Skip to main content

Advertisement

Log in

Internal mammary lymph node metastases in breast cancer: what should radiologists know?

  • Invited Review
  • Published:
Japanese Journal of Radiology Aims and scope Submit manuscript

Abstract

The internal mammary lymph node (IMLN) chain is a pathway through which breast lymphatic drainage flows. The internal mammary lymphatic vessel runs around the internal mammary artery and veins with IMLN in the parasternal intercostal spaces. IMLN metastasis, which forms a part of clinical TNM staging, may negatively affect the prognosis of primary breast cancer patients. IMLN metastasis is clinically detected using ultrasound, computed tomography, magnetic resonance imaging, and 18F-deoxyglucose positron emission tomography computed tomography. The uptake of radioactive tracers in IMLN with clinically negative axillary lymph nodes is often identified using sentinel lymph node mapping (SLNM) in primary breast cancer patients. The indication for IMLN biopsy or resection that is clinically detected or visualized using SLNM is controversial. The clinically suspicious IMLN may be considered for ultrasound-guided fine-needle aspiration. First IMLN recurrence needs to be biopsied. Irradiation of the breast, chest wall, and/or regional nodal irradiation, including IMLN, following lumpectomy or postmastectomy is recommended. Although radiation therapy for IMLN recurrence may improve clinical outcomes, it is also associated with pulmonary and cardiac toxicities. This review covers the local anatomy of IMLN, lymph drainage and image findings of IMLN with a discussion.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14

Similar content being viewed by others

References

  1. Cheon H, Kim HJ, Lee SW, Kim DH, Lee CH, Cho SH, et al. Internal mammary node adenopathy on breast MRI and PET/CT for initial staging in patients with operable breast cancer: prevalence and associated factors. Breast Cancer Res Treat. 2016;160:523–30.

    Article  CAS  Google Scholar 

  2. Habraken V, van Nijnatten TJ, de Munck L, Moossdorff M, Heuts EM, Lobbes MB, et al. Does the TNM classification of solitary internal mammary lymph node metastases in breast cancer still apply? Breast Cancer Res Treat. 2017;161:483–9.

    Article  CAS  Google Scholar 

  3. Manca G, Volterrani D, Mazzarri S, Duce V, Svirydenka A, Giuliano A, et al. Sentinel lymph node mapping in breast cancer: a critical reappraisal of the internal mammary chain issue. Q J Nucl Med Mol Imaging. 2014;58:114–26.

    CAS  PubMed  Google Scholar 

  4. Zhang X, Jaffer S, Bleiweiss IJ, Nayak A. The clinical significance of internal mammary lymph node (IMLN) biopsy during autologous reconstruction in breast cancer patients. Breast Cancer Res Treat. 2015;153:565–72.

    Article  CAS  Google Scholar 

  5. Postma EL, van Wieringen S, Hobbelink MG, Verkooijen HM, van den Bongard HJ, Borel Rinkes IH, et al. Sentinel lymph node biopsy of the internal mammary chain in breast cancer. Breast Cancer Res Treat. 2012;134:735–41.

    Article  CAS  Google Scholar 

  6. Recht A, Comen EA, Fine RE, Fleming GF, Hardenbergh PH, Ho AY, et al. Postmastectomy radiotherapy: an American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology focused guideline update. Pract Radiat Oncol. 2016;6:e219–34.

    Article  Google Scholar 

  7. Barros AC, Mori LJ, Nishimura D, Jacomo AL. Surgical anatomy of the internal thoracic lymph nodes in fresh human cadavers: basis for sentinel node biopsy. World J Surg Oncol. 2016;14:135.

    Article  Google Scholar 

  8. Suami H, Pan WR, Mann GB, Taylor GI. The lymphatic anatomy of the breast and its implications for sentinel lymph node biopsy: a human cadaver study. Ann Surg Oncol. 2008;15:863–71.

    Article  Google Scholar 

  9. Hultborn KA, Larsson LG, Ragnhult I. The lymph drainage from the breast to the axillary and parasternal lymph nodes, studied with the aid of colloidal Au198. Acta Radiol. 1955;43:52–64.

    Article  CAS  Google Scholar 

  10. Gradishar WJ, Anderson BO, Balassanian R, Blair SL, Burstein HJ, Cyr A, et al. NCCN guidelines insights: breast cancer, version 1.2017. J Natl Compr Canc Netw. 2017;15:433–51.

    Article  Google Scholar 

  11. Jochelson MS, Lebron L, Jacobs SS, Zheng J, Moskowitz CS, Powell SN, et al. Detection of internal mammary adenopathy in patients with breast cancer by PET/CT and MRI. AJR Am J Roentgenol. 2015;205:899–904.

    Article  Google Scholar 

  12. Dogan BE, Dryden MJ, Wei W, Fornage BD, Buchholz TA, Smith B, et al. Sonography and sonographically guided needle biopsy of internal mammary nodes in staging of patients with breast cancer. AJR Am J Roentgenol. 2015;205:905–11.

    Article  Google Scholar 

  13. American Joint Committee on Cancer (AJCC). AJCC cancer staging manual. 8th ed. New York: Springer; 2017.

    Google Scholar 

  14. Savaridas SL, Spratt JD, Cox J. Incidence and potential significance of internal mammary lymphadenopathy on computed tomography in patients with a diagnosis of primary breast cancer. Breast Cancer (Auckl). 2015;9:59–65.

    PubMed  PubMed Central  Google Scholar 

  15. Mack M, Chetlen A, Liao J. Incidental internal mammary lymph nodes visualized on screening breast MRI. AJR Am J Roentgenol. 2015;205:209–14.

    Article  Google Scholar 

  16. Zhang YJ, Oh JL, Whitman GJ, Iyengar P, Yu TK, Tereffe W, et al. Clinically apparent internal mammary nodal metastasis in patients with advanced breast cancer: incidence and local control. Int J Radiat Oncol Biol Phys. 2010;77:1113–9.

    Article  Google Scholar 

  17. Overgaard M, Christensen JJ. Postoperative radiotherapy in DBCG during 30 years. Techniques, indications and clinical radiobiological experience. Acta Oncol. 2008;47:639–53.

    Article  Google Scholar 

  18. Ohsumi S, Inoue T, Kiyoto S, Hara F, Takahashi M, Takabatake D, et al. Detection of isolated ipsilateral regional lymph node recurrences by F18-fluorodeoxyglucose positron emission tomography-CT in follow-up of postoperative breast cancer patients. Breast Cancer Res Treat. 2011;130:267–72.

    Article  Google Scholar 

  19. Oh JK, Chung YA, Kim YS, Jeon HM, Kim SH, Park YH, et al. Value of F-18 FDG PET/CT in detection and prognostication of isolated extra-axillary lymph node recurrences in postoperative breast cancer. Biomed Mater Eng. 2014;24:1173–84.

    CAS  PubMed  Google Scholar 

  20. Kwai AH, Stomper PC, Kaplan WD. Clinical significance of isolated scintigraphic sternal lesions in patients with breast cancer. J Nucl Med. 1988;29:324–8.

    CAS  PubMed  Google Scholar 

  21. Sutton EJ, Watson EJ, Gibbons G, Goldman DA, Moskowitz CS, Jochelson MS, et al. Incidence of internal mammary lymph nodes with silicone breast implants at MR imaging after oncoplastic surgery. Radiology. 2015;277:381–7.

    Article  Google Scholar 

  22. Soudack M, Yelin A, Simansky D, Ben-Nun A. Fluorodeoxyglucose—positive internal mammary lymph node in breast cancer patients with silicone implants: is it always metastatic cancer? Eur J Cardiothorac Surg. 2013;44:79–82.

    Article  Google Scholar 

  23. Barros AC, Barros MA, Andrade FE, Mori LJ, Costa PA, Sheng PY, et al. Combined radioguided nonpalpable lesion localization and sentinel lymph node biopsy for early breast carcinoma. Ann Surg Oncol. 2007;14:1472–7.

    Article  Google Scholar 

  24. Kong AL, Tereffe W, Hunt KK, Yi M, Kang T, Weatherspoon K, et al. Impact of internal mammary lymph node drainage identified by preoperative lymphoscintigraphy on outcomes in patients with stage I to III breast cancer. Cancer. 2012;118:6287–96.

    Article  Google Scholar 

  25. Wang CL, Eissa MJ, Rogers JV, Aravkin AY, Porter BA, Beatty JD. 18F-FDG PET/CT-positive internal mammary lymph nodes: pathologic correlation by ultrasound-guided fine-needle aspiration and assessment of associated risk factors. AJR Am J Roentgenol. 2013;200:1138–44.

    Article  Google Scholar 

  26. Whelan TJ, Olivotto IA, Parulekar WR, Ackerman I, Chua BH, Nabid A, et al. Regional nodal irradiation in early-stage breast cancer. N Engl J Med. 2015;373:307–16.

    Article  CAS  Google Scholar 

  27. Poortmans PM, Collette S, Kirkove C, Van Limbergen E, Budach V, Struikmans H, et al. Internal mammary and medial supraclavicular irradiation in breast cancer. N Engl J Med. 2015;373:317–27.

    Article  CAS  Google Scholar 

  28. EBCTCG, McGale P, Taylor C, Correa C, Cutter D, Duane F, et al. Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet. 2014;383:2127–35.

    Article  Google Scholar 

  29. Thorsen LB, Offersen BV, Dano H, Berg M, Jensen I, Pedersen AN, et al. DBCG-IMN: a population-based cohort study on the effect of internal mammary node irradiation in early node-positive breast cancer. J Clin Oncol. 2016;34:314–20.

    Article  Google Scholar 

  30. Hennequin C, Bossard N, Servagi-Vernat S, Maingon P, Dubois JB, Datchary J, et al. Ten-year survival results of a randomized trial of irradiation of internal mammary nodes after mastectomy. Int J Radiat Oncol Biol Phys. 2013;86:860–6.

    Article  Google Scholar 

  31. Chen L, Gu Y, Leaw S, Wang Z, Wang P, Hu X, et al. Internal mammary lymph node recurrence: rare but characteristic metastasis site in breast cancer. BMC Cancer. 2010;10:479.

    Article  Google Scholar 

  32. Cao L, Cai G, Chang C, Yang ZZ, Feng Y, Yu XL, et al. Early cardiac toxicity following adjuvant radiotherapy of left-sided breast cancer with or without concurrent trastuzumab. Oncotarget. 2016;7:1042–54.

    PubMed  Google Scholar 

Download references

Acknowledgements

This paper was presented in part at the 103rd annual meeting of the Radiological Society of North America (RSNA) in Chicago, 2017. It received a Certification of Merit for an education exhibit.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Misugi Urano.

Ethics declarations

Conflict of interest

The authors declare that there is no conflict of interest.

Research involving human and/or animal participants

This article does not contain any studies with human participants or animals performed by any of the authors.

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Urano, M., Denewar, F.A., Murai, T. et al. Internal mammary lymph node metastases in breast cancer: what should radiologists know?. Jpn J Radiol 36, 629–640 (2018). https://doi.org/10.1007/s11604-018-0773-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11604-018-0773-9

Keywords

Navigation