Abstract
BackgroundCurrent literature lacks a comparison of lymph node metastases and non-pathological lymph nodes distribution in breast cancer patients. The aim of the current retrospective study was to generate a comprehensive atlas of the lymph node system.Methods143 breast cancer patients underwent F-18-FDG-PET/CT (PET/CT) imaging for staging purposes and were diagnosed with regional lymph node metastases. Based on the PET/CT data set a total of 326 lymph node metastases and 1826 non-pathological lymph nodes were detected and contoured manually in the patient collective. Using rigid and deformable registration algorithms all structures were transferred to a template planning CT of a standard patient. Subsequently, a 3D-atlas of the distribution of lymph node metastases and non-pathological lymph nodes were generated and compared to each other.ResultsBoth, lymph node metastases and non-pathological lymph nodes, accumulated in certain areas (“hot-spots”) within the lymphatic drainage system. However large differences regarding the distribution patterns were detected: lymph node metastases hot spots occurred in close proximity to the subclavian vein in level I-III, whereas the non-pathological lymph nodes accumulated mostly (within a wider range) in level I. In level II and III lymph node metastases exceeded clearly the areas in which non-pathological lymph nodes occurred.ConclusionLymph node metastases and non-pathological lymph node distribution within the lymph node system differ clearly. Based on our results, an individual adjustment of the CTV in order to include visible lymph nodes in level II and III should be discussed.
Highlights
The lymphatic drainage system plays a crucial role in the treatment of breast cancer patients
Lymph node metastases hot spots occurred in close proximity to the subclavian vein in level I-III, whereas the non-pathological lymph nodes accumulated mostly
The primary tumor was located in 83 cases (58.0%) on the left side and in 60 cases (42.0%) on the right side. 47 patients (33.0%) received F-18-FDG-PET/Computed tomography (CT) staging during primary diagnosis or treatment of breast cancer, the remaining 96 patients (67.0%) had recurrent disease at the time of PET/CT imaging. 70 patients (48.9%) had distant metastases at the time the PET/CT image was acquired
Summary
The lymphatic drainage system plays a crucial role in the treatment of breast cancer patients. On the one hand lymph node involvement is an independent risk factor that needs to be taken into consideration for (neoadjuvant) systemic therapy decisions [1,2,3]. If several lymph nodes seem to be involved, surgical axillary lymph node dissection (ALND) is needed [3]. Several approaches for a better identification and selection of lymph nodes at risk during ALND are currently discussed and investigated [8, 9]. Analyses of the distribution of lymph node metastases (mLN) and comparison with visible nonpathological lymph nodes (npLN) could be helpful for a more targeted approach during axillary surgery for the large majority of patients in which no F-18-FDG-PET/ CT exam is available. Current literature lacks a comparison of lymph node metastases and non-pathological lymph nodes distribution in breast cancer patients. The aim of the current retrospective study was to generate a comprehensive atlas of the lymph node system
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