Abstract P3-12-12: Incidence of internal mammary node, sternum, and manubrium failure as detected by FDG-18 PET/CT
Authors: Grow JL , Choudhary G , Kuo P , Livingston RB , Gonzalez VJ 
Published: May 2016

Abstract
Introduction:
Elective radiotherapy to the internal mammary (IM) lymph nodes remains an ongoing subject of debate. While the incidence of occult IM involvement on extended mastectomy ranges from 15-65%, reported rates of IM failure are substantially lower (approximately 1%). Interest in this subject has resurfaced recently as randomized trials have shown a survival benefit to adjuvant regional node irradiation including the IM chain. The mechanism by which extended field radiotherapy leads to improved systemic outcomes has not been clearly demonstrated and the degree of benefit directly attributable to IM irradiation remains to be seen. We hypothesized that the IM lymphatic chain may provide a direct route for tumor cell dissemination into the the sternum or manubrium. As such, sternal metastases may be a manifestation of IM involvement rather than true hematogenous metastases. We sought to better elucidate patterns of failure by evaluating the incidence and timing of IM, sternal, or manubrial involvement identified by PET/CT imaging following diagnosis of metastatic breast cancer.
Patients and Methods:
Between 2007 and 2014, 96 patients with invasive breast cancer were found to have metastatic disease as diagnosed on FDG-18 PET/CT. Site of recurrence was scored as breast/chest wall, axilla/supraclav, IM chain, sternum/manubrium, or distant. IM or sternum/manubrium failure was scored as isolated (occurring without distant metastatic disease), synchronous (involved at initial diagnosis of distant metastatic disease), or metachronous (involved at any time after diagnosis of metastatic disease).
Results:
Isolated IM failures were observed in 3.1% of patients while isolated sternum/manubrium failures were recorded in 7.3% of patients. Isolated involvement of the sternum/manubrium or IM nodes occurred in 11.4%. The rate of synchronous IM failure was 11.4% with the rate of metachronous failure being 13.5%. The rate of synchronous sternum/manubrium failure was 17.7% with the rate of metachronous failure being 23.9%. The incidence of sternum/manubrium or IM involvement at the initial diagnosis of distant metastatic disease was 29.2% with the rate of involvement at any point increasing to 36.5%.
Conclusion:
The rate of internal mammary node failure by PET/CT at the time of metastatic diagnosis is higher than the incidence reported in previous trials. This discrepancy is likely due increased sensitivity of PET/CT and the difficulty of accurately assessing this region once patients have been found to have metastatic disease. Interestingly, sternum and manubrium were more often the first site of recurrence than the IM nodes. This could be due to a tropism of hematogenous metastases for these bones or could represent direct tumor cell dissemination from the internal mammary chain. This is of special interest as this region is incidentally included in the radiotherapy fields when targeting the IM nodes. Overall, our findings suggest that historic patterns of failure studies may underestimate the local benefit of internal mammary node radiotherapy.
Citation Format: Grow JL, Choudhary G, Kuo P, Livingston RB, Gonzalez VJ. Incidence of internal mammary node, sternum, and manubrium failure as detected by FDG-18 PET/CT. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-12-12.