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Implications of Internal Mammary Lymph Node Sampling During Microsurgical Breast Reconstruction

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

Abstract

Introduction

Internal mammary lymph node (IMN) chain assessment for breast cancer is controversial; however, current oncologic data have shed new light on its importance. Metastatic involvement of the IMN chain has implications for staging, prognosis, treatment, and survival. Here, we analyzed our data gathered during sampling of the IMN and the oncologic treatment changes that resulted from our findings.

Methods

A retrospective chart review was performed on 581 patients who underwent free-flap breast reconstruction performed by the senior author. All dissected IMNs were submitted for pathological examination. Patient demographics, oncologic data, and the results of IMN sampling were reviewed.

Results

581 patients undergoing 981 free flaps were identified. A total of 400 lymph node basins were harvested from 273 patients. Of these, nine had positive IMNs. Two of these nine patients had positive IMNs of the contralateral nonaffected breast. Five patients had positive axillary lymph nodes. Four patients had multifocal tumors, one of which was bilateral. Seven patients had an increase in cancer stage as a result of having positive IMNs. Six patients had a change in treatment: two patients required additional chemotherapy, one received adjuvant radiation therapy, and three necessitated both supplemental chemotherapy and radiation.

Conclusions

Opportunistic biopsy of the IMN while dissecting the recipient vessels is simple and results in no added morbidity. We recommend that biopsy of the IMN chain be performed whenever internal mammary vessels are dissected for microsurgical anastomosis in breast cancer patients. Positive IMN involvement should encourage thorough oncological workup and treatment reevaluation.

Level of Evidence IV

Case series.

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Authors and Affiliations

  1. Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX, USA

    Jessica F. Rose DO, Dmitry Zavlin MD, Zachery K. Menn MD, Liron Eldor MD, Vishwanath Chegireddy MD & Aldona J. Spiegel MD

  2. Department of Plastic Surgery, Rambam Hospital, Haifa, Israel

    Liron Eldor MD

  3. Department of Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX, USA

    Vishwanath Chegireddy MD, Treneth P. Baker MD & Sherry J. Lim MD

  4. Department of Radiation Oncology, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX, USA

    Bin S. Teh MD

Authors
  1. Jessica F. Rose DO
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  2. Dmitry Zavlin MD
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  3. Zachery K. Menn MD
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  4. Liron Eldor MD
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  7. Bin S. Teh MD
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  8. Sherry J. Lim MD
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  9. Aldona J. Spiegel MD
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Corresponding author

Correspondence to Dmitry Zavlin MD.

Ethics declarations

Conflict of interest

None of the authors, nor their close family members, have a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

Disclosures

Furthermore, the authors declare that no commercial associations or financial disclosures exist that might pose or create a conflict of interest with information presented in this manuscript.

Funding

No funding was received for the work presented in this manuscript.

Ethical considerations

The work described in this manuscript was approved by our institutional review board (Protocol Number 00011704: “Observational Research in the Department of Plastic and Reconstructive Surgery”). The authors adhered to the Declaration of Helsinki at all times.

Electronic supplementary material

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10434_2018_6679_MOESM1_ESM.tif

Supplemental Fig. 1. Image showing the location of IMN as seen through a surgical microscope prior to internal mammary vessel anastomosis. This image was taken of the third intercostal space, after making a window in the pectoralis and intercostal muscles to expose the vessels. The lymph nodes lie in a fat pad between the vessels and are easily removed with this exposure (TIFF 8705 kb)

10434_2018_6679_MOESM2_ESM.tif

Supplemental Fig. 2. Drainage to the IMN by tumor location. The accompanying chart (Table 3) shows that there is some variability in the literature of where the drainage to the IMN are coming from. It is generally accepted that the majority originates from the medial breast—particularly the upper inner quadrant, although the entire breast does contribute (TIFF 5739 kb)

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Rose, J.F., Zavlin, D., Menn, Z.K. et al. Implications of Internal Mammary Lymph Node Sampling During Microsurgical Breast Reconstruction. Ann Surg Oncol 25, 3134–3140 (2018). https://doi.org/10.1245/s10434-018-6679-z

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  • DOI: https://doi.org/10.1245/s10434-018-6679-z

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