Annals of Oncology Advance Access originally published online on January 19, 2009
Annals of Oncology 2009 20(6):977-984; doi:10.1093/annonc/mdn725
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reviews |
High-resolution lymphoscintigraphy is essential for recognition of the significance of internal mammary nodes in breast cancer
1 Department of Surgical Oncology, The University of Sydney, Sydney
2 Department of Surgical Oncology, The Mater Hospital, North Sydney
3 Department of Surgical Oncology, Royal North Shore Hospital, St Leonards
4 Royal Prince Alfred Hospital, Sydney
5 National Health and Medical Research Council Clinical Trials Centre, Camperdown
6 Nuclear Medicine and Ultrasound, Newtown, Australia
* Correspondence to: A. Prof. A. J. Spillane, Department of Surgical Oncology, The University of Sydney, 1A Eden Street, North Sydney 2060, Australia. Tel: +61-2-99117250; Fax: +61-2-99549938; E-mail: andrew.spillane{at}smu.org.au
Background: Sentinel node biopsy (SNB) of internal mammary nodes (IMNs) in breast cancer is controversial. Most centers rarely identify IMN on lymphoscintigraphy but others report up to 45% of cases. Controversy relates to the technique of lymphatic mapping, safety of IMN SNB, the significance of positive IMN, and potential to impact survival.
Methods: Assessment of drainage rates from two unrelated nuclear medicine departments’ databases. Review of related literature.
Results: High-resolution lymphoscintigraphy results in IMN drainage in one-third of breast cancers. There is a learning curve for the technique. In 1754 consecutive cases, internal mammary drainage occurred in 53% of medial tumors, 37% midline tumors and 24% of lateral tumors (overall 34%). Extended radical mastectomy series also demonstrate the (approximately) 1/3 ratio when comparing IMN positivity rates to axillary node positivity rates (18.8% : 48.3%) and in node-positive patients (31% : 100%). The management altering potential of IMN assessment and potential survival impact are discussed.
Conclusions: IMN mapping gives information that alters management in up to one-third of cases. These rates of IMN drainage are reproducible and reflect lymphatic density and anatomy of the breast. A priority need exists to establish a collaborative clinical trial to clarify the value of IMN assessment.
Key words: breast cancer, internal mammary nodes, lymphoscintigraphy, sentinel node biopsy
Received for publication September 27, 2008. Accepted for publication October 28, 2008.