Discussion

Lymph drainage from breast cancer across the midline is unusual. Occasionally, metastases are found in the contralateral axilla, but dissemination to the contralateral internal mammary node chain is rare. It was not observed by Uren et al. in a series of 92 patients [1].

Three recent studies describe internal mammary chain sentinel nodes [13]. The incidence in the Dutch study was 15%, the incidence in the U.S. study was remarkably similar: 18%. In the Australian series, the internal mammary drainage was observed in 34% of patients [1]. Direct drainage across the midline to the opposite internal mammary chain was not mentioned in these studies. Internal mammary nodes can be removed without additional morbidity [2].

Pathologists have several techniques to increase the sensitivity of sentinel node evaluation beyond that of routine H&E staining. Immunohistochemistry staining is widely available and improves the ability to detect metastatic disease by some 20%. Knowledge of the tumor status of a sentinel node in the internal mammary chain enhances the accuracy of staging. This case demonstrates that the pursuit of such a node may lead to the decision to treat a patient with adjuvant systemic treatment that would otherwise not have been given.

Although scientific evidence from clinical studies is lacking, it seems to make sense to treat a patient with a tumor-involved internal mammary node with adjuvant radiotherapy. Nodes higher up the parasternal chain may be involved as well. The decision of the radiotherapist not to treat this patient is therefore questionable. The tumor status of an internal mammary sentinel node has the potential to become the most important—ifnotonl—i—indication forradiotherapy to this lymph node field in the future.

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