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Background and aim Axillary lymph node metastasis is the most important prognostic factors in breast carcinoma. The metastatic burden can be determined either by the number of lymph nodes with metastases (pN) or by the metastatic ratio (LNR), which is the ratio of positive nodes to the total nodes removed. The aim of the present investigation was to quantify the anatomic distribution of axillary lymph nodes by levels as well as to compare the metastatic burden of breast cancer at different nodal levels. A hypothetical model of incomplete lymphadenectomy was tested to determine the risk of such operations if performed in Egyptian patients. Patients and methods This study included 110 patients.In all operations, axillary dissection was complete including the three levels of nodes. The total series (110 patients) was used to study the anatomic distribution of axillary nodes at different levels as well as to study the rate of metastases at different levels. However, cases with positive nodes (56 patients) were used to determine the metastatic burden. ResultsThe total number of lymph nodes removed in the 110 cases was 2463 nodes. There were 1196 (48.6%) nodes at level I, 919 (37.3%) at level II, and 348 (14.1%) at level III (P < 0.001). The rate of lymph node metastases was 50.9%. The rates of node metastases at axillary levels I, II, and III were 50.9, 34.5, and 20%, respectively. The median number of metastatic lymph nodes in node-positive cases was 4, whereas the median numbers per level were 3, 4, and 3, respectively. The median lymph node ratio (LNR) for positive patients was 0.18, whereas the median LNRs per level were 0.3, 0.5, and 1, respectively (P < 0.001). Most of the node-positive patients (55.4%), according to LNR, were considered to be at low risk (r 0.2), whereas 28.6% were at an intermediate risk (0.2-0.65) and 16% were at a high risk (> 0.65%).Conclusion It can be concluded from this study that Egyptian patients with operable breast cancer present at a late stage (63.6% of tumors are >T1 and 50.9% have positive nodes). Anatomically, axillary nodes are commonly located (85.9%) at levels I and II and most metastases (86.8%) affect these two levels. However, level III is also involved in metastases in 20% of patients, hence the importance of a complete axillary lymphadenectomy in Egyptian patients.