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Abstract
The axillary lymph nodes are the primary group responsible for lymphatic drainage in the breast and, consequently, are the most common location for breast cancer metastasis. However, lymphatic pathways running from the breast, via intercostal spaces, to parasternal lymph vessels have also been identified. According to the American Joint Committee on Cancer eighth edition manual, regional lymph node metastasis normally travels to the ipsilateral axillary, supraclavicular, subclavicular, and internal mammary lymph nodes. The presence of intercostal metastasis is out the range of these regional lymph nodes. It is very rare for intercostal lymph nodes to be the extra-axillary site of metastasis in breast cancer, and it has been little reported on in the literature. Despite its rarity, it has the capacity to adversely affect the prognosis of breast cancer and drastically influence treatment choice. Here, we analyze such a case, with a patient receiving a radical mastectomy and metastatic intercostal lymph node dissection due to the presence of intercostal lymph node metastasis indicated via MRI. Furthermore, the potential application of preoperative 3-dimensional (3D) visualization and surgical planning is also discussed.
Highlights
The predominant lymphatic drainage pathway drains from the breast toward the axilla (1)
The breast mass was confirmed to be invasive breast cancer by pathology (Figure 1E), while cancer cells were found in the right fourth intercostal nodule (Figure 1F) and two out of 12 resected axillary lymph nodes
Intercostal lymph node metastasis may negatively affect the prognosis of the primary breast cancer patient, exacerbating breast cancer progression
Summary
The predominant lymphatic drainage pathway drains from the breast toward the axilla (1). Intercostal lymph node metastasis of breast cancer is an extremely rare extra-axillary site, a drainage pathway largely absent in literature. The breast mass indicated malignancy (BI-RADS category 5), while the nodule in the right fourth intercostal rib was highly suspected to metastasize (Figures 1A–D). She received a radical mastectomy, dissection of isolated metastatic intercostal lymph node and axillary lymph nodes, and postoperative adjuvant chemotherapy. The breast mass was confirmed to be invasive breast cancer by pathology (Figure 1E), while cancer cells were found in the right fourth intercostal nodule (Figure 1F) and two out of 12 resected axillary lymph nodes.
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