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Breast
Treatment
Focused Issues in Treatment
Internal Mammary Adenopathy
Internal Mammary Adenopathy
Jessica W. T. Leung, MD; Wei Tse Yang, MBBS
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            TERMINOLOGY

            • Synonyms

              • Internal thoracic, parasternal nodes

            • Definitions

              • Enlarged, abnormal node(s) in internal mammary region
              • Physiologic internal mammary nodes (IMN) in 46% (50/108, Mack) and 49% (45/92, Ray) of screening MR
                • Mean size: 4.5 mm (range: 2-10 mm), 1-3 nodes
                • 71% (48/68) visible on left side; 29% (20/68) on right; 11/15 with multiple IMN had bilateral

            IMAGING

            • General Features

              • Ultrasonographic Findings

                • CT Findings

                  • MR Findings

                    • Nuclear Medicine Findings

                      • Imaging Recommendations

                        DIFFERENTIAL DIAGNOSIS

                          PATHOLOGY

                          • Staging, Grading, & Classification

                            CLINICAL ISSUES

                            • Natural History & Prognosis

                              • Treatment

                                Selected References

                                1. Boekel NB et al: Cardiovascular disease incidence after internal mammary chain irradiation and anthracycline-based chemotherapy for breast cancer. Br J Cancer. ePub, 2018
                                2. Joo JH et al: Evaluation of the prognostic stage in the 8th Edition of the American Joint Committee on Cancer in Patients with Breast Cancer and Internal Mammary Lymph Node Metastasis. Anticancer Res. 38(9):5357-5361, 2018
                                3. Wang K et al: Predictors of internal mammary lymph nodes (IMLN) metastasis and disease-free survival comparison between IMLN-positive and IMLN-negative breast cancer patients: Results from Western China Clinical Cooperation Group (WCCCG) database (CONSORT). Medicine (Baltimore). 97(28):e11296, 2018
                                4. Cahoon AR et al: Internal Thoracic Lymphadenopathy in Breast Cancer. Radiographics. 37(4):1024-1036, 2017
                                5. Jeong CJ et al: Metastatic internal mammary lymph nodes or mimickers on parasternal ultrasonography: focusing on their distribution and depth. Acta Radiol. 284185117702180, 2017
                                6. Nikolaevich NS et al: Why do we need irradiation of internal mammary lymph nodes in patients with breast cancer: Analysis of lymph flow and radiotherapy studies. Rep Pract Oncol Radiother. 22(1):37-41, 2017
                                7. Tan C et al: Is Sentinel node biopsy of the internal mammary lymph nodes relevant in the management of breast cancer? Breast J. ePub, 2017
                                8. Asadi M et al: Internal mammary sentinel lymph node biopsy in clinical practice. Int J Surg. 36(Pt A):332-334, 2016
                                9. Lee HW et al: Breast Magnetic Resonance Imaging for Assessment of Internal Mammary Lymph Node Status in Breast Cancer. J Breast Cancer. 19(2):191-8, 2016
                                10. Zhou ZR et al: Is internal mammary nodes irradiation as a part of breast cancer postoperative radiotherapy necessary? J Thorac Dis. 8(11):3427-3430, 2016
                                11. Dogan BE et al: Sonography and sonographically guided needle biopsy of internal mammary nodes in staging of patients with breast cancer. AJR Am J Roentgenol. 205(4):905-11, 2015
                                12. Jochelson MS et al: Detection of internal mammary adenopathy in patients with breast cancer by PET/CT and MRI. AJR Am J Roentgenol. 205(4):899-904, 2015
                                13. Mack M et al: Incidental internal mammary lymph nodes visualized on screening breast MRI. AJR Am J Roentgenol. 205(1):209-14, 2015
                                14. Madsen EV et al: Prognostic Significance of Tumor-Positive Internal Mammary Sentinel Lymph Nodes in Breast Cancer: A Multicenter Cohort Study. Ann Surg Oncol. 22(13):4254-62, 2015
                                15. Ray KM et al: Internal mammary lymph nodes as incidental findings at screening breast MRI. Clin Imaging. 39(5):791-3, 2015
                                16. Sutton EJ et al: Incidence of internal mammary lymph nodes with silicone breast implants at MR imaging after oncoplastic surgery. Radiology. 277(2):381-7, 2015
                                17. Fornage BD: Local and regional staging of invasive breast cancer with sonography: 25 years of practice at MD Anderson Cancer Center. Oncologist. 19(1):5-15, 2014
                                18. Fornage BD et al: Ultrasound-guided fine-needle aspiration biopsy of internal mammary nodes: technique and preliminary results in breast cancer patients. AJR Am J Roentgenol. 203(2):W213-20, 2014
                                19. Groheux D et al: 18F-FDG PET/CT in staging patients with locally advanced or inflammatory breast cancer: comparison to conventional staging. J Nucl Med. 54(1):5-11, 2013
                                20. Wang CL et al: (18)F-FDG PET/CT-positive internal mammary lymph nodes: pathologic correlation by ultrasound-guided fine-needle aspiration and assessment of associated risk factors. AJR Am J Roentgenol. 200(5):1138-44, 2013
                                21. Hindié E et al: Lymphoscintigraphy can select breast cancer patients for internal mammary chain radiotherapy. Int J Radiat Oncol Biol Phys. 83(4):1081-8, 2012
                                22. Kong AL et al: Impact of internal mammary lymph node drainage identified by preoperative lymphoscintigraphy on outcomes in patients with stage I to III breast cancer. Cancer. 118(24):6287-96, 2012
                                23. Koolen BB et al: Locoregional lymph node involvement on 18F-FDG PET/CT in breast cancer patients scheduled for neoadjuvant chemotherapy. Breast Cancer Res Treat. 135(1):231-40, 2012
                                24. Segaert I et al: Additional value of PET-CT in staging of clinical stage IIB and III breast cancer. Breast J. 16(6):617-24, 2010
                                25. Domènech-Vilardell A et al: Removal of the internal mammary sentinel node in breast cancer. Nucl Med Commun. 30(12):962-70, 2009
                                26. Spillane AJ et al: Axillary Staging and Sentinel Nodes. The anatomically correct incidence of internal mammary node drainage on lymphoscintigraphy. Cancer Research. 69(2): Supplement 1, 2009
                                27. Chen RC et al: Internal mammary nodes in breast cancer: diagnosis and implications for patient management -- a systematic review. J Clin Oncol. 26(30):4981-9, 2008
                                28. Groheux D et al: Effect of (18)F-FDG PET/CT imaging in patients with clinical Stage II and III breast cancer. Int J Radiat Oncol Biol Phys. 71(3):695-704, 2008
                                29. Yao MS et al: Internal mammary nodal chain drainage is a prognostic indicator in axillary node-positive breast cancer. Ann Surg Oncol. 14(10):2985-93, 2007
                                30. Benda RK et al: Should decisions on internal mammary lymph node irradiation be based on current lymphoscintigraphy techniques for sentinel lymph node identification? Cancer. 100(3):518-23, 2004
                                31. Shimazu K et al: Lymphoscintigraphic visualization of internal mammary nodes with subtumoral injection of radiocolloid in patients with breast cancer. Ann Surg. 237(3):390-8, 2003
                                32. Eubank WB et al: 18fluorodeoxyglucose positron emission tomography to detect mediastinal or internal mammary metastases in breast cancer. J Clin Oncol. 19(15):3516-23, 2001
                                33. Freedman GM et al: Should internal mammary lymph nodes in breast cancer be a target for the radiation oncologist? Int J Radiat Oncol Biol Phys. 46(4):805-14, 2000
                                34. Sugg SL et al: Should internal mammary nodes be sampled in the sentinel lymph node era? Ann Surg Oncol. 7(3):188-92, 2000
                                35. Cody HS 3rd et al: Internal mammary node status: a major prognosticator in axillary node-negative breast cancer. Ann Surg Oncol. 2(1):32-7, 1995
                                36. Scatarige JC et al: Internal mammary lymphadenopathy: imaging of a vital lymphatic pathway in breast cancer. Radiographics. 10(5):857-70, 1990
                                37. Veronesi U et al: Risk of internal mammary lymph node metastases and its relevance on prognosis of breast cancer patients. Ann Surg. 198(6):681-4, 1983
                                Related Anatomy
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                                Related Differential Diagnoses
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                                References
                                Tables

                                Tables

                                KEY FACTS

                                • Terminology

                                  • Imaging

                                    • Top Differential Diagnoses

                                      • Pathology

                                        • Clinical Issues

                                          TERMINOLOGY

                                          • Synonyms

                                            • Internal thoracic, parasternal nodes

                                          • Definitions

                                            • Enlarged, abnormal node(s) in internal mammary region
                                            • Physiologic internal mammary nodes (IMN) in 46% (50/108, Mack) and 49% (45/92, Ray) of screening MR
                                              • Mean size: 4.5 mm (range: 2-10 mm), 1-3 nodes
                                              • 71% (48/68) visible on left side; 29% (20/68) on right; 11/15 with multiple IMN had bilateral

                                          IMAGING

                                          • General Features

                                            • Ultrasonographic Findings

                                              • CT Findings

                                                • MR Findings

                                                  • Nuclear Medicine Findings

                                                    • Imaging Recommendations

                                                      DIFFERENTIAL DIAGNOSIS

                                                        PATHOLOGY

                                                        • Staging, Grading, & Classification

                                                          CLINICAL ISSUES

                                                          • Natural History & Prognosis

                                                            • Treatment

                                                              Selected References

                                                              1. Boekel NB et al: Cardiovascular disease incidence after internal mammary chain irradiation and anthracycline-based chemotherapy for breast cancer. Br J Cancer. ePub, 2018
                                                              2. Joo JH et al: Evaluation of the prognostic stage in the 8th Edition of the American Joint Committee on Cancer in Patients with Breast Cancer and Internal Mammary Lymph Node Metastasis. Anticancer Res. 38(9):5357-5361, 2018
                                                              3. Wang K et al: Predictors of internal mammary lymph nodes (IMLN) metastasis and disease-free survival comparison between IMLN-positive and IMLN-negative breast cancer patients: Results from Western China Clinical Cooperation Group (WCCCG) database (CONSORT). Medicine (Baltimore). 97(28):e11296, 2018
                                                              4. Cahoon AR et al: Internal Thoracic Lymphadenopathy in Breast Cancer. Radiographics. 37(4):1024-1036, 2017
                                                              5. Jeong CJ et al: Metastatic internal mammary lymph nodes or mimickers on parasternal ultrasonography: focusing on their distribution and depth. Acta Radiol. 284185117702180, 2017
                                                              6. Nikolaevich NS et al: Why do we need irradiation of internal mammary lymph nodes in patients with breast cancer: Analysis of lymph flow and radiotherapy studies. Rep Pract Oncol Radiother. 22(1):37-41, 2017
                                                              7. Tan C et al: Is Sentinel node biopsy of the internal mammary lymph nodes relevant in the management of breast cancer? Breast J. ePub, 2017
                                                              8. Asadi M et al: Internal mammary sentinel lymph node biopsy in clinical practice. Int J Surg. 36(Pt A):332-334, 2016
                                                              9. Lee HW et al: Breast Magnetic Resonance Imaging for Assessment of Internal Mammary Lymph Node Status in Breast Cancer. J Breast Cancer. 19(2):191-8, 2016
                                                              10. Zhou ZR et al: Is internal mammary nodes irradiation as a part of breast cancer postoperative radiotherapy necessary? J Thorac Dis. 8(11):3427-3430, 2016
                                                              11. Dogan BE et al: Sonography and sonographically guided needle biopsy of internal mammary nodes in staging of patients with breast cancer. AJR Am J Roentgenol. 205(4):905-11, 2015
                                                              12. Jochelson MS et al: Detection of internal mammary adenopathy in patients with breast cancer by PET/CT and MRI. AJR Am J Roentgenol. 205(4):899-904, 2015
                                                              13. Mack M et al: Incidental internal mammary lymph nodes visualized on screening breast MRI. AJR Am J Roentgenol. 205(1):209-14, 2015
                                                              14. Madsen EV et al: Prognostic Significance of Tumor-Positive Internal Mammary Sentinel Lymph Nodes in Breast Cancer: A Multicenter Cohort Study. Ann Surg Oncol. 22(13):4254-62, 2015
                                                              15. Ray KM et al: Internal mammary lymph nodes as incidental findings at screening breast MRI. Clin Imaging. 39(5):791-3, 2015
                                                              16. Sutton EJ et al: Incidence of internal mammary lymph nodes with silicone breast implants at MR imaging after oncoplastic surgery. Radiology. 277(2):381-7, 2015
                                                              17. Fornage BD: Local and regional staging of invasive breast cancer with sonography: 25 years of practice at MD Anderson Cancer Center. Oncologist. 19(1):5-15, 2014
                                                              18. Fornage BD et al: Ultrasound-guided fine-needle aspiration biopsy of internal mammary nodes: technique and preliminary results in breast cancer patients. AJR Am J Roentgenol. 203(2):W213-20, 2014
                                                              19. Groheux D et al: 18F-FDG PET/CT in staging patients with locally advanced or inflammatory breast cancer: comparison to conventional staging. J Nucl Med. 54(1):5-11, 2013
                                                              20. Wang CL et al: (18)F-FDG PET/CT-positive internal mammary lymph nodes: pathologic correlation by ultrasound-guided fine-needle aspiration and assessment of associated risk factors. AJR Am J Roentgenol. 200(5):1138-44, 2013
                                                              21. Hindié E et al: Lymphoscintigraphy can select breast cancer patients for internal mammary chain radiotherapy. Int J Radiat Oncol Biol Phys. 83(4):1081-8, 2012
                                                              22. Kong AL et al: Impact of internal mammary lymph node drainage identified by preoperative lymphoscintigraphy on outcomes in patients with stage I to III breast cancer. Cancer. 118(24):6287-96, 2012
                                                              23. Koolen BB et al: Locoregional lymph node involvement on 18F-FDG PET/CT in breast cancer patients scheduled for neoadjuvant chemotherapy. Breast Cancer Res Treat. 135(1):231-40, 2012
                                                              24. Segaert I et al: Additional value of PET-CT in staging of clinical stage IIB and III breast cancer. Breast J. 16(6):617-24, 2010
                                                              25. Domènech-Vilardell A et al: Removal of the internal mammary sentinel node in breast cancer. Nucl Med Commun. 30(12):962-70, 2009
                                                              26. Spillane AJ et al: Axillary Staging and Sentinel Nodes. The anatomically correct incidence of internal mammary node drainage on lymphoscintigraphy. Cancer Research. 69(2): Supplement 1, 2009
                                                              27. Chen RC et al: Internal mammary nodes in breast cancer: diagnosis and implications for patient management -- a systematic review. J Clin Oncol. 26(30):4981-9, 2008
                                                              28. Groheux D et al: Effect of (18)F-FDG PET/CT imaging in patients with clinical Stage II and III breast cancer. Int J Radiat Oncol Biol Phys. 71(3):695-704, 2008
                                                              29. Yao MS et al: Internal mammary nodal chain drainage is a prognostic indicator in axillary node-positive breast cancer. Ann Surg Oncol. 14(10):2985-93, 2007
                                                              30. Benda RK et al: Should decisions on internal mammary lymph node irradiation be based on current lymphoscintigraphy techniques for sentinel lymph node identification? Cancer. 100(3):518-23, 2004
                                                              31. Shimazu K et al: Lymphoscintigraphic visualization of internal mammary nodes with subtumoral injection of radiocolloid in patients with breast cancer. Ann Surg. 237(3):390-8, 2003
                                                              32. Eubank WB et al: 18fluorodeoxyglucose positron emission tomography to detect mediastinal or internal mammary metastases in breast cancer. J Clin Oncol. 19(15):3516-23, 2001
                                                              33. Freedman GM et al: Should internal mammary lymph nodes in breast cancer be a target for the radiation oncologist? Int J Radiat Oncol Biol Phys. 46(4):805-14, 2000
                                                              34. Sugg SL et al: Should internal mammary nodes be sampled in the sentinel lymph node era? Ann Surg Oncol. 7(3):188-92, 2000
                                                              35. Cody HS 3rd et al: Internal mammary node status: a major prognosticator in axillary node-negative breast cancer. Ann Surg Oncol. 2(1):32-7, 1995
                                                              36. Scatarige JC et al: Internal mammary lymphadenopathy: imaging of a vital lymphatic pathway in breast cancer. Radiographics. 10(5):857-70, 1990
                                                              37. Veronesi U et al: Risk of internal mammary lymph node metastases and its relevance on prognosis of breast cancer patients. Ann Surg. 198(6):681-4, 1983
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