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Internal mammary lymph node biopsy during delayed free flap breast reconstruction: case series and review of the literature

Abstract

Background

Internal mammary vessels are often used as recipient vessels during free flap breast reconstruction, especially in delayed reconstruction. Vessel dissection occasionally results in incidental identification of internal mammary lymph nodes (IMLNs). Some studies have reported the positivity of these nodes but few studies have focused on delayed reconstruction and no other study examined the difference between patients with and without artificial materials.

Methods

This is a retrospective review of patients undergoing delayed free flap breast reconstruction using internal mammary vessels. If IMLNs were accidentally identified during preparation of recipient vessels, the authors sent it for pathological review. Patient characteristics, tumor staging, IMLN positivity, treatment alteration after operation, and outcome were studied.

Results

Overall, 174 patients underwent delayed free flap breast reconstruction; internal mammary vessels were exposed in 167 patients. Of these, 68 IMLNs (65 patients, 38.9%) were identified and sampled. IMLNs were identified in 40 patients (43.0%) in patients with artificial materials such as tissue expander, silicone implant, and injected foreign material for breast augmentation, while in 25 patients (33.8%) without them. Three patients (4.6%) were tumor positive. One patient was found to have multiple metastasis and two of three patients had an increase in cancer stage after reconstruction. Two patients had changes in cancer treatment after reconstruction. All patients with positive IMLNs were alive at the last follow-up.

Conclusions

During delayed free flap breast reconstruction, IMLNs are identified more frequently in patients with artificial materials than patients without them. Its positivity is rare, but it might affect breast cancer reevaluation and treatment after reconstruction.

Level of evidence: Level IV, diagnostic study.

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Data availability

Not applicable.

Code availability

Not applicable.

References

  1. 1.

    Hindié E, Groheux D, Hennequin C, Zanotti-Fregonara P, Vercellino L, Berenger N et al (2012) Lymphoscintigraphy can select breast cancer patients for internal mammary chain radiotherapy. Int J Radiat Oncol Biol Phys 83(4):1081–1088. https://doi.org/10.1016/j.ijrobp.2011.09.016

    Article  PubMed  Google Scholar 

  2. 2.

    Madsen EV, Aalders KC, van der Heiden-van der Loo M, Gobardhan PD, van Oort PM, van der Ent FW, et al (2015) Prognostic significance of tumor-positive internal mammary sentinel lymph nodes in breast cancer: a multicenter cohort study. Ann Surg Oncol 22(13):4254–4262. https://doi.org/10.1245/s10434-015-4535-y

    Article  PubMed  Google Scholar 

  3. 3.

    Postma EL, van Wieringen S, Hobbelink MG, Verkooijen HM, van den Bongard HJ, Borel Rinkes IH et al (2012) Sentinel lymph node biopsy of the internal mammary chain in breast cancer. Breast Cancer Res Treat 134(2):735–741. https://doi.org/10.1007/s10549-012-2086-5

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Tan C, Caragata R, Bennett I (2017) Is sentinel node biopsy of the internal mammary lymph nodes relevant in the management of breast cancer? Breast J 23(4):410–414. https://doi.org/10.1111/tbj.12754

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Dupin CL, Allen RJ, Glass CA, Bunch R (1996) The internal mammary artery and vein as a recipient site for free-flap breast reconstruction: a report of 110 consecutive cases. Plast Reconstr Surg 98(4):685–9; discussion 90–2. https://doi.org/10.1097/00006534-199609001-00013

  6. 6.

    Hofer SO, Rakhorst HA, Mureau MA, Moolenburgh SE, van Huizum MA, van Geel AN (2005) Pathological internal mammary lymph nodes in secondary and tertiary deep inferior epigastric perforator flap breast reconstructions. Ann Plast Surg 55(6):583–586. https://doi.org/10.1097/01.sap.0000185887.04664.70

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Chen RC, Lin NU, Golshan M, Harris JR, Bellon JR (2008) Internal mammary nodes in breast cancer: diagnosis and implications for patient management – a systematic review. J Clin Oncol 26(30):4981–4989. https://doi.org/10.1200/jco.2008.17.4862

    Article  PubMed  Google Scholar 

  8. 8.

    Lorenzetti F, Kuokkanen H, von Smitten K, Asko-Seljavaara S (2001) Intraoperative evaluation of blood flow in the internal mammary or thoracodorsal artery as a recipient vessel for a free TRAM flap. Ann Plast Surg 46(6):590–593. https://doi.org/10.1097/00000637-200106000-00003

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Sacks JM, Chang DW (2009) Rib-sparing internal mammary vessel harvest for microvascular breast reconstruction in 100 consecutive cases. Plast Reconstr Surg 123(5):1403–1407. https://doi.org/10.1097/PRS.0b013e3181a07249

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Barros AC, Mori LJ, Nishimura D, Jacomo AL (2016) Surgical anatomy of the internal thoracic lymph nodes in fresh human cadavers: basis for sentinel node biopsy. World J Surg Oncol 14:135. https://doi.org/10.1186/s12957-016-0897-2

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Estourgie SH, Tanis PJ, Nieweg OE, Valdés Olmos RA, Rutgers EJ, Kroon BB (2003) Should the hunt for internal mammary chain sentinel nodes begin? An evaluation of 150 breast cancer patients. Ann Surg Oncol 10(8):935–941. https://doi.org/10.1245/aso.2003.02.015

    Article  PubMed  Google Scholar 

  12. 12.

    Yu JT, Provenzano E, Forouhi P, Malata CM (2011) An evaluation of incidental metastases to internal mammary lymph nodes detected during microvascular abdominal free flap breast reconstruction. J Plast Reconstr Aesthet Surg 64(6):716–721. https://doi.org/10.1016/j.bjps.2010.10.003

    Article  PubMed  Google Scholar 

  13. 13.

    Huang JJ, Wu CW, Allen RJ Jr, Shen SC, Yu CC, Cheng MH (2016) Routine sampling of internal mammary lymph nodes during microsurgical breast reconstruction-experience based on 524 microsurgical breast reconstructions. J Surg Oncol 114(2):133–139. https://doi.org/10.1002/jso.24295

    Article  PubMed  Google Scholar 

  14. 14.

    Karanetz I, Jin M, Nguyen K, Delmauro M, Lerman OZ, Smith ML et al (2021) Evaluation of internal mammary lymph node biopsy during microsurgical breast reconstruction: an analysis of 230 consecutive patients. Breast J 27(1):7–12. https://doi.org/10.1111/tbj.14105

    Article  PubMed  Google Scholar 

  15. 15.

    Kaewlai R, Digumarthy SR, Smith BL, Corben AD, Austen WG Jr, Shepard JA et al (2010) Significance of internal mammary lymph nodes in patients after mastectomy with tissue-expander reconstruction: a case-control study. Clin Radiol 65(6):453–459. https://doi.org/10.1016/j.crad.2010.01.015

    CAS  Article  PubMed  Google Scholar 

  16. 16.

    Sutton EJ, Watson EJ, Gibbons G, Goldman DA, Moskowitz CS, Jochelson MS et al (2015) Incidence of internal mammary lymph nodes with silicone breast implants at MR imaging after oncoplastic surgery. Radiology 277(2):381–387. https://doi.org/10.1148/radiol.2015142717

    Article  PubMed  Google Scholar 

  17. 17.

    Trignano E, Baccari M, Pili N, Serra PL, Rubino C (2020) Complications after breast augmentation with hyaluronic acid: a case report. Gland Surg 9(6):2193–7. https://doi.org/10.21037/gs-20-448

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Grant AL, Lutz KH, Temple-Oberle CF (2014) Incidental internal mammary nodes during recipient vessel dissection in breast reconstruction: are they significant? Plast Reconstr Surg Glob Open 2(12):e276. https://doi.org/10.1097/gox.0000000000000245

    Article  PubMed  Google Scholar 

  19. 19.

    Knight MA, Nguyen DT, Kobayashi MR, Evans GR, Cheng MH (2008) Incidental positive internal mammary lymph nodes: a multiple international institutional investigation. J Reconstr Microsurg 24(3):197–202. https://doi.org/10.1055/s-2008-1076088

    Article  PubMed  Google Scholar 

  20. 20.

    Wong KY, Yu JT, Mahler-Araujo B, Forouhi P, Malata CM (2013) Opportunistic internal mammary lymph node biopsy during microvascular free flap breast reconstruction: a useful technique? Int J Surg 11(9):1027–1028. https://doi.org/10.1016/j.ijsu.2013.07.011

    Article  PubMed  Google Scholar 

  21. 21.

    Wright EJ, Momeni A, Kraneburg UM, Otake LR, Echo A, Lee T et al (2016) Clinical significance of internal mammary lymph node biopsy during microsurgical breast reconstruction: review of 264 cases. Plast Reconstr Surg 137(6):917e-e922. https://doi.org/10.1097/prs.0000000000002174

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Network NCC NCCN clinical practice guidelines in oncology breast cancer. version 3. 2019. http://http://www.nccn.org/professionals/physician_gls/PDF/breast.pdf

  23. 23.

    van Geel AN, Wouters MW, van der Pol C, Schmitz PI, Lans T (2009) Chest wall resection for internal mammary lymph node metastases of breast cancer. Breast 18(2):94–99. https://doi.org/10.1016/j.breast.2009.01.005

    Article  PubMed  Google Scholar 

  24. 24.

    Chen L, Gu Y, Leaw S, Wang Z, Wang P, Hu X et al (2010) Internal mammary lymph node recurrence: rare but characteristic metastasis site in breast cancer. BMC Cancer 10:479. https://doi.org/10.1186/1471-2407-10-479

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Qiu PF, Zhao RR, Wang W, Sun X, Chen P, Liu YB et al (2020) Internal mammary sentinel lymph node biopsy in clinically axillary lymph node-positive breast cancer: diagnosis and implications for patient management. Ann Surg Oncol 27(2):375–383. https://doi.org/10.1245/s10434-019-07705-0

    Article  PubMed  Google Scholar 

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Affiliations

Authors

Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Misako Nakazono, Toshihiko Satake, Yui Tsunoda, Mayu Muto, Kouichi Hirotomi, Kazutaka Narui, Takashi Ishikawa, and Jiro Maegawa. The first draft of the manuscript was written by Misako Nakazono and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Toshihiko Satake.

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Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments. This is a retrospective study. Ethical approval was not required for this type of study.

Consent to participate

Informed consent was obtained from all individual participants included in the study. Additional informed consent was obtained from all individual participants for whom identifying information is included in this article.

Consent for publication

Patients signed informed consent regarding publishing their data and photographs.

Conflict of interest

Misako Nakazono, Toshihiko Satake, Yui Tsunoda, Mayu Muto, Kouichi Hirotomi, Kazutaka Narui, Takashi Ishikawa, and Jiro Maegawa declare no competing interests.

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Nakazono, M., Satake, T., Tsunoda, Y. et al. Internal mammary lymph node biopsy during delayed free flap breast reconstruction: case series and review of the literature. Eur J Plast Surg (2021). https://doi.org/10.1007/s00238-021-01879-1

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Keywords

  • Free flap breast reconstruction
  • Internal mammary lymph node
  • Lymph node biopsy
  • Autologous breast reconstruction
  • Delayed breast reconstruction