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ECG-derived Poincaré plot graphical metrics for differentiating axillary lymph node metastasis in breast cancer
Nannan Fang1, Aoqi Zhang1,2, Zhijing Song1
1Anhui Key Laboratory of Digital Medicine and Intelligent Health, School of Medical Imaging, Bengbu Medical University, Bengbu, China.
Frontiers in Physiology
|June 5, 2026
Summary
Poincaré plot analysis of electrocardiograms shows potential for identifying autonomic nervous system signatures linked to breast cancer axillary lymph node metastasis. Detrended Area Index offers a novel, non-invasive approach for assessing autonomic spatial asymmetry.
Area of Science:
- Cardiology
- Oncology
- Autonomic Neuroscience
Background:
- Axillary lymph node metastasis (ALNM) status is crucial for breast cancer (BC) treatment decisions.
- Autonomic nervous system (ANS) dysfunction is linked to tumor progression, but BC-ALNM-specific ANS signatures are underexplored.
- Conventional heart rate variability (HRV) metrics may not fully capture ANS alterations in BC.
Purpose of the Study:
- To investigate if Poincaré plot analysis of electrocardiograms can identify ANS signals associated with ALNM.
- To compare the effectiveness of Poincaré plot metrics against conventional HRV metrics for BC-ALNM detection.
- To explore novel, non-invasive markers for assessing autonomic spatial asymmetry in breast cancer patients.
Main Methods:
- Collected resting electrocardiograph data from 218 breast cancer patients (142 ALNM-positive, 76 ALNM-negative).
- Compared conventional HRV metrics and Poincaré plot-derived spatial metrics (raw and detrended data).
- Utilized multivariable Analysis of Covariance (ANCOVA) and Receiver Operating Characteristic (ROC) analysis with 10-fold cross-validation.
Main Results:
- Conventional HRV metrics showed no significant difference or predictive value for ALNM (AUC = 0.532).
- Detrended Poincaré plot Area Index (AI) showed significant differences between groups (p=0.006, Cohen's d=0.40).
- Detrended AI remained a significant independent predictor after multivariable adjustment (adjusted p=0.024) with a cross-validated AUC of 0.607.
Conclusions:
- Poincaré plot analysis, particularly detrended AI, shows potential for characterizing ALNM-associated autonomic spatial asymmetry.
- These non-invasive metrics may offer a novel pathophysiological perspective independent of general tumor burden.
- Further large-scale, multi-center prospective studies are required to validate clinical utility due to modest discriminative ability and single-center design.
