Annals of Surgical Oncology

, Volume 21, Issue 2, pp 389–394 | Cite as

The Number of Lymph Nodes Dissected in Breast Cancer Patients Influences the Accuracy of Prognosis

  • Lauren E. Wiznia
  • Donald R. Lannin
  • Suzanne B. Evans
  • Erin W. Hofstatter
  • Nina R. Horowitz
  • Brigid K. Killelea
  • Theodore N. Tsangaris
  • Anees B. ChagparEmail author
Breast Oncology



Recent trials have suggested that axillary node dissection may not be warranted in some breast cancer patients with one to two positive nodes. Given that lymph node ratio (LNR; number of positive lymph nodes divided by the total examined) has been shown to be a significant prognostic factor, we sought to determine whether the number of nodes removed in this low risk population predicted survival.


The National Cancer Database is a comprehensive clinical surveillance resource capturing 70 % of newly diagnosed malignancies in the United States; 309,216 breast cancer patients diagnosed between 1998 and 2005, with tumors ≤5 cm and one to two positive nodes, formed the cohort of interest.


Median age at diagnosis was 57 (range 18–90) years. Median tumor size was 2 (range 0.1–5) cm; 215,382 patients (69.7 %) had one positive node, and 93,834 (30.3 %) had two. The median number of lymph nodes examined was 11 (range 1–84). Patients were categorized into low (≤0.2), medium (0.21–0.65), or high (>0.65) LNR groups, with 228,822 (74 %), 55,797 (18 %), and 24,597 (8 %) patients in each of these categories, respectively. Median follow-up was 54.1 months. Median overall survival (OS) for low, intermediate, and high LNR was 66.1, 61.1, and 56.5 months, respectively (p < 0.001). In a Cox model controlling for clinicopathologic and therapy covariates, LNR category remained a significant predictor of OS (p < 0.001).


LNR is an independent predictor of OS in a low-risk population with one to two positive nodes and tumors ≤5 cm. Therefore, the number of lymph nodes excised may influence prognostic stratification.


Overall Survival Positive Node Axillary Node Dissection Lymph Node Ratio Positive Sentinel Node 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors have no disclosures of commercial interest in the subject of study. No financial support was provided for this study.


  1. 1.
    Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305:569–75.PubMedCrossRefGoogle Scholar
  2. 2.
    Galimberti V, Cole BF, Zurrida S, et al. Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): a phase 3 randomised controlled trial. Lancet Oncol. 2013;14:297–305.PubMedCrossRefGoogle Scholar
  3. 3.
    Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347:1227–32.PubMedCrossRefGoogle Scholar
  4. 4.
    Fisher B, Jeong JH, Anderson S, Bryant J, Fisher ER, Wolmark N. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med. 2002;347:567-75.PubMedCrossRefGoogle Scholar
  5. 5.
    Crawford JD, Ansteth M, Barnett J, Glissmeyer M, Johnson NG. Routine completion axillary lymph node dissection for positive sentinel nodes in patients undergoing mastectomy is not associated with improved local control. Am J Surg. 2013;205:581–4.PubMedCrossRefGoogle Scholar
  6. 6.
    Chagpar AB, Camp RL, Rimm DL. Lymph node ratio should be considered for incorporation into staging for breast cancer. Ann Surg Oncol. 2011;18:3143–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Kuru B. Prognostic significance of total number of nodes removed, negative nodes removed, and ratio of positive nodes to removed nodes in node positive breast carcinoma. Eur J Surg Oncol. 2006;32:1082–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Voordeckers M, Vinh-Hung V, Van de Steene J, Lamote J, Storme G. The lymph node ratio as prognostic factor in node-positive breast cancer. Radiother Oncol. 2004;70:225–30.PubMedCrossRefGoogle Scholar
  9. 9.
    Megale Costa LJ, Soares HP, Gaspar HA, et al. Ratio between positive lymph nodes and total dissected axillaries lymph nodes as an independent prognostic factor for disease-free survival in patients with breast cancer. Am J Clin Oncol. 2004;27:304–6.Google Scholar
  10. 10.
    Yildirim E, Berberoglu U. Lymph node ratio is more valuable than level III involvement for prediction of outcome in node-positive breast carcinoma patients. World J Surg. 2007;31:276–89.PubMedCrossRefGoogle Scholar
  11. 11.
    Vinh-Hung V, Verkooijen HM, Fioretta G, et al. Lymph node ratio as an alternative to pN staging in node-positive breast cancer. J Clin Oncol. 2009;27:1062–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Danko ME, Bennett KM, Zhai J, Marks JR, Olson JA. Improved staging in node-positive breast cancer patients using lymph node ratio: results in 1,788 patients with long-term follow-up. J Am Coll Surg. 2010;210:797–805.PubMedCrossRefGoogle Scholar
  13. 13.
    Schiffman SC, McMasters KM, Scoggins CR, Martin RC, Chagpar AB. Lymph node ratio: a proposed refinement of current axillary staging in breast cancer patients. J Am Coll Surg. 2011;213:45–52; discussion 53.PubMedCrossRefGoogle Scholar
  14. 14.
    Duraker N, Batı B, Caynak ZC, Demir D. Lymph node ratio may be supplementary to TNM nodal classification in node-positive breast carcinoma based on the results of 2,151 patients. World J Surg. 2013.Google Scholar
  15. 15.
    Vinh-Hung V, Joseph SA, Coutty N, Ly BH, Vlastos G, Nguyen NP. Age and axillary lymph node ratio in postmenopausal women with T1–T2 node positive breast cancer. Oncologist. 2010;15:1050–62.PubMedCrossRefGoogle Scholar
  16. 16.
    van der Wal BC, Butzelaar RM, van der Meij S, Boermeester MA. Axillary lymph node ratio and total number of removed lymph nodes: predictors of survival in stage I and II breast cancer. Eur J Surg Oncol. 2002;28:481–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Ibrahim EM, Elkhodary TR, Zekri JM, et al. Prognostic value of lymph node ratio in poor prognosis node-positive breast cancer patients in Saudi Arabia. Asia Pac J Clin Oncol. 2010;6:130–7.PubMedCrossRefGoogle Scholar
  18. 18.
    Zakaria S, Degnim AC, Kleer CG, et al. Sentinel lymph node biopsy for breast cancer: how many nodes are enough? J Surg Oncol. 2007;96:554–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Bilimoria KY, Bentrem DJ, Hansen NM, et al. Comparison of sentinel lymph node biopsy alone and completion axillary lymph node dissection for node-positive breast cancer. J Clin Oncol. 2009;27:2946–53.PubMedCrossRefGoogle Scholar
  20. 20.
    Yi M, Giordano SH, Meric-Bernstam F, et al. Trends in and outcomes from sentinel lymph node biopsy (SLNB) alone vs. SLNB with axillary lymph node dissection for node-positive breast cancer patients: experience from the SEER database. Ann Surg Oncol. 2010;17(Suppl 3):343–51.PubMedCrossRefGoogle Scholar
  21. 21.
    Ivens D, Hoe AL, Podd TJ, Hamilton CR, Taylor I, Royle GT. Assessment of morbidity from complete axillary dissection. Br J Cancer. 1992;66:136–8.PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Aigner J, Smetanay K, Hof H, et al. Omission of axillary dissection according to ACOSOG Z0011: impact on adjuvant treatment recommendations. Ann Surg Oncol. 2013;20:1538–44.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2013

Authors and Affiliations

  • Lauren E. Wiznia
    • 1
  • Donald R. Lannin
    • 1
  • Suzanne B. Evans
    • 2
  • Erin W. Hofstatter
    • 3
  • Nina R. Horowitz
    • 1
  • Brigid K. Killelea
    • 1
  • Theodore N. Tsangaris
    • 1
  • Anees B. Chagpar
    • 1
    Email author
  1. 1.Department of SurgeryYale University School of MedicineNew HavenUSA
  2. 2.Department of Therapeutic RadiologyYale University School of MedicineNew HavenUSA
  3. 3.Department of MedicineYale University School of MedicineNew HavenUSA

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