The Value of Level III Clearance in Patients With Axillary and Sentinel Node Positive Breast Cancer

Background:The value of level III axillary clearance is contentious, with great variance worldwide in the extent and levels of clearance performed. Objective:To determine rates of level III positivity in patients undergoing level I–III axillary clearance, and identify which patients are at highest risk of involved level III nodes. Methods:From a database of 2850 patients derived from symptomatic and population-based screening service, 1179 patients who underwent level I–III clearance between the years 1999–2007 were identified. The pathology, surgical details, and prior sentinel nodes biopsies of patients were recorded. Results:Eleven hundred seventy nine patients had level I–III axillary clearance. Of the patients, 63% (n = 747) were node positive. Of patients with node positive disease, 23% (n = 168) were level II positive and 19% (n = 141) were level III positive. Two hundred fifty patients had positive sentinel node biopsies prior to axillary clearance. Of these, 12% (n = 30) and 9% (n = 22) were level II and level III positive, respectively. On multivariate analysis, factors predictive of level III involvement in patients with node positive disease were tumor size (P < 0.001, OR = 1.36; 95% CI: 1.2–1.5), invasive lobular disease (P < 0.001, OR = 3.6; 95% CI: 1.9–6.95), extranodal extension (P < 0.001, OR = 0.27; 95% CI: 0.18–0.4), and lymphovascular invasion (P = 0.04, OR = 0.58; 95% CI: 0.35–1). Lobular invasive disease (P = 0.049, OR = 4.1; 95% CI: 1–16.8), extranodal spread (P = 0.003, OR = 0.18; 95% CI: 0.06–0.57), and having more than one positive sentinel node (P = 0.009, OR = 4.9; 95% CI: 1.5–16.1) were predictive of level III involvement in patients with sentinel node positive disease. Conclusion:Level III clearance has a selective but definite role to play in patients who have node positive breast carcinoma. Pathological characteristics of the primary tumor are of particular use in identifying those who are at various risk of level III nodal involvement.

[1]  N. Willich,et al.  Lymphödeme nach Mammakarzinom: Eine Studie über 5868 Fälle , 2008 .

[2]  K. Mokbel,et al.  Current management of the axilla in patients with clinically node-negative breast cancer: a nationwide survey of United Kingdom breast surgeons , 2007, International seminars in surgical oncology : ISSO.

[3]  E. Yıldırım,et al.  Lymph Node Ratio is More Valuable than Level III Involvement for Prediction of Outcome in Node-Positive Breast Carcinoma Patients , 2007, World Journal of Surgery.

[4]  I. Sayek,et al.  Re-evaluation of Axillary Skip Metastases in the Era of Sentinel Lymph Node Biopsy in Breast Cancer , 2006, Surgery Today.

[5]  Y. Nio,et al.  Ten-year follow-up results of a randomised controlled study comparing level-I vs level-III axillary lymph node dissection for primary breast cancer , 2006, British Journal of Cancer.

[6]  B. Barraclough,et al.  COMPLETE AXILLARY DISSECTION: A TECHNIQUE THAT STILL HAS RELEVANCE IN CONTEMPORARY MANAGEMENT OF BREAST CANCER , 2006, ANZ journal of surgery.

[7]  R. Zucali,et al.  A Randomized Trial Comparing Axillary Dissection to No Axillary Dissection in Older Patients With T1N0 Breast Cancer: Results After 5 Years of Follow-up , 2005, Annals of surgery.

[8]  J. Kao,et al.  Does the number of lymph nodes examined in patients with lymph node‐negative breast carcinoma have prognostic significance? , 2005, Cancer.

[9]  J. Forbes,et al.  A randomized trial comparing axillary clearance versus no axillary clearance in older patients (≥ 60 years) with breast cancer: First results of International Breast Cancer Study Group Trial 10-93. , 2004, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[10]  J. Dixon,et al.  A survey of surgical management of the axilla in UK breast cancer patients. , 2004, European journal of cancer.

[11]  H. Bonnefoi,et al.  Clinical trials update of the European Organization for Research and Treatment of Cancer Breast Cancer Group , 2004, Breast Cancer Research.

[12]  M. Kosir,et al.  Can a practicing surgeon detect early lymphedema reliably? , 2003, American journal of surgery.

[13]  E. Petru,et al.  T1 Breast Cancer: Identification of Patients at Low Risk of Axillary Lymph Node Metastases , 2002, Breast Cancer Research and Treatment.

[14]  W. Kwan,et al.  Chronic arm morbidity after curative breast cancer treatment: prevalence and impact on quality of life. , 2002, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[15]  Jong-Hyeon Jeong,et al.  Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. , 2002, The New England journal of medicine.

[16]  G. Hortobagyi,et al.  Long-term complications associated with breast-conservation surgery and radiotherapy , 2002, Annals of Surgical Oncology.

[17]  E. McDermott,et al.  Value of sentinel node biopsy in the management of breast cancer , 2001, Irish journal of medical science.

[18]  G. McGreal,et al.  Prospective evaluation of the morbidity of axillary clearance for breast cancer , 2001, The British journal of surgery.

[19]  J. Ragaz,et al.  Significance of axillary lymph node extranodal soft tissue extension and indications for postmastectomy irradiation , 2000, Cancer.

[20]  S. Gapstur,et al.  Factors associated with axillary lymph node metastasis from breast carcinoma , 1999, Cancer.

[21]  S. Piantadosi,et al.  Significance of axillary lymph node extranodal soft tissue extension and indications for postmastectomy irradiation , 1999, Cancer.

[22]  S. Edge,et al.  Treatment of early-stage breast cancer. , 1999, Current problems in cancer.

[23]  J. Yarnold,et al.  Lymphatic relapse in women with early breast cancer: a difficult management problem. , 1999, European journal of cancer.

[24]  J. Apffelstaedt,et al.  Axillary lymph node involvement in stage III breast cancer: Treatment implications , 1999, Journal of surgical oncology.

[25]  K. Bland,et al.  Axillary dissection in breast-conserving surgery for stage I and II breast cancer: a National Cancer Data Base study of patterns of omission and implications for survival. , 1999, Journal of the American College of Surgeons.

[26]  R. Severson,et al.  Axillary lymph node metastases associated with small invasive breast carcinomas , 1999, Cancer.

[27]  J. Ragaz,et al.  Prediction of axillary lymph node involvement of women with invasive breast carcinoma , 1998, Cancer.

[28]  P. Bruzzi,et al.  Prognostic role of lymph-node level involvement in patients undergoing axillary dissection for breast cancer. , 1998, European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology.

[29]  M. Choti,et al.  Association between extent of axillary lymph node dissection and survival in patients with stage I breast cancer , 1998, Annals of Surgical Oncology.

[30]  A. Hanlon,et al.  Identification of women with T1‐T2 breast cancer at low risk of positive axillary nodes , 1997, Journal of surgical oncology.

[31]  P M Ravdin,et al.  Prediction of axillary lymph node status in breast cancer patients by use of prognostic indicators. , 1994, Journal of the National Cancer Institute.

[32]  A. Ketcham,et al.  Total axillary lymphadenectomy in the management of breast cancer. , 1991, Archives of surgery.

[33]  S. Bonassi,et al.  Predictive value of some clinical and pathological parameters on upper level axillary lymph node involvement in breast cancer. , 1991, Anticancer research.

[34]  A. Luini,et al.  Extent of metastatic axillary involvement in 1446 cases of breast cancer. , 1990, European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology.

[35]  A. Hawasli,et al.  Axillary dissection for breast carcinoma. The myth of skip metastasis. , 1989, The American surgeon.

[36]  G. Hal,et al.  Distribution of axillary node metastases bylevel of invasion , 1987 .

[37]  R. Bussone,et al.  The correlation between the spread of metastases by level in the axillary nodes and disease-free survival in breast cancer. A multifactorial analysis. , 1987, European journal of cancer & clinical oncology.

[38]  A. Luini,et al.  Distribution of axillary node metastases by level of invasion. An analysis of 539 cases , 1987, Cancer.

[39]  S. Bonassi,et al.  Primary Tumor Site, Size, Patients Age and Axillary Lymph Nodes in Breast Cancers , 1986, Tumori.

[40]  S. Rosenberg,et al.  Complete axillary lymph node dissection for stage I-II carcinoma of the breast. , 1986, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[41]  M. Lesser,et al.  Discontinuous or “Skip” Metastases in Breast Carcinomae: Analysis of 1228 Axillary Dissections , 1983, Annals of surgery.

[42]  F. Rosato,et al.  Patterns of Axillary Nodal Involvement in Breast Cancer Predictability of Level One Dissection , 1982, Annals of surgery.

[43]  B. Kuru,et al.  Lymphedema after treatment of breast cancer. , 2004, American journal of surgery.

[44]  D. Krag,et al.  Breast Cancer Survival According to Number of Nodes Removed , 2003, Annals of Surgical Oncology.

[45]  J. Manola,et al.  The significance of extracapsular extension of axillary lymph node metastases in early-stage breast cancer. , 2000, International journal of radiation oncology, biology, physics.

[46]  N. Willich,et al.  [Lymphedema after breast carcinoma. A study of 5868 cases]. , 1997, Deutsche medizinische Wochenschrift.