Originally published as JCO Early Release 10.1200/JCO.2009.21.9139 on October 13 2009

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Prospective Multicenter Comparison of Models to Predict Four or More Involved Axillary Lymph Nodes in Patients With Breast Cancer With One to Three Metastatic Sentinel Lymph Nodes

Gabrielle Werkoff, Eric Lambaudie, Eric Fondrinier, Jean Levêque, Fréderic Marchal, Michele Uzan, Emmanuel Barranger, François Guillemin, Emile Darai, Serge Uzan, Gilles Houvenaeghel, Roman Rouzier, Charles Coutant

From the Department of Obstetrics and Gynecology, Hôpital Tenon, Assistance Publique–Hôpitaux de Paris (APHP), University Pierre et Marie Curie – Paris 6; Unité Propre de Recherche de I'Enseignement Supérieur Equipe d'Accueil 4053; Department of Obstetrics and Gynecology, Hôpital Lariboisière, APHP, Paris; Oncology Surgical Department, Institut Paoli-Calmettes, Marseille; Oncology Surgical Department, Institut Paul Papin, Angers; Oncology Surgical Department, Institut Eugène Marquis; Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire Rennes, Rennes; Oncology Surgical Department, Institut Alexis Vautrin, Nancy; and Department of Obstetrics and Gynecology, Hôpital Jean Verdier, APHP, Bondy, France.

Corresponding author: Charles Coutant, MD, Department of Obstetrics and Gynecology, Hôpital Tenon, 4 rue de la Chine, 75020 Paris, France; e-mail: charles.coutant{at}tnn.aphp.fr.

Purpose Three models have been developed to predict four or more involved axillary lymph nodes (ALNs) in patients with breast cancer with one to three involved sentinel lymph nodes (SLNs). Two scores were developed by Chagpar et al (Louisville scores excluding or including method of detection), and a nomogram was developed by Katz et al. The purpose of our investigation was to compare these models in a prospective, multicenter study.

Patients and Methods Our study involved a cohort of 536 patients having one to three involved SLNs who underwent ALN dissection. We evaluated the area under the receiver operating characteristic curve (AUC), calibration (for the Katz nomogram only), false-negative (FN) rate, and clinical utility of the three models. Results were compared with the optimal logistic regression (OLR) model that was developed from the validation cohort.

Results Among the 536 patients, 57 patients (10.6%) had four involved ALNs. The AUC for the Katz nomogram was 0.84 (95% CI, 0.81 to 0.86). The Louisville score excluding method of detection was 0.75 (95% CI, 0.72 to 0.78). The Louisville score including method of detection was 0.77 (95% CI, 0.74 to 0.79). The FN rates were 2.5% (eight of 321 patients), 1.8% (two of 109 patients), and 0% (zero of 27 patients) for the Katz nomogram and the Louisville scores excluding and including method of detection, respectively. The Katz nomogram was well calibrated. Optimism-corrected bootstrap estimate AUC of the OLR model was 0.86. Using this result as a reasonable target for an external model, the performance of the Katz nomogram was remarkable.

Conclusion We validated the three models for their use in clinical practice. The Katz nomogram outperformed the two other models.

Both R.R. and C.C. contributed equally to this work.

See accompanying editorial on page 5673

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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