Axillary lymph node dissection in node-positive breast cancer: are ten nodes adequate and when is enough, enough?

  • Laura H. RosenbergerEmail author
  • Yi Ren
  • Samantha M. Thomas
  • Rachel A. Greenup
  • Oluwadamilola M. Fayanju
  • E. Shelley Hwang
  • Jennifer K. Plichta
Clinical trial



National guidelines define adequate axillary lymph node dissections as those yielding ≥ 10 lymph nodes (LNs). We aimed to identify the optimal LN yield among node-positive patients.


Using the National Cancer Data Base (2010–2015), we categorized node-positive patients as follows: (1) neoadjuvant chemotherapy (NAC, cN1–3 or ypN1mi-3) or (2) upfront surgery (pN1–3). A restricted cubic splines model was used to estimate LN retrieval thresholds associated with change in overall survival (OS).


129,685 patients were identified: 21.2% NAC, 78.8% upfront surgery. Low, moderate, and high retrieval thresholds were estimated to be 1–6, 7–21, and > 21 LNs (upfront surgery), and 1–7, 8–22, and > 22 LNs (NAC). In an adjusted model, high versus low LN yield was associated with greater receipt of adjuvant chemotherapy (upfront surgery OR 1.96, p < 0.001) and greater use of adjuvant radiation (upfront surgery OR 1.08, p = 0.02; NAC OR 1.23, p = 0.002). After adjustment, high versus low LN retrieval was associated with improved OS (upfront surgery HR 0.86, p < 0.001; NAC HR 0.77, p < 0.001). Worse OS was associated with retrieving fewer LNs, likely as a result of an under-staged axilla and missed opportunity for adjuvant therapy, while better OS was independently associated with retrieval of up to approximately 20 LNs, after which survival did not improve.


In node-positive breast cancer, the number of nodes retrieved is significantly associated with an increased positive nodal count and greater use of adjuvant therapy. Removal of approximately 20 LNs may improve survival by both more accurate nodal staging and increased adjuvant therapy use.


Breast cancer Node-positive Axillary lymph node dissection Staging Guidelines Overall survival 



Dr. O. Fayanju is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) under Award Number 1KL2TR002554 (PI: Svetkey). Dr. R. Greenup is supported by the NIH BIRCWH K12HD043446 (PI: Andrews). This work is also supported by the Duke Cancer Institute through NIH Grant P30CA014236 (PI: Kastan).

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest to disclose.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Due to use of national de-identified data (National Cancer Data Base, NCDB), our institutional review board granted the study exempt status and no individual informed consent was needed.


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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of SurgeryDuke University Medical CenterDurhamUSA
  2. 2.Duke Cancer InstituteDuke UniversityDurhamUSA
  3. 3.Department of Biostatistics and BioinformaticsDuke UniversityDurhamUSA
  4. 4.Department of SurgeryDuke UniversityDurhamUSA

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