Abstract
Background: The extent of axillary lymph node dissection (ALND) in node-positive breast cancer remains controversial, particularly regarding routine assessment of level III and interpectoral (Rotter’s) nodes. This study evaluated the distribution of metastatic disease across axillary levels and the prevalence of skip metastasis, while exploring clinicopathological factors associated with non-level-I disease.
Methods: This prospective observational study was conducted at the Department of Surgical Oncology, Tertiary Cancer Centre, from July 2019 to November 2020. Patients aged 18–70 years with biopsy-proven breast cancer undergoing modified radical mastectomy or breast-conserving surgery with ALND were eligible; patients with recurrent or metastatic disease and those declining participation were excluded. Level I, level II, level III and Rotter’s nodes were dissected and labelled separately. Clinicopathological variables and postoperative morbidity were recorded. Associations were assessed using chi-square/Fisher’s exact tests and logistic regression as reported in the study; p<0.05 was considered significant.
Results: Among 146 recruited patients, 59 were pathologically node-positive and constituted the analysis cohort. Mean age was 52.5±8.5 years; 42.4% received neoadjuvant chemotherapy. Level I nodes were positive in 58/59 (98.3%) patients. Level III metastasis was identified in 5/59 (8.5%), Rotter’s node metastasis in 6/59 (10.2%), and skip metastasis in 1/59 (1.7%). Four patients (6.8%) had metastases involving levels I, II and III. Tumour location in the outer quadrant was independently associated with level III positivity (multivariable p=0.04). Grade 1/2 tumours, outer-quadrant location and HER2-negative status were independently associated with Rotter’s node positivity. Clinical examination and axillary ultrasonography had sensitivities of 45.7% and 74.5%, respectively, for detecting pathological nodal disease in this node-positive cohort. Seroma occurred in 23.7% and subjective upper-limb lymphedema symptoms in 8.5%.
Conclusions: In this small prospective cohort, skip metastasis was uncommon, whereas level III and Rotter’s node metastases occurred in a clinically relevant minority of node-positive patients. The findings support selective level III dissection based on suspicious level II disease or a high level-I nodal burden rather than routine level III clearance, while careful assessment of the interpectoral space may identify additional metastatic nodes. Larger studies with longer follow-up are required.
Keywords: breast cancer; axillary lymph node dissection; level III lymph nodes; Rotter’s nodes; skip metastasis; axillary metastasis; neoadjuvant chemotherapy