Study of targeted four node sampling of axilla in management of carcinoma of breast


  • Mrinalini M. Borkar Department of General Surgery, Government Medical College, Nagpur, Maharashtra, India
  • Aishwarya V. Peshattiwar Department of General Surgery, Government Medical College, Nagpur, Maharashtra, India
  • Abdul Quraishi Department of General Surgery, Government Medical College, Nagpur, Maharashtra, India
  • Girish M. Umare Department of General Surgery, Government Medical College, Nagpur, Maharashtra, India



Carcinoma of breast, Four node sampling of axilla, Methylene blue


Background: Axillary lymph node sampling is considered as one of the most pivotal investigations in determining the lymph node status in management of carcinoma breast. The present study attempts to assess sensitivity, specificity and positive predictive value of axillary four node sampling (FNS) in management of carcinoma of breast, and its efficacy in downstaged patients.

Methods: A total of 35 patients, node negative operable cases of carcinoma breast and locally advanced breast cancer (LABC) patients downstaged after 3 cycles of neoadjuvant chemotherapy, were enrolled. Lymph node mapping was done by injecting 3 - 5 ml of methylene blue dye, just before surgery. Level 1 lymph nodes stained by methylene blue were sampled and axillary dissection was carried out, level 3 lymph nodes were identified and sampled, rest of the axillary dissection specimen was sent as a separate sample for histopathological examination , node positivity was compared in level 1 and level 3 , and conclusions were drawn.

Results: The sensitivity, specificity for FNS in node negative operable cases were found to be 83.33% and 91.3% respectively.  The negative and positive predictive value were found to be 95.40% and 71.42% respectively. Specificity of FNS in LABC downstaged patients was found to be 40%.

Conclusions: Targeted four node sampling using methylene blue dye can be considered as an alternative method for sentinel lymph node. Further study should be conducted to establish it as a reliable method for axillary lymph node staging.

Author Biography

Mrinalini M. Borkar, Department of General Surgery, Government Medical College, Nagpur, Maharashtra, India

Department Of general Surgery, Senior Resident, 

Governement Medical college, Nagpur


WHO | Breast cancer: prevention and control. WHO Available at: breastcancer/en/. Accessed 15 Dec 2018.

Agarwal G, Ramakant P. Breast Cancer Care in India: The Current Scenario and the Challenges for the Future. Breast Care (Basel). 2008;3(1):21-7.

Steele RJC, Forrest APM, Gibson T, Stewart HJ, Chetty U. The efficacy of lower axillary sampling in obtaining lymph node status in breast cancer: A controlled randomized trial. Brit J Surg. 1985;72(5):368-9.

Gaston MS, Dixon JM. A survey of surgical management of the axilla in UK breast cancer patients. Europ J Cancer. 2004;40(11):1738-42.

Tanaka K, Yamamoto D, Kanematsu S, Okugawa H, Kamiyama Y. A four node axillary sampling trial on breast cancer patients. Breast. 2006;15(2):203-9.

Chintamani P, Garg M, Kaushik M, Saxena S, Agarwal U, Bansal A. Targeted four-node sampling of axilla: A simple, reliable, and cost-effective approach in the management of breast cancer. Astrocyte. 2014;1(2):84.

Parmar V, Hawaldar R, Nadkarni MS, Badwe RA. Low axillary sampling in clinically node-negative operable breast cancer. Nat Med J India 2009;22(5):3.

Parmar V, Hawaldar R, Nair NS, Shet T, Vanmali V, Desai S, et al. Sentinel node biopsy versus low axillary sampling in women with clinically node negative operable breast cancer. Breast. 2013;22(6):1081-6.

Macmillan RD, Barbera D, Hadjiminas DJ, Rampaul RS, Lee AHS, Pinder SE, et al. Sentinel node biopsy for breast cancer may have little to other four-node-samplers: results of a prospective comparison study. Europ J Cancer. 2001;5.

Ahlgren M, Sørensen T, Wohlfahrt J, Haflidadóttir A, Holst C, Melbye M. Birth weight and risk of breast cancer in a cohort of 106,504 women. Int J Cancer 2003;107(6):997-1000.

Barthelmes L, Al-Awa A, Murali-Krishnan VP, Crawford DJ. The role of lymph node sampling and radiotherapy in the management of the axilla in early breast cancer. Breast. 2002;11(3):236-40.

Hoar FJ, Stonelake PS. A prospective study of the value of axillary node sampling in addition to sentinel lymph node biopsy in patients with breast cancer. Europ J Surg Oncol. 2003;29(6):526-31.

Sato K, Tamaki K, Takeuchi H, Tsuda H, Kosuda S, Kusano S, et al. Management of the axilla in breast cancer: a comparative study between sentinel lymph node biopsy and four-node sampling procedure. J Clin Oncol. 2001;31(7):318-21.






Original Research Articles