Predicting negative sentinel lymph node biopsy in early-stage breast cancer: a potential model from clinical characteristics

Predicting negative sentinel lymph node biopsy in early-stage breast cancer: a potential model from clinical characteristics | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 24 March 2025 V1 Latest version Share on Predicting negative sentinel lymph node biopsy in early-stage breast cancer: a potential model from clinical characteristics Authors : Weilli , Jiaqi Li , Huiyue Li , Jinwei Chen , Ningxia Wang , and Hening Zhai 0009-0008-7423-5757 [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.174279812.27919179/v1 148 views 56 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Aims: The study aims to investigate the clinical characteristics of patients with negative sentinel lymph node biopsy (SLNB) results among those with low-risk early-stage breast cancer, providing evidence for criteria to exempt certain patients from SLNB. Methods: A retrospective observational study was conducted on patients with early-stage breast cancer (cT0-2 N0-1 M0) from January 2015 to December 2020. Patients were categorized into negative and positive groups based on their SLNB results. The clinical data collected included demographics, imaging findings, clinical stage, pathological information, and treatment outcomes. Results: Out of 385 patients, 252 had negative SLNB. Risk factors for negative SLNB included being under 40 years old, ductal carcinoma in situ (DCIS), early clinical staging, smaller tumor diameters (<2 cm), higher levels of estrogen receptor (ER) and progesterone receptor (PR) expression, negative Her-2 status, and lower Ki67 expression. Multivariate analysis revealed that positive lymph nodes from MRI correlated with higher rates of axillary lymph node metastasis, with MRI-detected positive findings being a significant risk factor for postoperative recurrence and metastasis. There was no significant difference in disease-free survival (DFS) time between the negative and positive SLNB groups. Conclusions: SLNB may not be necessary for early-stage breast cancer patients under 40 with tumors smaller than 2 cm, DCIS, positive ER and PR expression, and negative MRI findings. MRI was emphasized as a critical tool for predicting lymph node metastasis and assessing patient prognosis. Introduction Breast cancer has become the most prevalent malignant tumor in women, severely endangering women’s health. 1 With the improvement of medical conditions and the popularization of knowledge related to breast cancer, the detection rate of early-stage breast cancer has significantly increased in recent years through Doppler Ultrasound (DUS) and mammography screening. 2 For patients with early-stage breast cancer, the risk of lymph node metastasis and distant metastasis is relatively low. Currently, sentinel lymph node biopsy (SLNB) is necessary for the majority of early-stage breast cancer patients, which represents the optimal strategy for preserving axillary function in patients. 3 However, studies have proven that the SLNB results are negative in 60%-70% of patients post-surgery. 4,5 In response, current researches are advancing the evidence-based medical process of exempting SLNB by developing a predictive model based on preoperative screening. 6,7 However, literature on this subject is still limited. Identifying risk factors for sentinel lymph node metastasis in patients with low-risk early-stage breast cancer through stratified analysis is becoming a crucial step in optimizing the SLNB strategy, offering valuable insights for the management of sentinel lymph nodes. Therefore, the objective of this study is to explore the clinical characteristics of patients with negative SLNB results among those with low-risk early-stage breast cancer, and to provide evidence for criteria to exempt certain patients from SLNB. Study design This is a retrospective, observational, and single center study. Patients with early-stage breast cancer (cT0-2, N0-1, M0) with complete data from January 2015 to December 2020 were collected. Patients were categorized into two groups based on their SLNB results: negative SLNB and positive SLNB. The collected clinical data included age, menopausal status, imaging findings, clinical stage, pathological information (histological grade, ER, PR, Her-2, Ki67 status), and treatment outcomes (including chemotherapy, targeted therapy, and endocrine therapy). Inclusion and exclusion criteria Inclusion criteria were as follows: 1) comprehensive clinical data available, 2) negative SLNB, defined as postoperative pathology indicating no sentinel lymph node involvement or lymph node micro metastasis, and 3) positive SLNB, defined as postoperative pathology revealing 1-3 lymph node metastases. Exclusion criteria included incomplete clinical data and absence of follow-up. Follow-up All patients were followed up for more than 3 years post-surgery, with routine examinations for breast cancer recurrence or metastasis every 3-6 months within the first 3 years (physical examination, breast, DUS of axillary and supraclavicular lymph node, cervical lymph node, gynecological, and upper abdominal, chest X-rays, with a whole-body bone scan conducted once a year), re-examined every six months between 3-5 years, and annually after 5 years. Definition Menopausal status was determined for patients over 60 years old, those who had naturally ceased menstruation for more than one year, or after undergoing bilateral oophorectomy. Clinical staging followed the American Joint Committee on Cancer (AJCC) guidelines for breast cancer, with tumor size, lymph node status, and distant metastasis assessed through imaging. 8 Histological assessment Histological grading was independently evaluated based on duct formation, cellular atypia, and mitotic count, each scored from 1 to 3, cumulating in a classification of invasive cancer into high, medium, or low grades. Immunohistochemistry staining for estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER-2), and cell proliferation index (Ki67) was performed, with HER-2 2+ cases requiring further in situ hybridization testing. The pathology reports detailed the intensity and percentage of positive cells for ER and PR. Ki67 expression ≤14% was considered low, while >14% indicated high expression. Lymph node micro metastasis and macro metastasis were defined based on lesion size. Postoperative adjuvant therapy aligned with the National Comprehensive Cancer Network (NCCN) annual guidelines for breast cancer. 9 Outcome measures The primary outcome involved comparing the clinical and pathological features of the negative and positive SLNB groups. Secondary outcomes included a multivariate analysis of factors influencing lymph node metastasis, recurrence, distant metastasis risks, and the prognosis for both patient groups. Statistical analysis Data statistical analysis was performed using SPSS22.0 software, categorical data were presented as n (%), and the χ2 test was used for inter-group comparisons. Single-factor Logistic analysis was used to analyze the differences between the two groups, with factors with P<0.05 in single-factor analysis included in multivariate Logistic analysis to explore the association between risk factors and sentinel lymph node negativity. P<0.05 was considered statistically significant. Disease-free survival (DFS) curves were utilized to evaluate the recurrence in patients with negative and positive SLNB results. Results Baseline characteristics A total of 385 patients were included, of which 252 patients was in negative SNLB and 133 in positive SNLB groups. There was no statistical significance in the comparison of menopausal status between the two groups. However, patients with negative SNLB tended to be younger, with a higher proportion under the age of 40. Table 1 depicts the baseline charisticaries of the two groups. Clinical and pathological characteristics of patients with negative and positive SNLB Patients in the negative SNLB group were primarily diagnosed with ductal carcinoma in situ (DCIS), exhibited earlier clinical staging, and had smaller tumor diameters (p<0.05). DUS, Mammography, and magnetic resonance imaging (MRI) indicated a higher rate of negative lymph node findings and a lower recurrence rate in the negative SNLB group (Table 2). Furthermore, this group displayed significantly higher levels of ER and PR expression, negative Her-2 status, and lower Ki67 expression (p<0.05), as shown in Table 3. Clinical and pathological characteristics of invasive ductal carcinoma (IDC) Among patients with IDC, 106 were in the negative SNLB group and 116 in the positive SNLB group. No significant differences were noted in age, clinical staging, or chemotherapy between the IDC subgroups. Patients with negative SNLB had smaller tumors and a higher rate of negative lymph node findings, along with lower recurrence rates, as indicated in Table 4. Histological grading, ER expression, and Ki67 levels did not significantly differ between the groups. The Luminal B subtype was the most prevalent, followed by Her-2 positive, triple-negative, and Luminal A subtypes, as per Table 5. We further divided the patients with negative SNLB into IDC and DCIS, of which 93 and 106 patients were found, respectively. There were no significant differences in age or recurrence rate. Nevertheless, menopausal patients had a higher proportion of DCIS compared to IDC (Table 6). Multivariate Analysis of risk factors for metastasis and recurrence The analysis revealed that preoperative MRI detection (OR:16.45; 95% CI: 9.77-27.70; p=0.001) of positive lymph nodes significantly correlated with a higher rate of axillary lymph node metastasis. The risk of metastasis ranked as follows: IDC > special type carcinoma > DCIS (OR:2.97; 95% CI: 1.96-4.51; p=0.001). For early-stage IDC patients, MRI-detected positive findings (OR:37.2; 95% CI: 0.17-1.39; p=0.001) and tumor size (OR:7.56; 95% CI: 1.64- 63.33; p=0.006) were identified as risk factors for lymph node metastasis. Patients with negative SNLB who had positive MRI findings were at a 28-fold increased risk (OR:28.432; 95%CI: 3.20-248.68; p=0.003) of postoperative recurrence metastasis. Survival analysis for negative and positive SNLB Over a median follow-up of 92 months, there was no significant difference in Disease-Free Survival (DFS) time between the negative and positive SNLB groups (χ2=1.151, P=0.283). The DFS curve for both groups is illustrated in Figure 1. Discussion Our study identified that lymph node metastasis in early-stage breast cancer correlates with several factors, including age, tumor type and size, clinical stage, histological grade, and the expression levels of ER, PR, Her-2, and Ki67. Specifically, SLNB might not be necessary for patients older than 40 years, with tumor diameters less than 2 cm, diagnosed with DCIS, exhibiting strong positive expression of ER and PR, and showing negative MRI findings for lymph nodes. Furthermore, MRI was found to be an effective tool for predicting lymph node metastasis, serving as a critical indicator for assessing patient prognosis. Remarkably, the study revealed that the presence of sentinel lymph node metastasis does not significantly impact DFS time in early-stage breast cancer. Our findings aligned with current research on models predicting lymph node metastasis in early breast cancer. 10-12 However, the risk factors for recurrence and metastasis in early breast cancer with 0-3 lymph node metastases remain underexplored. Our analysis indicated that lymph node metastasis is associated with pathological type, tumor size, clinical stage, histological grade, and the expression of ER, PR, and Ki67. Therefore, patients with DCIS, clinical stages 0-I, tumors smaller than 2cm, negative imaging findings, positive ER and PR expression, and low Ki67 levels should be considered low-risk for axillary lymph node metastasis and recurrence, potentially exempting them from SLNB. Additionally, our analysis of early-stage IDC patients revealed a recurrence and metastasis rate of only 2% among those with negative SLNB, similar to DCIS patients. This supports the possibility of exempting early-stage IDC patients with negative SLNB results from SLNB, in line with the findings by Hughes KS et al. 13 Multivariate analysis further indicated that preoperative MRI findings of positive lymph nodes significantly increase the detection rate of positive SLNB results. Positive MRI findings of lymph nodes also predicted recurrence and metastasis, highlighting the importance of MRI in early breast cancer assessment. Despite negative axillary sentinel lymph nodes, the risk of local recurrence persists, particularly for larger tumors or those located in the inner quadrants without postoperative radiation therapy, making positive MRI findings a crucial predictive factor for recurrence and metastasis. 14-17 Our cohort demonstrated a higher prevalence of the Luminal B subtype in early breast cancer patients, who generally respond well to endocrine therapy. Postoperative adjuvant therapy can effectively control the risk of recurrence and metastasis in early breast cancer with 1-3 positive lymph nodes, as evidenced by studies such as The ACOSOG Z0011 (Alliance) Randomized Clinical Trial. 18,19 Recent NCCN guidelines also support the omission of axillary lymph node dissection for breast-conserving surgery patients with 1-2 positive lymph nodes, further supported by evidence suggesting a low rate of non-sentinel lymph node metastasis in patients with low-burden sentinel lymph node metastasis ((1-2 metastases or micro metastases). 20,21 These explain the findings in our study that there was no difference in DFS time for early breast cancer patients, regardless of lymph node metastasis and SLNB results. Notably, a significant proportion of early-stage breast cancer patients with negative SLNB in this study were under 40 years old, reflecting the effectiveness of standardized breast cancer screening, enhanced disease awareness, and specialized care in China. There are some limitation that should be noted. First, this study is limited to the data analysis of early breast cancer patients with 1-3 axillary lymph node metastases. In early breast cancer patients with ≥4 lymph node metastases, biopsy assessment of lymph node status is still required when the metastasis status is unclear. Second, due to retrospective design, the study may limit the generalizability of the findings and introduces potential biases in patient selection and data collection. In conclusion, SLNB may be unnecessary for patients under 40 with DCIS, tumors smaller than 2cm, positive ER and PR expression, and negative MRI findings for lymph nodes. MRI stands out as a valuable tool for predicting lymph node metastasis and assessing patient prognosis, with sentinel lymph node metastasis not significantly affecting DFS time in early-stage breast cancer. Future prospective studies are warranted to validate these findings. References: 1 Siegel, R. L., Miller, K. D., Fuchs, H. E. & Jemal, A. Cancer Statistics, 2021. CA Cancer J Clin 71 , 7-33, doi:10.3322/caac.21654 (2021).2 Majid, S., Ryden, L. & Manjer, J. Predictive factors for sentinel node metastases in primary invasive breast cancer: a population-based cohort study of 2552 consecutive patients. World J Surg Oncol 16 , 54, doi:10.1186/s12957-018-1353-2 (2018).3 Huang, Z. et al. Risk factors of non-sentinel lymph node metastasis in breast cancer with 1-2 sentinel lymph node macrometastases underwent total mastectomy: a case-control study. World J Surg Oncol 21 , 125, doi:10.1186/s12957-023-02888-z (2023).4 Heidinger, M. et al. Use of sentinel lymph node biopsy in elderly patients with breast cancer - 10-year experience from a Swiss university hospital. World J Surg Oncol 21 , 176, doi:10.1186/s12957-023-03062-1 (2023).5 Maeseele, N. et al. Axillary lymph node dissection on the run? Facts Views Vis Obgyn 9 , 45-49 (2017).6 Esposito, E., Di Micco, R. & Gentilini, O. D. Sentinel node biopsy in early breast cancer. A review on recent and ongoing randomized trials. Breast 36 , 14-19, doi:10.1016/j.breast.2017.08.006 (2017).7 Li, J. et al. Feasibility of sentinel lymph node biopsy omission after integration of (18)F-FDG dedicated lymph node PET in early breast cancer: a prospective phase II trial. Cancer Biol Med 19 , 1100-1108, doi:10.20892/j.issn.2095-3941.2022.0085 (2022).8 Amin, M. B. et al. AJCC Cancer Staging Manual . (Springer International Publishing, 2018).9 Gradishar, W. J. et al. NCCN Guidelines Insights: Breast Cancer, Version 1.2017. J Natl Compr Canc Netw 15 , 433-451, doi:10.6004/jnccn.2017.0044 (2017).10 Arisio, R. et al. Axillary Dissection vs. no Axillary Dissection in Breast Cancer Patients With Positive Sentinel Lymph Node: A Single Institution Experience. In Vivo 33 , 1941-1947, doi:10.21873/invivo.11689 (2019).11 Zheng, J. et al. Positive non-sentinel axillary lymph nodes in breast cancer with 1-2 sentinel lymph node metastases. Medicine (Baltimore) 97 , e13015, doi:10.1097/md.0000000000013015 (2018).12 Aleskandarany, M. A. et al. Impact of intratumoural heterogeneity on the assessment of Ki67 expression in breast cancer. Breast Cancer Res Treat 158 , 287-295, doi:10.1007/s10549-016-3893-x (2016).13 Hughes, K. S. et al. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol 31 , 2382-2387, doi:10.1200/jco.2012.45.2615 (2013).14 Zheng, X. et al. Deep learning radiomics can predict axillary lymph node status in early- stage breast cancer. Nat Commun 11 , 1236, doi:10.1038/s41467-020-15027-z (2020).15 Kuru, B., Yuruker, S., Sullu, Y., Gursel, B. & Ozen, N. Management of the Axilla in T1-2 Breast Cancer Patients with Macrometastatic Sentinel Node Involvement Who Underwent Breast-Conserving Therapy. J Invest Surg 32 , 48-54, doi:10.1080/08941939.2017.1375051 (2019).16 Kim, G. R. et al. Preoperative Axillary US in Early-Stage Breast Cancer: Potential to Prevent Unnecessary Axillary Lymph Node Dissection. Radiology 288 , 55-63, doi:10.1148/radiol.2018171987 (2018).17 Sun, S. X., Moseley, T. W., Kuerer, H. M. & Yang, W. T. Imaging-Based Approach to Axillary Lymph Node Staging and Sentinel Lymph Node Biopsy in Patients With Breast Cancer. AJR Am J Roentgenol 214 , 249-258, doi:10.2214/ajr.19.22022 (2020).18 Giuliano, A. E. 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 318 , 918-926, doi:10.1001/jama.2017.11470 (2017).19 Galimberti, V. et al. Axillary dissection versus no axillary dissection in patients with breast cancer and sentinel-node micrometastases (IBCSG 23-01): 10-year follow-up of a randomised, controlled phase 3 trial. Lancet Oncol 19 , 1385-1393, doi:10.1016/s1470-2045(18)30380-2 (2018).20 van la Parra, R. F., Peer, P. G., Ernst, M. F. & Bosscha, K. Meta-analysis of predictive factors for non-sentinel lymph node metastases in breast cancer patients with a positive SLN. Eur J Surg Oncol 37 , 290-299, doi:10.1016/j.ejso.2011.01.006 (2011).21 Gradishar, W. J. et al. Breast Cancer, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 20 , 691-722, doi:10.6004/jnccn.2022.0030 (2022). Table 1 Comparison of baseline between negative and positive SLNB groups Number of Cases 252 (65%) 133 (35%) Age 8.312 0.004 40 years old 107 (42%) 77 (58%) Menopausal Status 0.28 0.91 Pre-menopausal 167 (66%) 87 (65%) Post-menopausal 85 (34%) 46 (35%) SLNB, sentinel lymph node biopsy Table 2 Clinical characteristics of negative and positive SLNB groups Number of Cases 252 (65%) 133 (35%) Intraductal Cancer 93 (37%) 6 (5%) 74.835 0.001 Special Type Cancer 53 (21%) 11 (8%) Invasive Cancer 106 (42%) 116 (87%) Clinical Stage 55.923 0.001 0 93 (37%) 6 (4%) I 93 (37%) 53 (40%) II 66 (26%) 74 (56%) Tumor Size 4.6 0.03 0~2cm 161 (64%) 43 (32%) 2~5cm 91 (36%) 90 (68%) Ultrasound Lymph Nodes 7.5 0.001 Positive 84 (33%) 96 (72%) Negative 168 (67%) 37 (28%) Mammogram Lymph Nodes 75.209 0.001 Positive 63 (25%) 94 (71%) Negative 189 (75%) 39 (29%) MRI Lymph Nodes 133.92 0.001 Positive 42 (17%) 102 (77%) Negative 210 (83%) 31 (23%) Recurrence/Metastasis 6 (2%) 21 (16%) 24.01 0.001 No Recurrence/Metastasis 246 (98%) 112 (84%) SLNB, sentinel lymph node biopsy Table 3 Pathological characteristics of negative and positive SLNB groups Number of Cases 252 (65%) 133 (35%) ER 28.32 0.001 High Expression 189 (75%) 65 (49%) Low Expression 63 (25%) 68 (51%) PR 11.69 0.001 High Expression 163 (65%) 62 (47%) Low Expression 89 (35%) 71 (53%) Her-2 10.46 0.005 - 86 (34%) 25 (19%) +/- 72 (29%) 44 (32%) + 95 (38%) 64 (49%) Ki67 3.2 0.046 High Expression 149 (60%) 91 (66%) Low Expression 103 (40%) 42 (34%) SLNB, sentinel lymph node biopsy; ER, estrogen receptor; PR, progesterone receptor; HER-2, human epidermal growth factor receptor 2; Ki67, cell proliferation index Table 4 Clinical characteristics of invasive ductal carcinoma Number of Cases 106 116 Age 0.671 0.492 40 years 61 (57%) 73 (63%) Menopausal Status 0.1 0.879 Pre-menopausal 68 (64%) 72 (62%) Post-menopausal 38 (36%) 44 (38%) Tumor Size 19.61 0.001 0~2cm 69 (65%) 41 (35%) 2~5cm 37 (35%) 75 (65%) Clinical Stage 2.557 0.144 I 64 (60%) 44 (51%) II 42 (40%) 42 (49%) Ultrasound Lymph Nodes 10.999 0.001 Positive 58 (55%) 74 (64%) Negative 48 (45%) 88 (36%) Mammogram Lymph Nodes 24.299 0.001 Positive 44 (42%) 86 (74%) Negative 62 (58%) 30 (26%) MRI Lymph Nodes 64.548 0.001 Positive 28 (26%) 93 (80%) Negative 78 (74%) 23 (20%) Chemotherapy 0.08 0.851 Yes 91 (86%) 98 (84%) No 15 (14%) 18 (15%) Recurrence/Metastasis 6.56 0.009 Yes 5 (5%) 18 (16%) No 101 (95%) 98 (84%) SLNB, sentinel lymph node biopsy Table 5 Pathological characteristics of invasive ductal carcinoma Number of Cases 106 116 Histological Grade 1.235 0.539 Grade 1 42 (40%) 42 (36%) Grade 2 39 (37%) 51 (44%) Grade 3 25 (24%) 23 (20%) Molecular Typing 8.47 0.037 Luminal A 37 (18%) 21 (18%) Luminal B 38 (39%) 55 (47%) TNBC 16 (20%) 23 (20%) Her-2+ 15 (23%) 17 (15%) ER 1.948 0.179 High Expression 62 (59%) 57 (50%) Low Expression 44 (41%) 59 (50%) PR 4.628 0.038 High Expression 71 (67%) 59 (53%) Low Expression 35 (33%) 53 (47%) Her-2 15.81 0.001 - 17 (16%) 15 (13%) +/- 58 (54%) 37 (32%) + 31 (30%) 64 (55%) Ki67 0.525 0.553 High Expression 73 (69%) 85 (73%) Low Expression 33 (31%) 31 (27%) SLNB, sentinel lymph node biopsy; ER, estrogen receptor; PR, progesterone receptor; HER-2, human epidermal growth factor receptor 2; Ki67, cell proliferation index Table 6 Recurrence rates between DCIS and IDC in negative SLNB group Number of Cases 93 106 Age 0.143 0.846 40 years 79 (84%) 89 (84%) Menopausal Status 7.528 0.006 Pre-menopausal 38 (41%) 61 (58%) Post-menopausal 55 (59%) 45 (42%) Recurrence/Metastasis 1.106 0.249 Yes 0 (0%) 3 (2%) No 93 (100%) 103 (98%) SLNB, sentinel lymph node biopsy; DCIS, Ductal Carcinoma In Situ; IDC, invasive ductal carcinoma Figure 1 Disease-free survival curve for patients with negative and positive sentinel lymph node biopsy Information & Authors Information Version history V1 Version 1 24 March 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Authors Affiliations Weilli Jinan University First Affiliated Hospital View all articles by this author Jiaqi Li Jinan University First Affiliated Hospital View all articles by this author Huiyue Li County People's View all articles by this author Jinwei Chen County People's View all articles by this author Ningxia Wang Jinan University First Affiliated Hospital View all articles by this author Hening Zhai 0009-0008-7423-5757 [email protected] Jinan University First Affiliated Hospital View all articles by this author Metrics & Citations Metrics Article Usage 148 views 56 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Weilli, Jiaqi Li, Huiyue Li, et al. Predicting negative sentinel lymph node biopsy in early-stage breast cancer: a potential model from clinical characteristics. Authorea . 24 March 2025. 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