Internal Mammary Node Chain Research Articles

European Organization for Research and Treatment of Cancer – Breast Cancer Group (EORTC BCG)

This section provides current contact details and a summary of recent or ongoing clinical trials being coordinated by European Organization for Research and Treatment of Cancer – Breast Cancer Group (EORTC BCG). Clinical trials include: Postoperative adjuvant chemotherapy followed by adjuvant tamoxifen versus nil for node-negative and node-positive patients with operable breast cancer. EORTC Study No. 10901Randomized phase III study comparing short, intensive preoperative combination chemotherapy with similar therapy given postoperatively. EORTC Trial No. 10902Phase III randomized trial investigating the role of internal mammary and medial supraclavicular (IM-MS) lymph node chain irradiation in stage I–III breast cancer (joint study of the EORTC Radiotherapy Cooperative Group and the EORTC Breast Cancer Cooperative Group). EORTC Study No. 10925/22922A survey of the Breast International Group (BIG) to assess the attitude of patients aged <35 years, with early breast cancer, toward the risk of loss of fertility related to adjuvant therapies. BIG 3-98/EORTC 10002LAMANOMA: Conservative local treatment versus mastectomy after induction chemotherapy in locally advanced breast cancer: a randomized phase III study. BIG 2-00/EORTC Study No. 10974/22002p53 study: First prospective intergroup translational research trial assessing the potential predictive value of p53 using a functional assay in yeast in patients with locally advanced/inflammatory or large operable breast cancer, prospectively randomized to a taxane versus non-taxane regimen. BIG 1-00/EORTC 10994After mapping of the axilla: radiotherapy or surgery AMAROS. EORTC 10981/22023A randomized phase II–III trial evaluating the efficacy of capecitabine and vinorelbine in anthracycline and taxane pretreated metastatic breast cancer. EORTC 10001/160010Phase I study of lonafarnib (SCH 66336) in combination with Herceptin plus paclitaxel in HER-2 neu overexpressing breast cancer. EORTC 10051/16023MINDACT trial: A prospective, randomized study comparing the Amsterdam 70-gene expression signature (Mammaprint) with common clinical pathological criteria in selecting patients for adjuvant chemotherapy in node-negative breast cancer. BIG 3-04/EORTC 10041

Pathologic and Internal Mammary Lymph Nodes in Secondary and Tertiary DIEP Flap Breast Reconstruction

An increasing number of women develop breast cancer and wish for breast reconstruction with the DIEP flap(s). Anastomosing DIEP flaps to the internal mammary vessels provides information on part of the internal mammary chain lymph nodes (LN). The purpose of this study was to evaluate whether the current practice of preoperative screening should be changed in order to find those delayed breast reconstruction patients who have tumor-positive internal mammary nodes or recurrent disease.

Quality Assurance in the EORTC Randomized Trial 22922/10925 Investigating the Role of Irradiation of the Internal Mammary and Medial Supraclavicular Lymph Node Chain Works

A quality assurance (QA) program in conjunction with the EORTC trial investigating the role of adjuvant internal mammary and medial supraclavicular irradiation in stage I-III breast cancer is presented. The results of a dummy run procedure and of an individual case review are compared to each other. The effects of recommendations based on QA procedures on the protocol compliance are evaluated. Prior to protocol activation all participating institutes were asked to produce treatment plans according to the guidelines of the protocol based on manual outlines of an average patient. Thereafter, they were asked to provide data on each of their first six randomized patients. The dummy run provided a lot of information on specific treatment techniques. In the individual case review, additional patient- and tumor-related data were collected, showing the use of anatomic information for treatment planning. A comparison between both procedures revealed that the individual case reports concurred more accurately with protocol guidelines than the dummy run. It was observed that the number of systematic protocol deviations was substantially decreased in trial patients compared to the dummy run case. Therefore, it is concluded that this extensive QA program had a positive effect on the consistency of all institutes participating in the trial.

Pathologic Internal Mammary Lymph Nodes in Secondary and Tertiary DIEP Flap Breast Reconstructions

An increasing number of women develop breast cancer and wish for breast reconstruction with DIEP flap(s). Anastomosing DIEP flaps to the internal mammary vessels provides information on part of the internal mammary chain lymph nodes (LN). The purpose of this study was to evaluate whether the current practice of preoperative screening should be changed, in order to find those delayed breast reconstruction patients who have tumor–positive internal mammary nodes or recurrent disease.

Concurrent administration of weekly trastuzumab and adjuvant breast radiotherapy increases skin, esophageal, and cardiac acute toxicities

630 Background: Trastuzumab (T) combined with chemotherapy (CT) has been recently shown to improve the outcome in patients with HER2-positive breast cancer. Its administration either weekly or every 3 weeks for one year is recommended as adjuvant therapy. Nevertheless, little is known about the toxicity of radiotherapy (RT) and T administered concurrently. Methods: Since June 2005, 95 patients (pts) with stage II-III HER2-positive breast cancer were treated concurrently with adjuvant T and RT. At this time, 53 have completed their combined therapy. Median age was 48y and 22 pts were menopausal. Twelve and 41 pts received T weekly or every 3 weeks, respectively. Neoadjuvant CT using anthracyclin/taxane regimen was administered in 27 pts. T was initiated after the last cycle of anthracyclin. Hormonal treatment was given to 17 hormone-receptor positive pts. RT was delivered to the whole breast (45–50 Gy ± a 10 to 16 Gy-boost, n=24) or to the chest wall (50 Gy, n=29). Internal mammary chain (IMC) and supraclavicular nodes were irradiated in 41 pts. Toxicity assessment (dermatitis, esophagitis and left ventricular dysfunction) was implemented according to the CTC v3.0 criteria. Results: Grade (G) 2 or more skin and esophageal toxicities were observed in 27/53 (51%) and 7/53 (13%) pts, respectively. Post-RT left ventricular dysfunction was observed in 22 pts (G1 in 14, G2 in 6, and G3 in 2). In univariate analyses, unfavorable factors influencing G2 or more cardiac toxicity were postmenopausal status (p=0.03), IMC irradiation (p=0.005) and weekly T administration (p=0.0001). Multivariate analysis revealed the concurrent administration of weekly T and RT (WTRT) as an unfavorable independent prognostic factor for cardiac toxicity (p=0.0001) and for G2 or more dermatitis (p=0.05). The two unfavorable prognostic factors for esophagitis (G2 or more) were concurrent administration of WTRT (p=0.008) and total mastectomy (p=0.004). Conclusion: Our preliminary results show that in addition to increased skin and esophageal acute toxicities, concurrent administration of weekly T and RT significantly decreases the left ventricular ejection fraction compared to the 3-week schedule. Results for the whole cohort will be presented at the meeting. No significant financial relationships to disclose.

CT-scan based localization of the internal mammary chain and supra clavicular nodes for breast cancer radiation therapy planning

Background and purpose To evaluate the influence of the position and the exact localizations of supra clavicular nodes (SCN) and internal mammary chain (IMC) and their variability among patients in order to improve treatment planning in breast cancer (BC) patients. Patients and methods A total of 46 CT scans of the chest were examined. All patients were female treated with breast conserving surgery and radiotherapy. The study was divided into two phases. The first consisted of measurements on 20 diagnostic CT scans, performed in the supine position with both arms over the head. All patients received contrast. This first phase was performed as a training program for radiologist and radiation oncologist to prepare for the second phase of the study: 26 CT scans in treatment position on angled board without injection. For this second group, patients had one arm raised above the head (treated side) and the other kept by the side (contralateral side). Measurements were performed on both sides to evaluate the influence of the arm position. The depths of IM- and SC vessels were measured at five points: (1) the origin of the internal mammary artery, (2) the sterno-clavicular articulation, (3–5) the first, second and third rib interspaces (RI). Measurements of the depth and of the distance between the internal mammary vessels and the middle axis of the sternum were obtained using electronic calipers on a PACS workstation. Results There were important individual variations of the depth of SCN, as follows: 20–84 mm (diagnostic) and 19–64 (treatment position). No differences in the depth of the IMC were found between treated and contralateral side at the region of the I, II, and III rib interspaces. The lateral margin of the IMC was never more than 40 mm from the middle axis of the sternum (I, II, III rib interspaces). There was no difference in the lateral limits of IMC (the distance between the IM vessels and the middle axis of the sternum) between the two sides: treated and contralateral. Conclusions This study shows the importance of the patients' individual anatomy, their position and the large variability in the depth of SCN. It is important to visualize these regions to permit individual dosimetric optimization.

Fluorodeoxyglucose positron emission tomography with sentinel lymph node biopsy for evaluation of axillary involvement in breast cancer

This study analysed the value of [(18)F]fluorodeoxyglucose positron emission tomography (FDG-PET) in detecting axillary lymph node involvement in women with breast cancer. In the first 150 women in this prospective study, axillary lymph node dissection (ALND) was performed regardless of the PET results. In a second group (125 women) FDG-PET was complemented with sentinel lymph node biopsy (SLNB) only in those who did not have pathological axillary uptake. The sensitivity and specificity of FDG-PET in detecting axillary involvement was 84.5 and 98.5 per cent respectively in the whole series of 275 patients, with two false-positive and 22 false-negative results. False-negative results were associated with some intrinsic tumour characteristics. In 21 women, PET revealed pathological uptake, suggesting involvement of the internal mammary lymph node chain. Whole-body PET identified a second synchronous tumour in five asymptomatic patients and haematogenous metastases in two patients. The high positive predictive value of PET (98.4 per cent) suggests that FDG uptake in the axilla could be an indication for full ALND without previous SLNB.

The importance of patient's position in CT-scan based localization of the Internal Mammary Chain (IMC) and Supra Clavicular Nodes (SCN) for breast cancer (BC) radiation therapy planning

The importance of patient's position in CT-scan based localization of the Internal Mammary Chain (IMC) and Supra Clavicular Nodes (SCN) for breast cancer (BC) radiation therapy planning

The preoperative detection of internal mammary lymph node metastases in breast cancer.

Abstract The internal mammary lymph node chain has been studied in patients with breast cancer by radioiosotope imaging. The technique enabled the study of lymph node function in an area inaccessible to clinical examination or lymphography. Thirty-four patients with breast cancer have been studied by injecting the posterior sheath of the rectus abdominis muscle, in the subcostal region, with technetium-99m-labelled stannous phytate and subsequently imaging the anterior thorax. Lymph node metastases were diagnosed in 13 patients (38 per cent) in whom a suppressed uptake of the isotope by the internal mammary lymph nodes was observed. Eighteen patients (53 per cent) had normal scans and in 3 patients (9 per cent) the examination was technically unsatisfactory. Histopathological correlation of internal mammary node biopsy with the preoperative scan confirmed the scan findings in all but one case in which this was carried out. Radioassay of internal mammary lymph nodes confirmed that the agent was localized in them and that uptake was suppressed in the presence of metastases. Twenty-three patients in this study underwent sequential scanning using first 99Tcm-labelled stannous phytate and subsequently 99Tcm-labelled antimony sulphide colloid. The latter agent was able to demostrate the anatomical presence of nodes when a suppressed uptake had initially been observed using 99Tcm-labelled stannous phytate. Internal mammary lymphoscintigraphy may be of value in the preoperative of breast cancer.

Pathological Internal Mammary Lymph Nodes in Secondary and Tertiary Deep Inferior Epigastric Perforator Flap Breast Reconstructions

Use of internal mammary vessels during breast reconstruction provides information on part of the internal mammary chain lymph nodes (LNs). It was evaluated whether our current practice of screening should be changed to identify those delayed breast reconstruction patients with tumor-positive internal mammary nodes (IMNs) and whether breast reconstruction should be continued, in case suspicious IMNs were found intraoperatively. From February 2002 to December 2004, 81 patients had received 98 deep inferior epigastric perforator flaps for delayed breast reconstruction. Prospectively collected data for suspicious internal mammary LNs were evaluated. In 13 patients (16%) who had received a delayed breast reconstruction, macroscopically suspicious LNs were detected in the course of the internal mammary chain. Three patients (4%) had a pathologic diagnosis of malignancy, which was found to match their primary tumor. No relationship between positive internal mammary chain LNs and location of the primary tumor, TNM-stage, or previously administered adjuvant therapy was found. Suspicious internal mammary chain LNs found during recipient vessel dissection for breast reconstruction can have important consequences for treatment of malignant disease in individual patients. Presented data do not support changing the current perioperative approach of delayed breast reconstruction.

Implications of the sentinel lymph node procedure for local and systemic adjuvant treatment

The objective of the sentinel lymph node procedure in breast cancer is to perform an accurate axillary staging and provide good local control, while sparing the patients the morbidity of an axillary lymph node dissection. Since its routine clinical use, questions were raised concerning the implications for local and systemic adjuvant treatment. This review provides an update of the recent literature. As a result of a more detailed histopathologic work-up of the sentinel lymph node, higher rates of lymph node metastases are detected. This leads to an upstaging of a subset of node-negative patients and an increase in the overall percentage of node-positive patients. However, the clinical implications of micrometastases and isolated tumor cells remain unclear. Furthermore, sentinel lymph nodes may be found in the internal mammary lymph node chain but the treatment of these nodes is subject of debate. Current guidelines recommend axillary lymph node dissection in patients with a positive sentinel node. The surgical removal of the internal mammary lymph node is only indicated in the context of a clinical trial. Radiation therapy of the axilla is an acceptable alternative for patients who refuse an axillary lymph node dissection (clinical trial). The value of radiotherapy to the internal mammary lymph node has never been established. Systemic treatment decisions in patients with a macrometastasis or micrometastasis in the sentinel lymph node follow the guidelines of node-positive patients, whereas in patients with isolated tumor cells only, guidelines for node-negative patients are followed. The results of ongoing clinical trials will be important for the development of further guidelines.

Economic consequence of local control with radiotherapy: Cost analysis of internal mammary and medial supraclavicular lymph node radiotherapy in breast cancer

To investigate the financial implications of radiotherapy (RT) to the internal mammary and medial supraclavicular lymph node chain (IM-MS) in postoperative breast cancer. A cost-effectiveness and cost-utility analysis were performed, using Markov models, comparing the early and delayed costs and effects of IM-MS during a 20-year time span from a societal viewpoint. The outcome estimates were based on Level I evidence from postoperative RT literature and the cost estimates on the standard practice of the Leuven University Hospitals, with the RT costs derived from an activity-based costing program developed in the department. On the basis of the assumptions of the model and seen during a 20-year time span, primary treatment including IM-MS RT results in a cost savings (approximately 10,000) compared with a strategy without RT. Because IM-MS RT also results in better clinical effectiveness and greater quality of life, the treatment with IM-MS dominates the approach without IM-MS. Sensitivity analyses confirmed the robustness of these results in all tested circumstances. Although threshold values were found for the cost of IM-MS, the cost at relapse, and the quality of life after treatment, these were substantially different from the baseline estimates, indicating that it is very unlikely that omitting IM-MS would become superior. This ex-ante cost evaluation of IM-MS RT showed that the upfront costs of locoregional RT are easily compensated for by avoiding the costs of treating locoregional and distant relapse at a later stage. The cost-sparing effect of RT should, however, be evaluated for a sufficiently long time span and is most specifically found in tumors with a rather slow natural history and a multitude of available systemic treatments at relapse, such as breast cancer.

CT-scan Based Localization of the Internal Mammary Chain (IMC) and Supra Clavicular Nodes (SCN) for Breast Cancer (BC) Radiation Therapy Planning

CT-scan Based Localization of the Internal Mammary Chain (IMC) and Supra Clavicular Nodes (SCN) for Breast Cancer (BC) Radiation Therapy Planning

Effect of lymphoscintigraphy drainage patterns on sentinel lymph node biopsy in patients with breast cancer

Background Sentinel lymph node (SLN) biopsy examination is an accepted method of staging breast cancer patients. SLN biopsy examination in patients with drainage to the internal mammary chain (IMC) nodes is controversial. Methods A prospective study of SLN biopsy examination followed by axillary dissection was analyzed to determine how surgeons manage patients with IMC drainage and the rates of axillary SLN identification and positivity in these cases. Results Lymphoscintigraphy was performed in 2196 (53.2%) of the 4131 patients in this study. IMC drainage was noted in 80 patients (3.6%). An axillary SLN was identified in 29 of the 40 patients with IMC drainage alone (72.5%). The rate of finding a positive axillary lymph node did not differ based on the lymphoscintigraphic pattern ( P = .470). Conclusions Most surgeons do not perform IMC SLN biopsy procedures. Even when lymphoscintigraphy shows isolated drainage to IMC nodes, axillary SLNs usually are identified. Lymphoscintigraphy therefore has limited usefulness.

Sampling of Internal Mammary Chain Lymph Nodes during Breast Reconstruction by Free Flaps from the Abdomen

The role of internal mammary chain lymph node removal in breast cancer is still not clarified. Although it has been proven that elective dissection of the internal mammary chain nodes does not improve survival, their selective treatment based on sentinel lymph node biopsy is under evaluation. There is another possibility to establish the status of internal mammary chain nodes--sampling of the nodes during the preparation of the site for microvascular anastomosis to the internal mammary artery and vein for free flap transfer. From August 2002 to December 2003, 54 free flaps were performed for breast reconstruction. In 11 cases, an internal mammary chain lymph node was harvested. A positive internal mammary chain node was found in only one case. In this case, the treatment policy was changed by adding irradiation to the internal mammary chain. The sampling of internal mammary chain nodes during preparation of the site for microvascular anastomosis to the internal mammary artery and vein should be a part of the reconstructive procedure after total mastectomy for invasive breast cancer because it could change the treatment plan.

Aportación de la tomografía por emisión de positrones a la detección y estadificación del cáncer de mama

18F-fluorodeoxyglucose positron emission tomography (FDG-PET) is a diagnostic imaging tool with multiple applications in oncology. One of the more promising applications in breast cancer is noninvasive lymph node staging and detection of distant metastases, which may provide useful information about prognosis and treatment response. Published studies on FDG-PET applications in breast cancer detection and staging were reviewed. We also present our own experience in patients referred for preoperative staging of breast cancer. FDG-PET is very useful in evaluating dense breasts, multicentric disease and breast prostheses. The sensitivity of FDG-PET for nodal staging is low, and consequently it cannot replace either sentinel lymph node biopsy or histologic examination. However, it is more accurate than another noninvasive techniques and is very useful in internal mammary node chain evaluation. FDG-PET can improve and maybe replace conventional imaging in detecting metastatic disease, especially in high risk patients with locoregionally advanced recurrent breast cancer or increased serum tumor markers, and helps to characterize unclear findings of anatomic imaging techniques or scintigraphy. FDG-PET is useful in breast cancer staging. It complements and even improves information from other diagnostic techniques and changes therapeutic management in a high proportion of patients.

Improving radiotherapy treatment for left-sided breast cancer

Left-sided breast cancer patients with large irradiatedheart volumes are identified as patients at high risk for late cardiac mortality. This thesis describes the development of IMRT techniques where significant heart sparing is possible. First, dosimetric effects of contour changes and tissue inhomogeneities as a function of setup uncertainty were evaluated. The results suggest that these effects are negligible as long as the setup uncertainty probability function is symmetrical, and that rigid body dose distributions are sufficiently accurate. Furthermore, the optimal 2-beam orientation for heart sparing in left-sided breast cancer patients for uniform and nonuniform beam intensity techniques was investigated. An exhaustive search through all axial 2-beam combinations was performed. Optimal 2-beam IMRT orientations for left-sided breast cancers are bimodal, containing hinge angles around 160° and 210°. IMRT techniques are less sensitive to beam orientation compared to uniform beam techniques and result in significantly improved heart sparing, but at a cost of slightly compromised coverage of the PTV. The next study compared the reduction in cardiac and pulmonary complication rates between wedged and intensity-modulated beam plans for the left breast. Modifying the treatment technique from wedged rectangular to wedged conformal to intensity-modulated beams, reduced the cardiac complication rate, on average, from 5.9% to 4.0% to 2.0%, respectively. The results of that study lead to the design of a class solution to reduce late cardiac complications for left-sided breast cancer patients using simplified IMRT with predefined segments. Applying optimal IMRT beam orientations improves PTV coverage while maintaining significant heart sparing but increases the PTV dose heterogeneity. We also compared IMRT techniques against uniform beam (wide split tangents) and mixed modality (oblique electrons) treatment plans irradiating the left breast and internal mammary lymph node chain (IMC). The IMRT plan provides the best compromise in terms of heart sparing and target coverage. The wide split tangent plan tends to overdose the heart while the oblique electron plan tends to underdose the IMC. Based on these results clinical guidelines have been formulated for the treatment of a subgroup of left-sided breast cancer patients who present with a large amount of heart within conventional tangential fields.

Results of a survey regarding irradiation of internal mammary chain in patients with breast cancer: Practice is culture driven rather than evidence based

Purpose To examine the self-reported practice patterns of radiation oncologists in North America and Europe regarding radiotherapy to the internal mammary lymph node chain (IMC) in breast cancer patients. Methods and materials A survey questionnaire was sent in 2001 to physician members of the American Society for Therapeutic Radiology and Oncology and European Society for Therapeutic Radiology and Oncology regarding their management of breast cancer. Respondents were asked whether they would treat the IMC in several clinical scenarios. Results A total of 435 responses were obtained from European and 702 responses from North American radiation oncologists. Respondents were increasingly likely to report IMC irradiation in scenarios with greater axillary involvement. Responses varied widely among different European regions, the United States, and Canada ( p < 0.01). European respondents were more likely to treat the IMC ( p < 0.01) than their North American counterparts. Academic physicians were more likely to treat the IMC than those in nonacademic positions ( p < 0.01). Conclusion The results of this study revealed significant international variation in attitudes regarding treatment of the IMC. The international patterns of variation mirror the divergent conclusions of studies conducted in the different regions, indicating that physicians may rely preferentially on evidence from local studies when making difficult treatment decisions. These variations in self-reported practice patterns indicate the need for greater data in this area, particularly from international cooperative trials. The cultural predispositions documented in this study are important to recognize, because they may continue to affect physician attitudes and practices, even as greater evidence accumulates.

Incidence of internal mammary node metastases after a sentinel lymph node technique in breast cancer and its implication in the radiotherapy plan

Purpose To analyze the frequency in determining pathologically proven metastatic involvement of internal mammary nodes (IMN) after sentinel lymph node (SLN) technique in breast cancer and to evaluate the implications for radiotherapy (RT) management of patients. Methods and materials Two hundred and twenty-five patients who underwent lymphatic mapping for early breast cancer treated with breast-conserving surgery and radiation (80%) or mastectomy (20%) were evaluated. There were two phases in the study: the validation phase (105 patients, 52 T1, 53 T2 ≤ 4 cm), and the application phase (120 patients, 70 T1, 50 T2 ≤ 2.5 cm). In the validation, if a drainage pathway to the IMN was identified, no biopsy was performed in this phase. In the application, if the study showed metastases in the IMNs, biopsy was performed. When histologically proven IMN metastases were detected, RT was included on the IMN chain planned with a 3D treatment system using conformal techniques. At the beginning of the study the injection site was subdermal and subsequently, the injection site was changed to peritumoral and intratumoral to search for IMN. Results In 31 patients of 225 (14%) hot spots were observed in the internal mammary chain (11.5% and 17.2% in the validation and application phases, respectively). In the validation phase, in 11 cases (11.5%) IMN drainage was observed, and in the application phase, in 20 cases (17.2%). Sampling of the internal mammary basin based on lymphoscintigraphy results was successful in 69% of the cases (14 of 20) and revealed metastatic involvement in 14% (2 of 14). This represents incidence of only 1.7% (2 of 116) in early breast cancer patients with SLN study in the application phase. In both cases the axillary SLN was also positive. Both patients with metastatic involvement of the IMN area received RT on the IMN chain next to the remaining breast after conservative surgery. Conclusions We can conclude that 14% of the patients with intraoperative drainage into the IMN surgical examination of the lymph nodes had pathologically positive metastases. The percentage in pathologically proven metastatic involvement of IMN after the SLN technique in early breast cancer is low, but it is not negligible. Moreover, it is expected to increase since the international recommendations have established a 3-cm cutoff for practicing the SLN technique. Although the real value of IMN irradiation in early breast cancer is not known, including this chain in postoperative radiotherapy is not recommended unless pathologically proven IMNs have been produced by the SLN technique. To avoid overdosage or underdosage in the joint between the medial tangential and IMN fields, an individualized 3D dosimetry study is mandatory to enhance dose distribution and reduce the heart volume to lessen side effects.

Lymphatic stream from a breast tumor to a sentinel node in the parasternal node basin: Consideration of two cases with internal mammary node metastases

Prior to worldwide acceptance of the sentinel lymph node concept, internal mammary node dissection was regarded as unnecessary for diagnosis of breast cancer. More recently, the impact of internal mammary nodes dissection on the survival of breast cancer patients has come under scrutiny. We have encountered important breast cancer cases involving lymphatic streams that go from the tumor to both the internal mammary chain and axillary node basin simultaneously. Moreover, a lymphatic stream was found to go from the breast tumor to the internal mammary chain via intra-mammary gland lymph nodes. These cases indicate the dual importance of internal mammary sentinel node dissection as well as axillary sentinel node dissection.