World Journal of Surgery

, Volume 31, Issue 2, pp 276-289

First online:

Lymph Node Ratio is More Valuable than Level III Involvement for Prediction of Outcome in Node-Positive Breast Carcinoma Patients

  • Emin YildirimAffiliated withAnkara Oncology Training and Research Hospital Email author 
  • , Ugur BerberogluAffiliated withAnkara Oncology Training and Research Hospital

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We examined the relationship between different expressions of positive axillary lymph nodes (PN) and the outcomes of node-positive breast carcinoma patients to determine the best predictor(s) among these expressions and to assess whether anatomic high level involvement is an independent prognostic factor.

Study Design

In this retrospective study, the primary endpoints were distant recurrence (DR), locoregional recurrences (LRR), and disease-free survival (DFS). Univariate and multivariate prognostic factor analyses were carried out using survival and regression methods in the data of 704 patients with PN.


In multivariate analysis, the number of PN, ratio of PN, log odds of PN, and level III (L-III) involvement, separately, were significant factors for DR in addition to age, tumor size, and lymphovascular invasion (LVI). In the final model including all expressions of nodal involvement, age (continuous P = 0.001; hazard ratio [HR]: 0.98; 95% confidence Interval [95% CI]: 0.96–0.99), tumor size (continuous: P < 0.0001; HR: 1.3; 95% CI, 1.2–1.5), LVI (yes vs. no: P = 0.005; HR: 1.6; 95% CI, 1.2–2.2), and ratio of PN (continuous: P = 0.02; HR: 1.03; 95% CI, 1.01–1.06) were the independent prognostic factors for DR. For LRR, ratio of PN (continuous: P = 0.001; HR: 1.02; 95% CI, 1.01–1.03) was the most important factor in addition to age (continuous: P = 0.02; HR: 0.98; 95% CI, 0.97–0.99) and tumor size (continuous: P = 0.04; HR: 1.3; 95% CI, 1.1–1.6). When patients were stratified by number categories of PN (1–3 vs. 4–9 vs. ≥ 10), there was no difference between DFSs of patients with and without L-III involvement. In contrast, when patients were stratified by L-III involvement, DFSs according to the number categories were statistically different.


Ratio of PN was more valuable than number of PN for predicting outcome in node-positive breast carcinoma patients. Level III involvement was not an independent prognostic indicator either for locoregional or for distant recurrences.