Internal mammary node positivity and autologous mastectomy reconstruction: Implications for breast cancer treatment and aesthetic outcome

Brian P Dickinson*, Nikkie Vu-Huynh BS, Monica B Vu BS, Gregory Senofsky, Judy Pham RN, Ayushi Patel BS, Dennis R Holmes, Kelsey Shay, Rena Callahan and Peter Ashjian

Objective: To discuss how the results of internal mammary lymph node biopsy at the time of autologous flap reconstruction in both the immediate and delayed setting may impact breast cancer treatment and the aesthetic outcome of autologous mastectomy reconstruction.

Background: The internal mammary vessels are primary recipient vessels for autologous breast reconstruction with deep inferior epigastric artery perforator flaps. During exposure and preparation of recipient vessels, the internal mammary lymph nodes when discovered are submitted to pathology. We have found in some patients, these internal mammary lymph nodes return positive results in patients with clinically and histologically negative axillary nodes and negative preoperative MRI/PET scan imaging. We wished to examine if these results had an impact on the radiation or chemotherapy management of the patients post-operatively. We have also sought to provide long-term follow-up on patients who have been found to have positive internal mammary lymph nodes.

Methods: We performed a retrospective review of patients with breast cancer who underwent autologous breast reconstruction with deep inferior epigastric artery perforator flaps. A specific chart review was performed on all patients found to have a positive result at the time of internal mammary lymph node biopsy.

Results: Between 2008 and 2020 a total of 18 patients with positive internal mammary lymph nodes were identified after internal mammary recipient harvest and visible lymph node biopsy. In three cases the internal mammary lymph node was positive when the axilla was negative. In 3/18 (16%) cases the patient’s stage was changed based on the incidental findings of the internal mammary nodes. Positive results changed post-operative radiation management in all patients. In only 1/16 (6%) cases was there suspicion on preoperative MRI. There were no instances of pneumothorax or other serious complications associated with the internal mammary lymph node biopsy.

Conclusions: Incidental internal mammary lymph node biopsy performed during microvascular autologous breast reconstruction may prove positive for metastatic spread despite negative pathology results of the axillary lymph nodes. This may be seen even in patients with a normal pre-op MRI. Internal mammary node biopsy is feasible without serious adverse events when performed at the time of recipient vessel dissection. If preoperative imaging or intraoperative direct examination of the internal mammary nodes raises suspicion, frozen section evaluation may change flap harvest selection to acquire more perforators and potentially alter flap inset to protect the autologous flap from the adverse effects of radiation.

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Published on: Mar 23, 2021 Pages: 14-21

Full Text PDF Full Text HTML DOI: 10.17352/ijrro.000045
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