Case

A 59 year old female patient comes to your practice for a routine breast exam. She informs you that she knows how to administer self-breast exams and does so on a regular basis. She said she feels directly around the areola and has some concerns about what she is feeling on her left breast. When you administer a clinical breast exam, you find a sizeable lump at the 5cm, 11 o’clock location on the left breast located close to the skin. You schedule the patient for further imaging which shows a mass and large, swollen lymph nodes.   

Question 2/3 - Which lymph nodes are you most concerned about?

Click on your selected option(s) below  (correct = 2, over-thinking = 3+)

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Correct!  The tumor location close to the midline suggests that lymphatic drainage (and thus metastatic cell spread) could occur through perforator drainage to the parasternal region ('para-' meaning beside). Approximately 25% of lymph from the breast (medial breast) travels to the sternum. There is also a chance for lymph and metastatic cells to cross over the midline to the other breast, so as a precaution you would screen the right breast for metastatic nodules.

Correct!  Axilla lymph nodes are classified by their relationship to the pectoralis minor muscle.  Nodes lateral to the pectoralis minor muscle are level 1, receiving the bulk of breast lymph drainage.  The level 1 nodes feed to level 2 nodes located deep to the pectoralis minor, and the level 2 nodes feed into level 3 nodes located medial to the pectoralis minor muscle.

Unlikely to be a direct target. Axilla lymph nodes are classified by their relationship to the pectoralis minor muscle. Level 2 nodes are deep to the pectoralis minor muscle and receive the majority of their lymph flow from level 1 nodes. A deep tumor at or even within the pectoralis major muscle could drain directly into the interpectoral nodes and level 2 nodes, superficial tumors usually go the standard pathway of level 1 first.

Unlikely to be a direct target. Axilla lymph nodes are classified by their relationship to the pectoralis minor muscle. Level 3 nodes are medial to the pectoralis minor muscle and receive the majority of their lymph flow from level 2 nodes and interpectoral nodes. There is some direct drainage from the very most superior aspect of the breast (right up at or near to the clavicle), but that is very limited.  The described tumor location makes direct drainage to level 3 unlikely since the location is only 5cm from the nipple which from the patient image is ~10-15cm from the clavicle location.

Unlikey to be a direct target. If a mass is inferior on the breast spread to the abdomen is possible. In this case the mass is superior and slightly medial, making a low probability for some cells to make their way to the superior aspect of the abdomen. 

Unlikely to be a direct target. They receive lymph from the pectoralis major and deep breast glandular tissue located against the muscle tissue. Breast cancer can metastize to these nodes directly if the tumor is in the vicinity of the pectoralis musculature (i.e. superolateral aspect of the breast or deep pressed against the pectoralis major).  The described location of this patients tumor makes direct interpectoral node targeting unlikely.

Incorrect. Cervical lymph nodes are found along the carotid/jugular vessels in the neck and are involved in drainage of the head and neck. Lymph drainage from the breast does not pass superior to the clavicle.