Lymphatic Drainage Patterns From the Breast

Estourgie, Susanne H.; Nieweg, Omgo E.; Olmos, Renato A. Valdés; Rutgers, Emiel J.; Kroon, Bin B. R.

doi:10.1097/01.sla.0000109156.26378.90

Cited by 271 publications

(157 citation statements)

References 12 publications

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“…1 Surgical studies have shown that the incidence of metastatic involvement of the internal mammary nodes varies between 4% and 9% in patients with axillary node-negative breast cancer and between 16% and 65% in patients with axillary node-positive breast cancer. [2][3][4] As a consequence, surgical dissection of the internal mammary nodes was attempted but abandoned in the 1970s, since no improvement in survival was observed. 4,5 Elective irradiation of the regional nodes remained widely used until the late 1980s, when it became less popular on the basis of an overview of older trials that showed no survival benefit, despite improvement in control of locoregional disease.…”

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confidence: 99%

Internal Mammary and Medial Supraclavicular Irradiation in Breast Cancer

Collette²,

et al. 2015

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BACKGROUND The effect of internal mammary and medial supraclavicular lymph-node irradiation (regional nodal irradiation) added to whole-breast or thoracic-wall irradiation after surgery on survival among women with early-stage breast cancer is unknown. METHODS We randomly assigned women who had a centrally or medially located primary tumor, irrespective of axillary involvement, or an externally located tumor with axillary involvement to undergo either whole-breast or thoracic-wall irradiation in addition to regional nodal irradiation (nodal-irradiation group) or whole-breast or thoracicwall irradiation alone (control group). The primary end point was overall survival. Secondary end points were the rates of disease-free survival, survival free from distant disease, and death from breast cancer. RESULTS Between 1996 and 2004, a total of 4004 patients underwent randomization. The majority of patients (76.1%) underwent breast-conserving surgery. After mastectomy, 73.4% of the patients in both groups underwent chest-wall irradiation. Nearly all patients with node-positive disease (99.0%) and 66.3% of patients with node-negative disease received adjuvant systemic treatment. At a median followup of 10.9 years, 811 patients had died. At 10 years, overall survival was 82.3% in the nodal-irradiation group and 80.7% in the control group (hazard ratio for death with nodal irradiation, 0.87; 95% confidence interval [CI], 0.76 to 1.00; P=0.06). The rate of disease-free survival was 72.1% in the nodal-irradiation group and 69.1% in the control group (hazard ratio for disease progression or death, 0.89; 95% CI, 0.80 to 1.00; P=0.04), the rate of distant disease-free survival was 78.0% versus 75.0% (hazard ratio, 0.86; 95% CI, 0.76 to 0.98; P=0.02), and breast-cancer mortality was 12.5% versus 14.4% (hazard ratio, 0.82; 95% CI, 0.70 to 0.97; P=0.02). Acute side effects of regional nodal irradiation were modest. CONCLUSIONS In patients with early-stage breast cancer, irradiation of the regional nodes had a marginal effect on overall survival. Disease-free survival and distant disease-free survival were improved, and breast-cancer mortality was reduced. (Funded by Fonds Cancer; ClinicalTrials.gov number, NCT00002851.).

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Internal Mammary and Medial Supraclavicular Irradiation in Breast Cancer

Collette²,

et al. 2015

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“…Therefore, work-up should include additional breast imaging and needle biopsy prior to operation [20]. Interpectoral nodal metastases occurring in cN0 breast cancer patients have also been confirmed by preoperative lymphoscintigraphy, but routes of interpectoral involvement has shown a distinct difference in drainage patterns between palpable and nonpalpable lesions [21]. In univariate analysis of our patients, CerbB-2 expression did not correlate with nodal involvement in Level I-II, and Rotter.…”

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Immunohistochemical determination and grading of CerbB-2 expression in breast cancer: correlation with interpectoral, apical nodal involvement and other prognostic factors

et al. 2007

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AbstractWe aimed to investigate the correlation between quantitative CerbB-2 expressions with conventional prognostic factors, and distinct nodal involvement in patients with invasive breast carcinoma. One hundred fifty seven consecutive breast carcinoma patients were retrospectively analysed. Level I–II, Level III, and Rotter (Interpectoral) group lymph nodes were separately examined and recorded. For each patient estrogen receptor (ER), progesteron receptor (PR), CerbB-2, P53 status were defined using immunohistochemistry. Age, tumor localisation, menopausal status, grade and the presence of intraductal component were also recorded. CerbB-2 expression did not correlate with age, localisation and menopausal status. There was a reverse, but weak correlation with tumor size and CerbB-2 expression (p=0.034). In subgroup analysis of CerbB-2 positive cases, the magnitude of CerbB-2 positivity did not correlate with tumor size (p=0.551). In univariate analysis CerbB-2 expression did not correlate with nodal involvement in Level I-II, and Rotter. In subgroup analysis of patients with positive CerbB-2, positivity of CerbB-2 linearly increased with the number of positive lymph nodes in Level I-II, and this difference was significant (p=0,039). There was a significant correlation between CerbB-2 expression and Level III nodal metastases (p=0.005). But this correlation was not significant among CerbB-2 positive patients (p=0.82). P53, PR positivity and the presence of intraductal component did not differ according to oncogene expression. We detected a reverse correlation with ER positivity and CerbB-2 positivity (p=0.011). It is concluded that quantitative expression of CerbB2 positivity increases with nodal involvement in Level I–II axillary lymph nodes, and ER. Also, CerbB-2 positivity is more common among patients with Level III lymph node metastases.

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“…Patients with centrally or medially located primary tumors irrespective of axillary involvement or externally located tumors with axillary involvement were randomized in a 1:1 fashion to the addition of regional nodal irradiation to the standard breast or chest wall radiation. The rationale behind the study was a reported 4-9 % involvement of the internal mammary nodes in patients with axillary node-negative breast cancer and 16-65 % in those with axillary nodepositive breast cancer [2][3][4]. The results demonstrate a small but significant benefit in disease-free survival, distant disease-free survival, and breast-related mortality.…”

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confidence: 85%

A tailored approach to regional nodal irradiation

Avisar

2015

Breast Cancer Res Treat

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Regional nodal irradiation for breast cancer has recently been shown to improve disease-free survival, distant disease-free survival, and breast-related mortality but is associated with morbidity. A tailored approach adding regional nodal irradiation only to patients with involvement of the internal mammary nodes is improving prognosis while minimizing morbidity.The results of the EORTC trial on Internal Mammary and Medial Supraclavicular Irradiation in Breast Cancer were recently reported in NEJM (July 23 issue) [1]. Patients with centrally or medially located primary tumors irrespective of axillary involvement or externally located tumors with axillary involvement were randomized in a 1:1 fashion to the addition of regional nodal irradiation to the standard breast or chest wall radiation. The rationale behind the study was a reported 4-9 % involvement of the internal mammary nodes in patients with axillary node-negative breast cancer and 16-65 % in those with axillary nodepositive breast cancer [2][3][4]. The results demonstrate a small but significant benefit in disease-free survival, distant disease-free survival, and breast-related mortality. The study reports also a fourfold reduction in internal mammary (IM) recurrence rate but the numbers are small. In fact, it is precisely the unidentified/untreated metastatic drainage to the IM nodes that is usually blamed for the worse prognosis associated with medial tumors compared to otherwise similar lateral ones [5]. Unfortunately, regional nodal irradiation was also associated with an increased risk of pulmonary fibrosis, cardiac fibrosis, and cardiac disease. This associated morbidity might have contributed to the only marginal effect of regional irradiation on overall survival.The quoted rates of metastatic involvement of the IM nodes in the paper do not take into account the lymphatic drainage pattern from the primary tumor as easily mapped by lymphoscintigraphy. Drainage to the IM nodal chain is associated with an 8-27 % metastatic rate [6]. This subgroup of patients with metastatic IM nodes is the most likely to benefit from IM radiation. We routinely perform IM sentinel node biopsies for patients with lymphatic drainage to the IM chain, thereby selecting the specific subgroup for which additional IM radiation should be added and minimizing the morbidity associated with it. We have demonstrated [7] that this tailored approach to the IM chain can reverse the worse prognosis associated with lymphatic drainage to those nodes [8].

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Lymphatic Drainage Patterns From the Breast

Abstract: In each quadrant, a breast cancer may drain to sentinel nodes in various locations. There is a distinct difference in drainage patterns between palpable and nonpalpable lesions. These findings may improve the assessment of lymphatic dissemination in invasive breast cancer.

Cited by 271 publications

References 12 publications

Internal Mammary and Medial Supraclavicular Irradiation in Breast Cancer

Internal Mammary and Medial Supraclavicular Irradiation in Breast Cancer

Immunohistochemical determination and grading of CerbB-2 expression in breast cancer: correlation with interpectoral, apical nodal involvement and other prognostic factors

A tailored approach to regional nodal irradiation

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