ER+ / HER2- patients with limited involvement of axillary lymph nodes might be spared adjuvant chemotherapy if the tumor biology is favorable ( Ann Oncol 2018 29:2153).Per current NCCN guidelines, clinically node negative patients with only micrometastasis or with macrometastasis meeting ACOSOG Z11 criteria (T1 / T2 tumor, ≤ 2 positive nodes, breast conserving surgery, whole breast RT planned, no preoperative chemotherapy) may be spared ALND.Number of involved lymph nodes and size of deposit (micro / macrometastasis) are important for clinical decision making ( Ann Oncol 2018 29:2153).Notable exception per Choosing Wisely Society of Surgical Oncology recommendations: don't routinely use SLNB in clinically node negative women ≥ 70 years of age with early stage hormone receptor positive, HER2 negative invasive breast cancer.SLN biopsy (versus ALND) is standard of care in staging clinically node negative T1 / T2 tumors.Tumor is more likely at the inflow junction of afferent lymphatic vessels ( Am J Surg Pathol 2003 27:385).Medially located tumors are more likely to drain to internal mammary nodes (medial 28% lateral 15%) ( Am J Clin Pathol 2018 150:4).If metastases are present in these nodes, there are specific AJCC N categories.Internal mammary nodes, supraclavicular nodes and infraclavicular nodes are rarely removed for breast cancer staging.Intramammary nodes are most commonly present in the upper outer quadrant and are included with axillary nodes in AJCC N classification.Apical axilla or infraclavicular nodes: medial to the medial margin of the pectoralis minor muscle and inferior to the clavicle.Mid axilla: between the medial and lateral borders of the pectoralis minor muscle, plus the interpectoral (Rotter) lymph nodes.Low axilla: lateral to the lateral border of the pectoralis minor muscle. Axillary lymph nodes are divided into 3 levels:.Perforating system: traverses pectoralis muscles and drains into internal mammary node.Deep system: breast to axilla, anastomoses with perforating system.Superficial system: superficial breast and skin to axilla, independent.Breast lymphatic drainage ( Am J Clin Pathol 2018 150:4):.
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