Rotter's Nodes Research Articles

Interpectoral nodal dissection for invasive breast cancer: A retrospective single institution study from India.

e12585 Background: Interpectoral lymph nodes are one of the axillary lymphatic drainage sites in breast carcinoma. Usually dissection of Interpectoral nodes (IPN) avoided during axillary dissection as they are not the primary lymphatic drainage site. Our study aims to identify the rate of positivity of Interpectoral nodes in invasive breast cancer, predictors of IPN positivity in relation to tumour location, size, grade and hormone receptor status and to evaluate the need for IPN clearance during axillary dissection. Methods: A retrospective analysis of histopathology reports of 367 patients who underwent Axillary dissection in a single centre from Jan 2017-Dec 2022 for breast cancer was analysed. Inclusion criteria: Female Patients with operable Invasive Breast cancer with node positive axilla who underwent axillary dissection (upfront and post chemotherapy). Exclusion criteria: metastatic breast cancer, node-negative patients/sentinel lymph node biopsy, inadequate nodal dissection, and incomplete clinicopathological information. Data was analysed looking for presence of nodes in interpectoral tissue in Axillary dissection and to identify the positivity of interpectoral lymph nodes in specimens. Results: Interpectoral nodal dissection was done in n=216 of the 367 patients. The clinicopathological characters are described in Table. IPN were identified in 35% (n=77) of the 216 Axillary dissection specimens. IPN were positive in 7.8% (17 of 216) of patients who had interpectoral nodal dissection. 22% of the interpectoral lymph nodes removed were positive. As regards tumour size, Rotter's nodes were identified commonly in T3 and T4 tumours and positive in people with N2 and N3 disease. By multivariate analysis, T stage and N stage were the most important determinants of IPN yield and positivity. Site of tumour, neoadjuvant therapy, molecular subtype or Ki 67 were not found to be associated with either presence or positivity of interpectoral nodes. In 5 cases IPN positivity upstaged the nodal stage and in 1 patient it was the only positive node. Conclusions: As IPN is positive in most LABC, whenever axillary dissection is done in such cases Interpectoral nodes can be safely removed while dissecting level III nodes. Nodal recurrence is the most common site of recurrence post mastectomy and hence Interpectoral nodes need to be routinely removed in patients undergoing Axillary dissection for operable breast cancer to enable accurate staging and to prevent local or systemic failure. [Table: see text]

Dosimetry Comparison of Incidental Irradiation to the Low Axilla in Whole Breast Irradiation Using IMRT and IMPT Therapy

It has been hypothesized that incidental dose to low axilla contributes to regional control in patients receiving whole breast irradiation (WBI), especially in patients with limited metastatic sentinel nodes who were spared from subsequent axillary dissection. We aimed to compare axillary dose between intensity-modulated radiotherapy (IMRT) and intensity-modulated proton radiotherapy (IMPT). Dosimetric comparisons between IMRT and IMPT were conducted in 15 patients treated with WBI without planned regional node irradiation (RNI). The prescribed dose was 40.05 Gy (RBE)/15 Fx. Axillary lymph nodes levels I, II (ALN I, ALN II) and rotter's lymph nodes (RN) were contoured and evaluated. The dose to the axilla was generally low for IMPT, with mean dose to ALN I, ALN II, and RN of 896.31, 194.64, and 2111.58 cGy (RBE), respectively. The mean V90% and V50% of ALN I was higher for IMRT (11.5 cm3, 22.9% of structure volume, p < 0.0001; 36.1 cm3, 66.6%, p < 0.0001) compared to IMPT (1.1 cm3, 2.0%; 8.1cm3, 15.9%). Similar finding was found in other low axilla. Mean dose to total ALN caudal to axillary vein was 936.6 cGy (RBE) in IMPT compared to 2407.3 cGy in IMRT (p < 0.0001). Within all substructures of axilla, mean dose to RN was the highest, but it remains lower in IMPT than in IMRT [2111.58 cGy (RBE) versus 3510.88 cGy, p < 0.0001]. WBI treated with IMPT leads to a significant reduction of axilla dose compared to IMRT. In clinical scenarios like Z0011 or likewise requiring incidental irradiation to the low axilla without additional RNI, contouring should be modified based on individual risk.

Rotter's Lymph Nodes-Do We Really Need to Remove During Axillary Clearance?

Surgical management of node positive breast cancer requires axillary dissection. Interpectoral nodes (IPNs) or Rotter's nodes removal is controversial as there is hardly any tissue in this region. IPNs involvement is rarely seen among breast cancer patients. Developing an effective protocol for surgical management of axilla is necessary for uniformity, to reduce the risk of regional recurrence and to avoid the morbidity of interpectoral lymphatic tissue clearance.This study aimed to evaluate the detection of lymph nodes in Rotter's region and positive metastasis rate of IPNs in patients with node positive breast cancer for analyzing the prognostic and therapeutic value of IPN excision during axillary clearance. Fifty-six patients undergoing axillary clearance, aged ≥ 18years, were studied. Patients with recurrence or those who underwent neoadjuvant chemotherapy were excluded. Baseline investigations were done pre-operatively along with core needle biopsy, estrogen receptor (ER), progesterone receptor (PR), and Ki-67 status. Association between IPN status, age, and clinicopathological parameters were assessed by Kruskal Wallis and Chi-square test using R v 3.6.0. P value of ≤ 0.05 was considered statistically significant. Majority of patients had upper outer quadrant tumor location (22/56), and the most common histopathological type was invasive ductal carcinoma (46/56). IPNs were identified in 35.71% (20/56) of 56 patients, with metastasis prevalence of 27.27% (9/33 node positive patients). Patients having IPN metastasis had larger tumor size, later TNM classification, lower ER/PR, and higher Ki-67 positivity. Dissection of IPNs can be practiced routinely during axillary clearance and should be subjected to histopathological examination separately.

Dose variability in different lymph node levels during locoregional breast cancer irradiation: the impact of deep-inspiration breath hold.

Aim of the present analysis was to evaluate the movement and dose variability of the different lymph node levels of node-positive breast cancer patients during adjuvant radiotherapy(RT) with regional nodal irradiation (RNI) in deep-inspiration breath hold (DIBH). Thirty-five consecutive node-positive breast cancer patients treated from October 2016 to February 2018 receiving postoperative RT of the breast or chest wall including RNI of the supra-/infraclavicular lymph node levels (corresponding to levelsIV, III, Rotter LN (interpectoral), and some parts of levelII) were analyzed. To evaluate the lymph node level movement, acenter of volume (COV) was obtained for each lymph node level for free-breathing (FB) and DIBH plans. Geometric shifts and dose differences between FB and DIBH were analyzed. Asignificant movement of the COV in anterior(y) and cranial(z) dimensions was observed for lymph node levelsI-II and Rotter lymph nodes (p < 0.001) due to DIBH. Only minor changes in the lateral dimension (xaxis) were observed, without reaching significance for levelsIII, IV, and internal mammary. There was asignificant difference in the mean dose of levelI (DIBH vs. FB: 38.2 Gy/41.3 Gy, p < 0.001) and levelII (DIBH vs. FB: 45.9 Gy/47.2 Gy, p < 0.001), while there was no significant difference in levelIII (p = 0.298), levelIV (p = 0.476), or internal mammary nodes (p = 0.471). Asignificant movement of the axillary lymph node levels was observed during DIBH in anterior and cranial directions for node-positive breast cancer patients in comparison to FB. The movement leads to asignificant dose reduction in levelI and levelII.

Distribution of involved regional lymph nodes in recurrent and locally advanced breast cancer and its impact on target definition

Objective The frequency and the anatomic distribution of involved regional nodes in recurrent and locally advanced breast cancer were analyzed, in order to evaluate the rational of conventional regional node radiation technique and provide evidence for target definition of breast cancer . Methods Patients with recurrent or locally advanced breast cancer who were treated in our hospital from August 2003 to December 2009 were included in this study. 111 patients had contrast enhanced chest CT images of the whole regional nodes before treatment. The regional nodes were categorized into 8 anatomical substructures including medial and lateral supraclavicular nodes ( SC-M, SC-L), axilla nodes ( ALN )- Ⅰ , Ⅱ , Ⅲ,infraclavicular nodes (IFN), Rotter's nodes (RN) and internal mammary nodes (IMN). The frequency of involvement and anatomical distribution of the involved nodes on CT images were analyzed. Results A total of 111 patients were enrolled this study and 199 anatomical substructures with involved nodes were identified. The frequency of involvement were :SC-M 33, SC-L 21, ALN- Ⅰ 30, ALN-Ⅱ 25, ALN-Ⅲ + IFN 35, RN 27, IMN 28. Supraclavicular region and axilla were the most frequently involved area (72. 3% ).The average depth of the SC-M and SC-L nodes was 33.48 mm ± 10. 57 mm and 45.62 mm ±20. 45 mm,and 51.5% and 71.4% of the SC-M and SC-L nodes were located more than 3 cm deep from the skin. The axilla nodes were located cranial and caudal to the axillary vein in 5 and 20 locally advanced breast cancer patients and in 64 and 28 patients who received prior axillary dissection. The majority of involved IMN was located within the first 3 intercostal spaces (26/28). The average distance between the center of involved IMN and chest skin was 24. 23 mm ± 10. 28 mm. The average distance between the center of involved IMN and midline of the body was 29. 38 mm ±6. 7 mm. The center of involved IMN was 6.19 mm ±5.73 mm lateral and 5.73 mm ± 4. 56 mm posterior to the internal mammary vessels. Conclusions Conventional field design is unlikely to provide sufficient dose to the entire risk region because of individual differences.Individualized treatment planning based on CT would become feasible with increasing knowledge of natural risk of nodal involvement. Key words: Breast neoplasms; Target volume delineation; Regional lymphnodes

Management of Abnormal Rotter's Lymph Nodes Identified on Preoperative Breast Magnetic Resonance Imaging

Management of Abnormal Rotter's Lymph Nodes Identified on Preoperative Breast Magnetic Resonance Imaging

Analysis of Metastatic Involvement of Interpectoral (Rotter's) Lymph Nodes Related to Tumor Location, Size, Grade and Hormone Receptor Status in Breast Cancer

This study was aimed at analyzing metastatic involvement in interpectoral (Rotter's) lymph nodes in relation to tumor location, size, grade and hormone receptor status in primary breast cancer. The study included 172 female patients undergoing surgery for breast cancer at the University Hospital for Tumors, Zagreb, Croatia from November 2001 to August 2003. In addition to the standard surgical procedure, interpectoral (Rotter's) lymph nodes were removed in all of the patients. Serum levels of the tumor marker CA 15-3 were determined before surgery and hormone receptor status after surgery. Rotter's lymph nodes were identified in 67% of the patients, with metastatic involvement being found in 20% of the Rotter's nodes. Metastatic involvement of Rotter's nodes in patients with negative and positive axillary lymph nodes was 4% and 35%, respectively. When we looked at the location of the tumor in patients with metastatic involvement of Rotter's nodes, we found that tumors located in the upper quadrants were more prone to metastasis to Rotter's nodes; there was a significant positive correlation between tumor location and positive Rotter's nodes (r = 0.953, P = 0.012). As regards tumor size, Rotter's nodes were identified in 15%, 20% and 30% of stage T1 (< 2 cm), T2 (2-5 cm) and T3 (> 5 cm) tumors, respectively. Hormone receptor status showed no statistically significant difference in the expression of estrogen and progesterone receptors between patients with and those without positive Rotter's nodes. Of 35 Rotter's node-positive patients, 31.4% had elevated serum levels of CA 15-3; the level was significantly higher in Rotter's-positive patients compared to those with negative (or absent) Rotter's nodes. The results show that one-fifth of breast cancer patients, or even one-third of those with positive axillary lymph nodes, are discharged with positive interpectoral lymph nodes that remain undiagnosed. As the nodes can be surgically removed without additional mutilation, exploration of Rotter's lymph nodes should be introduced into routine clinical practice.

Analysis of axillary coverage during tangential radiation therapy to the breast

To evaluate the percent of the prescribed radiation dose to the breast delivered to the axillary tissue and to evaluate the volume of the axilla receiving 95% of the prescribed dose with normal and with high tangential fields. Computed tomographic scan images with 5-mm sections were retrospectively analyzed for 35 patients who had undergone three-dimensional (3D) planning for whole-breast radiation. The axillary nodal region was identified and divided into Levels I to III and Rotter's nodes (RN). Digitally reconstructed radiographs were created, and two plans were developed: (a) the standard clinical opposed tangential irradiation fields and (b) the high-tangential irradiation fields. Axillary coverage was examined by use of dose-volume histograms (DVH), and the average coverage for the four nodal groups was obtained. The data show that with the standard tangential irradiation fields, the average dose delivered to Levels I, II, III, and RN is 66% (standard deviation, or SD = 13%), 44% (SD = 18%), 31% (SD = 20%), and 70% (SD = 19%) of the prescribed dose, respectively. The coverage increases to 86% (SD = 9%), 71% (SD = 19%), 73% (SD = 17%), and 94% (SD = 8%) of the prescribed dose, respectively, for Levels I, II, III, and RN when the high tangential irradiation fields are used. 51% of Level I, 26% of Level II, and 15% of Level III receive 95% of the prescribed dose with normal tangents. The volume increases to 79%, 51%, and 49% of Levels I, II, and III, respectively, with high tangents. The tangential fields designed to treat only the breast do not adequately cover the axillary region and, therefore, cannot be relied upon for prophylactic therapy of the axilla. The high tangential irradiation fields increase the dosages received by the axillary region, but the average dosages received by the lower axillary regions are still less than 90% of the prescribed dose.

Clinical Significance of Rotter's Nodes in Patients with Breast Carcinomas

Clinical Significance of Rotter's Nodes in Patients with Breast Carcinomas

Lymph-node dissection in breast cancer.

Along with the ongoing modifications in treatment of primary breast cancer, the purpose and extent of lymph-node dissection has changed. The following is an overview of the current knowledge and practice of lymph-node dissection in breast cancer, with special regard to expected developments in the near future. Axillary dissection is described as a ten-step procedure, including dissection of level-I and -II and Rotter's nodes, without level-III nodes, providing at least ten lymph nodes for accurate staging information. Axillary dissection still offers the most efficient local control in node-positive patients, whereas, in primarily node-negative patients, irradiation seems to be equally effective. In general, lymph-node dissection does not alter overall survival but there is no doubt that surgical therapy still contributes to cure in early-breast-cancer patients and seems to be curative for certain patients with stage-I carcinoma. The lymph node status of the axilla is crucial for the indication of adjuvant therapy in early invasive breast cancer, but an increasing number of clinical node-negative patients could be managed with information based on features of the primary tumor, regardless of the nodal status. The most promising new concept for the selection of node-positive patients, while avoiding unnecessary morbidity of axillary dissection in early-breast-cancer patients, is the sentinel-node concept. The principle is based on the identification of the first "sentinel" lymph node reached by lymphatic flow. Thus, only proven node-positive patients undergo axillary dissection. Local failure of internal mammary lymph nodes is rarely recognized; however, internal mammary lymph nodes seem to have an underestimated prognostic significance in about 10-20% of axillary node-negative patients. This may lead to the withholding of systemic therapy for patients with early breast cancer. Nevertheless, there is no indication for a routine parasternal dissection today. The sentinel-node concept may also support the selection of diagnostic internal lymph-node biopsy and subsequent adjuvant therapy in cases with no axillary lymph-node metastases but with internal lymph-node metastases.

Clinical Significance of Rotter's Nodes in Patients with Breast Carcinomas

Clinical Significance of Rotter's Nodes in Patients with Breast Carcinomas

Interpectoral nodes in carcinoma of the breast: requiem or resurrection.

Fifty-eight consecutive patients undergoing a modified radical mastectomy were subjected to complete dissection and pathological assessment of the interpectoral fascia and the group of lymph nodes it contains. The dissection was carried out in all patients, irrespective of whether they were palpable or not. Interpectoral nodes (IPNs) were anatomically present in 28 patients (48%) and were completely absent in 30 patients (52%). Ten patients were Stage I, 18 were Stage II, and 30 were Stage III. Of the 25% (15/58) of patients with microscopic metastasis, only 12/15 had palpable nodes; 66% (10/15) of patients had axillary and apical nodes positive. Significantly, two patients with negative nodes in the axillary and apical group had metastatic Rotter's nodes. Of the 15 patients with positive IPNs, nine had primary tumors located within the upper quadrants of the breast, whereas only five had tumors in lower quadrants and one had a centrally located tumor. The neurovascular bundle to the pectoralis major could be safely preserved in 93% (54/58) of patients. The incidence of impalpable nodes with microscopic metastasis and the evidence of exclusively metastatic interpectoral nodes with uninvolved axillary and apical nodes prompt the following conclusions: (1) interpectoral fascia and nodes should be mandatorily dissected in all patients irrespective of the nodes being palpable or not; (2) the dissection is anatomic and is associated with almost no additional morbidity; (3) the group of patients with IPNs positive and the axillary group negative, would benefit maximally from the IPN dissection. Similarly, this dissection in all other groups of patients would enable a more accurate staging and selection of therapeutic strategies.

EVALUATION OF ROTTER'S LYMPHNODE METASTASIS IN BREAST CANCER

The interpectoral lymph nodes (Rotter's nodes) have a therapeutic importance in radical mastectomy, because these nodes are not completely dissected unless the pectoral major muscle is sacrificed. In our institution, Rotter's nodes were disclosed by hand dissection in 71.4% of 35 recent, consecutive radical mastectomy specimens. The average number of dissected Rotter's nodes was 1.9 per specimen. In recent 109 cases of curative radical mastectomy, ten had metastases to Rotter's nodes, which accounted for 9.2% of all cases and 28.6% of those with axillary node metastasis respectively. In all cases with Rotter's node metastasis, the tumors were larger than 2.1 cm in size by palpation and located in the lateral half of the breast. Metastasis found only in Rotter's nodes occurred in one case (0.9% of all cases). But in the other 9 cases, more than 3 of the axillary lymphnodes were positive for metastasis, and their porgnoses were significantly poor. These reuslts suggest that the dissection of Rotter's nodes might be negligible in a case with a tumor smaller than 2.0cm in size, and that a case with swollen or hardened Rotter's nodes which denotes metastasis should not be a candidate for modified radical mastectomy that preserves the pectoral major muscle.

CT of interpectoral lymph nodes.

The presence of lymph nodes between the pectoralis major and minor muscles (Rotter's nodes) has been noted in the anatomic and surgical literature. We analyzed the appearance of the interpectoral space and nodes on chest CT scans of 25 patients without known chest wall abnormalities or causes for lymphadenopathy. In some of these cases small structures were detected in the interpectoral fat that could be either vessels or nodes. In addition we studied chest CT scans in six patients with interpectoral adenopathy due to metastases from breast cancer. The nodes were oval soft-tissue densities ranging from 1.5 X 1 cm to 3.5 X 3 cm in diameter.

INDICATION FOR MODIFIED RADICAL MASTECTOMY -RETROSPECTIVE STUDIES OF OUR CASES-

In order to determine the indications for modified radical mastectomy, 65 patients with primary breast cancers who underwent radical mastectomies or extended radical mastectomies were studied. The authors determined the size and depth of the tumors, metastasis to lymph nodes, and stage microscopically and investigated the indication for modified radical mastectomy. Initially, cases with metastasis to Rotter's lymph nodes, subculavicular lymph nodes and internal mammary lymph nodes were excluded from the indications for modified radical mastectomy. From the viewpoint of lymph node metastasis, it was concluded that the indication for modified radical mastectomies was confined to T1n1α (axillary lymph node involvement less than 3) when the tumor was located laterally, and Tis when it was located medially. However, when it was examined from the viewpoint of the depth of the tumor, it was found that 12% of the patients had infiltration to the pectoralis major muscle, and 14% had infiltration to the retromammary space. It was revealed that even in the case of T1n0 (no lymph node involvement), the infiltration of the cancer reached very close to the pectoral fascia. Therefore, it was concluded that the indication for modified radical mastectomy must be limited to Tis.

Evaluation of Rotter's lymph nodes in radical mastectomy specimens as a guide to prognosis

CancerVolume 18, Issue 11 p. 1441-1444 ArticleFree Access Evaluation of Rotter's lymph nodes in radical mastectomy specimens as a guide to prognosis Saul Kay M.D., Saul Kay M.D. Laboratory of Surgical Pathology, Medical College of Virginia, Richmond, Va.Search for more papers by this author Saul Kay M.D., Saul Kay M.D. Laboratory of Surgical Pathology, Medical College of Virginia, Richmond, Va.Search for more papers by this author First published: November 1965 https://doi.org/10.1002/1097-0142(196511)18:11<1441::AID-CNCR2820181110>3.0.CO;2-RCitations: 15AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat References 1 Auchincloss, H.: Significance of location and number of axillary metastases in carcinoma of the breast—A justification for a conservative operation. Ann. Surg. 158: 37– 46, 1963. 2 Berkson, J., Harrington, S. W., Claqett, O. T., Kirklin, J. W., Dockerty, M. B., and McDonald, J. R.: Mortality and survival in surgically treated cancer of the breast—A statistical summary of some experience of the Mayo Clinic. Proc. Staff Mtg. Mayo Clinic 32: 645– 660, 1957. 3 Cutler, M.: Tumors of the Breast Philadelphia, J. B. Lippincott Co., 1962; pp. 252– 253. 4 Haagensen, C. D.: Diseases of the Breast, Philadelphia, W. B. Saunders Co., 1956; pp. 29– 30. 5 Diseases of the Breast: pp. 365– 366. 6 Diseases of the Breast: p. 629. 7 Kay, S., and Poulos, N. G.: Evaluation of the criteria of operability of carcinoma of the breast. Surg. Gynec. Obstet. 113: 562– 666, 1961. 8 Pickren, J. W.: Personal communication. Citing Literature Volume18, Issue11November 1965Pages 1441-1444 ReferencesRelatedInformation