Skip to main content

Advertisement

Log in

Internal Mammary Chain Sentinel Nodes in Early-Stage Breast Cancer Patients: Toward Selective Removal

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Removal of internal mammary chain sentinel nodes (IMCSNs) affects prognosis and treatment of breast cancer, and internal mammary chain radiotherapy (IMCRT) can improve survival for selected patients. This study aimed to determine the effect of IMCSN biopsy on recurrence-free survival (RFS) and overall survival (OS) and to identify predictive factors for IMCSN and distant metastasis.

Methods

Patients with IMCSNs were selected from a prospective database for the period 1999–2007. Lymphoscintigraphy was performed after intratumoral technetium-99 m injection, and all sentinel nodes were removed. Both RFS and OS were calculated for subgroups with tumor-positive, tumor-negative, or non-removed IMCSNs. Predictive factors were identified for tumor-positive IMCSNs and distant metastasis by regression analysis.

Results

For 287 (85%) of 336 patients, IMCSN biopsy was performed, and metastasis was detected in 38 patients (13%). The patients with tumor-positive IMCSNs had poorer OS than the patients with no IMCSN metastasis or non-removed IMCSNs (p = 0.002). These patients also had worse RFS due to distant metastasis (p = 0.002). Axillary metastasis was predictive for tumor-positive IMCSNs (positive predictive value, 38.5%). The predictive factors for distant metastasis were tumor-positive IMCSNs (hazard ratio [HR], 2.5), non-removed IMCSNs (HR, 2.3), tumor diameter greater than 1.5 cm (HR, 3.5), and age older than 65 years (HR, 3.1; reference, < 50 years).

Conclusions

Patients with IMCSNs have worse survival due to distant metastasis. The clinically relevant predictive factor for distant metastasis is tumor larger than 1.5 cm. According to the authors’ current protocol, IMCSN biopsy is performed for patients younger than 70 years who have a tumor larger than 1.5 cm, with the cardiotoxicity of the adjuvant IMCRT weighed against the survival benefit.

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

Similar content being viewed by others

References

  1. Estourgie SH, Nieweg OE, Olmos RA, Rutgers EJ, Kroon BB. Lymphatic drainage patterns from the breast. Ann Surg. 2004;239:232–7.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Chen RC, Lin NU, Golshan M, Harris JR, Bellon JR. Internal mammary nodes in breast cancer: diagnosis and implications for patient management: a systematic review. J Clin Oncol. 2008;26:4981–9.

    Article  PubMed  Google Scholar 

  3. Carcoforo P, Sortini D, Feggi L, et al. Clinical and therapeutic importance of sentinel node biopsy of the internal mammary chain in patients with breast cancer: a single-center study with long-term follow-up. Ann Surg Oncol. 2006;13:1338–43.

    Article  PubMed  Google Scholar 

  4. Caudle AS, Yi M, Hoffman KE, et al. Impact of Identification of internal mammary sentinel lymph node metastasis in breast cancer patients. Ann Surg Oncol. 2014;21:60–5.

    Article  PubMed  Google Scholar 

  5. Gnerlich JL, Barreto-Andrade JC, Czechura T, John JR, Turk MA, Kennedy TJ, Winchester DJ. Accurate staging with internal mammary chain sentinel node biopsy for breast cancer. Ann Surg Oncol. 2014;21:368–74.

    Article  PubMed  Google Scholar 

  6. Madsen E, Gobardhan P, Bongers V, et al. The impact on post-surgical treatment of sentinel lymph node biopsy of internal mammary lymph nodes in patients with breast cancer. Ann Surg Oncol. 2007;14:1486–92.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Ahmed M, Purushotham AD, Horgan K, Klaase JM, Douek M. Meta-analysis of superficial versus deep injection of radioactive tracer and blue dye for lymphatic mapping and detection of sentinel lymph nodes in breast cancer. Br J Surg. 2015;102:169–81.

    Article  PubMed  CAS  Google Scholar 

  8. Borrelli P, Donswijk ML, Stokkel MP, Teixeira SC, van Tinteren H, Rutgers EJ, Valdés Olmos RA. Contribution of SPECT/CT for sentinel node localization in patients with ipsilateral breast cancer relapse. Eur J Nucl Med Mol Imaging. 2017;44:630–7.

    Article  PubMed  Google Scholar 

  9. van der Ploeg IM, Oldenburg HS, Rutgers EJ, Baas-Vrancken Peeters MJ, Kroon BB, Valdés Olmos RA, Nieweg OE. Lymphatic drainage patterns from the treated breast. Ann Surg Oncol. 2010;17:1069–75.

    Article  PubMed  Google Scholar 

  10. Cody HS III, Urban JA. Internal mammary node status: a major prognosticator in axillary node-negative breast cancer. Ann Surg Oncol. 1995;2:32–7.

    Article  PubMed  Google Scholar 

  11. Estourgie SH, Tanis PJ, Nieweg OE, Valdés Olmos RA, Rutgers EJ, Kroon BB. Should the hunt for internal mammary chain sentinel nodes begin? An evaluation of 150 breast cancer patients. Ann Surg Oncol. 2003;10:935–41.

    Article  PubMed  Google Scholar 

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

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  13. Paredes P, Vidal-Sicart S, Zanón G, et al. Clinical relevance of sentinel lymph nodes in the internal mammary chain in breast cancer patients. Eur J Nucl Med Mol Imaging. 2005;32:1283–7.

    Article  PubMed  Google Scholar 

  14. Madsen EV, Aalders KC, van der Heiden-van der Loo M, et al. Prognostic significance of tumor-positive internal mammary sentinel lymph nodes in breast cancer: a multicenter cohort study. Ann Surg Oncol. 2015;22:4254–62.

    Article  PubMed  Google Scholar 

  15. Veronesi U, Cascinelli N, Greco M, et al. Prognosis of breast cancer patients after mastectomy and dissection of internal mammary nodes. Ann Surg. 1985;202:702–7.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  16. Poortmans PM, Collette S, Kirkove C, et al. Internal mammary and medial supraclavicular irradiation in breast cancer. N Engl J Med. 2015;373:317–27.

    Article  PubMed  CAS  Google Scholar 

  17. Whelan TJ, Olivotto IA, Parulekar WR, et al; MA.20 study investigators: regional nodal irradiation in early-stage breast cancer. N Engl J Med. 2015;373:307–16.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  18. Thorsen LB, Offersen BV, Danø H, 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  PubMed  Google Scholar 

  19. Veronesi U, Arnone P, Veronesi P, et al. The value of radiotherapy on metastatic internal mammary nodes in breast cancer: results on a large series. Ann Oncol. 2008;19:1553–60.

    Article  PubMed  CAS  Google Scholar 

  20. EBCTCG (Early Breast Cancer Trialists’ Collaborative Group), McGale P, Taylor C, Correa C, 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 

  21. Darby SC, Ewertz M, McGale P, et al. Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med. 2013;368:987–98.

    Article  PubMed  CAS  Google Scholar 

  22. Correa CR, Litt HI, Hwang WT, Ferrari VA, Solin LJ, Harris EE. Coronary artery findings after left-sided compared with right-sided radiation treatment for early-stage breast cancer. J Clin Oncol. 2007;25:3031–7.

    Article  PubMed  Google Scholar 

  23. Harris EE, Correa C, Hwang WT, Liao J, Litt HI, Ferrari VA, Solin LJ. Late cardiac mortality and morbidity in early-stage breast cancer patients after breast-conservation treatment. J Clin Oncol. 2006;24:4100–6.

    Article  PubMed  Google Scholar 

  24. Krengli M, Sacco M, Loi G, et al. Pulmonary changes after radiotherapy for conservative treatment of breast cancer: a prospective study. Int J Radiat Oncol Biol Phys. 2008;70:1460–7.

    Article  PubMed  Google Scholar 

  25. Vasiljevic D, Arnold C, Neuman D, et al. Occurrence of pneumonitis following radiotherapy of breast cancer: a prospective study. Strahlenther Onkol. 2018;194:520–32.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Oie Y, Saito Y, Kato M, et al. Relationship between radiation pneumonitis and organizing pneumonia after radiotherapy for breast cancer. Radiat Oncol. 2013;8:56.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Kim H, Bae H, Lee MY, et al. Analysis of predictive factors for lung injury after forward-planned intensity-modulated radiotherapy in whole-breast irradiation. J Breast Cancer. 2014;17:69–75.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Bontenbal M, Nortier JWR, Beex LVAM, et al. Adjuvant systemic therapy for patients with resectable breast cancer; guideline from the Dutch National Breast Cancer Platform and the Dutch Society for Medical Oncology. Ned Tijdschr Geneeskd. 2000;144:984–9.

    PubMed  CAS  Google Scholar 

  29. Salerno KE. NCCN guidelines update: evolving radiation therapy recommendations for breast cancer. J Natl Compr Cancer Netw. 2017;15:682–4.

    Article  Google Scholar 

  30. Recht A, Edge SB, Solin LJ, et al. Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol. 2001;5:1539–69.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Iris M. C. van der Ploeg PhD.

Ethics declarations

Disclosure

There are no conflicts of interest.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (PDF 208 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

van Loevezijn, A.A., Bartels, S.A.L., van Duijnhoven, F.H. et al. Internal Mammary Chain Sentinel Nodes in Early-Stage Breast Cancer Patients: Toward Selective Removal. Ann Surg Oncol 26, 945–953 (2019). https://doi.org/10.1245/s10434-018-7058-5

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-018-7058-5

Keywords

Navigation