Elsevier

The Breast

Volume 23, Issue 3, June 2014, Pages 291-294
The Breast

Original article
Contralateral axillary nodal involvement from invasive breast cancer

https://doi.org/10.1016/j.breast.2014.03.004Get rights and content

Abstract

Metastatic breast cancer to the contralateral axilla (CAM) is defined as stage IV disease. We postulate that CAM represents an extension of local-regional disease rather than distant metastasis and may have a better outcome. A single-institution, retrospective review of breast cancer cases from January 2005 and May 2011 was performed to identify cases with CAM. Eligibility for the study included unilateral primary breast cancer at presentation with synchronous/metachronous documented CAM without a documented primary invasive breast cancer within the contralateral breast by surgery or MRI. Clinicopathologic data was recorded for these patients (pts). Thirteen pts were identified. 12/13 (92%) pts presented with a locally advanced breast tumor or an ipsilateral in-breast recurrence. 10/13 (77%) pts had documented dermal involvement of tumor either at initial presentation or local recurrence. CAM occurred synchronously with the initial primary tumor (5 pts, 38%), concomitant with a local recurrence (5 pts, 38%), metachronously with the initial tumor (1 pt, 8%), and metachronously with a local recurrence (2 pts, 15%). Three patients had other distant disease at presentation. Of the other 10 pts, seven developed distant disease with a mean follow up of 3.6 years (range 0.3–7.6 years). Three pts have no evidence of disease at a mean follow up of 5.8 years (range 1.5–8.2). CAM may have different prognostic implications than other distant metastases and may occur through dermal lymphatic spread. Further study is warranted on the prognosis and management of these challenging and rare cases.

Introduction

Breast cancer staging is based on tumor involvement within the primary site, regional nodal disease, and the presence or absence of distant metastases. Regional nodal sites are defined as ipsilateral axillary, infraclavicular, supraclavicular, and internal mammary nodes [1]. Evidence of nodal metastasis outside this area has traditionally been considered distant disease (stage IV).

Nodal metastases in the contralateral axilla are an uncommon finding in breast cancer. This scenario mandates a thorough evaluation of the contralateral breast to rule out a primary tumor as a source of these metastases, typically by mammography, sonography, and physical breast exam, as well as consideration for magnetic resonance imaging (MRI). In the absence of an identifiable primary contralateral breast lesion, patients may have either truly contralateral metastatic disease (“crossover metastasis”) or an occult contralateral breast cancer. This subtle determination is typically made based on the histologic appearance and prognostic panel testing of the axillary lesions compared to the index breast cancer. Contralateral axillary lesions with different histology or different estrogen receptor status, progesterone receptor status, and Her2neu expression from the index cancer would be more suggestive of an occult primary tumor rather than a contralateral extension of disease.

We postulate that metastatic disease to the contralateral axilla represents an extension of local-regional disease rather than distant metastatic disease. Although rare, this presentation is more likely seen with locally advanced tumors involving the dermis or in situations where traditional, ipsilateral axillary drainage is affected by prior axillary surgery or nodal status. Prior reports have described lymphatic drainage patterns outside the ipsilateral axilla; this is more common in patients with prior axillary surgery whereby ipsilateral axillary lymphatic drainage has presumably been disrupted [2], [3], [4].

The presentation of contralateral axillary metastases, particularly in the absence of other distant metastatic disease, represents a therapeutic dilemma. The current approach for stage IV breast cancer patients has the potential to undertreat an individual if the only site of distant metastasis is the contralateral axilla. Although the approach to metastatic breast cancer is in evolution [5], [6], classic teaching relies on primarily systemic therapy with limited use for surgery and radiation as palliation of symptoms. Should these lesions actually represent regional extension, failure to address the primary and nodal lesions in these unusual cases may actually be under treatment of potentially curative disease.

Section snippets

Materials and methods

This is an IRB-approved (IRB # Pro 00005425), single-institution, retrospective review of breast cancer cases between January 2005 and May 2011 presenting with contralateral axillary disease. Eligibility for the study included unilateral primary breast cancer at presentation with synchronous/metachronous documented metastasis to the contralateral axilla. All patients included in the study group had no evidence of primary invasive tumor within the contralateral breast either by having a

Results

Thirteen patients were identified that fulfilled eligibility criteria. The average age was 53 years (range 26.3–72.2) with 5/13 (38%) patients presenting with a locally advanced initial breast cancer and 7/13 (54%) with an ipsilateral breast recurrence. Eleven of the 13 cases (85%) were invasive ductal carcinoma; the remaining two were invasive lobular carcinoma. Eight of the 13 (62%) cases were estrogen-receptor positive and 2/13 (15%) cases were positive for HER2/neu overexpression by both

Discussion

Contralateral axillary spread of breast cancer, also known as “crossover metastasis”, is associated with a poor prognosis but may have different prognostic implications than other metastatic disease. These patients may be similar to patients with supraclavicular disease where studies demonstrated outcomes more similar to stage III than stage IV [7]. Crossover disease is seen more frequently in locally advanced tumors, especially those involving the dermis, as well as recurrent tumors where

Conclusion

Contralateral axillary metastatic disease may occur through dermal lymphatic spread and requires individualized, multidisciplinary management. While prognosis is poor in patients with advanced disease, disease free survival is attainable in a few patients. Further study is warranted on the prognosis and management of these challenging and rare cases.

Conflict of interest

No authors have a conflict of interest in this study.

References (15)

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