Does the Level of Axillary Node Clearance Influence Adjuvant Treatment in Patients with Breast Cancer?

Abstract

Background: The SIGN (Scottish Intercollegiate Guidelines Network) guidelines on axillary surgery do not advise as to whether level 1/2 or level 3 clearances should be performed when axillary clearance is required. Although there is a theoretical risk of increased morbidity, in experienced hands a level 3 clearance reduces the chance of residual tumour and allows for full staging.Materials and Methods: 124 consecutive axillary clearances (level 1, 2 and 3) were performed by a single operator. Level 1 and 2 nodes were removed as a single specimen, with level 3 nodes removed separately. Patient case notes, operation notes and pathology reports were used in the collection of data and all data were recorded in an Excel databaseResults: Of the 124 axillary clearances performed, 64 (52%) had level 1/2 lymph nodes positive for carcinoma. Of these 64 patients, 14 (11%) also had positive level 3 nodes. One patient (1%) had negative level 1/2 nodes but positive level 3 nodes. The Nottingham Prognostic Index (NPI) value increased in two patients when the level 3 nodes were included (6.6 to 7.6 and 4.3 to 5.3).Discussion: While it is generally accepted that axillary radiotherapy deals with residual level 3 nodal involvement, basic surgical oncologic principles would suggest that removal of as much tumour as possible should be performed. The patient with positive level 3 nodes but negative level 1/2 nodes would have been under-treated, with viable tumour remaining. Furthermore, the under-estimate of the NPI when level 3 nodes are not included could lead to sub-optimal adjuvant therapy being offered. The performance of a level 3 clearance can preclude the need for axillary radiotherapy, thereby reducing morbidity. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3114.