Annals of Oncology 18: 1579–1587, 2007
letters to the editor
Small tumor of the medial breast
presenting with a contralateral
lymph node involvement
detected on positron emission
In February 2005, an apparently healthy 55-year-old
premenopausal female patient was admitted to our division.
At physical examination, she presented with a 4-cm node
mass at right axilla. No laboratory abnormalities were found.
Other masses were clinically not evident. Bilateral
mammography, breast and abdomen ultrasonography and total
body bone scintigraphy were all negative. The examination of
axillary node fine needle aspirated cytology (FNAC) showed
metastases from neoplastic cells positive for both Papanicolau
dye and cytokeratin 7, suggesting an adenocarcinoma.
Thereafter, the patient carried out a total body positron
emission tomography (PET) with18F-deoxyglucose showing
positive uptake at the right axilla (Figure 1A) and at the
Figure 1. (A)18F-deoxyglucose total body positron emission tomography at the initial presentation of disease. Solid arrow shows the increased uptake
corresponding to the right axillary mass. Dashed arrow shows the increased uptake corresponding to the left upper inner quadrant breast lesion. (B)
Chest computed tomography section showing both the right axillary mass (solid arrow) and the left upper inner quadrant breast lesion (dashed arrow).
(C)18F-deoxyglucose total body PET after 2 years from diagnosis. Ematoxylin–eosin staining of tissue from (D) primitive breast tumor and (E)
contralateral lymph node metastasis.
ª 2007 European Society for Medical Oncology
by guest on May 14, 2011
upper inner quadrant of left breast (Figure 1A). The computed
tomography showed a mass at the right axilla (Figure 1B) and
a nodule at left upper inner breast (Figure 1B). Magnetic
resonance imaging (MRI) was also carried out confirming the
absence of apparent nodules in the right breast. The patient
underwent left breast lumpectomy and right axillary nodal
dissection. The pathologic examination showed a high-grade
lobular invasive breast carcinoma of 1.8 cm size positive for
estrogen receptor (80%) and progesterone receptor (85%) and
with a c-erb-B2 score 1+ (DAKO kit) with metastases in 3 out
of 12 right contralateral axillary nodes (Figure 1D and E,
respectively). The pathologic stage was pT1c G3 Nx M1.
In April 2005, the patient started systemic chemotherapy
containing docetaxel and doxorubicin for a total of six
cycles. Radiation therapy on left breast and right axillary
region was also carried out. Thereafter, she continued on
therapy with anastrazole. The patient is still on follow-up
free of disease as demonstrated by a recent total body PET
after 28 months from diagnosis (Figure 1C). This is the first
report about the initial presentation of a small breast cancer
with contralateral axillary node metastases since unusual
draining sites are only reported either in surgically modified
breasts or at recurrence [1–3]. In fact, the lymphatics of the
lateral breast drain into the axillary while those of the medial
breast into the internal mammary lymph nodes. Obstruction
can alter the normal flow and contralateral internal mammary
and mediastinal lymph nodes can also receive the lymphatic
fluid. In our case, we cannot exclude the presence of a rare
anatomical variant. If the contralateral lymph node metastasis
was not clinically evident at diagnosis, preoperative sentinel
node biopsy (SNB) should be indicated. However, in our
case, the SNB procedure could under-stage the disease by
identifying negative internal mammary nodes and leaving
residual disease as suggested by PET. On the basis of our
report, in patients with small tumors of the medial breast,
PET could be useful to reveal axillary contralateral lymph
node involvement at first presentation. Moreover, PET/MRI
can be also indicated to exclude the presence of occult
cancer on both ipsilateral and contralateral breast.
In our case, open questions remain about the opportunity
to carry out: (i) SNB to test the internal mammary lymph
nodes, (ii) adjuvant or advanced chemotherapy schedules
and (iii) irradiation of internal mammary nodes.
G. Facchini1, M. Caraglia2*, G. Nasti1, A. Ottaiano3
R. Franco4, A. La Mura4, F. Fulciniti4, M. Libutti5
M. Ruberto6, M. Marra2, A. Budillon2& R. V. Iaffaioli1
1Department of Medical Oncology B,2Department of Experimental
Pharmacology,3Department of Clinical Immunology,4Pathology Unit,
National Institute of Tumours Fondazione G. Pascale, Naples;5Department
of Oncology ASL NA-5;6Terapia Antalgica e Cure Palliative-Azienda
Ospedaliera di Rilievo Nazionale S. Sebastiano, Caserta, Italy
1. Agarwal A, Heron DE, Sumkin J, Falk J. Contralateral uptake and metastases
in sentinel lymph node mapping for recurrent breast cancer. J Surg Oncol
2005; 92: 4–8.
2. Barranger E, Montravers F, Kerrou K et al. Contralateral axillary sentinel lymph
node drainage in breast cancer: a case report. J Surg Oncol 2004; 86: 167–169.
3. Jaffer S, Goldfarb AB, Gold JE et al. Contralateral axillary lymph node
metastasis as the first evidence of locally recurrent breast carcinoma. Cancer
1995; 75: 2875–2878.
letters to the editor
Annals of Oncology
1580 | letters to the editorVolume 18|No. 9|September 2007
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