A prospective study of use of a clinicopathological score to select patients for the type of axillary surgery T.D. Pinkney a , P. Nightingale b , A.R. Carmichael a, * a Russells Hall Hospital, Pensnett Road, Dudley, Stourbridge DY1 2HQ, UK b Wellcome Trust Clinical Research Facility, Birmingham, UK Accepted 3 October 2006 Available online 9 November 2006 Abstract Aims: The aim of this study was to prospectively assess a previously described and independently validated clinicopathological score for counselling and selecting patients for sentinel node biopsy or axillary clearance. The clinicopathological score is based on the size of pri- mary tumour, grade of primary tumour, age of the patient, quadrant of the breast and lymphovascular invasion, which are all independent predictors of lymph node involvement. The clinicopathological score may assist patients to decide if they would benefit from sentinel node biopsy or axillary clearance as a primary procedure. Methods: All patients with invasive breast cancer were counselled for the possible rate of lymph node positivity, need for a second operation and false negative rate for sentinel node biopsy. Based on a previously validated clinicopathological score (Table 1), patients with a score of 10 or below were classed as less likely to have positive lymph nodes and hence were offered for minimally invasive axillary surgery and patients with a score of 11 or above were regarded to have high risk of nodal involvement and were counselled for axillary clearance. Results: Only 3 of 31 patients in the low score group had axillary metastasis and needed further axillary treatment. The node positivity rate in the low score group was 10% compared to 63% for the high score group. Conclusion: It is concluded that until pre-operative axillary staging becomes widely available, by using the clinicopathological score for patient’s selection for minimally invasive axillary surgery, it may be possible to avoid a second axillary procedure in a large majority of patients. Ó 2006 Elsevier Ltd. All rights reserved. Keywords: Axilla; Biopsy; Breast neoplasms; Sentinel lymph node biopsy Introduction Traditionally, axillary lymph node dissection has served the dual purpose of staging the breast cancer and treating the involved axilla. 1e5 As axilla can be staged by sentinel node biopsy with minimum morbidity, it is argued that the axillary clearance can now be limited to patients with definite evidence of axillary node involvement sought either pre-operatively by ultrasound guided core cytology or histology of the suspicious axillary nodes, or intra- operatively by imprint cytology of sentinel nodes or post- operatively by sentinel node biopsy. All these techniques are useful but not without their limitations. 6e9 In order to treat patients with breast cancer with least morbidity and minimise the need for a second operation, a selective policy of management of axilla may be helpful. Axillary clearance may be appropriate as a primary procedure for a selected group of patients who have high likelihood of nodal in- volvement and carry a high possibility of failure of proce- dure of sentinel node biopsy. These patients are likely to need a second operation of completion axillary clearance and its consequent complications. The aim of this study was to prospectively assess a previously described and in- dependently validated clinicopathological score for coun- selling and selecting patients for sentinel node biopsy or axillary clearance. The clinicopathological score is based on the size of primary tumour, grade of primary tumour, age of the patient, quadrant of the breast and lymphovascu- lar invasion, which are all independent predictors of lymph node involvement. 10 * Corresponding author. Tel.: þ44 1384 244015; fax: þ44 1384 244072. E-mail address: homepac@doctors.org.uk (A.R. Carmichael). 0748-7983/$ - see front matter Ó 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2006.10.009 EJSO 33 (2007) 153e156 www.ejso.com