The finding that a high number of tumor-free axillary lymph nodes was associated with a poor outcome in women with breast carcinoma reported by Camp et al.1 stimulated our interest. Accordingly, we examined the relation between the number of lymph nodes examined and patient prognosis in 1147 patients with lymph node negative disease who were diagnosed at the Guy's Hospital Breast Unit in London between January 1, 1975 and December 31, 1998. The patients were treated with either modified radical mastectomy or breast conservation therapy (tumor excision and axillary lymph node clearance followed by breast irradiation). No patient received any adjuvant therapy. The median follow-up was 11.9 years (range, 0.1–25.9 years). Patients ranged in age from 23–86 years with a median age of 55 years. The total number of examined lymph nodes per case ranged from 1–59 lymph nodes with a median of 24 lymph nodes. As shown in Figure 1, there was no association noted between the number of tumor-free lymph nodes examined and patient prognosis (chi-square test = 5.4327, degrees of freedom = 1-; P = 0.8605). When the data were reanalyzed on a basis of histologic grade, number of negative lymph nodes, and prognosis, similar results were obtained. Recurrence-free interval of breast carcinoma cases in relation to the number of tumor-free lymph nodes examined pathologically. One explanation for the divergence of results is that the median number of lymph nodes examined in our series was higher than the 15 reported by Camp et al.1 The median of 24 lymph nodes was a consistent finding during over the 23-year study period, reflecting the completeness of the surgery and the assiduousness of the pathologic examination. It appears unlikely that the total number of negative lymph nodes would have any negative impact on prognosis. Indeed, the opposite has been found. The Danish Breast Cancer Cooperative Group (DBCG) examined the axillary lymph node status in 13,851 patients entered into 2 trials, DBCG 77 and DBCG 82.2 A total of 7145 patients (52%) were found to be pathologically lymph node negative and these patients were followed for a median of 76 months. There was a nearly linear relation between the number of lymph nodes examined by the pathologist and the percentage of positive lymph nodes. Thus, of those patients in whom only 1 lymph node was examined, 70% were negative whereas this rate fell to 45% if ≥ 10 lymph nodes were examined. This finding indicates that the fewer lymph nodes removed and examined, the greater the likelihood of understaging disease and leaving residual involved lymph nodes in the axilla. The Guy's Hospital wide excision trials clearly demonstrated that inadequately treated axillary lymph node disease led to an increased risk of distant metastases and a greater risk of death from breast carcinoma.3 We suggest that the findings of Camp et al. are due to chance, particularly in view of the lack of an apparent association between the number of lymph nodes examined and other histopathologic markers of aggressive disease. It would be interesting to review results from other centers. Rosemary R. Millis M.D.*, Robert J. Springall M.D.*, Andrew M. Hanby M.D. , Kenneth Ryder M.D.*, Ian S. Fentiman M.D.*, * Division of Oncology, and Palliative Care, ICRF Department of, Clinical Oncology, Guy's Hospital, Guy's, King's. and St. Thomas', School of Medicine, London, United Kingdom, Department of Histopathology, St. James's University Hospital, Leeds, United Kingdom