Practice ABC of Breast Diseases, 4th Edition

Management of Regional Nodes in Breast Cancer

BMJ 2013; 347 doi: (Published 19 December 2013) Cite this as: BMJ 2013;347:bmj.f3291
  1. Nigel Bundred1,
  2. J Michael Dixon2,
  3. Jeremy Thomas3
  1. 1University Hospital of South ManchesterAcademic Department of Surgery Manchester, UK
  2. 2Western General HospitalEdinburgh Breast Unit Edinburgh, UK
  3. 3Western General HospitalPathology Department Edinburgh, UK

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  • The single most important factor predicting patients' prognosis is the presence or absence of cancer in the regional nodes

  • All patients with invasive cancer should have their regional node status assessed by node biopsy

  • An effective method of assessing lymph node status in patients with clinically and imaging node-negative nodes is to perform a sentinel lymph node biopsy

  • It has been standard care until recently to treat all patients with histologically proven involved axillary nodes by axillary node clearance or axillary radiotherapy

  • New data suggest that selected patients with limited node positivity on sentinel lymph node biopsy who have whole-breast radiotherapy and adequate systemic therapy may be spared further treatment of the axilla

Lymph drainage of breast

Lymph drainage from the breast is via the axillary and internal mammary nodes (Figure 1). To a lesser extent, lymph also drains by intercostal routes to nodes adjacent to the vertebrae. The axillary nodes receive about 95% of the total lymph drainage, and this is reflected in the greater frequency of tumour metastases to these nodes.

Figure 1 

Lymph drainage of the breast.

The axillary nodes, which lie below the axillary vein, can be divided into three groups in relation to the pectoralis minor muscle: level I nodes lie lateral to the muscle; level II (central) nodes lie behind the muscle; and level III (apical) nodes lie between the muscle's medial border, the first rib, and the axillary vein (Figures 2 and 3). There are on average 20 nodes in the axilla, with about 13 nodes at level I, …

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