INTERESTING IMAGE
Contralateral Axillary Node Metastasis From Recurrence After Conservative Breast Cancer Surgery Satoko Nishimura, MD, Mitsuru Koizumi, MD, PhD, Junko Kawakami, MD, and Masamichi Koyama, MD, PhD Abstract: Sentinel lymph node detection (SLND) with radiocolloid has become widely used for evaluation of nodal metastasis in primary breast cancer. However, the procedure for recurrent breast cancer is not well established. Contralateral axillary node metastasis is uncommon. We report 2 cases of contralateral axillary node metastasis with recurrent breast cancer. In the first case, contralateral node metastasis was found by SLND. In the other case without SLND, contralateral node metastasis developed after resection of local recurrence. FDG-avid contralateral node was pathologically diagnosed as metastasis. The SLND might be useful in patients with local recurrence after conservative breast cancer surgery. Key Words: breast cancer, recurrence, contralateral axilla node, sentinel node biopsy, FDG PET/CT (Clin Nucl Med 2014;39: 181Y183)
Received for publication September 2, 2012; revision accepted December 29, 2012. From the Department of Nuclear Medicine, Cancer Institute Hospital, Tokyo, Japan. Conflicts of interest and sources of funding: none declared. Reprints: Mitsuru Koizumi, MD, PhD, Department of Nuclear Medicine, Cancer Institute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3902Y0181
Clinical Nuclear Medicine
& Volume 39, Number 2, February 2014
REFERENCES 1. Koizumi M, Nomura E, Yamada Y, et al. Sentinel node detection using Tc-99m rhenium sulfide colloid in patients with breast cancer: 1-day and 2-day protocols with dose finding study. Nucl Med Commun. 2003;24:663Y670. 2. Koizumi M, Koyama M, Yamashita T, et al. Our experience with intradermal injection and intradermal-plus-deep injection in the radioguided sentinel node biopsy of early breast cancer patients. Eur J Surgical Oncol. 2006;32: 738Y742. 3. Veronesi U, Paganelli G, Viale G, et al. A randomized comparison of sentinelnode biopsy with routine axillary dissection in breast cancer. N Engl J Med. 2003;349:546Y553. 4. Mascaro A, Farina M, Gigli R, et al. Recent advances in surgical care of breast cancer patients. World J Surg Oncol. 2010;8:5. 5. Koizumi M, Koyama M, Tada K, et al. The feasibility of sentinel node biopsy in the previously treated breast. Eur J Surg Oncol. 2008;34:365Y368. 6. Intra M, Trifiro G, Galimberti V, et al. Second axillary sentinel node biopsy for ipsilateral breast tumour recurrence. Br J Surg. 2007;94:1216Y1219. 7. Port ER, Fey J, Gemignani ML, et al. Reoperative sentinel lymph node biopsy: a new option for patients with primary or locally recurrent breast carcinoma. J Am Coll Surg. 2002;195:167Y172. 8. Taback B, Nygyen P, Hansen N, et al. Sentinel lymph node biopsy for local recurrence of breast cancer after breast conserving therapy. Ann Surg Oncol. 2006;13:1099Y1104. 9. Kaur P, Kiluk JV, Meade T, et al. Sentinel lymph node biopsy in patients with previously ipsilateral complete axillary lymph node dissection. Ann Surg Oncol. 2011;18:727Y732. 10. Sood A, Youssef IM, Heiba SI, et al. Alternative lymphatic pathway after previous axillary node dissection in recurrent/primary breast cancer. Clin Nucl Med. 2004;29:698Y702.
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181
Clinical Nuclear Medicine
Nishimura et al
& Volume 39, Number 2, February 2014
FIGURE 1. Sentinel node scintigraphic images anterior, right anterior oblique (RAO) 30 degrees, and RAO 60 degrees. A 50-year-old woman with second recurrence of left breast cancer was referred to undergo SLN biopsy 12 years after initial left lumpectomy and breast radiotherapy. First recurrence was 5 years later with second lumpectomy and adjuvant chemotherapy. Second local recurrence developed in her left breast and 2-day SLN protocol using radiocolloid was performed.1 Radiocolloid was injected adjacent to the left breast recurrent tumor using the combination of superficial and deep injection techniques.2 Radiocolloid migrated only to a right (contralateral) axillary node and did not reach an ipsilateral axillary node. Blue dye injected subareolarly just before surgery localized an ipsilateral single axillary node. Left mastectomy and bilateral SLN biopsies were performed. Pathological examination revealed malignancy in the recurrent left breast tumor and contralateral right axillary lymph node and negative ipsilateral left axillary node. She received adjuvant chemotherapy and is alive with no evidence of disease after 6 years. SLN biopsy procedure has been established with initial evaluation of breast cancer, but has not been applied to local recurrence or ipsilateral second cancer.3,4 Recently, several publications have reported on the feasibility and usefulness of this technique for these patients.5Y10 Unusual contralateral spread of recurrent cancer enabled us to select an appropriate adjuvant therapy.
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* 2013 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 39, Number 2, February 2014
Contralateral Axillary Node Metastasis
FIGURE 2. 18F-FDG PET MIP images: anterior (A), lateral (B), and FDG-PET/CT fusion (C) image at the level of the left axilla. A 39-year-old woman presented with left axillary mass suggestive of metastasis. Nine years ago, the patient had lumpectomy with complete axillary lymph node dissection for right breast cancer and received postoperative adjuvant radiotherapy, chemotherapy, and endocrine therapy. Five years ago, local right breast recurrence was suspected, and second lumpectomy was performed confirming local recurrent malignancy in the previously treated breast. SLN biopsy was not performed at that time. Postoperative adjuvant endocrine therapy was given. Four years later, FDG PET/CT study showed an enlarged lymph node in the contralateral left axilla, which was FDG-avid (maximum standardized uptake value 12.9). No other abnormal FDG accumulation was detectable including in the left breast. Left axillary surgery was performed revealing breast cancer metastasis (adenocarcinoma), presumably from the right breast recurrence. If SLN biopsy had been performed at the surgery of recurrent tumor, this contralateral SLN may have been identified at that time.
* 2013 Lippincott Williams & Wilkins
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183
Contralateral Axillary Node Metastasis From Recurrence After Conservative Breast Cancer Surgery Satoko Nishimura, MD, Mitsuru Koizumi, MD, PhD, Junko Kawakami, MD, and Masamichi Koyama, MD, PhD Abstract: Sentinel lymph node detection (SLND) with radiocolloid has become widely used for evaluation of nodal metastasis in primary breast cancer. However, the procedure for recurrent breast cancer is not well established. Contralateral axillary node metastasis is uncommon. We report 2 cases of contralateral axillary node metastasis with recurrent breast cancer. In the first case, contralateral node metastasis was found by SLND. In the other case without SLND, contralateral node metastasis developed after resection of local recurrence. FDG-avid contralateral node was pathologically diagnosed as metastasis. The SLND might be useful in patients with local recurrence after conservative breast cancer surgery. Key Words: breast cancer, recurrence, contralateral axilla node, sentinel node biopsy, FDG PET/CT (Clin Nucl Med 2014;39: 181Y183)
Received for publication September 2, 2012; revision accepted December 29, 2012. From the Department of Nuclear Medicine, Cancer Institute Hospital, Tokyo, Japan. Conflicts of interest and sources of funding: none declared. Reprints: Mitsuru Koizumi, MD, PhD, Department of Nuclear Medicine, Cancer Institute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3902Y0181
Clinical Nuclear Medicine
& Volume 39, Number 2, February 2014
REFERENCES 1. Koizumi M, Nomura E, Yamada Y, et al. Sentinel node detection using Tc-99m rhenium sulfide colloid in patients with breast cancer: 1-day and 2-day protocols with dose finding study. Nucl Med Commun. 2003;24:663Y670. 2. Koizumi M, Koyama M, Yamashita T, et al. Our experience with intradermal injection and intradermal-plus-deep injection in the radioguided sentinel node biopsy of early breast cancer patients. Eur J Surgical Oncol. 2006;32: 738Y742. 3. Veronesi U, Paganelli G, Viale G, et al. A randomized comparison of sentinelnode biopsy with routine axillary dissection in breast cancer. N Engl J Med. 2003;349:546Y553. 4. Mascaro A, Farina M, Gigli R, et al. Recent advances in surgical care of breast cancer patients. World J Surg Oncol. 2010;8:5. 5. Koizumi M, Koyama M, Tada K, et al. The feasibility of sentinel node biopsy in the previously treated breast. Eur J Surg Oncol. 2008;34:365Y368. 6. Intra M, Trifiro G, Galimberti V, et al. Second axillary sentinel node biopsy for ipsilateral breast tumour recurrence. Br J Surg. 2007;94:1216Y1219. 7. Port ER, Fey J, Gemignani ML, et al. Reoperative sentinel lymph node biopsy: a new option for patients with primary or locally recurrent breast carcinoma. J Am Coll Surg. 2002;195:167Y172. 8. Taback B, Nygyen P, Hansen N, et al. Sentinel lymph node biopsy for local recurrence of breast cancer after breast conserving therapy. Ann Surg Oncol. 2006;13:1099Y1104. 9. Kaur P, Kiluk JV, Meade T, et al. Sentinel lymph node biopsy in patients with previously ipsilateral complete axillary lymph node dissection. Ann Surg Oncol. 2011;18:727Y732. 10. Sood A, Youssef IM, Heiba SI, et al. Alternative lymphatic pathway after previous axillary node dissection in recurrent/primary breast cancer. Clin Nucl Med. 2004;29:698Y702.
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
181
Clinical Nuclear Medicine
Nishimura et al
& Volume 39, Number 2, February 2014
FIGURE 1. Sentinel node scintigraphic images anterior, right anterior oblique (RAO) 30 degrees, and RAO 60 degrees. A 50-year-old woman with second recurrence of left breast cancer was referred to undergo SLN biopsy 12 years after initial left lumpectomy and breast radiotherapy. First recurrence was 5 years later with second lumpectomy and adjuvant chemotherapy. Second local recurrence developed in her left breast and 2-day SLN protocol using radiocolloid was performed.1 Radiocolloid was injected adjacent to the left breast recurrent tumor using the combination of superficial and deep injection techniques.2 Radiocolloid migrated only to a right (contralateral) axillary node and did not reach an ipsilateral axillary node. Blue dye injected subareolarly just before surgery localized an ipsilateral single axillary node. Left mastectomy and bilateral SLN biopsies were performed. Pathological examination revealed malignancy in the recurrent left breast tumor and contralateral right axillary lymph node and negative ipsilateral left axillary node. She received adjuvant chemotherapy and is alive with no evidence of disease after 6 years. SLN biopsy procedure has been established with initial evaluation of breast cancer, but has not been applied to local recurrence or ipsilateral second cancer.3,4 Recently, several publications have reported on the feasibility and usefulness of this technique for these patients.5Y10 Unusual contralateral spread of recurrent cancer enabled us to select an appropriate adjuvant therapy.
182
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* 2013 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 39, Number 2, February 2014
Contralateral Axillary Node Metastasis
FIGURE 2. 18F-FDG PET MIP images: anterior (A), lateral (B), and FDG-PET/CT fusion (C) image at the level of the left axilla. A 39-year-old woman presented with left axillary mass suggestive of metastasis. Nine years ago, the patient had lumpectomy with complete axillary lymph node dissection for right breast cancer and received postoperative adjuvant radiotherapy, chemotherapy, and endocrine therapy. Five years ago, local right breast recurrence was suspected, and second lumpectomy was performed confirming local recurrent malignancy in the previously treated breast. SLN biopsy was not performed at that time. Postoperative adjuvant endocrine therapy was given. Four years later, FDG PET/CT study showed an enlarged lymph node in the contralateral left axilla, which was FDG-avid (maximum standardized uptake value 12.9). No other abnormal FDG accumulation was detectable including in the left breast. Left axillary surgery was performed revealing breast cancer metastasis (adenocarcinoma), presumably from the right breast recurrence. If SLN biopsy had been performed at the surgery of recurrent tumor, this contralateral SLN may have been identified at that time.
* 2013 Lippincott Williams & Wilkins
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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