Breast Cancer with Internal Mammary Node Metastases: A Case Presented in a Tumor Board Session and Decision Making

Main Article Content

Léamarie Meloche-Dumas
Erica Patocskai
Kerianne Boulva
Moishe Liberman
Younan Rami

Keywords

Breast cancer, Internal mammary node metastasis, Lymph nodes dissection, Radiotherapy, Tumor board

Abstract

Background: There are several therapeutic options available for breast cancer treatment, now incorporating innovative targeted molecular therapies. Metastatic breast cancer is usually treated with chemotherapy and/or hormonotherapy. Surgery has not been shown to improve survival. Adjuvant radiotherapy (RT) has been proven to be effective in the treatment of locally advanced breast cancer, reducing locoregional recurrence. The optimal treatment of internal mammary lymph nodes (IMN) metastases remains controversial.


Case presentation: A 48-year-old woman was diagnosed with invasive breast cancer with ipsilateral metastases to axillary lymph nodes and a contralateral IMN metastasis. This case was presented twice during the tumor board sessions of the Surgical Oncology Service at the Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Canada.


Question: Does the internal mammary chain (IMC) dissection could be used as a treatment approach in breast cancer with IMC metastasis?


Conclusion: Internal mammary chain dissection should be discussed in tumor board sessions on a case-by-case basis. There are no strong guidelines on the management of IMN metastasis in breast cancer, but there is growing evidence that these women should be treated with curative intent.

References

1. Canadian Cancer Statistics Advisory Committee. Canadian Cancer Statistics 2019. Toronto, ON: Canadian Cancer Society; 2019. Available at: cancer.ca/Canadian-Cancer-Statistics-2019-EN (online [2019-10-01]).
2. Overgaard M, Jensen MB, Overgaard J, Hansen PS, Rose C, Andersson M, et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial. Lancet. 1999;353:1641–48.
3. Ragaz J, Olivotto IA, Spinelli JJ, Phillips N, Stewart MJ, Wilson KS, et al. Loco regional radiation therapy in patients with high-risk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized trial. J Nat Cancer Inst. 2005; 97:116–26.
4. McGuire SE, Gonzalez-Angulo AM, Huang EH, Tucker SL, Kau SW, Yu TK, et al. Postmastectomy radiation improves the outcome of patients with locally advanced breast cancer who achieve a pathologic complete response to neoadjuvant chemotherapy. Int J Radiat Oncol Biol Phys. 2007;68(4):1004–1009.
5. Nagar H, Boothe D, Ginter PS, Sison C, Vahdat L, Shin S, et al. Disease-free survival according to the use of postmastectomy radiation therapy after neoadjuvant chemotherapy. Clin Breast Cancer. 2015;15(2):128–134.
6. Estourgie SH, Nieweg OE, Olmos RA, Rutgers EJ, Kroon BB. Lymphatic drainage patterns from the breast. Ann Surg. 2004;239:232–7.
7. Chen RC, Lin NU, Golshan M, Harris JR, Bellon JR. Internal mammary nodes in breast cancer: diagnosis and implications for patient management: a systematic review. J Clin Oncol. 2008;26:4981–9.
8. Caudle AS, Yi M, Hoffman KE, et al. Impact of Identification of internal mammary sentinel lymph node metastasis in breast cancer patients. Ann Surg Oncol. 2014;21:60–5.
9. Madsen EV, Aalders KC, van der Heiden-van der Loo M, et al. Prognostic significance of tumor-positive internal mammary sentinel lymph nodes in breast cancer: a multicenter cohort study. Ann Surg Oncol. 2015;22:4254–62.
10. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology: Breast Cancer Version 3.2019. Available at: https:// www.nccn.org/professionals/physician_gls/default.aspx (online [2019-10-01]).
11.Badwe R, Hawaldar R, Nair N, et al. Locoregional treatment versus no treatment of the primary tumour in metastatic breast cancer: an open-label randomized controlled trial. Lancet Oncol. 2015;16(13):1380-1388.
12. Bishop AJ, Ensor J, Moulder SL, et al. Prognosis for Patients With Metastatic Breast Cancer Who Achieve a No-Evidence-of-Disease Status After Systemic or Local Therapy. Cancer. 2015; 121(24):4324-32.
13. Lacour J, Bucalossi P, Cacers E, et al: Radical mastectomy versus radical mastectomy plus internal mammary dissection: Five-year results of an international cooperative study. Cancer. 1976;37:206-214.
14. Veronesi U, Valagussa P: Inefficacy of internal mammary nodes dissection in breast cancer surgery. Cancer. 1981;47:170-175.
15. Meier P, Ferguson DJ, Karrison T: A controlled trial of extended radical versus radical mastectomy: Ten-year results. Cancer. 1989;63:188-195.
16. Veronesi U, Marubini E, Mariani L, Valagussa P, Zucali R : The dissection of internal mammary nodes does not improve the survival of breast cancer patients. 30-year results of a randomized trial. European Journal of Cancer. 1999;35(9): 1320-1325.
17. van Loevezijn AA, Bartels SAL, van Duijnhoven FH, et al. Internal mammary chain sentinel nodes in early-stage breast cancer patients: toward selective removal. Ann Surg Oncol. 2019;26(4): 945-953.
18. Poortmans PM, Collette S, Kirkove C, et al. Internal mammary and medial supraclavicular irradiation in breast cancer. New Engl J Med. 2015;373:317–27.
19.EBCTCG (Early Breast Cancer Trialists’ Collaborative Group), McGale P, Taylor C, Correa C, et al. Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet. 2014;383:2127–2135.
20. Thorsen LB, Offersen BV, Danø H, et al. DBCG-IMN: a population-based cohort study on the effect of internal mammary node irradiation in early node-positive breast cancer. J Clin Oncol. 2016;34:314–20.
21. Darby SC, Ewertz M, McGale P, et al. Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med. 2013;368:987–998.