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.

From February 2002 to December 2004, 81 patients (average age: 49 years, range: 26 to 69 years) received 105 DIEP for secondary or tertiary breast reconstruction. Retrospective evaluation from a prospective database for suspicious internal mammary LN was performed. Mastectomies had taken place 0.5 to 27 years before (avg. 4.1 years). SN procedure alone had been performed in 20 patients and axillary node dissection with(out) SN procedure in 55 patients. No information on internal mammary LN status at the time of tumor ablative surgery was available.

In 13 patients (16%) who had received a secondary or tertiary breast reconstruction with DIEP flap(s), macroscopically suspicious LN 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. Treatment for malignant disease was started in these patients, not affecting their cosmetic result. No relationship between positive internal mammary chain LN and location of the primary tumor, TNM stage, or previously administered adjuvant therapy was found.

Suspicious internal mammary chain LN found during recipient vessel dissection for breast reconstruction can have important consequences for treatment of malignant disease in individual patients. In the authors' opinion, current data do not yet call for a change in approach of delayed breast reconstruction. Preoperative internal mammary LN screening should be used, once reliable non-invasive imaging techniques become available.