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Impact of Internal Mammary Lymph Node Drainage Identified by Preoperative Lymphoscintigraphy on Outcomes in Patients With Stage I to III Breast Cancer
Impact of Internal Mammary Lymph Node Drainage Identified by Preoperative Lymphoscintigraphy on Outcomes in Patients With Stage I to III Breast Cancer Kong AL, Tereffe W, Hunt KK, et al (The Univ of Texas MD Anderson Cancer Ctr, Houston) Cancer 118:6287-6296, 2012
Background.dInvolvement of internal mammary (IM) lymph nodes is associated with a poor prognosis for patients with breast cancer. This study examined the effect of drainage to IM nodes identified by lymphoscintigraphy on oncologic outcomes. Methods.dA prospectively maintained breast cancer patient database at the University of Texas MD Anderson Cancer Center was used to identify patients with stage I to III breast cancer who underwent preoperative lymphoscintigraphy with peritumoral injection of colloid and intraoperative lymphatic mapping from 1996 to 2005. Medical records were reviewed of 1772 patients who had drainage to any lymph node basin on lymphoscintigraphy but who did not undergo IM nodal biopsy. Patients with IM drainage, with or without axillary drainage, were compared with patients without IM drainage. Local-regional recurrence, distant disease-free survival (DDFS), and overall survival were evaluated. Results.dWe identified IM drainage in 334 patients (18.8%). Patients with IM drainage were significantly younger, less likely to have upper outer quadrant tumors, and more likely to have smaller and medial tumors than patients without IM drainage. Rates of IM irradiation did not differ between the 2 groups. The median follow-up
time was 7.4 years. On multivariate analysis, IM drainage was significantly associated with a worse DDFS (hazard ratio, 1.6; 95% confidence interval, 1.03-2.6; P ¼.04) but not localregional recurrence or overall survival. Conclusions.dIM drainage on preoperative lymphoscintigraphy was found to be significantly associated with worse DDFS. Further study is needed to determine the role of lymphoscintigraphy in the personalization of breast cancer staging and therapy. In this retrospective study, Kong and colleagues considered internal mammary lymph node (IMLN) drainage as a prognostic factor in invasive breast cancer. They concluded that IMLN drainage was associated with worse DDFS but not with localregional recurrence or overall survival. The study was well designed and well executed; however, the authors excluded patients who had sentinel IMLN biopsy. This exclusion may have led to selection bias in their results. It would be interesting to have the data and outcomes of the patients who underwent sentinel IMLN biopsy, as a third group for analyses. Nevertheless, I would assume that if sentinel IMLN biopsy patients were included, the results would be even more strongly in favor of IMLN drainage as a prognostic factor. Management of IMLN resembles the Back to the Future saga. IMLN metastasis is a long-established, wellknown poor prognostic factor.1 We also know that, as is the case with axillary lymph node dissection,2,3 routine IMLN dissection does not improve survival.4 Axillary sentinel lymph node biopsy is the current standard of care for breast cancer lymph node staging. In contrast, sentinel IMLN biopsy is
controversial because it changes the clinical management of only 2% to 4% of cases1 and comes with a risk of potential adverse complications and technical difficulties.1 In the gene expression profiling era, it is hard to characterize IMLN mapping or staging as a “new,” clinically relevant prognostic factor. I would include IMLN drainage in the same category of lymphovascular invasion as a prognostic factor. Indeed, lymphovascular invasion and IMLN drainage are somehow correlated and perhaps even correspond to the same biological event. J. L. B. Bevilacqua, MD, PhD
References 1. Bevilacqua JL, Gucciardo G, Cody HS, et al. A selection algorithm for internal mammary sentinel lymph node biopsy in breast cancer. Eur J Surg Oncol. 2002;28:603-614. 2. Fisher B, Jeong JH, Anderson S, Bryant J, Fisher ER, Wolmark N. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med. 2002;347: 567-575. 3. Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305:569-575. 4. 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 randomised trial. Eur J Cancer. 1999; 35:1320-1325.
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Background.dInvolvement of internal mammary (IM) lymph nodes is associated with a poor prognosis for patients with breast cancer. This study examined the effect of drainage to IM nodes identified by lymphoscintigraphy on oncologic outcomes. Methods.dA prospectively maintained breast cancer patient database at the University of Texas MD Anderson Cancer Center was used to identify patients with stage I to III breast cancer who underwent preoperative lymphoscintigraphy with peritumoral injection of colloid and intraoperative lymphatic mapping from 1996 to 2005. Medical records were reviewed of 1772 patients who had drainage to any lymph node basin on lymphoscintigraphy but who did not undergo IM nodal biopsy. Patients with IM drainage, with or without axillary drainage, were compared with patients without IM drainage. Local-regional recurrence, distant disease-free survival (DDFS), and overall survival were evaluated. Results.dWe identified IM drainage in 334 patients (18.8%). Patients with IM drainage were significantly younger, less likely to have upper outer quadrant tumors, and more likely to have smaller and medial tumors than patients without IM drainage. Rates of IM irradiation did not differ between the 2 groups. The median follow-up
time was 7.4 years. On multivariate analysis, IM drainage was significantly associated with a worse DDFS (hazard ratio, 1.6; 95% confidence interval, 1.03-2.6; P ¼.04) but not localregional recurrence or overall survival. Conclusions.dIM drainage on preoperative lymphoscintigraphy was found to be significantly associated with worse DDFS. Further study is needed to determine the role of lymphoscintigraphy in the personalization of breast cancer staging and therapy. In this retrospective study, Kong and colleagues considered internal mammary lymph node (IMLN) drainage as a prognostic factor in invasive breast cancer. They concluded that IMLN drainage was associated with worse DDFS but not with localregional recurrence or overall survival. The study was well designed and well executed; however, the authors excluded patients who had sentinel IMLN biopsy. This exclusion may have led to selection bias in their results. It would be interesting to have the data and outcomes of the patients who underwent sentinel IMLN biopsy, as a third group for analyses. Nevertheless, I would assume that if sentinel IMLN biopsy patients were included, the results would be even more strongly in favor of IMLN drainage as a prognostic factor. Management of IMLN resembles the Back to the Future saga. IMLN metastasis is a long-established, wellknown poor prognostic factor.1 We also know that, as is the case with axillary lymph node dissection,2,3 routine IMLN dissection does not improve survival.4 Axillary sentinel lymph node biopsy is the current standard of care for breast cancer lymph node staging. In contrast, sentinel IMLN biopsy is
controversial because it changes the clinical management of only 2% to 4% of cases1 and comes with a risk of potential adverse complications and technical difficulties.1 In the gene expression profiling era, it is hard to characterize IMLN mapping or staging as a “new,” clinically relevant prognostic factor. I would include IMLN drainage in the same category of lymphovascular invasion as a prognostic factor. Indeed, lymphovascular invasion and IMLN drainage are somehow correlated and perhaps even correspond to the same biological event. J. L. B. Bevilacqua, MD, PhD
References 1. Bevilacqua JL, Gucciardo G, Cody HS, et al. A selection algorithm for internal mammary sentinel lymph node biopsy in breast cancer. Eur J Surg Oncol. 2002;28:603-614. 2. Fisher B, Jeong JH, Anderson S, Bryant J, Fisher ER, Wolmark N. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med. 2002;347: 567-575. 3. Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305:569-575. 4. 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 randomised trial. Eur J Cancer. 1999; 35:1320-1325.
Breast Diseases: A Year BookÒ Quarterly Vol 24 No 3 2013
229