Case presentation
Case 1
A 63-year-old patient was referred to our team for the surgical management of a squamous cell carcinoma of the skin with axillary metastases. Apart from obesity (i.e., BMI=34) and a history of lower back skin burns, the patient did not have any previous medical history. Prior to referral, the primary lesion had been resected with negative margins. The carcinoma was a poorly differentiated 5 mm thick ulcerated lesion, measuring 6 cm in diameter, located in the patient’s right dorsolumbar region. The tumor did not extend beyond the subcutaneous fat. Two months after the resection of the primary tumor, plastic surgery performed a thoracodorsal perforator flap and two metastatic axillary lymphatic nodes were found on pathological analysis. A postoperative PET/CT revealed the presence of a hypermetabolic axillary lymph node on the right side (Figure 1A). A biopsy of the axillary node confirmed the diagnosis of carcinoma and a metallic marker was inserted. Due to increased risks of side effects, related to the patient history of burns, radiation oncology decided against adjuvant radiotherapy. After presentation of the case at the multidisciplinary cancer conference, we proceeded with a bilateral axillary lymph node dissection. Surprisingly, neither metastatic node nor marker was retrieved in the right axilla on pathological analysis, and two nodes out of 10 were positive in the left axilla. We concluded that the previously proven metastatic node in the right axilla had been missed during the dissection. A postoperative ultrasound confirmed the presence of a 1.1 cm lymph node, containing a metallic marker, localized posteriorly, near the latissimus dorsi. Therefore, an I125 seed (Figure 2) was inserted under ultrasound guidance. The metastatic node was resected using radioactive seed localization. A small incision in the muscle fibers of the latissimus dorsi was needed to access the node. No subsequent recurrence was diagnosed at 21 months of follow-up.
Case 2
An 82-year-old patient was referred by his general practitioner for the surgical management of a recently diagnosed malignant melanoma on his left shoulder. The tumor was an ulcerated mass with a Breslow thickness of 5.9 mm and 16 mitoses per mm 2. A preoperative PET/CT demonstrated the presence of an ipsilateral hypermetabolic retropectoral lymph node measuring 2.9 cm (Figure 1B). A radioactive seed was inserted in the radiology department into this nonpalpable node. We performed local excision with 2 cm margins, together with the targeted removal of the seed node and a sentinel lymph node biopsy. Both Technetium-99 and methylene blue were used during the procedure. In addition to the seed node, five distinct sentinel nodes were resected. On the final pathology report, a 3 cm metastatic invasion was found in the seed node. The patient was followed by medical oncology in another center.
Case 3
A 41-year-old patient was seen in consultation for a second opinion concerning a positive retropectoral node. The patient had been previously operated for a triple-positive ipsilateral invasive ductal carcinoma (IDC) following neoadjuvant chemotherapy. The tumor was T3N3b and an abnormal internal mammary node was detected on initial imaging. An axillary lymph node dissection was performed, and metastases were detected in three out of nine harvested nodes. Sixty-two Gy of radiotherapy were administered in the adjuvant setting on the left anterior thorax, the left axilla, and the supraclavicular area. A bilateral prophylactic salpingo-oophorectomy was realized during the following year and the patient received endocrine therapy. Eighteen months later, a suspicious 1 cm retropectoral lymph node was detected on diagnostic chest CT performed to rule out pulmonary embolism in the context of acute dyspnea. A biopsy of the lymph node revealed the presence of breast carcinoma. There was no evidence of local recurrence or other distant metastatic sites on PET/CT (Figure 1C). The patient and the oncology team opted for a level III lymphadenectomy with the targeted resection of the metastatic node. The node was accessible for I125 seed insertion under ultrasound guidance. During surgery, a frozen section and radiography of the specimen both confirmed the successful removal of the positive seed node. No other nodes were found in the specimen on pathological analysis. The patient received adjuvant endocrine therapy and no recurrence was noted at 25 months of follow-up. Figure 3 illustrates a transpectoral approach.
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Case 4
A 66-year-old patient was referred to our academic hospital center for breast cancer recurrence in level I, II, and III left axillary lymph nodes. The patient’s past medical record included disseminated lupus erythematosus. Three years prior, the patient was diagnosed with a T2N1a invasive ductal carcinoma in the left breast. The tumor was estrogen receptor (ER)-positive and human epidermal growth factor receptor 2 (HER2)-negative. Due to lupus skin involvement precluding radiotherapy, a modified radical mastectomy was performed followed by adjuvant chemotherapy and endocrine therapy. Two years later, several enlarged ipsilateral axillary lymph nodes were found on a thoraco-abdominal CT, prescribed to investigate increased carcinoembryonic antigen (CEA) levels. A PET/CT and a biopsy confirmed a recurrence (Figure 1D). An axillary MRI demonstrated multiple abnormal nodes in level I, one 3.2 cm abnormal node in level II and one 1.2 cm node in level III. Before referral to our institution, the patient had a partial radiological response to systemic treatment including an aromatase inhibitor and a CDK4/6 inhibitor.
On a second PET/CT, obtained nine months later, a decrease in size of the axillary lymph node was noted with no distant metastases. An axillary lymph node dissection (ALND) with radioactive seed localization was performed. An I125 seed and a clip were implanted in the level III lymphadenopathy, located posterior to the pectoralis major. Due to fibrosis, the axillary lymph node dissection was arduous. After opening the pectoralis major muscle, the seed node, as well as three distinct enlarged nodes were removed. Five of 13 lymphatic nodes were metastatic on pathological analysis, including the targeted node. The patient continued receiving endocrine therapy and did not develop any recurrence at 23 months of follow-up.
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Case 5
A 53-year-old patient was diagnosed with invasive ductal carcinoma and a biopsy proven nonpalpable metastatic axillary lymph node. Partial mastectomy and sentinel lymph node biopsy were performed. However, the metallic clip implanted before surgery to mark the metastatic node was not detected on the intraoperative radiography of the specimen. Pathological analysis revealed two micrometastases in one of the three resected nodes. A second axillary ultrasound was undertaken postoperatively. The metastatic node and the metallic clip were both identified. A radioactive iodine-125 seed was inserted in the lymph node to help perform a subsequent targeted lymphadenectomy. The surgery was successful. The patient received adjuvant chemotherapy (i.e., doxorubicin, cyclophosphamide, and paclitaxel) followed by locoregional radiotherapy and endocrine therapy. The patient remained free of recurrence at 43 months of follow-up.
