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Contralateral axillary lymph node metastasis in second primary breast cancer: Case report and review of the literature

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tagspaper/contralateral-drainage, status/verified

4 min read

Gingerich et al 2017 — CAM in Second Primary Breast Cancer

Southampton Hospital, New York. Full text now obtained — both quotes below confirmed verbatim, upgraded from no-access.

The case

81-year-old woman, right breast invasive ductal carcinoma 18 years prior (lumpectomy + SLNB + radiotherapy + 5 years tamoxifen; original SLN and 4 additional axillary nodes all negative). Presented 18 years later with a new left axillary nodal metastasis (lobular carcinoma, signet-ring features) found incidentally on mammography, plus a new 2 cm right breast lesion on MRI (a second primary, right-sided, confirmed on biopsy). Lymphoscintigraphy showed no axillary uptake bilaterally. Treated as locoregional disease (curative intent) rather than stage IV: right mastectomy + left ALND (29/44 nodes positive), chemotherapy, radiotherapy, endocrine therapy. Disease-free at 18 months.

Verified verbatim quotes

Confirmed against full text (Discussion)

Although ipsilateral axillary lymph node metastasis in breast cancer is relatively common, contralateral axillary lymph node metastasis (CAM) is quite uncommon. Literature reports the incidence to be anywhere from 1.9% to 6%. Of the cases of CAM reported in the literature, the overwhelming majority are metachronous CAM, making synchronous CAM even more uncommon. The true incidence of CAM is difficult to estimate. The rates may be overestimated due to lack of MRI for diagnosis of occult contralateral tumors. On the other hand, the incidence may be underestimated because patients may ignore physical exam findings or fail to have adequate follow-up.

Based on the information above, one could conclude that CAM due to altered lymphatic drainage and aberrant pathways is secondary to lymphatic rather than hematogenous spread. With that theory in mind, one could begin treating CAM with a curative intent rather than a palliative intent.

Key stats cited within (new to this vault)

  • Tokmak et al.: 2/330 (0.6%) patients showed contralateral axillary drainage on lymphoscintigraphy — and both had a prior SLNB or ALND. Direct precedent for “prior ipsilateral axillary surgery → later contralateral drainage,” in breast cancer rather than melanoma. (World J Surg Oncol 2014;12:205–210)
  • Maaskant-Braat et al., meta-analysis of repeat SLNB in locally recurrent breast cancer: aberrant drainage found in 43.2% of patients. (Breast Cancer Res Treat 2013;138:13–20) — a strikingly high number for exactly our scenario: re-operative mapping in a patient with prior ipsilateral nodal surgery.
  • Haagensen (1972) hypothesised breast cancer could spread to the contralateral axilla via permeation of the deep lymphatic plexus of the chest wall — an early precursor of the “collateral pathway” mechanism used throughout this vault.

My take

This is a stronger comparator than previously credited. The 18-year latency between the original ipsilateral axillary surgery and the contralateral finding is close to our case’s ~20 years — the two longest-latency comparators in the whole vault are now this one and Uren et al.’s 2003 internal-mammary case. It’s breast cancer, not melanoma, and there’s no ICG involved (lymphoscintigraphy alone, which was negative bilaterally here — the CAM was found on cross-sectional imaging, not lymphatic mapping), so it doesn’t erase the case’s novelty claim, but it does mean the “no source combines long latency + prior ipsilateral surgery + contralateral involvement” line needs a caveat: this paper gets two of three, in a different tumour type. The Maaskant-Braat 43.2% figure is worth featuring prominently in the Discussion — it’s the single best evidence that aberrant drainage in a re-operative field, our exact clinical situation, is common rather than exotic.

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