The trend in breast cancer surgery is toward more
conservative operative procedures, and many have questioned
the value of complete axillary dissections in the management of primary breast cancer [4
]. It is widely
held that involvement of the lymph nodes occurs in a stepwise
continuous fashion from the periphery of the axilla
medially, and that the level of involvement at diagnosis
has an important bearing on prognosis [8
]. This concept
has been questioned by some who believe that prognosis
is best predicted from the number of involved nodes and
also because so-called discontinuous or skip metastases
have been described in the literature [8
Axillary lymph node status is the single most important
prognostic variable in patients with breast cancer and is an
important determinant of which patients should receive
adjuvant systemic therapy . However, management of
the axilla is far from being uniform. By the way, any of
the lesser axillary surgical procedures would require the
addition of therapy to the axilla for disease control [4,11].
Fisher et al.  have noted a 21% axillary recurrence rate
in patients with clinically negative axilla who received no
additional treatment for that region. This recurrence rate
can be reduced to 1% with complete axillary dissection
[4,12]. It has been shown that clinical examination of the
axilla is notoriously inaccurate in staging with up to a
30% false (+) rate and up to a 45% false (-) rate.
As many as 40% or more of patients with positive level I axillary nodes will have involvement of higher levels
in the axilla as well [4,9]. In the analysis of five studies by
Danforth et al. , metastatic lymph nodes would be left
behind in 51.2% to 82% of patients after Level I dissection
and 21.4% to 44.8% of patients after Level I+II dissection.
In a study of Chevinsky et al. , 60% of patients
with involved Level I lymph nodes had involvement of
nodes in Levels II and III as well. If these nodes were left
unattended, recurrence in local axillary nodes might take
place, leaving the physician with a dilemma.
The studies in the literature revealed that approximately
35% to 50% of patients with clinically detected
invasive cancer prove to be node positive following axillary
lymph node dissection (ALND) . The skip level
III metastases are ranging 0.1% to 12% in the literature.
Furthermore, the highest level as well as number of LN
metastases are significantly related to prognosis .
In our study, 62 out of 87 patients (71.2%) had axillary
lymph node metastases (pN+). Lymph node metastases in
level I+II were detected Forty-two percent of the patients
that had involved level I+II lymph nodes also had metastases
in level III. Level III skip metastasis was detected in
one patient (1.14%). Our result of pN (+) patients (71.2%)
is impressively higher than the reported studies.
Although the extent of the ALND seems to have no
effect on breast cancer mortality, it does influence the risk
of axillary relapse offering a more adequate local control.
The greater the extent of ALND, the less the risk of axillary
relapse is. In a retrospective review of 3128 clinically
node negative patients, the 5 year risk of axillary recurrence
ranged from 19% when no nodes were removed to
3% when more than five nodes were removed .
In some series of the literature it has been shown that
apical metastases were more frequent (43.8% as compared
with 6.1%) when gross disease was found in level I
and II nodes . In our study, the Level III LN metastases
were more frequent when there were more than 2 involved
nodes in the Level I+II and when gross conglomerated
LN -a sign of capsule invasion- was detected. Our study
revealed that the Level III LN metastases were rare in
the subgroup of patients who had 2 and lower metastatic
nodes in the axilla; which may suggest performing Level
I+II LN dissection would be appropriate in that group of
Axillary recurrences are a marker of tumor biology, indicating
an increased risk for distant metastases and death
. Nonetheless, women are often emotionally devastated
following a loco-regional relapse. Many regard such
recurrences as a death sentence. Furthermore, recurrences
often cause morbidity: major vessels and nerves of the axilla
are sometimes invaded, causing pain or lymph edema.
In such cases, the axilla is difficult to manage, and the
risk of complications associated with axillary treatment is
greatly increased. Thus, adequate treatment of the axilla
at initial diagnosis of primary breast cancer is important.
Failure to provide adequate treatment can adversely affect
the quality of life and may cause significant morbidity in
later years [1,13,14].
In conclusion, according to results of these series level
III lymph node metastases are not rare cases and for today
CAL offers a highly effective local control and appropriate
staging except for a very selected group of patients
who might have lower than two or less metastases in level
I and II.