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0 nodes involved

1-3 nodes involved

4+ nodes involved

0 12 24 36 48 60 72 84 96 108 120 Time (months)

Figure 17.24. Relationship of lymph node status to survival in patients with breast cancer.

Figure 17.25. Ductal carcinoma infiltrating into a lymph node, pleomorphic cells in a lymphoid background (x150).

Figure 17.26. Invasive ductal carcinoma invading into vascular lymphatic spaces (x250).

Figure 17.25. Ductal carcinoma infiltrating into a lymph node, pleomorphic cells in a lymphoid background (x150).

Lymph node status

This has been shown to be the single most important prognostic indicator (Fig. 17.24). If there is no lymph node involvement by tumour patients have an 85% 5-year survival. However, if there is lymph node involvement then the 5-year survival is reduced to 65%. Furthermore, this reduction in survival is related to the number of lymph nodes being involved - the greater the number the poorer the survival (Fig. 17.25).

Lymphatic or vascular invasion

Invasion of the lymphatic system or blood vessels (Fig. 17.26) has also been shown to be a poor prognostic indicator.

Hormone receptor status

OR status has been shown to be a prognostic indicator, with approximately 60% of tumours being OR positive. Those patients whose tumours strongly express OR receptors have a survival advantage, when compared with patients who have no OR expression. Progesterone receptors (PR) depend on a

Figure 17.26. Invasive ductal carcinoma invading into vascular lymphatic spaces (x250).

Table 17.5. The Nottingham Prognostic Index (NPI).

• NPI = 0.2 X tumour size (cm) + lymph node status (1-3 according to stage A-C) + tumour grade (I—III).

• An NPI of less than or equal to 3.4 is good prognosis, 3.41-5.4 is moderate prognosis, and greater than 5.4 is a poor prognosis. Patients in the good prognostic group have a 15-year survival of 85%, but patients with an NPI of equal to or less than 2.4 have a 15-year survival of 94%.

satisfactory OR pathway for their presence, which correlates, therefore, with OR status. However, there is some evidence to suggest that the presence of both OR and PR expression is associated with a better prognosis than OR expression alone.

Other prognostic indicators

A variety of other possible prognostic indicators are currently being evaluated. These include the expression of growth factor receptors (e.g. epidermal growth factor and its receptor, EGFR), expression of cell adhesion molecules, expression of oncogenes and products (e.g. c-erbB-2) and mutations of wild-type-suppressor genes (e.g. p53).

Prognostic indices

Combinations of these prognostic indicators have been developed using statistical modelling techniques in an attempt to improve prognostic information. One such example is the NPI which takes into account the tumour size, tumour grade and lymph node staging. This allows the identification of the likelihood of survival of patients with breast cancer (Table 17.5).

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