Merits of Level III Axillary Dissection in Node-Positive Breast Cancer: A Prospective, Single-Institution Study From India

Abstract

PURPOSE A complete axillary lymph node (ALN) dissection is therapeutic in node-positive breast cancer. Presently, there is no international consensus regarding anatomic levels to be addressed in complete axillary dissection. We assessed the burden of disease in level III axilla. MATERIALS AND METHODS A prospectively maintained database was assessed for 1,591 consecutive patients with nonmetastatic breast cancer registered at Tata Memorial Center, Mumbai, between January 2009 and December 2014. RESULTS A median of four (zero to 20) level III ALNs were dissected and a median of two (one to 17) nodes were positive. A total of 27.3% (434 of 1,591) patients had level III ALN metastasis, and 4.7% of patients had positive interpectoral nodes. Some 53.2% of patients had level III metastases in the presence of four or more positive level I and II ALNs. A total of 9.4% of patients had level III involvement when one to three ALNs were positive in level I and II ( P < .001). Some 53.2% of patients had level III metastases in the presence of four or more positive level I and II ALNs. On logistic regression analysis, four or more positive ALNs in level I or II ( P < .001), inner/central quadrant tumor location ( P = .013), and perinodal extension ( P < .001) were associated with level III ALN involvement. At a median follow-up of 36 months, the disease-free survival was significantly worse for level III ALN metastases on univariate analysis ( P < .001). On multivariate Cox regression analysis, histologic grade ( P = .006), four or more positive ALNs ( P < .001), hormone receptor status ( P < .001), and tumor size ( P = .037) were independent prognostic factors for disease-free survival. CONCLUSION The axillary nodal burden is high in patients with breast cancer in developing countries like India. One of two women with four or more positive level I and II ALNs may have residual disease in level III if it is not cleared during surgery. Intraoperative interpectoral space clearance should be considered in the presence of either palpable interpectoral lymph nodes or multiple positive ALNs.

The Findings of SPECT/CT Concerning Bypass Lymph Circulation in Lymphedema Following Breast Cancer Surgery

“…Moreover, occasionally the short type discharges directly into the medial upper arm bundle and the deep axillary collector. Level III ALND is located between the costoclavicular ligament of Halsted and the medial border of the pectoralis minor, which is close to the apical and subclavicular lymph nodes [ 16 , 17 ]. Therefore, we speculated that the connection between superficial bypass circulation and periclavicular lymph nodes was removed through ALND.…”

The Role of Level III Dissection in Locally Advanced Breast Cancer following Neoadjuvant Chemotherapy—A Prospective Study

“…14 In the primary surgery setting, the level III positivity was 27.3% as per a recent Indian study. 15 The current pathological complete response (pCR) rate is 12% in hormone receptor (HR)-positive, HER2-negative, 36% in HR-positive, HER2positive, 38% in triple-negative, and 55% in HR-negative, HER2-positive cancer. 16 Thus, there is possibility of residual disease in level III in a significant proportion of patients.…”

Interpectoral Lymph Node Dissection Can Be Spared in pN0/N1 Invasive Breast Cancer Undergoing Modified Radical Mastectomy: Single-Institution Experience from Mainland China

“… 4 However, other surgeons had moderate views that IPN dissection was only necessary for patients with locally advanced disease (large tumour or positive ALNs). 10 Limited to rare high-quality studies of evidence-based medicine, the authoritative guideline of the National Comprehensive Cancer Network (NCCN) had no definite recommendation on the management of IPN for breast cancer patients. Whether IPN dissection or biopsy was performed often depended on the experience of the surgeons.…”