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Surgical management of node positive breast cancer requires axillary dissection. Interpectoral nodes (IPNs) or Rotter's nodes removal is controversial as there is hardly any tissue in this region. IPNs involvement is rarely seen among breast cancer patients. Developing an effective protocol for surgical management of axilla is necessary for uniformity, to reduce the risk of regional recurrence and to avoid the morbidity of interpectoral lymphatic tissue clearance. This study aimed to evaluate the detection of lymph nodes in Rotter's region and positive metastasis rate of IPNs in patients with node positive breast cancer for analyzing the prognostic and therapeutic value of IPN excision during axillary clearance. Fifty-six patients undergoing axillary clearance, aged ≥ 18 years, were studied. Patients with recurrence or those who underwent neoadjuvant chemotherapy were excluded. Baseline investigations were done pre-operatively along with core needle biopsy, estrogen receptor (ER), progesterone receptor (PR), and Ki-67 status. Association between IPN status, age, and clinicopathological parameters were assessed by Kruskal Wallis and Chi-square test using R v 3.6.0. P value of ≤ 0.05 was considered statistically significant. Majority of patients had upper outer quadrant tumor location (22/56), and the most common histopathological type was invasive ductal carcinoma (46/56). IPNs were identified in 35.71% (20/56) of 56 patients, with metastasis prevalence of 27.27% (9/33 node positive patients). Patients having IPN metastasis had larger tumor size, later TNM classification, lower ER/PR, and higher Ki-67 positivity. Dissection of IPNs can be practiced routinely during axillary clearance and should be subjected to histopathological examination separately. [ABSTRACT FROM AUTHOR]

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In Indian females, breast cancer is the most common cancer with a late stage of presentation leading to one-third of patients undergoing modified radical mastectomy (MRM). Our study is undertaken to find out predictors of level III axillary lymph node metastasis in breast cancer and who needs complete axillary lymph node dissection (ALND). Retrospective study of 146 patients who undergone MRM or breast-conserving surgery (BCS) with complete ALND at Kidwai Memorial Institute of Oncology was done, and data was analyzed to find out the frequency of level III lymph nodes and the demographic relation and its relation to positive lymph nodes in level I + II. Positive metastatic level III lymph node was found in 6% of patients, with the median age of the patient in our study with level III positivity was 48.5 years with 63% pathological stage II with 88% perinodal spread (PNS)– and lymphovascular invasion (LVI)–positive. Involvement of level III lymph node was associated with gross disease in level I + II lymph node having more than four lymph node-positive and with pT3 stage or more which has higher chances of level III lymph node involvement. Level III lymph node involvement, though rare in early-stage breast cancer, is associated with larger clinical and pathological sizes (T3 or more), more than 4 lymph node-positive in level I + II and with PNS and LVI. Hence, based on these results, we recommend that for inpatient with more than 5-cm tumor size and those with the gross disease in axilla, complete ALND is recommended. [ABSTRACT FROM AUTHOR]

Purpose of Review: A chest wall recurrence after mastectomy for breast cancer requires multimodality treatment. In this article, we review local and systemic therapy treatments for recurrent chest wall disease. Recent Findings: There appears to be a survival benefit for patients who can undergo local resection in combination with radiation therapy. Retrospective series have shown an overall benefit with minimal risk of re-irradiation. The success of performing a sentinel lymph node biopsy after a mastectomy and after a previous sentinel node biopsy has been reported. Overall, there is limited data on systemic therapy options; however, there is no benefit to adjuvant chemotherapy compared to endocrine therapy alone with the non-metastatic hormone-receptor-positive disease. Summary: Local resection may require a comprehensive surgical team to achieve negative margins and reconstruct defects. Radiation therapy should be considered, even if the setting of previous radiation and systemic therapy is based on receptor status and previous systemic treatment. [ABSTRACT FROM AUTHOR]

Purpose: Nationwide mass vaccination against Covid-19 started in Israel in late 2020. Soon we identified on [18F]FDG PET-CT studies vaccine-associated hypermetabolic lymphadenopathy (VAHL) in axillary or supraclavicular lymph nodes (ASLN) ipsilateral to the vaccination site. Sometimes, differentiation between the malignant and benign nature of the hypermetabolic lymphadenopathy (HLN) could not be made, and equivocal HLN (EqHL) was reported. The purpose of the study was to determine the overall incidence of VAHL after BNT162b2 vaccination and also its relevance to PET-CT interpretation in oncologic patients. Methods: A total of 951 consecutive patients that underwent [18F]FDG PET-CT studies in our department were interviewed regarding the sites and dates of the vaccine doses. A total of 728 vaccinated patients (All-Vac group) were included: 346 received the first dose only (Vac-1 group) and 382 received the booster dose as well (Vac-2 group). Studies were categorized as no HLN, malignant-HLN (MHL), VAHL, or EqHL. In studies with VAHL, location, [18F]FDG-intensity uptake and nodes size were recorded. Results: The incidences of HLN were 45.6%, 36.4%, and 53.9% in All-Vac, Vac-1, and Vac-2 groups, respectively. VAHL was reported in 80.1% of vaccinated patients with HLN. Lower incidences of VAHL were found during the first 5 days or in the third week after the first vaccine and beyond 20 days after the booster dose. In 49 of 332 (14.8%) vaccinated patients, we could not determine whether HLN was MHL or VAHL. Breast cancer and lymphoma were the leading diseases with EqHL. Conclusion: VAHL is frequently observed after BNT162b2 administration, more commonly and with higher intensity following the booster dose. To minimize false and equivocal reports in oncological patients, timing of [18F]FDG PET-CT should be based on the time intervals found to have a lower incidence of VAHL, and choice of vaccine injection site should be advised, mainly in patients where ASLN are a relevant site of tumor involvement. [ABSTRACT FROM AUTHOR]

Purpose: We performed a systematic review to document the spatial location of local recurrences (LR) after mastectomy. Methods: A PubMed search was conducted in August 2019 for the following terms: breast [Title/Abstract] AND cancer [Title/Abstract] AND recurrence [Title/Abstract] AND mastectomy [Title/Abstract]. The search was filtered for English language. Exclusion criteria included studies that did not specify the LR location or studies reporting LR associated with inflammatory breast cancer, or other breast cancers such as phyllodes tumours, lymphoma or associated with sarcoma/angiosarcoma. Results: A total of 3922 titles were identified, of which 21 publications were eligible for inclusion in the final analysis. A total of 6901 mastectomy patients were included (range 25–1694). The mean LR proportion was 3.5%. Among the total of 351 LR lesions, 81.8% were in the subcutaneous tissue and the skin, while 16% were pectoral muscle recurrences. Conclusion: Local recurrences are mostly located within the subcutaneous tissue and the skin, assumed to result from unrecognized/subclinical tumour foci left behind after mastectomy, surgical implantation of tumour cells in the wound/scar and/or tumour emboli within the subcutaneous lymphatics. Pectoral muscle recurrences are less frequent and may be attributed to residual disease along the posterior surgical margin and/or lymphatic involvement. [ABSTRACT FROM AUTHOR]

Background: The specificity of breast MRI is only moderate. The unsatisfactory specificity of breast MRI has prompted evaluation of high signal intensity (SI) on T2-weighted imaging (T2WI). The purpose of the study was to investigate the prevalence of prepectoral edema determined using high SI on T2WI with fat-suppression 3 T MRI and to correlate its presence with prognostic factors of breast cancer. Methods: The retrospective study comprised 589 consecutive histopathologically confirmed lesions, 460 malignant and 129 benign, identified by 3 T MRI. Presence of prepectoral edema was evaluated on T2WI with fat suppression, and its diagnostic value for malignancies and correlation with clinicopathological findings in histopathologically confirmed breast cancer were assessed. Results: Prepectoral edema was present in 54 of the 460 breast cancers (9 % of the total 589) and none of the 129 benign lesions. Its sensitivity and specificity were 12 and 100 %, respectively. The positive predictive value was 100 %. Young age ( p = 0.01), large tumor size ( p < 0.0001), high histological grade ( p < 0.0001), invasive ductal carcinoma ( p < 0.0001), high lymphovascular invasion degree ( p < 0.0001), high axillary lymph node positivity ( p < 0.0001), high inflammatory breast cancer rate ( p < 0.0001), high neoadjuvant chemotherapy rate ( p < 0.0001), and chemoresistant breast cancers ( p < 0.0001) were significantly associated with prepectoral edema. There was no association of the morphological lesion type on MRI and dynamic enhancement imaging pattern with the presence of prepectoral edema. Conclusion: Prepectoral edema has low prevalence but is specific for breast cancer and correlated with prognostic factors. [ABSTRACT FROM AUTHOR]

Occult inflammatory breast cancer (IBC) is defined as an invasive cancer without any clinical inflammatory signs but with pathologically proven dermal lymphovascular invasion. The purpose of this study is to evaluate the ability of 3-T breast MRI to predict occult IBC before pathological examination and compare its effectiveness with that of mammography (MMG) and ultrasound (US). A retrospective review of clinical, radiological, and pathological records of 460 consecutive breast cancers revealed five proved occult IBCs. We analyzed the findings of 3-T MRI, MMG, and US for these five occult IBCs. Primary breast lesions were detected by 3-T MRI, MMG, and US in all five breasts with occult IBCs. 3-T MRI revealed 40 % mass type lesions and 60 % non-mass-like type lesions. Kinetic curve analysis of the primary breast lesions showed a rapid initial kinetic phase in 80 % of lesions and a delayed washout pattern in 60 % of lesions. 3-T MRI showed slight skin thickness in 60 % of breasts, whereas MMG and US showed slight skin thickness in 40 and 20 % of breasts, respectively. Subcutaneous and prepectoral edema, as evaluated on T2-weighted images, was present in all five breasts with occult IBCs. The presence of subcutaneous and prepectoral edema on T2-weighted 3-T breast MRI is an important finding that should suggest the diagnosis of occult IBC before pathological examination. [ABSTRACT FROM AUTHOR]

Axillary staging in patients with locally recurrent breast cancer is important for obtaining locoregional control and predicting prognosis. The aim of the present study is to determine technical feasibility, validity, aberrant drainage patterns and clinical consequences of performing repeat sentinel node biopsy (SNB) in these patients. We performed a systematic review and meta-analysis of the literature and included all studies on repeat SNB in locally recurrent breast cancer. A total of 692 patients were described, 301 after a previous SNB, 361 after a previous axillary lymph node dissection (ALND), and 30 with no previous axillary surgery. Sentinel node identification was successful in 452 of the 692 patients (65.3 %), which was significantly higher in patients who had undergone previous SNB compared to previous ALND (81.0 vs. 52.2 %) ( P < 0.0001). In 175 of 405 patients with successful lymphatic mapping aberrant drainage pathways were visualized (43.2 %), which were seen more frequently after previous ALND than after previous SNB (69.2 vs. 17.4 %) ( P < 0.0001). In 19.2 % of the patients the sentinel node was tumor positive and 27.5 % of these metastases were found in aberrant lymph drainage basins. Overall, 213 patients could be spared an ALND and in 17.9 % of the patients the information derived from the repeat SNB led to a change in adjuvant radiotherapy or systemic treatment plans. The procedure had a false-negative rate of 0.2 %. Repeat SNB is technically feasible and accurate. Next to sparing patients an unnecessary ALND, the information can lead to a change in adjuvant treatment strategy. [ABSTRACT FROM AUTHOR]

Inflammatory breast carcinoma (IBC) is rare; however, it is the most aggressive variant of breast cancer with a very poor outcome. Locally advanced breast cancer and acute mastitis have a presentation similar to that of IBC. Therefore, the diagnosis of IBC remains a challenge in breast imaging. MRI can play a crucial role in the differential diagnosis by providing criteria indicative of IBC. Several MRI findings, especially T2-weighted images, are promising for more reliable and accurate interpretation of IBC. [ABSTRACT FROM AUTHOR]

Background: A minimum of 10 level I/II axillary nodes is recommended for accurate breast cancer staging. The goal of this study was to assess the effect of neoadjuvant chemotherapy on lymph node yield at axillary lymph node dissection. Methods: A single-institution National Comprehensive Cancer Network (NCCN) breast cancer database was queried for cases with axillary node dissection from 2000 to 2008. All dissections were performed at the same institution. Demographic, chemotherapy, and clinicopathologic data were collected. Age and body mass index at diagnosis were calculated for subset analyses. Statistical analyses used Student's t-test or analysis of variance with Tukey multiple comparison and Fisher's exact test. Results: Two hundred forty patients had axillary node dissection after neoadjuvant chemotherapy; an additional 903 women with primary lymph node dissection were identified as contemporaneous control subjects. There was a far lower nodal yield in patients undergoing axillary dissection after neoadjuvant chemotherapy than those undergoing primary surgery. Patients with pathologic stage II or III disease undergoing primary surgery had more lymph nodes at axillary dissection than stage I disease. Conclusions: Age, type of breast surgery, body mass index, and clinical stage have no effect on yield of lymph nodes at axillary lymph node dissection. Neoadjuvant chemotherapy, however, is associated with a far fewer nodes at axillary dissection, and alteration of the guidelines should be considered for this population of patients. [ABSTRACT FROM AUTHOR]

It would be extremely useful if the location of the sentinel lymph node in breast cancer could be identified based on body surface landmarks. However, the identification of the sentinel node location by using surface landmarks in many reports is based on empirical methodologies. We studied the distribution of the sentinel node location in 70 breast cancer patients based on the lateral line of the major pectoral muscle, the axillary skin fold that divides the trunk and the upper arm, and the nipple of the breast. The location of the sentinel node could be predicted using an ellipse with a semi-major axis of 2.8 cm and a semi-minor axis of 2.2 cm with a probability of 95% for a patient with the mean body size. Our data demonstrate that the location of the sentinel nodes can be predicted within a narrow area based on body landmarks. [ABSTRACT FROM AUTHOR]

At our institution, tracer fluids are administered in the primary breast cancer and, in addition to the ones in the axilla, sentinel nodes outside the axilla are rigorously pursued. The objective of the present study of sentinel node-negative breast cancer patients was to determine the lymph node recurrence rates in the axilla and elsewhere, the false-negative rates, and the survival. Between January 1999 and November 2005, 1,019 breast cancer patients underwent a sentinel node biopsy. In 748 of them, 755 sentinel node biopsies did not reveal a tumor-positive sentinel node and they did not undergo axillary node dissection. Metastases were revealed in 284 sentinel node biopsies performed in the remaining 271 patients: 247 in the axilla, 20 outside the axilla, and 17 both in the axilla and elsewhere. The median follow-up duration was 46 months. Two of the 748 sentinel node-negative patients developed an axillary lymph node recurrence (0.25%) and two others developed a supraclavicular lymph node recurrence (0.25%). The overall lymph node recurrence rate was 0.5%. The false-negative rates were 1.4% overall, 0.8% for the axilla, and 5.1% for the extra-axillary nodes. After five years, 95.9% of all sentinel node-negative patients were alive and 89.7% were alive without evidence of disease. The low recurrence and false-negative rates and promising survival figures show that our lymphatic mapping method with intralesional tracer administration is accurate for the axilla. Outside the axilla, 5.1% of involved sentinel nodes were missed. [ABSTRACT FROM AUTHOR]

A regional nodal recurrence is a major concern after a sentinel lymph node biopsy (SLNB) alone in patients with breast cancer. In this study we investigated patterns and risk factors of regional nodal recurrence after SLNB alone. Between January 1999 and March 2005, a series of 1,704 consecutive breast cancer cases in 1,670 patients (34 bilateral breast cancer cases) with clinically negative nodes or suspicious nodes for metastasis who underwent SLNB at a single institute (Saitama Cancer Center) were studied. All 1,704 cases were classified based upon presence or absence of a metastatic lymph node, treated with or without axillary lymph node dissection (ALND). The site of first recurrence was classified as local, regional node, or distant. The regional node recurrences were subclassified as axillary, interpectoral, infraclavicular, supraclavicular, or parasternal. After a median follow-up period of 34 months (range, 2-83 months), first recurrence occurred in local sites in 32 (1.9%) cases, regional nodes in 26 (1.5%) cases, and distant sites in 61 (3.6%) cases. In 1,062 cases with negative nodes treated without ALND and 459 cases with positive nodes treated with ALND, 11 (1.0%) and 15 (3.3%) recurred in regional nodes, respectively, and 4 (0.4%) and 2 (0.6%) recurred in axillary nodes, respectively. Of 822 cases of invasive breast cancer with negative nodes treated with SLNB alone, 10 (1.4%) recurred in regional nodes, and 4 (0.5%) recurred in axillary nodes. In the 10 patients with regional nodal failure, all of the tumors were negative for estrogen receptor (ER) and/or progesterone receptor (PR) and were nuclear grade (NG) 3. The axillary recurrence rate was low in patients treated with SLNB alone. Omitting ALND is concluded to be safe after adequate SLNB. Risk factors for regional nodal failure after SLNB alone are negative hormone receptor status and high NG. [ABSTRACT FROM AUTHOR]

Purpose: Lymph node status is a major factor in determining the stage, appropriate therapy and outcome in patients with breast cancer. It is therefore of clinical importance to accurately identify all sentinel nodes (SNs) for each individual tumour before surgery. The purpose of this study was to assess the role of SPECT-CT lymphoscintigraphy in SN identification in patients with breast cancer. Methods: Lymphoscintigraphy comprising planar and SPECT-CT acquisition was performed in 157 consecutive patients with breast cancer (mean age 54.7±10.6, range 27-81 years) with a palpable mass (n=100), with a non-palpable mass (n=52) or post lumpectomy (n=5). Planar and SPECTCT images were interpreted separately and the two imaging techniques were compared with respect to their ability to identify hot nodes. Results: Planar imaging alone was negative for identification of hot nodes in 15% of the patients. SPECT-CT alone was negative in 10% and both techniques were negative in 9% of the patients. Forty-six of the total of 361 (13%) hot nodes identified by lymphoscintigraphy were detected only on SPECT-CT, including 21 nodes obscured by the scattered radiation from the injection site, nine adjacent nodes misinterpreted on planar images as a single node and 16 nodes which were missed on planar images and detected on SPECT data. SPECT-CT detected additional sites of drainage unexpected on planar images, including axillary (n=23 patients), internal mammary (n=5 patients), interpectoral (n=3 patients) and intramammary (n=2 patients) lymph node sites. Fourteen of the 329 (4%) hot lesions seen on planar images were false positive non-nodal sites of uptake that were accurately assessed by SPECT-CT and further validated by surgery. In a single patient, SPECT-CT was negative while planar images identified the SN. Conclusion: SPECT-CT may improve the preoperative localisation of draining nodes in patients with breast cancer. It may detect hot nodes missed by planar imaging, exclude non-nodal false positive sites of uptake and accurately localise axillary and extra-axillary nodes. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to determine the visualization rate, identification rate, and clinical implications of biopsy of sentinel nodes in the internal mammary chain (IMC) in patients with breast cancer. Methods: From January 1999 to December 2002, 691 sentinel node procedures were performed. Preoperative lymphoscintigraphy was performed after injection of 99mTc-labeled nanocolloid into the tumor (.2 mL; 115 MBq; 3.1 mCi). The sentinel node was surgically identified with the aid of patent blue dye and a gamma ray detection probe. Results: The sentinel node in the IMC could be harvested in 130 (87%) of the 150 patients in whom it was visualized on the images and contained metastases in 22 (17%) of these 130 cases. In nine patients (7%), the IMC sentinel node was tumor positive, whereas the axilla was tumor-free. Stage migration was seen in all patients with a tumor-positive IMC sentinel node (17%). There was a change of management in 38 (29%) of the 130 patients: institution or omission of radiotherapy to the IMC, adjuvant systemic therapy, or omission of an axillary lymph node dissection. Conclusions: Pursuit of IMC sentinel nodes improves the staging of patients with breast cancer and enables treatment to be better adjusted to the needs of the individual patient. [ABSTRACT FROM AUTHOR]

Presents a foreword to the "International Journal of Clinical Oncology."

The purpose of this study was to evaluate the occurrence of lymphatic drainage to non-axillary sentinel nodes and to determine the implications of this phenomenon. A total of 549 breast cancer patients underwent lymphoscintigraphy after intratumoural injection of (99m)Tc-nanocolloid. The sentinel node was intraoperatively identified with the aid of intratumoural administered patent blue dye and a gamma-ray detection probe. Histopathological examination of sentinel nodes included step-sectioning at six levels and immunohistochemical staining. A sentinel node outside level I or II of the axilla was found in 149 patients (27%): internal mammary sentinel nodes in 86 patients, other non-axillary sentinel nodes in 44 and both internal mammary and other non-axillary sentinel nodes in nineteen patients. The intra-operative identification rate was 80%. Internal mammary metastases were found in seventeen patients and metastases in other non-axillary sentinel nodes in ten patients. Staging improved in 13% of patients with non-axillary sentinel lymph nodes and their treatment strategy was changed in 17%. A small proportion of clinically node negative breast cancer patients can be staged more precisely by biopsy of sentinel nodes outside level I and II of the axilla, resulting in additional decision criteria for postoperative regional or systemic therapy. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to determine the feasibility of both lymphatic mapping and probe-guided primary tumor excision by use of intralesional tracer administration in clinically occult breast cancer. Methods: Sixty patients with a clinically occult breast lesion were prospectively included. Lymphoscintigraphy was performed after intratumoral injection of 99mTc-labeled nanocolloid guided by ultrasound or stereotaxis. A catheter over a localization wire was inserted for intraoperative blue dye administration by using the same imaging techniques. After sentinel node identification, the gamma-ray detection probe was used for radio-guided wide local excision in patients who underwent breast-conserving therapy. Results: A sentinel node was visualized on the scintigrams in 56 patients 93% and could be identified intraoperatively in 58 patients 97%. A sentinel node contained tumor in 10 17% of these patients. Extra-axillary sentinel nodes were visualized in 43%, were collected in 38%, and contained metastasis in 7% of the patients. Complete excision of the primary tumor could be accomplished in 39 87% of 45 patients. Conclusions: Both sentinel node biopsy and probe-guided excision of a nonpalpable breast cancer is feasible with the aid of intralesional tracer administration. Sentinel node metastasis was found in 17% of the patients. A remarkably high percentage of extra-axillary drainage 43% was observed. [ABSTRACT FROM AUTHOR]

The article presents abstracts on topics in nuclear medicine, including the use of gated perfusion SPECT (single-photon emission computed tomography) to diagnose coronary artery disease in women, or regional wall motion abnormalities, and the use of planar scintigraphy for the detection of post pyelonephritic scars in piglets.

We report herein, a case of a 75 year old woman with breast cancer in whom lymph node metastasis within the pectoralis major muscle was found. The breast mass measured 10×6 cm, and its overlying skin was red and edematous, suggesting inflammatory carcinoma. An extended radical mastectomy was performed and the lesion was histologically confirmed to be solid-tubular carcinoma with regional lymph node involvement. In the pectoralis major muscle, where lymph nodes do not usually exist, one positive metastatic lymph node and another metastatic lymph node-like nodule were histopathologically confirmed. To our knowledge, no other such case has ever been reported, yet the possibility of lymph nodes existing in the pectoralis major muscle, albeit rare, should nevertheless be considered in the treatment of breast cancer. [ABSTRACT FROM AUTHOR]

We have developed a new type of modified radical mastectomy, the method and clinical results of which are reported herein. In this operation, axillary dissection is performed by the following two approaches. Firstly, the axillary contents are dissected from the highest possible subclavicular point to the pectoralis minor muscle, after partially cutting the sternocostal origin of the pectoralis major muscle. The second approach is from the posterior aspect of the pectoralis minor muscle to the lateral portion of the latissimus dorsi muscle. Parasternal dissection can also be performed for stage II and IIIa cancers with a central or medial tumor. After lymph node dissection, the detached edge of the sternocostal origin of the pectoralis major muscle is resutured to cover the parasternal region. Thus, complete dissection of the axillary nodes is performed whilst preserving the pectoralis major and pectoralis minor muscles. Good clinical results were achieved with respect to radicality, cosmetic effects and function in 28 patients with stage I, II and IIIa breast cancers who were followed up for between 5 to 8 years. This new operation may therefore be adopted for the majority of patients with Stage I, II, or IIIa cancers, unless massive infiltration into the pectoralis major muscle has occurred. Preservation of both the pectoralis major and pectoralis minor muscles results in a good cosmetic appearance, good functioning of the arm and easy reconstruction of the breast following mastectomy. [ABSTRACT FROM AUTHOR]