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Handchir Mikrochir Plast Chir 2025; 57(02): 112-121
DOI: 10.1055/a-2560-1560
Original Article

Incidental Findings of Internal Mammary Lymph Node Recurrence after Breast Cancer during Microsurgical Breast Reconstruction: Discussion of Treatment Options and Review of the Literature

Zufallsbefunde von parasternalen Lymphknotenmetastasen im Rahmen einer sekundären mikrochirurgischen Brustrekonstruktion nach Mammakarzinom – Behandlungsoptionen und Darstellung der Literatur
Roland Hoffmeister 
1   Department of Plastic and Aesthetic Surgery, Handsurgery, HELIOS Klinikum Emil von Behring Berlin-Zehlendorf, Berlin, Germany
,
Therese Pross
2   Department of Gynecology, Charite – Universitatsmedizin Berlin, Berlin, Germany
,
Lutz Moser
3   Department of Radiotherapy, HELIOS Klinikum Emil von Behring Berlin-Zehlendorf, Berlin, Germany
,
Alba Fricke
1   Department of Plastic and Aesthetic Surgery, Handsurgery, HELIOS Klinikum Emil von Behring Berlin-Zehlendorf, Berlin, Germany
,
Uwe von Fritschen
4   Klinik für Plastische und Ästhetische Chirurgie, Helios-Klinikum Emil von Behring, Berlin, Germany
5   Plastic and Aesthetic Surgery, HELIOS Hospital Emil von Behring, Berlin, Germany
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Abstract

Background

Lymphatic drainage through the internal mammary lymph nodes (IMLN) is a key pathway for breast cancer metastasis, although IMLN metastasis is rare following primary treatment. In earlier years, treatment protocols primarily addressed axillary lymph node metastasis.

Patients and Methods

We present five cases where IMLN metastases were discovered incidentally during autologous free-flap breast reconstruction. These cases highlight implications for both the reconstructive plastic surgeon and subsequent adjuvant therapy.

Recommendations and Conclusion

From a plastic-reconstructive perspective, we recommend performing routine biopsies on any incidentally identified IMLN during autologous breast reconstruction. Positive findings may upstage the patient’s disease and influence further treatment planning. However, we do not recommend actively searching for or extending dissections to harvest IMLN specimens. Only in the presence of a suspicious perinodal tumour mass do we perform an intraoperative frozen-section analysis, with reconstruction paused if malignancy is confirmed. After complete staging and discussion in a multidisciplinary conference, we proceed with tumour resection according to oncological standards if curative resection is deemed feasible. Reconstruction can then be performed during the same procedure. For locoregional recurrence of breast cancer, treatment continues to be a multimodal approach involving surgery, radiation, and systemic therapy to ensure local control and optimise long-term survival. In primary treatment, current national and international guidelines now recommend locoregional irradiation of the internal mammary chain for high-risk cases, which may further reduce the incidence of incidental IMLN metastasis findings in the future.

Zusammenfassung

Hintergrund

Die lymphatische Drainage der Brustdrüse erfolgt vorwiegend über die Axilla. Der parasternale Lymphabfluss entlang der A. mammaria interna (IMLN) stellt jedoch ebenfalls einen wichtigen Drainageweg dar. Parasternale Lymphknotenmetastasen sind nach einer primären Systemtherapie des Mammakarzinoms selten. Früher wurden daher in Nachbehandlungsprotokollen regelhaft primär nur die axillären Lymphknoten adressiert.

Patienten und Methoden

Wir stellen 5 Fälle mit einem Zufallsbefund von parasternalen Lymphknotenmetastasen vor, die im Rahmen einer autologen sekundären Brustrekonstruktion mittels freier mikrochirurgischer Lappenplastik aufgefallen sind. Die Diagnose hat nicht nur einen direkten Einfluss für den operierenden rekonstruktiven Plastischen Chirurgen, sondern beeinflussen auch maßgeblich die anschließende adjuvante Therapie.

Empfehlung und Schlussfolgerung

Wir empfehlen jeden Lymphknoten der parasternalen Region, der im Rahmen der Präparation des Anschlussgefäßes einer autologen Brustrekonstruktion zufällig gefunden wird, histologisch zu untersuchen. Es wird jedoch nicht empfohlen explizit nach Lymphknoten zu suchen oder eine erweiterte Exploration anzustreben. Im Falle eines positiven Befundes, hat dies Auswirkungen auf die weitere onkologische Therapie. Das direkt intraoperative Vorgehen richtet sich hingegen nach der Ausdehnung des Befundes. Nur im Falle eines auffälligen Befundes erfolgt eine histopthologische Schnellschnittanalyse und Unterbrechung der Rekonstruktion bei positivem Befund. Wenn nach komplettem Staging in einer interdisziplinären Entscheidung die Resektion in kurativer Absicht möglich erscheint, erfolgt die Tumorresektion nach onkologischen Standards. Die Brustrekonstruktion führen wir dann in derselben Sitzung durch. Ein lokoregionäres Tumorrezidiv beeinflusst die Nachbehandlung als multimodalen Ansatz von Operation, Strahlentherapie und systemischer Behandlung. In den aktuellen nationalen und internationalen Leitlinien spiegelt sich das nun auch im Bereich der Primärtherapie des Mammakarzinoms wieder. Insbesondere die parasternale Lymphknotenreihe wurde nun ebenfalls Ansatzpunkt für eine lokoregionale Bestrahlung bei Hochrisikofällen, was das Risiko eines Lokalrezidives in der Zukunft reduzieren sollte.

Keywords

breast cancer recurrence - internal mammary lymph node - breast reconstruction - microsurgical free flap

Schlüsselwörter

Rezidiv Mammakarzinom - parasternale Lymphknoten - mikrochirurgische freie Lappenplastik - Brustrekonstruktion - Lymphknotenmetastase


Publikationsverlauf

Eingereicht: 18. November 2024

Angenommen: 28. Februar 2025

Artikel online veröffentlicht:
14. April 2025

© 2025. Thieme. All rights reserved.

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

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