Axillary Lymph Node Yield and Nodal Burden in Breast Cancer: Experience From a Large Cancer Center in Sub‐Saharan Africa

Abstract

BACKGROUND: Axillary lymph node yield (LNY) is a critical component of breast cancer staging and treatment planning. International guidelines recommend retrieving ≥ 10 lymph nodes during axillary lymph node dissection (ALND) to ensure adequate staging. This study assessed LNY and its association with pathological nodal burden among patients with breast cancer undergoing ALND at Muhimbili National Hospital (MNH), Tanzania. MATERIALS AND METHODS: We conducted a retrospective analysis of female patients with breast cancer who underwent ALND between January 2018 and December 2024. Clinical and pathological data were abstracted from institutional records. LNY was categorized as < 5, five to nine, or ≥ 10 nodes. Ordinal logistic regression was used to identify factors associated with the pathological nodal stage (pN0-pN3). RESULTS: Among 871 patients, only 27% had ≥ 10 lymph nodes retrieved. Median LNY was 7 (IQR: 4-10). Higher LNY was strongly associated with higher pN category (aOR for five to nine nodes: 2.33; 95% CI: 1.67-3.26; aOR for ≥ 10 nodes: 8.93; 95% CI: 5.89-13.53; and p < 0.001). Additional independent predictors of higher nodal burden included tumor size (T2: aOR 2.34; 95% CI: 1.26-4.34; T3: aOR 2.54; 95% CI: 1.40-4.60; T4: aOR 3.34; and 95% CI: 1.84-6.09), histological grade 2 (aOR 1.63 and 95% CI: 1.09-2.45), and lobular histology (aOR 4.96 and 95% CI: 1.41-17.38). Neoadjuvant chemotherapy was associated with lower nodal burden category in univariate analysis but not after adjusting for LNY. CONCLUSION: Low LNY is prevalent and strongly associated with understaging of pathological nodal burden. Targeted quality improvement interventions are needed to optimize nodal evaluation and accurate staging to ensure appropriate treatment strategies in resource-limited settings.