Clinico-Immuno-Histo-Chemical Interpretation- Approach to Level III Axilla in Operable Breast cancers

Author(s): Ajay Krishna Boralkar, Harshad Gorakh Chavan, Anagha S Varudkar, Abhishek Rajendra Potnis


Management involves upfront surgery or neoadjuvant chemotherapy followed by surgery. Surgery involves Modified radical mastectomy (MRM) or Breast Conservation surgery followed by axillary dissection with level I, II with or without III node clearance or sentinel lymph node biopsy. It is possible to forgo level III clearance in a clinically node negative axilla, which can reduce morbidity of ipsilateral arm oedema. The risk of partial axillary clearance is residual positive axilla. This study aims to correlate various primary tumour characteristics with level III lymph nodal positivity in a clinically positive axilla, to provide a pre-operative insight in the level of dissection to be performed.


A total of 75 patients who satisfied the inclusion criteria were evaluated pre-, intra- and post-operatively to obtain a correlation with level III nodal metastasis. This data was then analysed and significance of each parameter in influencing level III nodal positivity was determined.


It is seen that size, site of tumour, pre- and post-operative pathological grade do not significantly affect the level III nodal metastasis (p= 0.352, 0.351, 0.475, 0.072 respectively) while intra-operative palpability, number of nodes, lymphovascular invasion (LVI), extranodal extension and oestrogen receptor (ER) and progesterone receptor (PR) negativity significantly affect level III nodal positivity.


Preoperative ER, PR, LVI assessment of primary tumour with intraoperative assessment of different levels of axillary lymph nodes gives an idea about the need for further axillary dissection. Axillary involvement and thus the need for additional loco-regional treatment can be predicted from the patients clinicohistochemical characteristics.

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