Clinical significance of internal mammary lymph node incidentally detected during free-flap breast reconstruction: Case report and systematic review of the literature

Abstract

The internal mammary lymph node (IMN) chain, along with the axillary lymph node (ALN) chain, is the first echelon nodal drainage site in breast cancer (BC). ALN with/without IMN nodal involvement is known to have a prognostic value for loco-regional and distant recurrences in BC patients. Yet, IMN sampling is not routine in clinical practice, although its invasion by tumor cells may lead to an abrupt shift in the management of BC patients. We report a case of a patient presenting with early invasive ductal carcinoma (IDC) BC treated with modified radical mastectomy and axillary sentinel lymph node biopsy (SLNB) without evidence of pathologic involvement. Several months later, during free-flap breast reconstruction using IM vessels, an accidental IMN was harvested and sent for histopathological analysis, which confirmed IMN metastasis. This unexpected finding totally modified the patient's ultimate management. We also conducted a systematic review of the literature on the implications of IMN sampling during recipient site preparation in free-flap breast reconstruction (FFBR) on the prognosis and treatment of patients in the modern “personalized-medicine” era.

Keywords

• Breast cancer
• Internal lymph node
• Free-flap breast reconstruction
• Prognosis
• Adjuvant treatment