Application of the Memorial Sloan Kettering Cancer Center Van Zee nomogram to a cohort of Algerian patients with breast tumours equal to or larger than 4 cm without clinical axillary invasion

Abstract

Axillary node status remains the most important prognostic factor in breast cancer, although axillary lymph node dissection (ALND) is increasingly questioned in patients with positive sentinel lymph nodes (SLN). The Memorial Sloan Kettering Cancer Center Van Zee nomogram may support decision-making regarding completion of ALND after positive SLN. This study evaluated the performance of the Van Zee model in 32 Algerian patients with cN0 breast cancer ≥ 4 cm (8 cT2 and 24 cT3) and positive SLN who underwent routine ALND. Using a 35% cut-off, the nomogram achieved 88.9% sensitivity, 78.2% specificity, and 84.3% accuracy, with positive and negative predictive values of 84.2% and 84.6%, respectively. The area under the receiver operating characteristic (ROC) curve was 0.85, indicating good discriminatory performance. Predictors of non-SLN involvement included lymphovascular invasion, luminal subtype, and a higher number of positive SLNs. Although predictive models for axillary invasion are well established, data from the Middle East and North Africa region remain limited. These findings suggest that the Van Zee nomogram is applicable to Algerian patients with breast tumours ≥ 4 cm without clinical axillary involvement. However, larger studies are required before definitive validation.

Keywords

Large breast tumours / Sentinel lymph node / Nomogram / Cut-off values

References

[1] Giuliano AE, Ballman KV, McCall L, et al. Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: the ACOSOG Z0011 (Alliance) randomized clinical trial. JAMA. 2017; 318(10):918-926. doi: 10.1001/jama.2017.11470

[2] Van Zee KJ, Manasseh DM, Bevilacqua JL, et al. A nomogram for predicting the likelihood of additional nodal metastases in breast cancer patients with a positive sentinel node biopsy. Ann Surg Oncol. 2003; 10(10):1140-1151. doi: 10.1245/ASO.2003.03.015

[3] Haddadi S, Touati R. Ganglion sentinelle: Elargissement des indications aux tumeurs de plus de 03 cm sans envahissement axillaire clinique (Grands T2N0M0 et T3N0M0) [thesis]. Faculté de Médecine, Université d’Alger 1 Benyoucef Benkhedda; 2023.

[4] van den Hoven I, van Klaveren D, Voogd AC, Vergouwe Y, Tjan-Heijnen V, Roumen RMH. A Dutch prediction tool to assess the risk of additional axillary non-sentinel lymph node involvement in sentinel node-positive breast cancer patients. Clin Breast Cancer. 2016; 16(2):123-130. doi: 10.1016/j.clbc.2015.09.003

[5] Van Lappara RFD, de Roos WK, Constant C, Bavelaar-Croon CDL, Barneveld PC, Bosscha K. A prospective validation study of sentinel lymph node biopsy in multicentric breast cancer: SMMaC trial. Eur J Surg Oncol. 2014; 40:1250-1255. doi: 10.1016/j.ejso.2013.11.004

[6] Wu Q, Deng L, Jiang Y, Zhang H. Application of the machine-learning model to improve prediction of non-sentinel lymph node metastasis status among breast cancer patients. Front Surg. 2022; 9:797377. doi: 10.3389/fsurg.2022.797377

[7] Sun S, Chen Y, Liu Y, et al. A multicenter cohort study on ultrasound-based deep learning nomogram for predicting post-neoadjuvant chemotherapy axillary lymph node status in breast cancer patients. Acad Radiol. 2025; 32(3):1252-1263. doi: 10.1016/j.acra.2024.09.065

[8] Reyal F, Belichard C, Rouzier R, et al. Non-sentinel lymph node metastasis prediction in breast cancer with metastatic sentinel lymph node: impact of molecular subtypes classification. PLoS ONE. 2012; 7(10):e47390. doi: 10.1371/journal.pone.0047390