Abstract

In 4060 breast cancer patients undergoing ALND, lymph node ratio (LNR) outperformed pN staging as an independent predictor of DFS and OS. Higher LNR significantly correlated with worse survival, with optimal cutoffs of 0.2 and 0.5. LNR-based stratification demonstrated clear prognostic separation, supporting its role in refining risk assessment beyond conventional nodal staging.
Background: Pathological nodal (pN) staging in breast cancer is based on the number of positive nodes but may be influenced by surgical extent and technique. Lymph node ratio (LNR)—the ratio of positive to total nodes—accounts for both tumor burden and nodal yield, potentially improving prognostic accuracy.
Methods: We retrospectively analyzed data from 4060 breast cancer patients who underwent axillary lymph node dissection (ALND) between 1995 and 2021 at a tertiary cancer center in India. Disease-free survival (DFS) and overall survival (OS) were assessed using Kaplan Meier curves and log-rank tests. Correlation analysis and multivariate analysis were used to compare prognostic utility
of LNR versus pN stage. Optimal LNR cutoffs were identified using Youden’s index. Results: The median follow-up was 93.8 months. On multivariate analysis, LNR retained a strong independent prognostic value for both DFS (HR = 2.00 for LNR 0.2-0.5; HR = 3.29 for LNR > 0.5; P < .001) and OS (HR = 1.77 for LNR 0.2 to 0.5; HR = 2.77 for LNR > 0.5; P < .001). LNR cutoffs of 0.24 (DFS) and 0.21 (OS) were identified. Stratification into 3 LNR groups ( ≤0.20, 0.21-0.50, > 0.50) showed significantly different survival outcomes (log-rank P < 0.001).
Conclusions: LNR is a superior and independent prognostic marker compared to pN stage in breast cancer patients undergoing ALND. Incorporating LNR into prognostic models may enhance risk stratification and guide adjuvant treatment decisions.