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Is It Time to Redefine Clinical Nodal Staging for Breast Cancer?
Pooja M Varman1, David A Taft2, Monik Patel2
1Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA. varmanp@ccf.org.
Annals of Surgical Oncology
|July 16, 2026
Summary
In breast cancer, having four or more suspicious lymph nodes on imaging (cN1b) predicts higher pathologic stage after neoadjuvant chemotherapy (NAC). This finding suggests a need to refine clinical staging for cN1 breast cancer patients.
Area of Science:
- Oncology
- Radiology
- Pathology
Background:
- Current American Joint Committee on Cancer (AJCC) staging defines cN1 by node mobility, not number.
- Pathologic staging stratifies by lymph node count.
- The clinical significance of ≥ 4 suspicious nodes in cN1 breast cancer remains unclear.
Purpose of the Study:
- To investigate if cN1 breast cancer patients with ≥ 4 suspicious nodes on pretreatment imaging exhibit different pathologic staging and survival outcomes.
- To compare outcomes between cN1a (1-3 nodes), cN1b (≥ 4 nodes), and cN2a (matted nodes) groups.
Main Methods:
- Retrospective review of 618 biopsy-proven cN1/cN2a breast cancer patients treated with neoadjuvant chemotherapy (NAC).
- Pretreatment imaging categorized patients into cN1a, cN1b, or cN2a groups.
- Clinicopathologic characteristics, response rates, and survival (DFS, OS) were analyzed.
Main Results:
- No significant difference in pathologic complete response (pCR) rates across groups.
- Patients in cN1b and cN2a groups had significantly more residual positive lymph nodes post-NAC.
- cN1b was independently associated with pathologic upstaging (OR 1.958, P=0.009).
- Three-year disease-free survival (DFS) and overall survival (OS) did not differ significantly across groups.
Conclusions:
- Imaging-defined nodal burden of ≥ 4 nodes in cN1 breast cancer independently predicts upstaging and greater residual nodal burden after NAC.
- This imaging-based subcategorization may align pathologically with cN2a disease.
- Findings have implications for staging, surgical planning, and clinical trial eligibility.
