Dissection of Level III Axillary Lymph Nodes in Breast Cancer

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

Nisha Prasannan Breast cancer is the most common female cancer in India, with a significant number presenting as locally advanced breast cancer (LABC). Level III clearance is routinely performed in our institute in LABC following neoadjuvant chemotherapy (NACT). In our previous retrospective study, level III positivity rate was 15.5%. We aim to prospectively assess level III positivity rate in LABC patients post-NACT. This is a prospective study of female patients with LABC (defined as cT3N1-3M0 or cT4N0-3M0 or cT any N2,3M0) who received NACT and underwent surgery including level III dissection from November 2019 to October 2021. Data collected included age, menopausal status, TNM stage at presentation, grade, hormone receptor and HER2 status, treatment response, ycT and ycN stage, and final histopathology. Univariate and multivariate analysis was undertaken. p -Value less than or equal to 0.05 was considered significant. Study recruited 598 patients. Level III node positivity rate was 8.4%. The clinical complete response rate (cCR) was 36% (215/598). On univariate analysis, significant association was present between level III node and cCR ( p  < 0.01), ycT0 stage ( p  = 0.001), ycN0 stage ( p  = 0.028), level II node positivity ( p  = 0.001), ypT stage ( p  = 0.001), and ypN stage ( p  = 0.001). On multivariate analysis, significant association was present between level III node and ycT stage ( p  < 0.001), ypT stage ( p  = 0.001), and ypN stage ( p  = 0.001). Level III positivity rate in LABC post-NACT is high. In patients with advanced ycT stage, it would be advisable to offer complete axillary dissection including level III. Level III dissection may be avoided in patients with ycT0 or ycN0 or with cCR.

Axillary Lymphadenectomy: Safe Dissection Through a Correct Technique

The primary treatment of breast cancer in sentinel-positive ganglia includes axillary lymphatic nodal dissection. The LAD (lymphatic axillary dissection) has decreased in overall numbers but due to the increasing incidence of breast cancer, it is practised on a daily basis, even though there is a myriad of complications such as numbness of the upper limb and chest wall, movement restriction of the upper limb, and chronic pain which appear due to trauma to the nerves which pass through the axilla. However, the utility in the overall survival or DFS (disease-free survival) of the patient is unquestionable.  In our study, through the dissection of cadavers, we exposed the vital structures and the anatomical relations of this region. We aimed to offer a map or technique for the surgeon to follow to decrease the overall morbidity of this procedure.

Future Directions in the Assessment of Axillary Lymph Nodes in Patients with Breast Cancer

Background and Objectives: Breast cancer (BC) is a leading cause of morbidity and mortality worldwide, and accurate assessment of axillary lymph nodes (ALNs) is crucial for patient management and outcomes. We aim to summarize the current state of ALN assessment techniques in BC and provide insights into future directions. Materials and Methods: This review discusses various imaging techniques used for ALN evaluation, including ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography. It highlights advancements in these techniques and their potential to improve diagnostic accuracy. The review also examines landmark clinical trials that have influenced axillary management, such as the Z0011 trial and the IBCSG 23-01 trial. The role of artificial intelligence (AI), specifically deep learning algorithms, in improving ALN assessment is examined. Results: The review outlines the key findings of these trials, which demonstrated the feasibility of avoiding axillary lymph node dissection (ALND) in certain patient populations with low sentinel lymph node (SLN) burden. It also discusses ongoing trials, including the SOUND trial, which investigates the use of axillary ultrasound to identify patients who can safely avoid sentinel lymph node biopsy (SLNB). Furthermore, the potential of emerging techniques and the integration of AI in enhancing ALN assessment accuracy are presented. Conclusions: The review concludes that advancements in ALN assessment techniques have the potential to improve patient outcomes by reducing surgical complications while maintaining accurate disease staging. However, challenges such as standardization of imaging protocols and interpretation criteria need to be addressed. Future research should focus on large-scale clinical trials to validate emerging techniques and establish their efficacy and cost-effectiveness. Over-all, this review provides valuable insights into the current status and future directions of ALN assessment in BC, highlighting opportunities for improving patient care.