Complete axillary lymph node dissection for stage I-II carcinoma of the breast.

Abstract

We reviewed the complete axillary dissection specimens of 136 patients with stage I-II breast cancer to clarify the distribution of axillary lymph node metastases in this disease. Our series included 71 patients undergoing axillary dissection as part of a modified radical mastectomy (MRM) and 65 patients undergoing axillary dissection in conjunction with conservative surgery of the breast and definitive postoperative breast radiotherapy (CAD). These two groups of patients were comparable according to age, menopausal status, tumor size, and clinical stage. In all patients the pectoralis minor muscle was excised and all axillary tissue removed. Each specimen contained a median of 23 lymph nodes. The axillary levels (I, II, III) were determined according to the relationship of axillary tissue to the pectoralis minor muscle (lateral, inferior, medial). Thirty-nine percent of the lymph nodes were contained in level I, 41% in level II, and 20% in level III. There were no significant differences noted in the number of lymph nodes or in the distribution of lymph nodes according to axillary level between dissections performed as part of the MRM or those done as a single procedure (CAD). Sixty-five patients (47.8%) had one or more positive lymph nodes in their axillary specimen. The clinical and pathologic stage was determined and compared for all patients. Among patients judged to have a clinically negative axilla, 37.6% had histologically positive lymph nodes (clinical false-negative rate). For patients with a clinically positive axilla, 11.1% had, histologically, no evidence of metastatic disease (clinical false-positive rate). When the distribution of lymph node metastases according to axillary level was studied, it was found that 29.2% of lymph node-positive patients (or 14.0% of all patients) had metastases only to level II and/or III of the axilla, with level I being negative (skip metastases). This incidence of skip metastases was greater among clinically node-negative than among clinically node-positive patients, but was not related to the size or location of the primary tumor in the breast. In addition, it was found that 20.0% of lymph node-positive patients (or 9.6% of all patients) were converted from three or fewer to four or more positive nodes by analysis of lymph nodes contained in levels II and III. This conversion from three or fewer to four or more positive nodes was due primarily to information contained in level II, with level III contributing to a smaller degree.(ABSTRACT TRUNCATED AT 400 WORDS)

Variability in axillary lymph node dissection for breast cancer

“…Differences in procedures for and the extent of the axillary dissection may have contributed to the observed variation. Low level axillary dissection, limited axillary sampling, or biopsy of selected lymph nodes have been shown to carry a significant risk of false negative axillary staging [9][10][11][12]28,29]. Effect of older age at diagnosis on number of reported nodes for tumors 5 cm and tumors >5 cm, respectively (interaction of age and tumor size).…”

“…Currently, the UICC/AJCC TNM classification requires the removal and analysis of at least the proximal axillary nodes (level I), which should yield a minimum of six nodes, for assigning a pathological nodal stage [8]. A radical axillary lymph node dissection ideally comprises removal of all level I, II, and III axillary nodes, although a negative axillary lymph node dissection limited to level I and II lymph nodes probably carries a negligible (0-5%) risk of metastasis to the level III nodes [9][10][11][12][13][14][15][16]. Although an axillary lymph node dissection is foremost a staging procedure providing prognostic information, it can also be regarded as an effective means for establishing local control.…”

Complications of Level I and II Axillary Dissection in the Treatment of Carcinoma of the Breast

“…12,13 Although the incidence of isolated metastases to level II was still Ͻ2% in some series, 14,15 the incidence of "skip" metastases did exceed 20% in other reports. 16,17 As a result, level I and II dissection, with preservation of the pectoralis minor, has come to represent the anatomic extent of axillary lymphadenectomy in most reports. 18 Curiously, there are limited data, either with breast-conservation surgery or with mastectomy, on the complications of level I and II lymphadenectomy.…”

The prognostic significance of the percentage of positive/dissected axillary lymph nodes in breast cancer recurrence and survival in patients with one to three positive axillary lymph nodes

“…2,3 There is general agreement that the Level I and II lymph nodes located lateral to and deep to the pectoralis minor muscle should be removed for accurate staging and to reduce axillary recurrence. [15][16][17][18][19][20][21] A study of 13,851 patients registered by the Danish Breast Cancer Cooperative Group suggests that the number of lymph nodes removed with Level I and II dissection should be at least 10 to exclude misclassification of patients with positive lymph nodes as lymph node-negative. 16 In the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-04 study, the estimate of quantitative lymph node status (1-3 vs. Ն 4 positive lymph nodes) was more reliable when at least 10 lymph nodes were removed.…”