Pathology Research International 5 Table 3: Summary of results of American College of Surgeons Oncology Group (ACOSOG) Z0011 study. 3.4. Important Aspects of a Standard Pathology Report. See Table 4. 5-year in-breast recurrence 5-year nodal recurrence 5-year overall survival 5-year disease-free survival ALND 3.7% 0.6% 91.9% 82.2% SN biopsy P values 2.1% 13% 92.5% 83.8% .16 .44 .24 .13 Table 4: Summary of important aspects of a standard pathology report—this would enable oncologists to make individual decision on management, including completion ALND and adjuvant sys- temic treatment. Primary tumor Multifocal or multicentric In-situ component Grade Necrosis Lymphovascular invasion Margin Histologic subtype Immunohistochemical HER2, ER, PR Involvement of nipple or skeletal muscle Abnormalities of surrounding breast tissue NODE Volume or size of nodal metastasis Location within the node Extranodal extension Number of involved sentinel node Number of involved nonsentinel node Total number of sentinel node Total number of nodes on axillary dissection, if performed in prognostic factors. Median followup is 6.2 years. Table 4 summarizes the results. So despite the widely held belief that ALND improves survival, no signiﬁcant diﬀerence was recognized by this study of SN node-positive women. Although the study closed early because of low accrual/event rate, it is the largest phase III study of ALND for node-positive women, and it demonstrates no trend toward clinical beneﬁt of ALND for patients with limited nodal disease and given adjuvant systemic therapy. Based on the above evidence, the authors of this paper believe that when the estimated risk of nonSN involvement is low enough, a completion ALND is not necessary. Even if there is further involved nonSN(s), they may be treated by systemic therapy or tangent ﬁeld RT which covers level I and some level II axillary nodes. The survival beneﬁt from radiation is best explained by the prevention of an isolated loco-regional recurrence, which could serve as a source of fatal distant metastases and parallels the diﬀerence in the total incidence of distant metastases [42]. 4. Conclusion We have summarized the studies and analyzed them as a whole to draw the following conclusions. Misleading studies due to small patient numbers and short followup have clouded the issue of poor outcome of pN1mi before. The authors of this paper felt that pN1mi patients have worse outcome than node-negative patients. Patients with micrometastases or ITC beneﬁt from adjuvant systemic treatment as evident from de Boer et al. [21]. When the estimated risk of nonSN involvement is low enough, a completion ALND is not necessary. Even if there is further involved nonSN(s), they may be treated by systemic therapy or tangent ﬁeld RT which covers level I and some level II axillary nodes. In the ACOSOG study, for clinically node-negative patients who under- went SN biopsy and had 1 or 2 SN with metastases detected by H&E, completion ALND would not aﬀect local recurrence, OS or DFS [41]. Hence provided patients had limited nodal disease and receive adjuvant systemic treatment, completion ALND after SN biopsy is not warranted. References [1] http://www.cancer.ca/. [2] P. T. Truong, E. Berthelet, J. Lee, H. A. Kader, and I. A. Olivotto, “The prognostic signiﬁcance of the percentage of positive/dissected axillary lymph nodes in breast cancer recurrence and survival in patients with one to three positive axillary lymph nodes,” Cancer, vol. 103, no. 10, pp. 2006–2014, 2005. [3] M. Voordeckers, V. Vinh-Hung, J. van de Steene, J. Lamote, and G. Storme, “The lymph node ratio as prognostic factor in node-positive breast cancer,” Radiotherapy and Oncology, vol. 70, no. 3, pp. 225–230, 2004. [4] B. C. H. van der Wal, R. M. J. M. Butzelaar, S. van der Meij, and M. A. Boermeester, “Axillary lymph node ratio and total number of removed lymph nodes: predictors of survival in stage I and II breast cancer,” European Journal of Surgical Oncology, vol. 28, no. 5, pp. 481–489, 2002. [5] Y. Nieto, P. J. Cagnoni, E. J. Shpall et al., “A predictive model for relapse in high-risk primary breast cancer patients treated with high-dose chemotherapy and autologous stem- cell transplant,” Clinical Cancer Research, vol. 5, no. 11, pp. 3425–3431, 1999. [6] L. J. Megale Costa, H. Prado Soares, H. Amaral Gaspar et al., “Ratio between positive lymph nodes and total dissected axillaries lymph nodes as an independent prognostic factor for disease-free survival in patients with breast cancer,” American Journal of Clinical Oncology, vol. 27, no. 3, pp. 304–306, 2004. [7] J. Martinez-Trufero, A. Artal-Cortes, M. Zorrilla et al., “New distinctive features on the study of prognostic factors in patients with locally advanced breast cancer (LABC) treated with neoadjuvant chemotherapy (NAC),” Proceedings of the American Society of Clinical Oncology, vol. 20, abstract 3069, 2001.