Drainage Across Midline to Sentinel Nodes in the Contralateral Axilla in Breast Cancer

Contralateral lymph node metastasis in recurrent ipsilateral breast cancer with Lynch syndrome: a locoregional event

INTRODUCTION

Contralateral axillary lymph node metastasis (CALNM) in breast cancer (BC) is considered a distant metastasis, marking stage 4cancer. Therefore, it is generally treated as an incurable disease. However, in clinical practice, staging and treatment remain controversial due to a paucity of data, and the St. Gallen 2021 consensus panel recommended a curative approach in patients with oligometastatic disease. Aberrant lymph node (LN) drainage following previous surgery or radiotherapy is common. Therefore, CALNM may be considered a regional event rather than systemic disease, and a re-sentinel procedure aided by lymphoscintigraphy permits adequate regional staging.

CASE REPORT

Here, we report a 37-year-old patient with Lynch syndrome who presented with CALNM in an ipsilateral relapse of a moderately differentiated invasive ductal BC (ER 90%, PR 30%, HER2 negative, Ki-67 25%, microsatellite stable), 3 years after the initial diagnosis. Lymphoscintigraphy detected a positive sentinel LN in the contralateral axilla despite no sign of LN involvement or distant metastases on FDG PET/CT or MRI. The patient underwent bilateral mastectomy with sentinel node dissection, surgical reconstruction with histological confirmation of the CALNM, left axillary dissection, adjuvant chemotherapy, and anti-hormone therapy. In addition to her regular BC follow-up visits, the patient will undergo annual colonoscopy, gastroscopy, abdominal, and vaginal ultrasound screening. In January 2023, the patient was free of progression for 23 months after initiation of treatment for recurrent BC and CALNM.

CONCLUSION

This case highlights the value of delayed lymphoscintigraphy and the contribution of sentinel procedure for local control in the setting of recurrent BC. Aberrant lymph node drainage following previous surgery may be the underlying cause of CALNM. We propose that CALNM without evidence of systemic metastasis should be considered a regional event in recurrent BC, and thus, a curative approach can be pursued. The next AJCC BC staging should clarify the role of CALNM in recurrent BC to allow for the development of specific treatment guidelines.

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.

Contralateral lymph node recurrence in breast cancer: Regional event rather than distant metastatic disease. A systematic review of the literature

AIMS

After treatment for breast cancer, some patients experience a contralateral lymph node recurrence (CLNR). Traditionally, contralateral nodes are considered a distant site. However, aberrant lymph drainage after previous surgery is common. This might indicate that CLNR is a regional event. This study aimed to review the literature to determine prognosis after CLNR.

METHODS

PubMed was searched up until July 2014. Articles on CLNR with or without ipsilateral breast tumour recurrence (IBTR), and repeat sentinel node (SN) studies reporting on positive contralateral nodes were included. Exclusion criteria were synchronous contralateral breast cancer and synchronous distant events.

RESULTS

24 articles were included, describing 48 patients. Of these 48, 26 patients had an isolated CLNR, 7 IBTR and clinically detected CLNR, and 15 IBTR with a positive contralateral repeat SN. Isolated CLNR occurred earlier (45.9 months) than IBTR with CLNR (126.6 months, p < 0.001) or with a positive contralateral repeat SN (217.2, p = 0.02). Surgical treatment was described for 38 patients, and consisted of axillary lymph node dissection for 34 (89.5%). Information on adjuvant therapy was available for 27 patients, 21 (77.8%) received chemotherapy. Follow-up information after CLNR was available for 23 patients (47.9%). Mean follow-up was 50.3 months. Overall survival and disease-free survival were 82.6% [95% CI 67.1-98.1] and 65.2% [45.7-84.7] respectively at last follow-up.

CONCLUSIONS

Although observed in a small population, the survival of CLNR is not comparable to distant disease. Most patients received locoregional and systemic treatment suggesting a curative approach. This indicates that CLNR should be regarded as a regional event.

Management of sentinel node re-mapping in patients who have second or recurrent breast cancer and had previous axillary procedures

BACKGROUND

In patients with recurrent or second primary ipsilateral breast cancer, axillary staging is the key factor in locoregional control and a strong prognostic characteristic. The efficient evaluation of lymphatic drainage of re-sentinel lymph node biopsies (re-SLNBs) has remained a challenge in the management of ipsilateral primary or recurrent breast cancer patients who are clinically lymph node negative. This study explores whether a SLNB for patients with primary or recurrent breast cancer is possible after previous axillary surgery. It evaluates potential reasons for mapping failure that might be associated with patients in this group.

METHODS

Between March 2006 and November 2013, 458 patients were subjected to a breast SLNB. A lymphoscintigraphy procedure was performed on 330 patients for sentinel lymph node (SLN) mapping on the day of surgery. Seven patients with either a second primary cancer in the same breast or recurrent breast cancer were described. Two of these seven patients had axillary lymph node dissection (ALND) during previous treatments and five had SLNB. A dual mapping method was used for all patients. Preoperative lymphoscintigraphy was performed four hours before surgery.

RESULTS

SLNs were successfully remapped in six of seven (85.7%) patients, of whom five (71.43%) had previously undergone SLNB and two (28.57%) previous ALND. Localizations of SLNs were ipsilateral axillary in three patients, ipsilateral internal mammary in one patient, and contralateral axillary in two patients. An altered distribution of lymph nodes was discovered in both patients with previous ALND. In one of the two patients, metastases were found in an aberrant lymph drainage basin at the location of a non-ipsilateral axillary node (contralateral axillary SLN). The second previously ALND patient had an internal mammary SLN. In one patient, mapping was unsuccessful and the SLN was not identified.

CONCLUSIONS

Altered lymphatic drainage incidence increases following breast-conserving surgery for an initial breast cancer, and the location of SLNs becomes unpredictable at the time of a second primary or recurrent ipsilateral breast cancer. This leads to the necessity of using a radionuclide (lymphoscintigraphy) for a successful re-mapping procedure. A re-SLNB is precise and beneficial even though there are few patients. A lymphoscintigraphy can identify SLNs at their new unpredicted location.

Bilateral axillary and internal mammary drainage in breast cancer without prior surgery during sentinel node mapping

Lymphatic drainage outside the ipsilateral axilla in breast cancer is discovered in as many as 25% of all sentinel lymph node procedures and it is evidenced by lymphoscintigraphy. Contralateral axillary drainage is a rare clinical situation, mostly if there is not prior breast surgery, but this situation is extremely exceptional if we also found internal mammary chain drainage. We have not found such a case published in literature. This atypical finding is source of doubts because it could have clinical implications in the management of patients. We present a woman just diagnosed of breast carcinoma with hot nodes in bilateral axillary and ipsilateral internal mammary chain lymph nodes, shown by preoperative lymphoscintigraphy. We review published cases with contralateral axillary drainage, which enhance the role of scintigraphic procedure in such cases and show induced controversies in selecting the most adequate management.

Repeat sentinel node biopsy in patients with locally recurrent breast cancer: a systematic review and meta-analysis of the literature

Axillary staging in patients with locally recurrent breast cancer is important for obtaining locoregional control and predicting prognosis. The aim of the present study is to determine technical feasibility, validity, aberrant drainage patterns and clinical consequences of performing repeat sentinel node biopsy (SNB) in these patients. We performed a systematic review and meta-analysis of the literature and included all studies on repeat SNB in locally recurrent breast cancer. A total of 692 patients were described, 301 after a previous SNB, 361 after a previous axillary lymph node dissection (ALND), and 30 with no previous axillary surgery. Sentinel node identification was successful in 452 of the 692 patients (65.3 %), which was significantly higher in patients who had undergone previous SNB compared to previous ALND (81.0 vs. 52.2 %) (P < 0.0001). In 175 of 405 patients with successful lymphatic mapping aberrant drainage pathways were visualized (43.2 %), which were seen more frequently after previous ALND than after previous SNB (69.2 vs. 17.4 %) (P < 0.0001). In 19.2 % of the patients the sentinel node was tumor positive and 27.5 % of these metastases were found in aberrant lymph drainage basins. Overall, 213 patients could be spared an ALND and in 17.9 % of the patients the information derived from the repeat SNB led to a change in adjuvant radiotherapy or systemic treatment plans. The procedure had a false-negative rate of 0.2 %. Repeat SNB is technically feasible and accurate. Next to sparing patients an unnecessary ALND, the information can lead to a change in adjuvant treatment strategy.

[Detection of contralateral axillary sentinel lymph node by lymphoscintigraphy in breast cancer: prognostic implications]

The role of nuclear medicine in the detection of sentinel lymph nodes (SLNs) in primary breast cancer is very useful to determine regional lymphatic drainage from the affected breast, mainly its anatomical and/or tumoral individual variability and to determine the initial tumor stage. We present the case of an infiltrating ductal carcinoma of the breast (T2) in the junction of the inner quadrants of the right breast studied by lymphoscintigraphy and gamma probe detection. Three non-metastatic sentinel lymph nodes were found with the selective lymphadenectomy: two in the ipsilateral axilla and one in the contralateral axilla. The lymphoscintigraphic finding of the axillary sentinel lymph node contralateral to the affected breast demonstrates the individual anatomical variability in mammary drainage. It emphasizes the importance of nuclear medicine imaging techniques in its detection and generates new prognostic approaches with impact on therapeutic measures and patient follow-up.

Stereoscopic scintigraphic imaging of breast cancer sentinel lymph nodes

BACKGROUND

Lymphoscintigraphy is used preoperatively to identify sentinel lymph nodes (SLNs). Conventional planar scintigraphy cannot provide three-dimensional(3D) information for SLN biopsy. We applied stereoscopic imaging to preoperative lymphoscintigraphy to obtain 3D information and evaluated its usefulness.

METHODS

Forty-four clinical stage I breast cancer patients (1 male, 43 females; age, 59.4+/-11.4 years) were enrolled in this study. Three hours after the injection of Tc-99m, 10 degrees of oblique images and routine anterior and lateral images were acquired. Anterior and lateral stereoscopic images were obtained in all studies, except for 2 patients; only lateral views were done for those. Two experienced radiologists enumerated the visualized hot nodes.

RESULTS

Stereoscopic imaging delineated more hot axillary lymph nodes compared to routine planar imaging in 8 of 42 patients (19.0%) on anterior view, 5 of 44 patients (11.4%) on lateral view, and 11 of 44 patients (25.0%) on either the anterior or lateral view. Statistically significant differences were observed between stereoscopic and routine planar imaging method on the anterior (p=0.012) and the lateral views (p=0.043). The stereoscopic imaging provided 3D information and effectively separated closely located hot nodes that were viewed as one hot node on conventional planar images. Thirty-eight out of 42 cases (90%) with anterior stereoscopic images identified the same number or more axillary hot nodes compared with lateral stereoscopic images.

CONCLUSION

The stereoscopic imaging method could improve the preoperative identification of SLNs. This method is technically simple, and could be a powerful diagnostic tool for SLN imaging breast cancer.

Lymphatic mapping and sentinel node harvesting in patients with recurrent breast cancer

AIMS

To evaluate the feasibility and consequences of lymphatic mapping and a ("repeat") sentinel lymph node (SLN) procedure in patients with breast cancer relapse after previous breast and axillary surgery.

METHODS

Review and presentation of a patient cohort. All SLN procedures included lymphoscintigraphy and blue dye injection technique.

RESULTS

Twelve cases are described: two patients after a previous SLN procedure and ten after a previous complete axillary lymph node dissection (ALND). Ten patients (83%) had a successful repeat SLN biopsy. After previous ALND, lymphoscintigraphy revealed drainage towards the internal mammary chain in three patients, and contralateral axillary drainage in four. Based on the information from the "repeat" SLN biopsy further treatment strategy was altered in seven of the 12 patients.

CONCLUSION

Lymphatic mapping and (repeat) SLN biopsy is possible and can be informative in patients who present with a relapse of breast cancer after previous surgery for primary breast cancer.

Sentinel Lymph Node Surgery in Locally Recurrent Breast Cancer

BACKGROUND

Patients with locally recurrent breast cancer can also harbor regional nodal disease. Sentinel lymph node (LN; SLN) surgery is an accepted method for LN evaluation in early-stage breast cancer. We sought to evaluate the feasibility of SLN surgery in patients with locally recurrent breast cancer.

PATIENTS AND METHODS

Patients undergoing SLN surgery at the time of treatment for recurrent breast cancer were identified. Clinical, pathologic, and operative details of initial and recurrent breast cancer events were analyzed.

RESULTS

From 2001 to 2005, 21 patients underwent SLN surgery for locally recurrent breast cancer. Previous breast procedures included segmental mastectomy in 17 patients and mastectomy in 4 patients. Previous axillary procedures included axillary LN dissection in 12 patients, SLN surgery in 5 patients, and no axillary surgery in 4 patients. Twelve patients had received breast irradiation. The SLN was identified and excised in 13 patients (62%). Six patients had drainage to nodal basins outside of the axilla (internal mammary and/or contralateral axilla). As the number of axillary nodes removed at primary surgery increased, the incidence of alternative lymphatic drainage increased: no previous axillary surgery, 0; 1-10 LNs removed, 30%; > 10 LNs removed, 50%.

CONCLUSION

Sentinel LN surgery is feasible in patients with locally recurrent breast cancer regardless of previous axillary node surgery or radiation. The incidence of alternative lymphatic drainage is increased in patients with > 10 axillary LNs removed at original operation or when radiation was part of the previous treatment. Sentinel LN surgery is a tool for guiding local-regional management of patients with locally recurrent breast cancer.

Clinical implications of contralateral axillary sentinel lymph nodes

Extra-axillary sentinel lymph nodes can only be detected if radioactive tracer is used and pre-operative scans are carried out. The presence of metastatic sentinel lymph nodes in most extra-axillary sites will upstage patients if the ipsilateral axillary sentinel lymph node is normal. Paradoxically, the presence of metastatic sentinel lymph nodes in the contralateral axilla has the potential to prevent upstaging to stage IV, but only if detected as a sentinel node at the initial surgery rather than as a systemic recurrence at some later time. We describe a case of bilateral axillary sentinel lymph nodes detected by pre-operative lymphoscintigraphy in a patient with a medial quadrant breast cancer and discuss the possible implications of such a finding.

Lymphoscintigraphy and triangulated body marking for morbidity reduction during sentinel node biopsy in breast cancer

Current trends in patient care include the desire for minimizing invasiveness of procedures and interventions. This aim is reflected in the increasing utilization of sentinel lymph node biopsy, which results in a lower level of morbidity in breast cancer staging, in comparison to extensive conventional axillary dissection. Optimized lymphoscintigraphy with triangulated body marking is a clinical option that can further reduce morbidity, more than when a hand held gamma probe alone is utilized. Unfortunately it is often either overlooked or not fully understood, and thus not utilized. This results in the unnecessary loss of an opportunity to further reduce morbidity.

Optimized lymphoscintigraphy and triangulated body marking provides a detailed 3 dimensional map of the number and location of the sentinel nodes, available before the first incision is made. The number, location, relevance based on time/sequence of appearance of the nodes, all can influence 1) where the incision is made, 2) how extensive the dissection is, and 3) how many nodes are removed. In addition, complex patterns can arise from injections. These include prominent lymphatic channels, pseudo-sentinel nodes, echelon and reverse echelon nodes and even contamination, which are much more difficult to access with the probe only. With the detailed information provided by optimized lymphoscintigraphy and triangulated body marking, the surgeon can approach the axilla in a more enlightened fashion, in contrast to when the less informed probe only method is used. This allows for better planning, resulting in the best cosmetic effect and less trauma to the tissues, further reducing morbidity while maintaining adequate sampling of the sentinel node(s).