Breast malignant, males, children
Breast cancer
Axillary lymph node examination

Author: Dina Kandil, M.D. (see Authors page)

Revised: 20 October 2016, last major update January 2012

Copyright: (c) 2002-2016,, Inc.

PubMed Search: Axillary lymph node [title] breast

See also: Sentinel nodes

Cite this page: Axillary lymph node examination. website. Accessed December 12th, 2017.
  • Macrometastases: > 2mm
  • Micrometastases: 2 mm or less
  • Isolated tumor cells: 0.2 mm or less
Clinical features
  • Presence of axillary lymph node metastases is the most important prognostic factor for disease free and overall survival, and important for determining treatment
  • Presurgical staging of axillary nodes (ultrasound with FNA) is increasingly popular (Cancer 2008;114:89)
  • Axillary nodal dissection may not be indicated if negative sentinel node examination, even if false-negative (Breast Cancer 2010;17:9, Eur J Cancer 2009;45:1381)
  • Occult metastases (identified retrospectively by step-sectioning and immunohistochemical staining) are an independent predictor of disease-free survival, but not overall survival, in node-negative patients, particularly if > 0.5 mm (Am J Surg Pathol 2002;26:1286); recent study reports no prognostic significance of occult metastasis in early stage breast cancer (Cancer 2012;118:1507)
  • Significance of micrometastases is controversial (Arch Pathol Lab Med 2009;133:869)
  • Clearing solutions, such as ethanol, diethyl ether, Carnoy√≠s solution (Chin Med J (Engl) 2007;120:1762), glacial acetic acid and formalin may identify additional lymph nodes (Am J Surg Pathol 1997;21:1387, Arch Pathol Lab Med 2001;125:642)
  • Neoadjuvant chemotherapy may be associated with identification of fewer lymph nodes (J Am Coll Surg 2008;206:704), but see Am J Surg 2009;198:46

  • Regional lymph nodes are:
    • Axillary (ipsilateral), subdivided as follows (image):
      • Level I (low axilla): lateral to the lateral border of pectoralis minor muscle
      • Level II (mid axilla): between medial and lateral borders of pectoralis minor muscle, plus the interpectoral (Rotter's) lymph nodes
      • Level III (apical axilla): medial to the medial margin of the pectoralis minor muscle, including those designated as apical, excluding those designated as subclavicular or infraclavicular
    • Infraclavicular (subclavicular, ipsilateral)
    • Internal mammary (ipsilateral): lymph nodes in the intercostal spaces along the edge of the sternum in the endothoracic fascia
    • Supraclavicular (ipsilateral)
  • Side effects of axillary nodal dissection include lymphedema, shoulder restriction, numbness, weakness and pain syndromes (Cancer J 2008;14:216)
  • Dissection of the brachial, acromiothoracic, humeral, Rotter's and scapular lymph nodes is recommended for proper staging (J Egypt Natl Canc Inst 2011;23:25)
Case reports
Clinical images

Images hosted on PathOut server:

Courtesy of Mark R. Wick, M.D.

Microscopic (histologic) images

Scroll to see all images:

Images hosted on PathOut server:

Courtesy of Mark R. Wick, M.D.

False positives (i.e. not metastatic breast carcinoma):

Intramammary lymph node

Metastatic ovarian serous papillary adenocarcinoma

Left: heterotopic glands with structure of mammary lobule; right: myoepithelial cells (arrows) and basement membrane are present

Lactational histiocytosis

Clusters of nevus cells have indistinct cell borders and small uniform nuclei, and are S100+ (as are histiocytes)


Tattoo pigment

Dilated dermal
vascular channels with
prominent endothelial cells

thickened dermis with
edema, elastosis, fibrosis,
congested capillaries
(arrow) and lymphocytes

hyperplasia, hyperkeratosis,
dilated dermal vascular channels

Images hosted on other servers:

Axillary nodal metastases

Metastatic breast carcinoma and melanoma

Subcapsular metastasis: H&E and keratin

Metastatic tumor (A) with adjacent histiocytes (B)

Various images

Metastatic carcinoma,
benign inclusions and nevus cells

False positives (i.e. not metastatic breast carcinoma):

DCIS arising in intraductal papilloma

Sclerosing adenosis

Benign epithelial inclusions - Fig 1: CK 5/6+; Fig 2: p63+

Histiocytes (FNA)

Lipogranulomatosis due to triglyceride-filled breast implant

Cytology description

Images hosted on other servers:

Various images


Differential diagnosis