[Contralateral axillary drainage in breast tumor recurrence]

Contralateral Axillary Metastasis in Breast Carcinoma: Case Report and Review of Literature

The clinical dilemma of management of isolated contralateral axillary metastasis (CAM) in carcinoma breast remains unsolved. We report a case of metachronous contralateral left axillary metastasis in a 54-year-old postmenopausal woman, its management, and review of literature. After ruling out distant metastasis and occult primary in the opposite breast, curative treatment was planned. She underwent left axillary lymph node dissection which on histopathology showed metastatic carcinoma. Management of CAM with curative or palliative intent and whether to consider them as locoregional or distant metastasis remains controversial. CAM may occur due to the locoregional spread of disease, and hence, curative intent of treatment should be offered to these patients.

Therapeutic options for contralateral axillary lymph node metastasis in breast cancer

Contralateral axillary lymph node metastasis (CAM) in breast cancer is rare, and the reason is unclear. CAM may be found at the time of primary breast cancer diagnosis or following primary tumor treatment. CAM staging and treatment methods are controversial. Hence, we summarized the features of CAM patients and explored the therapeutic options. We report the case of an 82-year-old woman with right breast cancer accompanied by CAM. The records of breast cancer patients with CAM in PubMed (January 2000-May 2020) were also reviewed. After undergoing comprehensive treatments (neoadjuvant chemotherapy, surgery, radiotherapy, endocrine therapy, and targeted therapy), no signs of recurrence and metastasis were noted during the 25-month follow-up. Overall, 17 studies (36 patients) were selected for the review, of which 15 had synchronous CAM and 21 had metachronous CAM. Nineteen of 22 patients had histologic grade 3. Forty percent (12/30) had ≥4 positive lymph nodes. Among these 36 patients, 9 had triple-negative breast cancers, and 9 were human epidermal growth factor receptor 2 positive. Among the 30 patients staged, 6 (20%) were in stage I; 7 (23.33%), stage II; and 17 (56.67%), stage III. Two patients received systemic therapy, while one received an unknown treatment. The remaining 33 patients all received local treatment (surgery or radiotherapy). The survival time of synchronous and metachronous CAM patients was 12-72 months with the death rate of 1/7 and 12-144 months with that of 3/12, respectively. CAM may be a regional manifestation rather than a distant metastasis. Comprehensive treatment, including surgery and radiotherapy, may provide better control.

Contralateral Axillary Lymph Node Metastases from Breast Carcinoma: Is it Time to Review TNM Cancer Staging?

BACKGROUND

Contralateral axillary lymph node metastasis (CAM) is an infrequent clinical condition currently considered an M1, stage IV, disease. Due to the absence of shared data on CAM significance and on its therapeutic approach, be it curative or simply palliative, its management is still uncertain and undoubtedly represents a clinical challenge.

PATIENTS AND METHODS

Patients with pathologically confirmed metachronous CAM were retrospectively evaluated. All patients had been managed at the European Institute of Oncology, Milan, Italy, from 1997. Patients with distant metastases at the time of CAM were excluded. Possible treatments included surgery, systemic therapy and RT (radiotherapy). Outcomes were evaluated as rates of disease-free survival (DFS) and of overall survival (OS).

RESULTS

Forty-seven patients with CAM were included in the study. Metachronous CAM occurred 73 months (range 5-500 months) after diagnosis of the primary tumor. The median follow-up time was 5.4 years (interquartile range 2.9-7.0 years). The estimated OS was 72% at 5 years (95% CI 54-83), and 61% at 8 years (95% CI 43-75). The estimated DFS was 61% at 5 years (95% CI 44-74), and 42% at 8 years (95% CI 25-59).

CONCLUSION

These findings, together with those from previous studies, show that CAM outcome, particularly if measured as OS, appear better than at other sites of distant dissemination, when CAM is subjected to surgical and systemic treatments with a curative intent. Therefore, a new clinical scenario is suggested where, in the TNM system, CAM is no longer classified as a stage IV, but as an N3 disease.