J Reconstr Microsurg 2006; 22 - A057
DOI: 10.1055/s-2006-955177

Positive Internal Mammary Lymph Nodes: Incidental Intraoperative Finding during Free TRAM Flap Breast Reconstruction

Mark A.F Knight 1, Nguyen Dinh 1, Mark R Kobayashi 1, Nadine B Semer 1, Gregory R.D Evans 1
  • 1Kaiser Bellflower and University of California, Irvine, Orange, California, USA

The internal mammary lymph nodes (IMN) have been documented as potentially important prognostic factors in breast cancer. There is increasing evidence in the recent literature that there may be both a survival benefit and an extension of the disease-free interval that are gained by evaluating and treating the IMN. As these nodes become more important in treatment paradigms, the reconstructive surgeon must become aware of decisions regarding analysis for reconstruction.

A chart review documented 250 free transverse rectus abdominis myocutaneous flap cases performed from 1998 to 2004. In addition, a literature review was conducted to survey the current protocols in the surgical, oncologic, and radiologic communities. A new algorithm for post mastectomy breast reconstruction was presented with the IMN in mind.

A population of the 250 patients with breast reconstructions performed by free TRAM flaps was identified. Patient age range was 42–68 years, with a median age of 54 years. Two cases were documented with positive internal mammary lymph nodes intraoperatively. The literature review revealed that the frequency of isolated positive IMN nodes was noted to be as high as 20%. Additionally, the frequency in association with positive axillary lymph nodes was as high as 50% in some reports.

Given the impact on survival from IMN metastasis, failure to account for the status of the internal mammary lymph nodes may risk understaging and preclude appropriate treatment stratification. Discussions regarding breast reconstruction must take this new oncologic focus into consideration. The authors presented an expanded algorithm to optimize pre-reconstruction oncologic evaluation. The outcome of such evaluation may impact the timing and technique of breast reconstruction.