Axillary lymph nodes - surgical levels

Case contributed by Dr. Israel Rodriguez-Suarez

Presentation

Breast cancer patient. Right breast, ultrasound for axillary staging.

Patient Data

Age: 45 years
Gender: Female
Annotated image

Extended field-of-view sonography of the right axilla in the muscles transverse plane.

Axillary lymph nodes are described according to their position relative to the pectoralis minor muscle (between yellow lines):

  • level I: lateral and inferior to the muscle.
  • level II: posterior to the muscle.
  • level III (infraclavicular): medial and superior to the muscle.

In the first image, there are abnormal lymph nodes in levels I and II (absence of fatty hilum).

In the second figure we have the hypothetic case in which level II is clear but not level I and III, this is called, discontinuous or skip metastases. An uncommon finding.

Right breast with biopsy-proven malignancy and suspicious ipsilateral axillary lymph nodes at the level I, manifested by a rounded morphology, loss of fatty hilum, and heterogeneous enhancement.

Annotated image

Abnormal lymph nodes at levels I and II (including Rotter's lymph nodes in the last image, between the pectoralis major and pectoralis minor muscles).

Case Discussion

Axillary lymph nodes are described according to their position relative to the pectoralis minor muscle:

  • level I: lateral and inferior to the muscle
  • level II: posterior to the muscle
  • level III (infraclavicular): medial and superior to the muscle

Rotter nodes are located between the pectoralis major and minor muscles and are considered at level II. Also known as interpectoral lymph nodes.

Breast cancer commonly infiltrates lymph nodes from level I to level II, to level III.

When the spread does not follow that pattern, this is called discontinuous or skip metastases. An uncommon finding.

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