Characteristics of and therapeutic options for contralateral axillary lymph node metastasis in breast cancer

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Abstract

Aim

Contralateral axillary metastasis (CAM) from breast cancer is uncommon. This papers aims to identify the features of our patients with CAM, as well as clarify management options.

Methods

We reviewed all of our breast cancer patients during the period from 2004 to 2009. All patients with a proven pathological diagnosis of CAM were included. Patients were evaluated for demographics, tumor features and management modalities.

Results

A total of 21 patients were included, forming 1.9% of our breast cancer population. The median age was 51 years (range 29–71). Twelve patients had large central or diffuse tumors. Most of the tumors were of invasive ductal type (95%), of high grade (81%) and with lymphovascular invasion (81%). The majority of cases were locally advanced (stage III: 90%). Hormonal receptor positivity and HER-2 overexpression were seen in 48% and 42% of cases, respectively. Those pathological features were significantly worse than those of patients without CAM. Ten patients had synchronous and 11 patients had metachronous CAM. Treatment modalities included axillary dissection, chemotherapy and hormonal therapy. Four patients died from metastatic disease and 5 patients are still alive without evidence of metastasis.

Conclusion

CAM is associated with tumors with aggressive pathological features. Hormonal therapy is associated with an excellent response in patients whose tumors are hormone-receptor positive. Axillary dissection is indicated in patients with early-stage tumors, when there is no response to systemic therapy, or for palliation. It is associated with excellent local control.

Introduction

Lymph node metastasis is the most important prognostic factor in breast cancer. The axilla is the most commonly involved region. Extra-axillary lymph node involvement of areas like the supraclavicular and internal mammary regions can occur, and is considered to be a more advanced regional disease than axillary metastasis according to the American Joint Committee on Cancer (AJCC) staging manual.1

Contralateral axillary metastasis (CAM) from breast cancer is uncommon.2 It is considered as distant metastasis since the contralateral axilla is not a regional draining basin of the breast. Pathological examination, in addition to clinical and radiological evaluation is essential to exclude an occult primary in the associated breast or, rarely, metastasis from another tumor outside the breast.

Management of patients with CAM is not straightforward, especially with the absence of metastatic disease elsewhere. Options include surgery, chemotherapy and hormonal therapy. In this paper we present data on 21 patients with pathologically proven CAM. A discussion of the lymphatic drainage of the breast to the contralateral axilla and the characteristics of and management options for CAM ensues.

Section snippets

Patients and methods

All patients diagnosed with breast cancer and treated at King Hussein Cancer Center during the period from 2004 to 2009 were reviewed. Patients with a confirmed pathological diagnosis of CAM were included. Core biopsy was performed in order to provide adequate pathological information, including hormone receptors and HER-2 status. A general clinical examination as well as mammography and an ultrasound evaluation of the contralateral breast were performed to exclude a contralateral primary

Results

During the study period, 21 women fulfilled the inclusion criteria. They comprised 1.9% of all our breast cancer patients during the same period. The median age at diagnosis of the primary tumors was 50 years (range 29–71). Family history of breast cancer was present in 3 patients (14%). The features of the primary tumors are shown in Table 1. Twelve of the 21 patients had a central or diffuse tumor, and most of the tumors were invasive ductal carcinomas (95%), of high grade (81%) and with

Lymphatic drainage to the contralateral axilla

Lymphatic drainage of the breast is primarily to the ipsilateral axillary lymph nodes. Drainage to other areas, like the supraclavicular and internal mammary regions is less common, and occurs in up to 25% of cases.3 Contralateral axillary drainage is uncommon but has been shown in some lymphography and sentinel lymph node studies of the breast.4, 5, 6 It is thought that blockage of or damage to the usual axillary lymphatics might lead to the development of alternative routes of drainage. This

Conclusion

Contralateral axillary metastasis in breast cancer is uncommon. It occurs mainly in patients whose tumors have aggressive pathological features. The time of development of CAM, on the other hand, might be more related to how advanced the stage is, with locally advanced tumors developing CAM earlier. Management of these patients is controversial and should be individualized. Patients with locally advanced disease should probably receive systemic therapy, as the possibility of future distant

Conflict of interest

Nothing to disclose.

References (9)

  • M. Carmon et al.

    Clinical implications of contralateral axillary sentinel lymph nodes

    Breast

    (2006)
  • F.L. Green et al.

    AJCC cancer staging manual

    (2002)
  • J.E. Devitt et al.

    Significance of contralateral axillary metastases in carcinoma of the breast

    Can J Surg

    (1969)
  • O.E. Nieweg et al.

    Lymphatics of the breast and the rationale for different injection techniques

    Ann Surg Oncol

    (2001)
There are more references available in the full text version of this article.

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