Carcinoma of the male breast is a relatively rare disease that accounts for less than 1% of all the cases of cancer in men. Intracystic Papillary Carcinoma (IPC) is an extremely rare disease of the male breast, with a few case reports. The prognosis is excellent for the patients who are diagnosed with IPC, regardless of whether the tumour is in-situ or of an invasive type. We are reporting the case of a 50 year old man who presented with a painless cystic lump in the left breast. Ultrasonography revealed an intracystic tumour. Fine needle aspiration suggested a papillary tumour. The patient underwent simple mastectomy without a sentinel lymph node biopsy. The final pathologic examination revealed an intracystic papillary carcinoma of a low nuclear grade without an invasion.
Intracystic papillary carcinoma; Male breast cancer
The term "intracystic papillary ductal carcinoma in situ" has recently changed and is now more appropriately referred to "intracystic papillary carcinoma". Intracystic papillary carcinoma in men is an extremely rare disease with only a few case presentations published in the literature so far.
We discuss a case of a 44-year-old Caucasian man with an intracystic papillary carcinoma treated with simple mastectomy, sentinel lymph-node biopsy and contralateral risk-reducing mastectomy. These were followed by adjuvant radiotherapy of the breast.
Triple assessment (i.e. clinical examination and radiological and histological assessment) with a high level of clinical suspicion is necessary to diagnose intracystic papillary carcinoma in men due to its rarity. Furthermore, genetic testing and risk-reducing mastectomy should also be considered in cases of a strong family history for male breast cancer.
Intracystic (encysted) papillary cancer (IPC) is a rare entity of breast cancer accounting for approximately (1–2%) of all breast tumours , usually presenting in postmenopausal women and having an elusive natural history. The prediction of the biological behaviour of this rare form of breast cancer and the clinical outcome showed its overall favourable prognosis; however, its consideration as a form of ductal carcinoma in situ with non-invasive nature is to be reconsidered as it has been shown to present histologically with invasion of basement membrane and even metastasis . The objective of this review is to shed some light on this rare, diagnostically challenging form of breast cancer, including its radiological, histological, and molecular characteristics and its pathological classification. The final goal is to optimize the clinical management including the role of sentinel lymph node biopsy (SLNB), general management with adjuvant radiotherapy (RT), mammary ductoscopy, and hormonal treatment.
A literature review, facilitated by Medline, PubMed, and the Cochrane database, was carried out using the terms ‘Intracystic (encysted) papillary breast cancer’.
Intracystic papillary breast cancer (IPC) is best managed in the context of a multidisciplinary team. Surgical excision of the lump with margins in excess of 2 mm is considered satisfactory. Sentinel lymph node biopsy (SLNB) is recommended as data have shown the possibility of the presence of invasive cancer in the final histology. RT following IPC alone is of uncertain significance as this form of cancer is usually low grade and rarely recurs. However, if it is associated with DCIS or invasive cancer and found in young women, radiotherapy may be prudent to reduce local recurrence. Large tumours, centrally located or in cases where breast conserving surgery is unable to achieve a favourable aesthetic result, a skin sparing mastectomy with the opportunity for immediate reconstruction can be offered. Adjuvant endocrine therapy may be suggested as almost certainly these tumours are hormonal positive.
Further research is required to determine the role of adjuvant radiotherapy and endocrine therapy in IPC. Understanding the low-grade nature of this form of breast cancer allows treatment options to be less radical and safely omitted.
intracystic papillary breast cancer; wide local excision; ductal carcinoma in situ; mammary ductoscopy; sentinel lymph node biopsy; radiotherapy; endocrine therapy; local recurrence
We herein report a case of synchronous bilateral solid papillary carcinoma of the breast. A 73-year-old female had a mass that was detected in the right breast on mammography. An ultrasound examination revealed one intracystic tumor in the right breast and two tumors in the left breast. A fine-needle aspiration biopsy of these three tumors was performed, which revealed a diagnosis of malignancy. A magnetic resonance imaging examination of the breasts showed diffuse small nodules surrounding these tumors bilaterally. Bilateral partial mastectomy and a sentinel lymph node biopsy were performed. Lymph node metastasis was detected in the right axilla, and additional lymph node dissection was performed. The pathological diagnosis was synchronous bilateral breast cancer, invasive ductal carcinoma NOS of the right breast, mucinous carcinomas of the left breast, and bilateral SPCs. A wide range of surgical margins were positive for SPCs, and additional bilateral total mastectomy was then performed. To the best of our knowledge, little is known about synchronous bilateral SPCs. Our case indicates that some SPCs can be widely scattered and make up a variety of invasive carcinomas. It is difficult to make a correct preoperative evaluation in such cases.
This study reports two cases of intracystic papillary carcinoma of the breast, which had been biopsied preoperatively using a 14 gauge (14G) core biopsy needle. In each case, a needle tract containing groups of epithelial cells within granulation tissue could be identified on histology of the excised specimen. Both cases showed extracapsular tumour, which was interpreted as displacement of epithelium related to preoperative core biopsy. Subsequent axillary lymph node sampling showed no evidence of metastasis. In one case, extracapsular tumour appeared to be in blood vessels, but flattened cells lining the spaces containing tumour failed to react with factor 8 related antigen or CD34 on immunohistochemistry. It is likely that intracystic papillary carcinomas are particularly prone to this artefact because friable tumour fragments escape, accompanied by cyst fluid, when the capsule is punctured by a 14G core biopsy needle.
papillary carcinoma of breast; displaced epithelium; pseudoinvasion; core biopsy
Intracystic papillary carcinoma represents a small distinctive subgroup of noninvasive breast cancer, accounts for <0.5% of breast malignancies and is extremely rare in men, it was originally reported as a localized non-invasive carcinoma, but is usually associated with ductal carcinoma in situ around the main tumor or invasive carcinoma.
We report a case of 50-year-old man with intracystic papillary carcinoma in man with ductal carcinoma in situ who underwent a tumorectomy following by a radical Patey intervention (Halsted).
Nowadays, there is still no clear consensus regarding optimal treatment of intracystic papillary carcinoma. Most papers reinforce the importance of an adequate surgical margin in conservative treatment. Surgeons must pay much attention to the potential for ductal carcinoma in situ around the tumor when selecting the operative procedure.
Intracystic papillary carcinoma (IPC) is an uncommon breast neoplasm. There are limited data about its epidemiology and only small studies focusing on outcomes. Using a large, population-based database, this study aims to identify specific characteristics of patients with IPC, investigate its natural history, and determine its long-term prognosis.
Materials and Methods
The California Cancer Registry (CCR), a population-based registry, was reviewed from the years 1988 to 2005. The data were analyzed with relation to patient gender, age at presentation, tumor stage, and overall survival. Cumulative relative actuarial survival was determined using a Berkson-Gage life table method. The CCR classifies IPC as either in-situ (CIS) or invasive, as determined by the local pathologist.
A total of 917 cases of IPC were identified. Forty-seven percent of cases (n=427) were CIS while 53% of cases had invasion (n=490). Most of the invasive cases were localized at the time of diagnosis (89.6%, n=439). At 10 years, patients with CIS and invasive disease had a similar relative cumulative survival (96.8% and 94.4%, P=0.18).
Intracystic papillary carcinoma is a rare disease. There is no significant difference in the long-term survival of patients in the two histologically-derived subgroups of IPC. There is an excellent prognosis for patients diagnosed with IPC regardless of whether the tumor is diagnosed as in-situ or invasive. Clinicians should keep this in mind when planning surgical and adjuvant treatments. Sentinal lymph node biopsy may be a prudent way to evaluate axillary involvement in patients with IPC
intracystic papillary carcinoma; breast cancer; California Cancer Registry
Breast carcinoma is an uncommon neoplastic condition among man, accounting for not more than 1% of all breast cancers. Intracystic papillary carcinoma in man is an extremely rare condition and represents only 5–7,5% of all male breast carcinomas. Clinical and radiological manifestations of intracystic papillary carcinomas are not specific. Pathologic diagnosis can be difficult at classical histological examination and identification of myoepithelial cells layer by immunohistochemical study can be useful. Adjuvant therapy is still controversial and prognosis is excellent. We report a case of this rare histological type of breast cancer in 48-year-old male patient and review the literature.
The presence of ectopic breast tissue in axillary lymph nodes (ALN) is a benign condition that must be differentiated from primary or metastatic carcinoma. Here we report a patient who underwent excision of enlarged ALN 10 years after she had received surgical treatment of ipsilateral breast for an intracystic intraductal papilloma (IDP). Histological examination of the removed ALN revealed that the proliferative lesion consisted of papillary and tubular structures lined by luminal cuboidal cells and a distinct outer layer of myoepithelial cells resembling IDP of the breast. Immunostaining with a set of immunohistochemical markers including AE/AE3, alpha-smooth muscle actin and p63 in combination with estrogen and progesterone receptors confirmed the diagnosis of ectopic IDP.
This case shows that even though benign proliferative change in ectopic breast tissue is an extremely rare phenomenon, this possibility should be taken into account for correct diagnosis.
Intracystic papillary carcinoma is a rare malignant tumor of the breast. It occurs communally in postmenopausal women. Clinically it can be asymptomatic or manifested by a breast mass or a nipple discharge. On imaging intracystic papillary carcinoma has usually benign features. Pathologic diagnosis can be difficult at classical histological examination and identification of myoepithelial cells layer by immunohistochemical study can be useful. In the majority of cases of pure intracystic papillary carcinoma, conservative management is possible. Adjuvant therapy is still controversial and prognosis is excellent. We report three cases of intracystic papillary carcinoma diagnosed on immunohistochemical examination and managed with conservative surgery.
A 56-year-old woman noticed a palpable mass in her left breast during self-examination. Patient was admitted to our hospital and malignant bifocal tumour was diagnosed by ultrasonography, digital mammography, magnetic resonance, and core-cut biopsy. The patient underwent planned conservative surgery (biquadrantectomy) with a sentinel node examination, but after results of the frozen section with positive resection margins and positive sentinel lymph nodes subsequent mastectomy with axillary lymph node dissection were realized. Histology in the resection specimen revealed two isolated and distinct tumours. One of the lesions represented conventional invasive ductal carcinoma of histological grade 3, and the second tumour was evaluated as invasive lipid-rich carcinoma, containing tumour cells with clear and foamy cytoplasm. Lipids in neoplastic cells were detected by Oil Red O staining and ultrastructural examination. Immunohistochemical analysis of both carcinomas was almost identical with negative steroid receptors, positive staining of HER-2, and p53 and with high proliferation activity (Ki-67). Mastectomy specimen contained residual foci of invasive ductal carcinoma and dissected axillary lymph nodes were free of metastasis. Patient underwent first cycles of chemotherapy with paclitaxel and Herceptin together with local radiotherapy and two month after surgery is without any evidence of the disease.
Introduction. Fibrocystic disease of the male breast is uncommon. The presence of a spectrum of changes ranging from fibrocystic disease to duct papilloma to papillary carcinoma in the same patient renders the case a rarity and therefore reportable. Case Report. A case of intracystic papillary carcinoma of the male breast is presented. Discussion. The pathological, clinical, diagnostic, and therapeutic options are discussed after reviewing the literature. Conclusion. Modified radical mastectomy with axillary clearance is the safest option for established cases.
Patient: Female, 66
Final Diagnosis: Infiltrating ductal carcinoma • small lymphocytic lymphoma
Clinical Procedure: Sentinel Lymph Node Biopsy • lumpectomy • axillary lymph node dissection
Specialty: Breast cancer surgery
Rare presentation of two concomitant malingancies
Lymphatic mapping of axillary breast cancer metastases in the presence of concomitant lymphoproliferative disease is still a controversial topic. Previous reports have postulated that tumor collision in the lymph nodes could lead to false-negative results of sentinel lymph node biopsy, leading to erroneous staging.
We present the case of a 66-year-old woman with infiltrating ductal breast carcinoma and small lymphocytic lymphoma in whom we performed a lumpectomy and sentinel lymph node biopsy with Technetium-99 and 1% methylene blue, followed by axillary lymph node dissection regardless of the intraoperative status, which was negative. Final pathology confirmed the absence of lymph node metastases.
Previously published cases reported correct assessment of SLNB in patients with concomitant small lymphocytic lymphoma and breast carcinoma. We postulate a possible pathological explanation for this: lymphoid cell clusters with pseudofollicles or proliferative centers of small lymphocytic lymphoma are localized outside the nodal sinuses of the lymph node, maintaining its capability of draining, and thus, the feasibility of SLNB in these patients, as in the presented case.
breast cancer; lymphoid malignancies; Sentinel Lymph Node Biopsy (SLNB)
Axillary lymph node status is the strongest prognostic indicator of survival for women with breast cancer. The purpose of this study was to evaluate whether sentinel lymph node biopsy (SLNB) is required in patients with an initial diagnosis of ductal carcinoma in situ (DCIS).
A retrospective analysis was performed of 78 patients with an initial diagnosis of DCIS between December 2002 and April 2010 and who proceeded to have either SLNB or axillary node dissection performed as part of their primary surgical procedure. The study focused on the rates of axillary node metastasis and the underestimation of invasive carcinoma at an initial diagnosis.
Forty-eight patients underwent SLNB and 18 patients underwent axillary node dissection. Only 1 of 66 patients (1.5%) had a positive sentinel lymph node. After definite surgery, the final diagnosis was changed to invasive ductal carcinoma (IDC) in 12 patients and DCIS with microinvasion in 2 patients; 14 of 78 patients (17.9%) were therefore underestimated at preoperative histological examinations. In 35 patients who were diagnosed DCIS by core needle biopsy (CNB), 13 patients (37.1%) were upstaged into IDC or DCIS with microinvasion in the final diagnosis. The statistically significant factors predictive of invasive breast cancer were a large tumor size and HER2 overexpression.
The rates of SLNB positivity in pure DCIS are very low, and there is continuing uncertainty about its clinical importance. However in view of the high rate of underestimation of invasive carcinoma in patients with an initial diagnosis of DCIS, SLNB appears to be appropriate in these patients, especially in the case when DCIS is diagnosed by a core needle biopsy. In patients with an initial diagnosis of DCIS by CNB, SLNB should be considered as part of the primary surgical procedure, when preoperative variables show a tumor larger than 2.35 cm and with HER2 overexpression.
Breast; Ductal carcinoma in situ; Sentinel lymph node
Secretory mammary carcinoma is a rare breast neoplasia originally described in children but sometimes also found in adults. It presents a more favourable outcome than more common histological types of breast carcinoma; published literature in fact reports only a few cases with axillary lymph node metastases and only four cases with distant metastases.
In this paper we report a rare case of secretory breast carcinoma with axillary lymph node metastases in a 33-year-old woman. To our knowledge, this is the first case of secretory carcinoma involving biopsy of the sentinel lymph node and investigation of the e-cadherin expression.
We found positivity for e-cadherin, which would support the hypothesis that this type of tumour is a variant of the infiltrating ductal carcinoma.
After a careful analysis of reported data, we have come to the conclusion that the treatment of choice for patients with secretory breast carcinoma should be conservative surgery with sentinel lymph node biopsy, followed by accurate follow-up. We are of the opinion that while post-operative radiotherapy is indicated in adult patients who have undergone quadrantectomy, it should not be used in children. Although several cases of secretory carcinoma have been treated with adjuvant chemotherapy, there are still no reliable data regarding the real value of such a choice.
A 47-year-old female presented with a 1-year history of ‘eczematous change’ to the right nipple. Bilateral mammography and ultrasound were entirely normal. Free hand biopsy demonstrated invasive adenocarcinoma of the nipple. The patient underwent a right-sided central segmentectomy and sentinel node biopsy. Histology demonstrated that the nipple was almost completely replaced by an invasive ductal carcinoma with a maximum diameter of 13 mm. Invasion of the underlying breast tissue was to a depth of 3 mm. A single sentinel lymph node demonstrated metastatic carcinoma. Her oestrogen receptor status was positive while HER-2 status was negative. The patient subsequently underwent right-sided axillary node clearance to level three nodes. All 17 nodes in the specimen were found to be within normal limits. She is scheduled to undergo radiotherapy, chemotherapy and hormonal treatment.
Pure mucinous carcinoma of the male breast is an extremely rare neoplasm. It is characterized by a lower incidence of metastatic nodal involvement and a higher survival rate than invasive ductal carcinomas.
We report the case of a 75-year-old male who presented with a retroareolar mass of the right breast. The patient underwent radical mastectomy including right axillary lymph node dissection. The tumor was well demarcated and had a friable consistency with a gelatinous appearance. Histologically, the diagnostic of pure mucinous carcinoma with lymph node metastasis was performed. After surgery, the patient received chemotherapy, radiotherapy, and hormonotherapy (Tamoxifen). The patient remained free of disease for 36 months after surgery.
Pure mucinous carcinoma of the male breast is a very rare tumor; in which axillary nodal disease is exceptional.
Mucinous carcinoma; male breast cancer; axillary lymph node metastasis
Papillary carcinoma of the male breast is very rare. In this case report, we describe the cytologic, histologic, immunohistochemical, and radiological findings of a papillary carcinoma of male breast. A 67-yr-old man, who had a previous history of prostatic adenocarcinoma, presented with a retroareolar painless mass. There was no known history of breast cancer in his family. A fine-needle aspiration biopsy (FNAB) was performed. Cytological examination revealed a cellular aspirate with three-dimensional papillary clusters. A diagnosis of papillary lesion favoring papillary carcinoma was rendered. Immunohistochemical staining of the cell-block of the FNAB revealed the presence of mammaglobin, and the absence of prostatic specific antigen. The patient underwent lumpectomy, which showed a moderately differentiated infiltrating papillary carcinoma with adjacent areas of ductal carcinoma in situ. FNAB is a useful technique in identifying male breast carcinoma. In conjunction with ancillary studies, this procedure can effectively differentiate between a primary versus metastatic lesion.
male breast malignant tumor; papillary carcinoma; prostatic carcinoma; mammaglobin
Intramammary lymph nodes (ILN) are often diagnosed by final histological examination. Recently, sentinel lymph node biopsy (SLNB) has been developed as a new standard in the treatment of breast cancer. However, reports describing intramammary sentinel nodes (ISLNs) are relatively rare, and the clinical significance of metastases in ISLNs is still unclear.
We herein report a patient with breast cancer with an ISLN that was detected prior to surgery. In the current case, the ISLN contained foci of carcinoma, but the axillary SLNs (aSLN) did not contain such foci. Previous reports related to ISLNs and aSLNs, including our case, are reviewed. Interestingly, there was no case with negative ISLNs and positive aSLNs.
The current and previous cases have shown that axillary lymph node dissection (ALDN) might rely on the aSLN status but not on the ISLN status. The effect on the prognosis or clinical significance in cases with positive ISLNs has not been fully elucidated. Cases of ISLNs found by SLN navigation are discussed in relation to their clinical significance.
Breast cancer; Intramammary node; Sentinel node
Cystic breast masses are a common presentation to breast clinics. While the majority of cysts can be managed by simple aspiration, a small proportion are malignant. Histology records for a 10-year period have been examined to identify patients with cystic breast carcinomas. In all, 31 patients were identified. Of these, 18 had cystic degeneration of high-grade tumours, while 13 had intracystic papillary carcinoma. Both of these tumour types were diagnosed by a combination of cyst fluid cytology and breast imaging. The prognosis of high-grade tumours was poor, while that of intracystic papillary carcinomas was excellent. After cyst aspiration, bloodstained fluid should be sent for cytology and breast imaging arranged in all patients. Patients in whom a cyst refills within 2 week of aspiration require a careful re-evaluation. Cysts in postmenopausal women should be viewed with suspicion. Excision should be performed in patients with positive cytology or imaging.
One of the most exciting and talked about new surgical techniques in breast cancer surgery is the sentinel lymph node biopsy. It is an alternative procedure to standard axillary lymph node dissection, which makes possible less invasive surgery and side effects for patients with early breast cancer that wouldn't benefit further from axillary lymph node clearance. Sentinel lymph node biopsy helps to accurately evaluate the status of the axilla and the extent of disease, but also determines appropriate adjuvant treatment and long-term follow-up. However, like all surgical procedures, the sentinel lymph node biopsy is not appropriate for each and every patient.
In this article we review the absolute and relative contraindications of the procedure in respect to clinically positive axilla, neoadjuvant therapy, tumor size, multicentric and multifocal disease, in situ carcinoma, pregnancy, age, body-mass index, allergies to dye and/or radio colloid and prior breast and/or axillary surgery.
Certain conditions involving host factors and tumor biologic characteristics may have a negative impact on the success rate and accuracy of the procedure. The overall fraction of patients unsuitable or with multiple risk factors that may compromise the success of the sentinel lymph node biopsy, is very small. Nevertheless, these patients need to be successfully identified, appropriately advised and cautioned, and so do the surgeons that perform the procedure.
When performed by an experienced multi-disciplinary team, the SLNB is a highly effective and accurate alternative to standard level I and II axillary clearance in the vast majority of patients with early breast cancer.
OBJECTIVE: To review recent advances in radiation therapy in treatment of breast cancer. QUALITY OF EVIDENCE: MEDLINE and CANCERLIT were searched using the MeSH words breast cancer, ductal carcinoma in situ, sentinel lymph node biopsy, and postmastectomy radiation. Randomized studies have shown the efficacy of radiation treatment for ductal carcinoma in situ (DCIS) and for invasive breast cancer. MAIN MESSAGE: Lumpectomy followed by radiation is effective treatment for DCIS. In early breast cancer, shorter radiation schedules are as efficacious for local control and short-term cosmetic results as traditional fractionation regimens. Sentinel lymph node biopsy is done in specialized cancer centres; regional radiation is recommended for patients with four or more positive axillary lymph nodes. Postmastectomy radiation has been shown to have survival benefits for high-risk premenopausal patients. Systemic metastases from breast cancer usually respond satisfactorily to radiation. CONCLUSION: Radiation therapy continues to have an important role in treatment of breast cancer. There have been great advances in radiation therapy in the last decade, but they have raised controversy. Further studies are needed to address the controversies.
Neck lymph node status is the most important factor for prognosis in head and neck squamous cell carcinoma. Sentinel node detection reliably predicts the lymph node status in melanoma and breast cancer patients. This study evaluates the predictive value of sentinel node detection in 50 patients suffering from pharyngeal and laryngeal carcinomas with a N0 neck as assessed by ultrasound imaging. Following 99m-Technetium nanocolloid injection in the perimeter of the tumour intraoperative sentinel node detection was performed during lymph node dissection. Postoperatively the histological results of the sentinel nodes were compared with the excised neck dissection specimen. Identification of sentinel nodes was successful in all 50 patients with a sensitivity of 89%. In eight cases the sentinel node showed nodal disease (pN1). In 41 patients the sentinel node was tumour negative reflecting the correct neck lymph node status (pN0). We observed one false-negative result. In this case the sentinel node was free of tumour, whereas a neighbouring lymph node contained a lymph node metastasis (pN1). Although we have shown, that skipping of nodal basins can occur, this technique still reliably identifies the sentinel nodes of patients with squamous cell carcinoma of the pharynx and larynx. Future studies must show, if sentinel node detection is suitable to limit the extent of lymph node dissection in clinically N0 necks of patients suffering from pharyngeal and laryngeal squamous cell carcinoma.
British Journal of Cancer (2002) 87, 711–715. doi:10.1038/sj.bjc.6600445 www.bjcancer.com
© 2002 Cancer Research UK
sentinel node; N0 neck; squamous cell carcinoma; larynx; pharynx; occult metastases
Papillary thyroid carcinoma presenting as isolated cervical lymphadenopathy with clinically and histologically normal thyroid gland is rarely reported.
We report a case of 31 years old female who presented with a left cervical mass and clinically normal thyroid gland. After inconclusive FANC, excision biopsy of her cervical lymph nodes revealed metastatic papillary thyroid carcinoma. The patient subsequently underwent total thyroidectomy with bilateral lymph node dissection. Interestingly pathological examination showed no primary carcinoma in the gland. Postoperative radioactive iodine scan revealed no other metastasis.
Total thyroidectomy is the next best step despite clinically and radiologically normal appearing thyroid gland once cervical lymph nodes are proven to be metastatic in nature followed by a RAI therapy to treat occult foci of PTC.
papillary thyroid micro carcinoma (PTMC); fine needle aspiration cytology (FNAC); computed tomography (CT); papillary thyroid carcinoma (PTC)
For accurate nodal staging, all blue and radioactive lymph nodes should be sampled during the sentinel lymph node biopsy for breast cancer. We report a case of anomalous drainage in which one of the sentinel lymph nodes was unexpectedly found in the level III axillary space.
A 40-year-old female underwent mastectomy for extensive high-grade ductal carcinoma in-situ (DCIS) with micro-invasion. The index lesion was located in the right upper inner quadrant. Lymphoscintigraphy was performed on the morning of surgery. Two sentinel lymph nodes were identified. At operation, 5 mls of isosulfan blue dye was injected at the same site of the radio-colloid injection. The first sentinel lymph node was found at level I and was blue and radioactive. The second sentinel node was detected in an unexpected anomalous location at level III, medial to the pectoralis minor. Both sentinel nodes were negative.
Sentinel node staging can lead to unexpected patterns of lymphatic drainage. For accurate staging, it is important to survey all potential sites of nodal metastasis either with preoperative lymphoscintigraphy and/or rigorous examination of regional nodal basins with the intra-operative gamma probe.