Annals of Oncology Advance Access published online on January 19, 2009
Annals of Oncology, doi:10.1093/annonc/mdn725
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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.
breast cancer, internal mammary nodes, lymphoscintigraphy, sentinel node biopsy
Received for publication September 27, 2008. Accepted for publication October 28, 2008.