Mammographic and clinical predictors of drainage patterns in breast lymphoscintigrams obtained during sentinel node procedures

Incidental Findings of Internal Mammary Lymph Node Recurrence after Breast Cancer during Microsurgical Breast Reconstruction: Discussion of Treatment Options and Review of the Literature

Lymphatic drainage through the internal mammary lymph nodes (IMLN) is a key pathway for breast cancer metastasis, although IMLN metastasis is rare following primary treatment. In earlier years, treatment protocols primarily addressed axillary lymph node metastasis.We present five cases where IMLN metastases were discovered incidentally during autologous free-flap breast reconstruction. These cases highlight implications for both the reconstructive plastic surgeon and subsequent adjuvant therapy.From a plastic-reconstructive perspective, we recommend performing routine biopsies on any incidentally identified IMLN during autologous breast reconstruction. Positive findings may upstage the patient's disease and influence further treatment planning. However, we do not recommend actively searching for or extending dissections to harvest IMLN specimens. Only in the presence of a suspicious perinodal tumour mass do we perform an intraoperative frozen-section analysis, with reconstruction paused if malignancy is confirmed. After complete staging and discussion in a multidisciplinary conference, we proceed with tumour resection according to oncological standards if curative resection is deemed feasible. Reconstruction can then be performed during the same procedure. For locoregional recurrence of breast cancer, treatment continues to be a multimodal approach involving surgery, radiation, and systemic therapy to ensure local control and optimise long-term survival. In primary treatment, current national and international guidelines now recommend locoregional irradiation of the internal mammary chain for high-risk cases, which may further reduce the incidence of incidental IMLN metastasis findings in the future.

Apoptotic Janus-faced mycotoxins against thoracal and breast metastases

Abdominal organs (liver, kidney, spleen) are frequent targets of cancer cell invasion but their primary tumours are less known for their metastatic potential to other organs e.g. to the breast. Despite the known connection of the pathogenesis from breast cancer to liver metastasis, the study of the spread in the opposite direction has been neglected. The notion that breast cancer could be a metastasis besides being a primary tumour is based on rodents' tumour models upon implantation of tumour cells under the capsule of the kidney or under the Glisson's capsule of the liver of rats and mice. Tumour cells develop into a primary tumour at the site of subcutaneous implantation. The metastatic process starts with peripheral disruptions of blood vessels near the surface of primary tumours. Tumour cells released into the abdomen cross the apertures of the diaphragm, enter the thoracal lymph nodes and accumulate in parathymic lymph nodes. Abdominal colloidal carbon particles injected into the abdomen faithfully mimicked the migration of tumour cells and deposited in parathymic lymph nodes (PTNs). An explanation is provided why the connection between abdominal tumours and mammary tumours escaped attention, notably, parathymic lymph nodes in humans were referred to as internal mammary or parasternal lymph nodes. The apoptotic effect of Janus-faced cytotoxins is suggested to provide a new approach against the spread of abdominal primary tumours, and metastatic development.

Triple-site radiotracer application in breast lymphoscintigraphy and sentinel node discordance

Sentinel lymph node (SLN) biopsy (SLNB) has demonstrated accuracy in the axillary staging of breast cancer patients. Despite variability in selection criteria and technique, an SLN is consistently identified in approximately 96% of cases and in most series predicts the status of remaining axillary LNs in >95% of cases. The false-negative rate of sentinel lymph node biopsy (SLNB) was originally reported as 5%–10% (sensitivity 90%–95%), but improved rates are attainable by experienced surgeons. Radiolocalization with lymphoscintigraphy (LSG) increases SLN identification rates. LSG is a useful tool to establish the abnormal lymphatic drainage patterns and to detect the extra-axillary nodes, particularly internal mammary nodes. Despite controversy regarding the optimal injection method, studies have generally suggested high concordance between the various radiotracer application sites and axillary SLN identification. Discordant SLN identification would have implications for nodal staging as the true SLN might not be identified with individual injection techniques. In the current study, imaging from consecutive patients presenting for breast LSG over a-19 month period was retrospectively reviewed. Radiotracer application was performed with simultaneous injection of peritumoral, subcutaneous, and subareolar regions. This application method provided a mechanism to assess the LSG drainage patterns with a view to assessing injection site concordance and SLN identification rates. Data from 123 breast LSG patients were reviewed. Using our radiotracer technique, the axillary SLN identification rate was 98%. A single axillary node was detected in 110, two axillary nodes were detected in 10, and no axillary node was detected in three patients. Among those 10 patients in whom two axillary nodes were seen, at least two cases of discordant drainage occurred from different injection sites. This study demonstrates that different LSG injection sites can result in the identification of different axillary sentinel nodes although this appears to be a rare event. This finding may be of clinical importance if the true SLN is sought. In addition, the multisite injection technique appears to be an optimal method of axillary SLN identification, with high SLN detection rates.

A meta-analysis of internal mammary lymph node metastasis in breast cancer patients

BACKGROUND

Knowing the status of the internal mammary lymph (IML) nodes is important for accurate staging and appropriate selection of subsequent treatment in breast cancer. We conducted a meta-analysis to clarify the rate of IML node metastasis in breast cancer patients and discussed the importance of this finding.

METHODS

We retrieved articles from the literature that reported positive rates of IML node metastasis in breast cancer patients. The quality of the selected articles was assessed using the 'Methodological Index for Non-Randomized Studies'. The heterogeneity was tested, and publication bias was assessed using a funnel plot. Finally, the positive rate of IML node metastasis in breast cancer patients was calculated using the random-effects model.

RESULTS

15 articles met the inclusion criteria and a total of 4,248 patients were included in the analysis. Heterogeneity across the studies was statistically significant (p = 0.014); thus, the random-effects model was used and the calculated positive rate of IML node metastasis was 23% (95% confidence interval (CI), 0.21-0.25).

CONCLUSIONS

Approximately 23% of the breast cancer patients had IML node metastases, for which the prognosis is generally poor. Accurate staging and integrated treatment are necessary to improve the survival of these patients.

Internal Mammary Sentinel Node Biopsy in Breast Cancer. Is it Indicated?

Axillary sentinel node (A-SN) biopsy is a standard procedure in breast cancer surgery. Sampling of intenal mammary sentinel nodes (IM-SN) is not performed routinly, although it is also considered an important prognostic factor of breast cancer. The role of this latter procedure was investigated in cases of IM-SN visualized on lymphoscintigraphy. Between January 2001 and June 2012 1542 patients with clinically node negative operable primary breast cancer had sentinel node biopsy (SNB). Both axillary and IM-SN were sampled (whenever detected), based on lymphoscintigraphy, intraoperative gamma probe detection and blu dye mapping. Lymphoscintigraphy showed IM-SN in 83 cases. IM-SN biopsy (IM-SNB) was succesfull in 77 patients (93%). A total of 86 IM-SNs were removed. IM-SN involvement was identified in 14 cases, representing 18% of patients who underwent IM-SNB. This included macrometastases (MAC) in 5 cases, micrometastases (MIC) in 2 cases, isolated tumor cells (ITC) in 7 cases. No significant differences were found between patients with and without IM-SN involvement in terms of age, tumor location, tumor size, axillary involvement, tumor grade or estrogen receptor status. The IM-SN involvement has lead to new therapeutic indications in 2 cases (2.6%), both of them due to MAC in the IM-SN: in 1 case change in chemotherapy and in 1 case change in radiotherapy, with the addition of iradiation of the internal mammary chain. Based on this series and information from the literature, we conclude that the indication for an IM-SNB procedure is very limited and its routine use should not be recommended.

Internal mammary lymph node recurrence: rare but characteristic metastasis site in breast cancer

Background

To assess the frequency of IMLN recurrence, its associated risk factors with disease-free interval (DFI) and its predicting factors on overall survival time.

Methods

133 cases of breast cancer IMLN recurrence were identified via the computerized CT reporting system between February 2003 and June 2008, during which chest CT for patients with breast cancer (n = 8867) were performed consecutively at Cancer Hospital, Fudan University, Shanghai, China. Patients' charts were retrieved and patients' characteristics, disease characteristics, and treatments after recurrence were collected for analysis. The frequency was 1.5% (133/8867).

Results

IMLN recurrence was presented as the first metastatic site in 121 (91%) patients while 88 (66.2%) had other concurrent metastases. Typical chest CT images included swelling of the IMLN at the ipsilateral side with local lump and sternal erosion located mostly between the second and third intercostal space. The median disease-free interval (DFI) of IMLN recurrence was 38 months. The independent factors that could delay the IMLN recurrence were small tumor size (HR 0.5 95%CI: 0.4 - 0.8; p = 0.002), and positive ER/PR disease (HR 0.6, 95% CI: 0.4 - 0.9; p = 0.006). The median survival time after IMLN recurrence was 42 months, with a 5-year survival rate of 30%. Univariate analysis showed four variables significantly influenced the survival time: DFI of IMLN recurrence (p = 0.001), no concurrent distant metastasis (p = 0.024), endocrine therapy for patients with positive ER/PR (p = 0.000), radiotherapy (p = 0.040). The independent factors that reduced the death risk were no concurrent distant metastases (HR: 0.7, 95% CI: 0.4 - 0.9; p = 0.031), endocrine therapy for patients with positive ER/PR status (HR: 0.2, 95% CI: 0.1 - 0.5; p = 0.001) and palliative radiotherapy (HR: 0.3, 95% CI: 0.1- 0.9; p = 0.026).

Conclusions

The risk of IMLN recurrence is low and there are certain characteristics features on CT images. ER/PR status is both a risk factor for DFI of IMLN recurrence and a prognostic factor for overall survival after IMLN recurrence. Patients with only IMLN recurrence and/or local lesion have a good prognosis.

Chest wall resection for internal mammary lymph node metastases of breast cancer

Evaluation of morbidity, mortality and oncologic outcome of patients treated with a chest wall resection for isolated breast cancer recurrences in the Internal Mammary Chain. Retrospectively we retrieved data from 29 patients. Multivariate analysis was performed to identify prognostic factors for (disease-free) survival. There were no postoperative deaths. Complications occurred in 11 patients. The median follow-up after CWR for all 16 patients still alive at the end of this study is 18.4 months. Nine patients were free of cancer. The 3-year overall and disease-free survival is 59.2% and 8.6%. The median survival is 40.7 months. After multivariate analysis for each of the four endpoints studied, only one prognostic factor remains significant for survival: systemic therapy before CRW (p=0.004). For local recurrence-free survival a first CRW recurrence (p<0.00001) and for disease-free survival radicality of the resection (p=0.008) are independent prognostic factors. Chest wall resection is a safe and effective treatment for isolated breast cancer recurrences in the IMC. Surgically treated patients have a fair survival and some of them are even cured.

Internal mammary nodes in breast cancer: diagnosis and implications for patient management -- a systematic review

The management of internal mammary nodes (IMNs) in breast cancer is controversial. Surgical series from the 1950s showed that one third of breast cancer patients had IMN involvement, with a higher risk in patients with medial tumors and/or positive axillary nodes. IMN metastasis has similar prognostic importance as axillary nodal involvement. However, after three randomized trials showed no survival benefit from extended mastectomy compared with radical or modified radical mastectomy, IMN dissection was largely abandoned. Recently, lymphoscintigraphy studies have renewed interest in IMN evaluation. Approximately one fifth of internal mammary sentinel nodes are pathologic, although most centers do not perform IMN biopsies because of concerns about morbidity and lack of established survival benefit. In addition, results from randomized trials testing the value of postmastectomy irradiation and a meta-analysis of 78 randomized trials have provided high levels of evidence that local-regional tumor control is associated with long-term survival improvements. This benefit was limited to trials that used systemic therapy, which was not routinely administered in the earlier surgical studies, although the contribution from IMN treatment is unclear. IMN irradiation has also been shown to cause increased cardiac morbidity. Before mature results from current randomized trials assessing the benefit of IMN irradiation become available, lymphoscintigraphy may be used to help guide decisions regarding systemic and local-regional treatment. However, even in patients with visualized primary IMN drainage, the potential benefit of treatment should be balanced against the risk of added morbidity.

Should internal mammary chain (IMC) sentinel node biopsy be performed?

INTRODUCTION

Although the status of the regional lymph nodes is an important determinant of prognosis in breast cancer, harvesting sentinel nodes (SN) detected in the internal mammary chain (IMC) is still controversial.

AIMS

To determine in how many patients a positive IMC-SN might change the systemic or locoregional adjuvant therapy, with a possible benefit in outcome.

PATIENTS AND METHODS

During 6 1/2 years data of T1-2 breast cancer patients, having an SN procedure, were prospectively collected. Our policy was not to explore the IMC even if it was the only localization of an SN.

RESULTS

In 86 of 571 patients lymphoscintigraphy showed an IMC-SN. In 64 of these, the axillary SN was negative and only 25 of these patients did not have an indication for adjuvant systemic treatment based on their tumor characteristics. In the literature, IMC metastases are found in 0-10% of axillary negative patients. Routine IMC-SN biopsies would have resulted in an indication for adjuvant systemic therapy in 2-3 of our patients. Four parasternal recurrences were found during a median follow-up of 51 months.

CONCLUSIONS

Harvesting IMC-SNs is a procedure of which only a limited number of patients have therapeutical benefit. Even with a thorough selection of patients, the extra morbidity of the procedure should be weighed against the potential benefit for the patient.

Pathological Internal Mammary Lymph Nodes in Secondary and Tertiary Deep Inferior Epigastric Perforator Flap Breast Reconstructions

Use of internal mammary vessels during breast reconstruction provides information on part of the internal mammary chain lymph nodes (LNs). It was evaluated whether our current practice of screening should be changed to identify those delayed breast reconstruction patients with tumor-positive internal mammary nodes (IMNs) and whether breast reconstruction should be continued, in case suspicious IMNs were found intraoperatively. From February 2002 to December 2004, 81 patients had received 98 deep inferior epigastric perforator flaps for delayed breast reconstruction. Prospectively collected data for suspicious internal mammary LNs were evaluated. In 13 patients (16%) who had received a delayed breast reconstruction, macroscopically suspicious LNs were detected in the course of the internal mammary chain. Three patients (4%) had a pathologic diagnosis of malignancy, which was found to match their primary tumor. No relationship between positive internal mammary chain LNs and location of the primary tumor, TNM-stage, or previously administered adjuvant therapy was found. Suspicious internal mammary chain LNs found during recipient vessel dissection for breast reconstruction can have important consequences for treatment of malignant disease in individual patients. Presented data do not support changing the current perioperative approach of delayed breast reconstruction.

Effect of lymphoscintigraphy drainage patterns on sentinel lymph node biopsy in patients with breast cancer

BACKGROUND

Sentinel lymph node (SLN) biopsy examination is an accepted method of staging breast cancer patients. SLN biopsy examination in patients with drainage to the internal mammary chain (IMC) nodes is controversial.

METHODS

A prospective study of SLN biopsy examination followed by axillary dissection was analyzed to determine how surgeons manage patients with IMC drainage and the rates of axillary SLN identification and positivity in these cases.

RESULTS

Lymphoscintigraphy was performed in 2196 (53.2%) of the 4131 patients in this study. IMC drainage was noted in 80 patients (3.6%). An axillary SLN was identified in 29 of the 40 patients with IMC drainage alone (72.5%). The rate of finding a positive axillary lymph node did not differ based on the lymphoscintigraphic pattern (P = .470).

CONCLUSIONS

Most surgeons do not perform IMC SLN biopsy procedures. Even when lymphoscintigraphy shows isolated drainage to IMC nodes, axillary SLNs usually are identified. Lymphoscintigraphy therefore has limited usefulness.

Factors predicting failure to identify a sentinel lymph node in breast cancer

BACKGROUND

Although sentinel lymph node (SLN) biopsy is widely accepted as a minimally invasive method of nodal staging, failure to identify an SLN mandates a level I/II axillary node dissection. The purpose of this study was to elucidate factors that independently predict failure to identify an SLN.

METHODS

Using a large multicenter prospective study of SLN biopsy for patients with invasive breast cancer, we performed univariate and multivariate regression analyses to determine clinicopathologic factors predictive of failure to identify an SLN.

RESULTS

Of the total 4131 patients in the study, an SLN was not identified in 249 (6.0%). Tumor location (P = .409), biopsy type (P = .079), surgery type (P = .380), and histologic subtype (P = .999) were not significant predictors of failure to identify an SLN. On multivariate analysis, age greater than 60 years (OR = 1.469; 95% CI, 1.116-1.934, P = .006), nonpalpable tumors (OR = 0.639; 95% CI, 0.479-0.852, P = .002), injection technique with blue dye alone (OR = 0.389, 95% CI, 0.259-5.86, P < .001), and surgical experience of less than 10 SLN biopsy cases (OR = 1.886; 1.428-2.492, P < .001) were significant independent predictors of failure to identify an SLN. Optimal SLN biopsy technique using an intradermal and/or subareolar injection of radioactive colloid and blue dye can improve SLN identification rates regardless of patient and tumor characteristics.

CONCLUSIONS

Patient age and tumor palpability significantly affect the ability to identify an SLN in patients with breast cancer. Optimal injection technique can significantly improve sentinel node identification rate regardless of these factors.