Four Node Sampling: Is It an Effective Alternative to Sentinel Lymph Node Biopsy in Low-resource Settings for Breast Cancer Management

Abstract Background: Breast cancer is the most common malignancy among women globally, with regional lymph nodal involvement being a key determinant in staging. “Node positive” breast cancer patients have 40% higher mortality. Axillary lymph node dissection (ALND) is the standard of care in the surgical management of the axilla but is associated with significant morbidity, especially lymphedema. To decrease morbidity especially in node-negative patients, sentinel lymph node biopsy (SLNB) has emerged as an alternative due to its low false-negative rates (FNRs), better sensitivity and specificity. However, in austere settings scenarios where the facility for SLNB is not available, four-node axillary sampling (FNAS) has been explored with variable outcomes. This study evaluates the feasibility of FNAS in the management of node-negative, postneoadjuvant, operable breast cancer patients at our institution. Methods and Results: This observational prospective study included 37 patients with clinically node-negative, operable breast cancer, following neoadjuvant chemotherapy. FNAS was performed using methylene blue dye to identify and dissect four axillary nodes and sent for a frozen section. Subsequently, ALND was done as per standard practice. The performance of FNAS as an alternative to SLNB showed a sensitivity of 81%, specificity of 100%, positive predictive value of 100%, and negative predictive value (NPV) of 69%. The FNR was 19.2% with an overall diagnostic accuracy of 86%. Conclusion: While ALND remains the standard for axillary staging in operable breast carcinoma, SLNB is validated as a useful method for axillary staging in node-negative patients. FNAS demonstrated high false-negative rates and limited diagnostic value in this study. Further research, including larger studies and randomized controlled trials comparing FNAS with SLNB is needed to establish its efficacy and potential role in the management of node-negative breast cancer.