern Medical School and Hospital, Ragolu, Srikakulam, Andhra Pradesh, India

Date of Web Publication4-Apr-2018

Correspondence Address:
Dr. S V Satyanarayana Rao
Department of Surgery, Great Eastern Medical School and Hospital, Ragolu, Srikakulam - 532 484, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_15_17

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  Abstract 


Background: Breast lump in women is a common clinical condition encountered in day-to-day surgical practice and needs thorough evaluation. This study is focused on co-relation between axillary lymph nodal status and the size of the breast tumor through clinical, radioimaging, and pathological studies. The axillary lymph node study also helps to differentiate benign from malignant breast lumps.
Patients and Methods: This study was carried out in the Department of Surgery, Great Eastern Medical School (GEMS) Hospital, Ragolu, Srikakulam, Andhra Pradesh, India. A total of 45 patients were selected for the study from among admitted cases to the Department of Surgery through clinical assessment, laboratory investigations, and ultrasound findings. After confirming the diagnosis of breast malignancy by fine needle aspiration cytology and Trucut biopsy in few cases, the patient had undergone operative intervention. Later, the specimens were sent for histopathological study.
Results: Breast malignancy was found more commonly among female patients of 45–64 years of age with an incidence of 66% in present studies. Lump in the breast was the common presenting feature in all patients. Ultrasound findings and Trucut biopsy have shown high sensitivity and specificity up to 97–99%.
Conclusion: The present study concludes that for the tumor size <10 mm, axillary lymph node dissection may not be needed. Larger the size of the tumor, the more probability of lymph nodal metastasis.

Keywords: Axillary lymph node dissection, axillary lymph node invasion, breast conservation therapy, fine needle aspiration cytology, modified radical mastectomy, ultrasonography


How to cite this article:
Rao S V, Patra RK, Sonnathi Y. Clinical study of co-relation between positive axillary lymph node status and size of the tumor in breast malignancies. Arch Int Surg 2017;7:1-6

How to cite this URL:
Rao S V, Patra RK, Sonnathi Y. Clinical study of co-relation between positive axillary lymph node status and size of the tumor in breast malignancies. Arch Int Surg [serial online] 2017 [cited 2021 May 15];7:1-6. Available from: https://www.archintsurg.org/text.asp?2017/7/1/1/229176




  Introduction Top


Breast carcinoma accounts for 23% of all new cancer cases in women worldwide and 13.7% of all cancer deaths.[1],[2] Majority of new cases are diagnosed in premenopausal women. Studies have shown a rising trend with increasing rates since mid-1980s with largest increase observed in Bangalore, Mumbai, and Delhi cities of India. The age adjusted incidence rate of breast carcinoma in India is 30.9 for Bangalore, 29.3 for Mumbai, and 31.4 for Delhi for 100,000 population as per National Cancer Registry's report of India.[3] Majority of new cases present at a locally advanced stage at the time of diagnosis. Breast cancer rates tend to be higher in women of higher education and in specific communities that have adopted a more westernized lifestyle such as the Christian's, Parsi's and is lowest in Muslim communities in India.[4] The mortality rates are declining in the developed world as a result of early diagnosis, screening, and improved cancer treatment programs, while the converse is true in the developing world.[5] Several factors determine the stage at which patients present with breast carcinoma to the hospital such as educational status, financial capability, occupation, location, and presence of health care facilities. However, a common denominator of these factors is the level of awareness and attitude toward breast cancer. The results of detection of breast cancer in clinics are not very encouraging in India. However, public education toward breast self-examination should be encouraged, since it is practical and affordable.

Axillary lymph node dissection (ALND) is the gold standard in evaluation of axillary lymph node metastasis and is an integral part of treatment of breast carcinoma. It provides benefit for patients by rendering regional control and may improve overall survival by surgical removal of microscopic nodal metastasis.[6] It has also been long known about co-relation between the tumor size and presence of malignant disease in axillary lymph nodes.[7] The presence and absence of axillary lymph node involvement is the most important prognostic indicator for patients with early stage of breast cancer.[8],[9] Prognostic factors that are considered valuable in predicting axillary nodal status for patients with invasive breast cancer include age, vascular invasion, hormonal receptors, menopausal status, histological grade, nuclear grade, lymphovascular invasion, DNA ploidy, and palpability of the primary tumor. But only the size of the primary tumor as an independent factor seems to have statistically significant relationship with lymph node metastasis. The status of axillary lymph nodes prior to surgery will help us avoid unnecessary full ALND. For many years, the idea of omitting full axillary dissection for patients with small tumor of size (<1 cm) has been a subject of controversy. It is also a cause of concern if we can use the size of the tumor as a reliable predictive factor for axillary lymph node invasion (ALNI). Another challenge is sparing any special group of patients from an unnecessary ALND on the basis of primary tumor size.


  Patients and Methods Top


A prospective study was carried out in Department of Surgery, Great Eastern Medical School & Hospital, Ragolu, Srikakulam, India from July 1, 2012 to July 31, 2016. After adhering to the selection criteria, 45 participants were included in the study. Ethical clearance from Institutional Committee was obtained before the start of the study.

Selection criteria

Inclusion criteria

  • Female cases more than 18 years of age diagnosed as breast malignancy
  • Fine needle aspiration cytology (FNAC)/Trucut biopsy diagnostic of breast cancer
  • Those who consented to participate in this study.


Exclusion criteria

  • Seriously ill patients in terminal stage of breast carcinoma requiring ventilator support
  • Pregnant females
  • Features suggestive of inoperability, distant metastasis, and locally advanced breast carcinoma.


Patients with clinical diagnosis of carcinoma of the breast were evaluated with a thorough history and clinical examination. The associated comorbid conditions were also recorded. Ultrasound imaging studies of the breast was the main stay of the investigation to determine the size of lump. All the patients were subjected to FNAC and in few cases Trucut biopsy, When the results of FNAC were inconclusive. Then detailed hematological and biochemical tests, including serum alkaline phosphatase levels, radiological imaging studies such as ultrasonography abdomen, chest X-ray, lumbar spine X-ray, and contrast-enhanced computed tomography abdomen were done in selected cases. Later, surgery was performed and the specimens were examined for tumor size and axillary lymph nodes for their number, size, and groups involved. Subsequently, the specimens were sent for histopathological study to know the malignant invasion in axillary lymph node and pathological grading of tumor. During the postoperative period, the patients were advised for chemotherapy and/or radiotherapy as per the requirement.

Statistical analysis

Data were entered into Microsoft Excel and analyzed using Statistical Package for the Social Sciences, version 23. Spearman's correlation coefficient (Spearman's rho) was calculated to determine relationship between axillary lymph node positivity status and tumor size.


  Results Top


A total of 45 cases of breast cancer were enrolled in the study and all the cases were female patients.

In the present study, the maximum incidence of breast cancer was found in age group 45–54 years (33.33%) followed by age group 55–64 years (26.66%) [Table 1].[10]
Table 1: Age distribution

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Lump in breast is the commonest presenting symptom in all cases (100%) in the present study [Table 2] and [Figure 1].[11]
Table 2: Symptomatology

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Figure 1: Lump in the breast - the most common presenting complaint in carcinoma Breast

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Diabetes mellitus is the most common comorbid condition in 11 cases (24%) [Table 3].
Table 3: Preoperative comorbidities

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On FNAC, maximum numbers of patients were found to have ductal carcinoma (86.66%) [Table 4].
Table 4: FNAC findings

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In the present study, the maximum patients were in Stage IIIA (40%) followed by IIA (26.65%) [Table 5].
Table 5: Stage-wise categorization of cases

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Forty three cases (95.55%) underwent modified radical mastectomy, which is comparable with North Indian study [Table 6] and [Figure 2].[11]
Table 6: Surgical procedure performed

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Figure 2: Modified radical mastectomy

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Flap necrosis was the most common postoperative complication encountered in seven cases (15.5%) [Table 7].
Table 7: Postoperative complications

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In the present study, 42 cases (93.33%) of patients were found to have infiltrating ductal carcinoma [Table 8] and [Figure 3].
Table 8: Histopathological grading of tumor

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Figure 3: Micro section showing ductal carcinoma

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In the present study, 28 cases showed pathological involvement of lymph nodes. Patients were classified into five groups according to tumor size from “I to V” as depicted in [Table 9]. The co-relation between axillary lymph node status and tumor size was calculated using Spearman's correlation. The strength of the co-relation can be denoted by r, which lies between −1 and +1.
Table 9: Spearman's correlation

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In our study, an “r” value of 1 was obtained, which was found to be statistically significant with P value < 0.05, which indicates a strong co-relation between tumor size and lymph node status.


  Discussion Top


Breast cancer commonly presents as a painless lump in most of the cases and usually discovered by the patient herself. In our study, most of the cases were in the age group of 45–54 years, which accounted for 33.33% of all cases. As per SE ER [11] register, majority of patients presented in the age group of 55–64 years, which accounted for 26.6%, and in the study done by Elahe Orang et al.,[12] patients presented in the age group of 46–51 years. In the present study, all the patients presented with lump in breast, which accounts for 100%. In North Indian study [13] also, 96.5% presented with lump in breast.

In the present study, maximum patients presented with stage IIIA (40%) of the disease followed by stage IIA (26%). In North Indian study,[13] majority of the cases were in stage II (74%), while in NCDB-USA majority were in early stage (58%). These data indicate that patients in developed countries are detected at an early stage of disease due to better awareness and early medical consultation. However, in the developing countries such as India, patients with breast cancer were seen in the late stage of the disease due to lack of awareness and nonavailability of medical facilities in rural areas.

In the present study, out of 45 patients, 43 patients (95%) underwent modified radical mastectomy and 2 patients (5%) underwent breast conservation surgery with ALND. In North Indian study,[13] modified radical mastectomy was the commonest procedure performed in 88.7% patients, which is comparable with the present study. In USA according to NCDB data, 57.5% underwent breast conservation surgery and only 20.5% had modified radical mastectomy. The present trend in developed countries is more toward breast conservation surgery, whereas in developing countries the trend is more toward radical surgery such as modified radical mastectomy. The postoperative complication encountered in the present study was flap necrosis (15.5%), which is well within the acceptable limits.

During the study of tumor size and its co-relation with ALNI, patients were divided into five groups according to the primary tumor size (I–V). Our results demonstrated the strong co-relation between the primary tumor size and ALNI. In our study, group V had higher ALNI compared to the other groups. Axillary node involvement is the most significant and durable prognostic factor for women with breast cancer (Gajdos et al., 1999).[14] A common route of spread of breast cancer is first through the axillary lymph nodes, and the incidence of ALNI increases with large tumors (Silverstein et al., 2001; Lee et al., 2010).[15] Our results are consistent and comparable with other studies (Zaghloul et al., 2001; Colleoni et al., 2005).[16],[17],[18],[19] These findings suggest that tumor size is an important prognostic factor that is significantly associated with increased risk of axillary metastases. The present study has shown an incidence of ALNI in patients with tumor size ≤2 cm as 14.28%, which is comparable to studies by Silverstein et al., 2001[15] for T1a and T1b tumors, i.e., 5–15%. In another study, overall incidence of ALNI for tumor size ≤20 mm was 29%, as reported by Yenidunya et al., 2011.[20],[21] The primary tumor size can be used to avoid full ALND in patients with T1 tumor as reported (Bader et al., 2002).[22] It is now concluded that routine ALND could be spared in clinically node negative patients with T1a disease (Chua et al., 2001).[23]

In the present study for group II cases with tumor size >2 cm axillary nodal metastasis was found to be as 61.11%. For group III (70%), group IV (80%), and group V (100%), full axillary nodal clearance was recommended. On the contrary, for group I patients with tumor size ≤2 cm, only 14.28% had nodal metastases. Hence a full axillary dissection would be an overtreatment for majority of these patients. A sentinel lymph node biopsy was recommended in these cases prior to surgery to assess axillary lymph nodal status.


  Conclusion Top


The present study concluded that tumor size is a significant predictor of axillary lymph nodal status. Larger the size of tumor, the more probability of lymph nodal metastasis. An exact estimation of the size of primary tumor is necessary prior to surgery to make the best decision for management of patients with invasive breast cancer. Now studies like mammography, magnetic resonance imaging for measuring the breast tumor size are available to assess the exact size of the tumor. Sentinel lymph node biopsy has become the standard of care in the management of axilla in patients with clinically node negative disease. Hence sentinel lymph node biopsy is utilized worldwide to assess the axillary nodal status prior to surgery to avoid unnecessary axillary nodal dissection and its associated morbidity and complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
Ferlay JS, Bray F, Forman D, Mathers C, Parkin DM. GLOBOCAN 2008 v. 1.2, Cancer incidence and mortality worldwide. IARC Cancer Base no. 10 [internet] 2010 [Last accessed on 2011 Oct 25].  Back to cited text no. 2
    
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Gajdos C, Tartter PI, Bleweiss IJ. Lymphatic invasion, tumor size, and age are independent predictors of axillary lymph node metastases in women with T1 breast cancers. Ann Surg 1999;230:692-6.  Back to cited text no. 14
    
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Silverstein MJ, Skinner KA, Lomis TJ. Predicting axillary nodal positivity in 2282 patients with breast carcinoma. World J Surg 2001;25:767-72.  Back to cited text no. 15
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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