© 2007 European Society for Medical Oncology
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Small tumor of the medial breast presenting with a contralateral lymph node involvement detected on positron emission tomography scan
In February 2005, an apparently healthy 55-year-old premenopausal female patient was admitted to our division. At physical examination, she presented with a 4-cm node mass at right axilla. No laboratory abnormalities were found. Other masses were clinically not evident. Bilateral mammography, breast and abdomen ultrasonography and total body bone scintigraphy were all negative. The examination of axillary node fine needle aspirated cytology (FNAC) showed metastases from neoplastic cells positive for both Papanicolau dye and cytokeratin 7, suggesting an adenocarcinoma. Thereafter, the patient carried out a total body positron emission tomography (PET) with 18F-deoxyglucose showing positive uptake at the right axilla (Figure 1A) and at the upper inner quadrant of left breast (Figure 1A). The computed tomography showed a mass at the right axilla (Figure 1B) and a nodule at left upper inner breast (Figure 1B). Magnetic resonance imaging (MRI) was also carried out confirming the absence of apparent nodules in the right breast. The patient underwent left breast lumpectomy and right axillary nodal dissection. The pathologic examination showed a high-grade lobular invasive breast carcinoma of 1.8 cm size positive for estrogen receptor (80%) and progesterone receptor (85%) and with a c-erb-B2 score 1+ (DAKO kit) with metastases in 3 out of 12 right contralateral axillary nodes (Figure 1D and E, respectively). The pathologic stage was pT1c G3 Nx M1. In April 2005, the patient started systemic chemotherapy containing docetaxel and doxorubicin for a total of six cycles. Radiation therapy on left breast and right axillary region was also carried out. Thereafter, she continued on therapy with anastrazole. The patient is still on follow-up free of disease as demonstrated by a recent total body PET after 28 months from diagnosis (Figure 1C). This is the first report about the initial presentation of a small breast cancer with contralateral axillary node metastases since unusual draining sites are only reported either in surgically modified breasts or at recurrence [1–3]. In fact, the lymphatics of the lateral breast drain into the axillary while those of the medial breast into the internal mammary lymph nodes. Obstruction can alter the normal flow and contralateral internal mammary and mediastinal lymph nodes can also receive the lymphatic fluid. In our case, we cannot exclude the presence of a rare anatomical variant. If the contralateral lymph node metastasis was not clinically evident at diagnosis, preoperative sentinel node biopsy (SNB) should be indicated. However, in our case, the SNB procedure could under-stage the disease by identifying negative internal mammary nodes and leaving residual disease as suggested by PET. On the basis of our report, in patients with small tumors of the medial breast, PET could be useful to reveal axillary contralateral lymph node involvement at first presentation. Moreover, PET/MRI can be also indicated to exclude the presence of occult cancer on both ipsilateral and contralateral breast.
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In our case, open questions remain about the opportunity to carry out: (i) SNB to test the internal mammary lymph nodes, (ii) adjuvant or advanced chemotherapy schedules and (iii) irradiation of internal mammary nodes.
1 Department of Medical Oncology B
2 Department of Experimental Pharmacology
3 Department of Clinical Immunology
4 Pathology Unit, National Institute of Tumours Fondazione G. Pascale, Naples
5 Department of Oncology ASL NA-5
6 Terapia Antalgica e Cure Palliative-Azienda Ospedaliera di Rilievo Nazionale S. Sebastiano, Caserta, Italy
* E-mail: michele.caraglia{at}fondazionepascale.it
References
1. Agarwal A, Heron DE, Sumkin J, Falk J. Contralateral uptake and metastases in sentinel lymph node mapping for recurrent breast cancer. J Surg Oncol (2005) 92:4–8.[CrossRef][Web of Science][Medline]
2. Barranger E, Montravers F, Kerrou K, et al. Contralateral axillary sentinel lymph node drainage in breast cancer: a case report. J Surg Oncol (2004) 86:167–169.[CrossRef][Web of Science][Medline]
3. Jaffer S, Goldfarb AB, Gold JE, et al. Contralateral axillary lymph node metastasis as the first evidence of locally recurrent breast carcinoma. Cancer (1995) 75:2875–2878.[CrossRef][Web of Science][Medline]
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