Amin Safavi - Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran- Kaviani Breast Diseases Institute (KBDI), Tehran, Iran
Ahmad Kaviani - Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran- Kaviani Breast Diseases Institute (KBDI), Tehran, Iran
Narjes Mohammadzadeh - Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran
Sanaz Zand - Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran- Kaviani Breast Diseases Institute (KBDI), Tehran, Iran
Ahmad Elahi - Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran
David N.Krag - Division of Surgical Oncology, Department of Surgery, College of Medicine, University of Vermont, Burlington, USA

Background: The AJCC pN-staging system is the current risk stratificationstrategy for axillary nodal staging in most cancer centers. Recently, another stagingsystem named "Lymph Node Ratio" or LNR has been developed and alsopostulated to have prognostic value. Precise prognostication of breast cancer bythese two systems has multiple methodological dilemmas which are overlooked inthe literature and still remain matters of debate.Methods: These two issues are categorized into seven queries, including: thenumber of nodes considered adequate for proper axillary staging; attitude towardZ-۰۰۱۱ trial; impacts of neo-adjuvant therapies; the origin and evolution ofstratification cutoffs; the position where patients without axillary involvementshould be placed; role of diverse endpoints in survival definition, outcomeanalyses and prognosis prediction; and ultimately the current opinion regardingthe superiority of the ۲ systems. This review sought to explore these topics throughanalysis of ۵۸ recently published articles found by MEDLINE search.Results: The analysis revealed that precise prognostication by pN-stagingsystem requires at least ۱۰ excised-nodes, but LNR system minimally depends onthe quantity of excised-nodes. Adhering to Z-۰۰۱۱ trial findings obstructs theprovision of sufficient nodes for pN-staging. Neo-adjuvant chemotherapy altersthe axillary nodal climate and therefore disrupts proper axillary staging. Cutoffs ofLNR system have a more clear history of formation than the pN-staging's. Breastcancer-specific survival is the type of survival better portraying cancer-relatedevents.Conclusions: LNR system seems at least as accurate as pN-staging inprognostication of breast cancer patients.

Breast cancer, prognostication, pathologic node staging, lymph node ratio, Z-۰۰۱۱ trial, neo-adjuvant chemotherapy