The use of onestep nucleic acid amplification (OSNA) and tumour related factors in the treatment of axillary breast cancer: A predictive model

Published:March 01, 2016DOI:



      We aimed to determine the effectiveness of CK19 mRNA copy number and tumour related factors in predicting non-sentinel axillary nodal involvement, in order to facilitate the formulation of local treatment guidelines for axillary clearance (ANC) following intra-operative analysis of the sentinel node biopsy (SNB) using one-step nucleic acid amplification (OSNA).


      Patients due to have (SNB) at our institution for breast cancer as well as patients with high grade ductal carcinoma in situ with pre-operative negative assessment of the axilla were included. Alternate slices of each node were sent for assessment by either OSNA or histopathology. Immediate ANC was performed if OSNA was positive. The CK19 mRNA nodal copy number, the total tumour load (TTL) measured by summation of mRNA copy numbers of all positive nodes, the nodal status at ANC and tumour characteristics for each patient were recorded. A model of risk probability was constructed using TTL and tumour related factors.


      664 nodes were analysed from 425 patients who had SNB performed between 2011 and 2014. ANC was performed on 105 of these patients. The concordance between OSNA and histology was 91.4% and negative predictive value (NPV) was 97%.
      TTL (p = 0.003) and LVI (p = 0.04) were identified as risk factors for non-sentinel nodal involvement. The risk probability model identified all patients with pN2 disease for ANC.


      In the future a decision to perform ANC will be based on a risk stratification model based on TTL and tumour related factors.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Surgical Oncology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Tsujimoto M.
        • Nakabayashi K.
        • Yoshidome K.
        • et al.
        One step nucleic acid amplification for intra-operative detection of lymph node metastasis in breast cancer patients.
        Clin Cancer Res. 2007; 13: 4807-4816
        • Visser M.
        • Jiwa M.
        • Horstman A.
        • et al.
        Intra-operative rapid diagnostic method based on CK19 m RNA expression for the detection of lymph node metastases in breast cancer.
        Int J Cancer. 2008; 122: 2562-2567
        • Schem C.
        • Maass N.
        • Bauerschlag D.O.
        • et al.
        One step nucleic acid amplification – a molecular method for the detection of the lymph node metastases in breast cancer patients; results of the German study group.
        Virchows Arch. 2009; 454: 203-210
        • Tamaki Y.
        • Akiyama F.
        • Iwase T.
        • et al.
        Molecular detection of lymph node metastases in breast cancer patients: results of a multicenter trial using the one-step nucleic acid amplification assay.
        Clin Cancer Res. 2009; 15: 2879-2884
        • Snook K.L.
        • Layer G.T.
        • Jackson P.A.
        • et al.
        Multicentre evaluation of intraoperative molecular analysis of sentinel lymph nodes in breast carcinoma.
        BJS. 2011; 98: 527-535
        • Feldman S.
        • Krishnamurthy S.
        • Gillanders W.
        • et al.
        A novel automated assay for the rapid identification of metastatic breast carcinoma in sentinel lymph nodes.
        Cancer. 2011; 117: 2599-2607
        • Bernet L.
        • Cano R.
        • Martinez M.
        • et al.
        Diagnosis of the sentinel lymph node in breast cancer: a reproducible molecular method: a multicentric Spanish study.
        Histopathology. 2011; 58: 863-869
        • Le Frere-Belda M.A.
        • Bats A.S.
        • Gillaizeau F.
        • et al.
        Diagnostic performance of one step nucleic acid amplification for intra-operative sentinel node metastasis detection in breast cancer patients.
        Int J Cancer. 2012; 130: 2377-2386
        • Cserni G.
        Sentinel lymph node biopsy based prediction of further breast cancer metastases in the axilla.
        Eur J Surg Oncol. 2001; 6: 532-538
        • Osako T.
        • Iwase T.
        • Kimura K.
        • et al.
        Intra-operative molecular assay for sentinel lymph node metastases in early stage breast cancer: a comparative analysis between one-step nucleic acid amplification whole node assay and routine frozen section histology.
        Cancer. 2011; 117: 4365-4374
        • Tiernan J.P.
        • Verghese E.T.
        • Nair A.
        • et al.
        Systematic review and meta-analysis of cytokeratin 19-based one-step nucleic acid amplification versus histopathology for sentinel lymph node assessment in breast cancer.
        BJS. 2014; 101: 298-306
      1. NICE clinical guideline 80: early and locally advanced breast cancer: diagnosis and treatment. National Collaborating Centre for Cancer, 2009
        • Klingler S.
        • Marchal F.
        • Rauch P.
        • et al.
        Using one-step nucleic acid amplification (OSNA) for intra-operative detection of lymph node metastasis in breast cancer patients avoids second surgery and accelerates initiation of adjuvant therapy.
        Ann Oncol. 2013; 24: 2305-2309
        • Buglioni S.
        • Di Filippo F.
        • Terrenato I.
        • et al.
        Quantitative molecular analysis of sentinel lymph node may be predictive of axillary node status in breast cancer classified by molecular subtypes.
        PLoS One. 2013; 8: e58823
        • Deambrogio C.
        • Isabella Castellano I.
        • Paganotti A.
        • et al.
        A new clinical cut-off of cytokeratin 19 mRNA copy number in sentinel lymph node better identifies patients eligible for axillary lymph node dissection in breast cancer.
        J Clin Pathol. 2014; 67: 702-706
        • Sagara Y.
        • Ohi Y.
        • Matsukata A.
        • et al.
        Clinical application of the one-step nucleic acid amplification method to detect sentinel lymph node metastasis in breast cancer.
        Breast Cancer. 2013; 20: 181-186
        • Peg V.
        • Espinosa-Bravo M.
        • Vieites B.
        • et al.
        Intraoperative molecular analysis of total tumour load in sentinel lymph node: a new predictor of axillary status in early breast cancer patients.
        Breast Cancer Res Treat. 2013; 139: 87-93
        • Piñero-Madrona A.
        • Ruiz-Merino G.
        • Bernet L.
        • et al.
        Tumoral load quantification of positive sentinel lymph nodes in breast cancer to predict more than two involved nodes.
        Breast. 2014;
        • Osako T.
        • Iwase T.
        • Kimura K.
        • Horii R.
        • Akiyama F.
        Sentinel node tumour burden quantified based on cytokeratin 19 mRNA copy number predicts non-sentinel node metastases in breast cancer: molecular whole-node analysis of all removed nodes.
        Eur J Cancer. 2013; 49: 1187-1195
        • Espinosa-Bravo M.
        • Sansano I.
        • Perez-Hoyos S.
        • et al.
        Prediction of non-sentinel lymph node metastasis in early breast cancer by assessing total tumoral load in the sentinel lymph node by molecular assay.
        EJSO. 2013; 39: 766-773
        • Heilmann T.
        • Mathiak M.
        • Hofmann J.
        • et al.
        Intra-operative use of one-step nucleic acid amplification (OSNA) for detection of the tumour load of sentinel lymph nodes in breast cancer patients.
        J Cancer Res Clin Oncol. 2013; 139: 1649-1655
        • Sahin A.A.
        • Guray M.
        • Hunt K.K.
        Identification and biologic significance of micrometastases in axillary lymph nodes in patients with invasive breast cancer.
        Arch Pathol Lab Med. June 2009; 133: 869-878
        • Bernet L.
        • Pinero A.
        • Vidal-Sicart S.
        • et al.
        Consensus on sentinel lymph node biopsy in breast cancer. Review of the Spanish Society of Senology and Breast Pathology 2013.
        Rev Senol Patol Mamar. 2014; 27: 43-53
        • Banerjee S.M.
        • Michalopoulos N.V.
        • Williams N.
        • et al.
        Detailed evaluation of one step nucleic acid (OSNA) molecular assay for intraoperative diagnosis of sentinel lymph node metastasis and prediction of non-sentinel nodal involvement: experience from a London teaching hospital.
        Breast. 2014; 23: 378-384
        • Ohi Y.
        • Umekita Y.
        • Sagara Y.
        • et al.
        Whole sentinel lymph node analysis by molecular assay predicts axillary node status in breast cancer.
        Br J Cancer. 2012;Oct 9; 107: 1239-1243
        • Ogiya A.
        • Iwase T.
        • Kitagawa D.
        • et al.
        Non-sentinel lymph node analysis with one-step nucleic acid amplification in breast cancer patients.
        Breast. 2015; 24: 476-480
        • Cserni G.
        Sentinel lymph-node biopsy-based prediction of further breast cancer metastases in the axilla.
        Eur J Surg Oncol. 2001; 27: 532-538
        • Degnim A.C.
        • Griffith K.A.
        • Sabel M.S.
        • et al.
        Clinicopathologic features of metastasis in non-sentinel lymph nodes of breast carcinoma patients. A metaanalysis.
        Cancer. 2003; 98: 2307-2315
        • Fujii T.
        • Yajima R.
        • Tatsuki H.
        • et al.
        Significance of lymphatic invasion combined with size of primary tumor for predicting sentinel lymph node metastasis in patients with breast cancer.
        Anticancer Res. 2015; 35: 3581-3584
        • Lyman G.H.
        • Giuliano A.E.
        • Somerfield M.R.
        • et al.
        American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer.
        J Clin Oncol. 2005; 23: 7703-7720
        • Edge S.B.
        • Byrd D.R.
        • Compton C.C.
        • Fritz A.G.
        • Greene F.L.
        • Trotti A.
        American Joint Committee on Cancer cancer staging manual.
        7th ed. Springer, New York, NY2010
        • Giuliano A.E.
        • Hunt K.K.
        • Ballman K.V.
        • et al.
        Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial.
        JAMA. 2011; 305: 569-575
        • Galimberti V.
        • Cole B.F.
        • Zurrida S.
        • et al.
        • International Breast Cancer Study Group Trial 23-01 investigators
        Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): a phase 3 randomised controlled trial.
        Lancet Oncol. 2013; 14: 297-305
        • Gainer S.M.
        • Hunt K.K.
        • Beitsch P.
        • et al.
        Changing behaviour in clinical practice in response to the ACOSOG Z0011 trial: a survey of the American Society of Breast Surgeons.
        Ann Surg Oncol. 2012; 19: 3152-3158
        • Lyman G.H.
        • Temin S.
        • Edge S.B.
        • et al.
        Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology clinical practice guideline update.
        (Published online before print)March 24, 2014
        • Milner T.D.
        • de Lusignan S.
        • Jones S.
        • et al.
        Breast cancer metastasis burden in sentinel nodes analysed using one-step nucleic acid amplification predicts axillary nodal status.
        Breast. 2015; 24: 568-575
        • Rutgers E.J.
        • Donker M.
        • EvelienStraver M.
        • et al.
        Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer patients: final analysis of the EORTC AMAROS trial (10981/22023).
        J Clin Oncol. 2013; (ASCO Annual Meeting Abstracts. 2013; 31:8_suppl (June 20 Supplement): LBA1001© 2013 American Society of Clinical Oncology)
        • Goyal A.
        • Dodwell D.
        POSNOC: A randomised trial looking at axillary treatment in women with one or two sentinel nodes with macrometastases.
        Clin Oncol (R Coll Radiol). 2015 Dec; 27 (Epub 2015 Aug 5): 692-695
        • Holm-Rasmussen E.V.
        • Jensen M.-B.
        • Balslev E.
        • Kroman N.
        • Tvedskov T.F.
        Reduced risk of axillary lymphatic spread in triple-negative breast cancer.
        Breast Cancer Res Treat. December 2014; (Published online 09)
        • Tamaki Y.
        One-step nucleic acid amplification assay (OSNA) for sentinel lymph node biopsy.
        Breast Cancer. 2012;
        • Alvarenga C.A.
        • Paravidino P.I.
        • Alvarenga M.
        • et al.
        Expression of CK19 in invasive breast carcinomas of special histological types: implications for the use of one-step nucleic acid amplification.
        J Clin Pathol. 2011; 64: 493-497
        • Vilardell F.
        • Novell A.
        • Martin J.
        • et al.
        Importance of assessing CK19 immunostaining in core biopsies in patients subjected to sentinel node study by OSNA.
        Virchows Arch. 2012; Jun; 460: 569-575