ULTRASOUND EXAMINATION IN THE COMPREHENSIVE DIAGNOSTIC IMAGING OF PARASTERNAL LYMPH NODE METASTASES IN A PATIENT WITH BREAST CANCER: A CASE REPORT

Background. The parasternal lymphatic collector is an important pathway of the lymph drainage from the breast in breast cancer patients. Evaluation of parasternal lymph nodes is not available during physical examination. To date, no algorithm for diagnostic imaging of the parasternal lymphatic pathway has been developed. The presence of metastases in parasternal lymph nodes upstages the breast cancer patient to a minimum of clinical stage III disease.

Case description. We present the case of breast cancer progression in a 40-year-old woman. The patient received treatment for triple-negative stage IIA breast cancer (Т2N0M0) in 2018. In August, 2019, 18-FDG PET /CT images revealed a solitary metastasis in the parasternal lymph node. Ultrasound images also showed the same lymph node assessed by PET -CT and the additional parasternal lymph node metastasis. A fine-needle aspiration biopsy of both lymph nodes confirmed the specific involvement of the parasternal lymph nodes.

Conclusion. Ultrasound scans are used to assess the axillary, subclavian and supraclavicular lymphatic collectors, but there is little evidence in the literature on the use of ultrasound in the assessment of parasternal lymph nodes. Our clinical case shows the feasibility of using ultrasound in assessing the status of the parasternal of lymph nodes, as well as the feasibility of performing fine-needle aspiration biopsy by ultrasound navigation.

1. An Y.Y., Kim S.H., Kang B.J., Lee A.W. Comparisons of Positron Emission Tomography/Computed Tomography and Ultrasound Imaging for Detection of Internal Mammary Lymph Node Metastases in Patients With Breast Cancer and Pathologic Correlation by Ultrasound-Guided Biopsy Procedures. J Ultrasound Med. 2015 Aug; 34(8): 1385–94. doi: 10.7863/ultra.34.8.1385.

2. Eubank W.B., Mankoff D.A., Takasugi J., Vesselle H., Eary J.F., Shanley T.J., Gralow J.R., Charlop A., Ellis G.K., Lindsley K.L., AustinSeymour M.M., Funkhouser C.P., Livingston R.B. 18fluorodeoxyglucose positron emission tomography to detect mediastinal or internal mammary metastases in breast cancer. J Clin Oncol. 2001 Aug; 19(15): 3516–23. doi: 10.1200/JCO.2001.19.15.3516.

3. Segaert I., Mottaghy F., Ceyssens S., De Wever W., Stroobants S., Van Ongeval C., Van Limbergen E., Wildiers H., Paridaens R., Vergote I., Christiaens M.R., Neven P. Additional value of PET-CT in staging of clinical stage IIB and III breast cancer. Breast J. 2010; 16(6): 617–24. doi: 10.1111/j.1524-4741.2010.00987.x.

4. Orsaria P., Chiaravalloti A., Caredda E., Marchese P.V., Titka B., Anemona L., Portarena I., Schillaci O., Petrella G., Palombi L., Buonomo O.C. Evaluation of the Usefulness of FDG-PET/CT for Nodal Staging of Breast Cancer. Anticancer Res. 2018 Dec; 38(12): 6639–52. doi: 10.21873/anticanres.13031.

5. Sobin L.H., Gospodarowicz M.K., Wittekind Ch. TNM Classification of Malignant Tumours. 7th ed. New York: Wiley-Blackwell; 2009.

6. Gradishar W.J., Anderson B.O., Balassanian R., Blair S.L., Burstein H.J., Cyr A., Elias A.D., Farrar W.B., Forero A., Giordano S.H., Goetz M.P., Goldstein L.J., Isakoff S.J., Lyons J., Marcom P.K., Mayer I.A., McCormick B., Moran M.S., O’Regan R.M., Patel S.A., Pierce L.J., Reed E.C., Salerno K.E., Schwartzberg L.S., Sitapati A., Smith K.L., Smith M.L., Soliman H., Somlo G., Telli M., Ward J.H., Shead D.A., Kumar R. NCCN Guidelines Insights: Breast Cancer, Version 3.2018. J Natl Compr Canc Netw. 2019 Feb; 17(2): 118–26.

7. Whelan T.J., Olivotto I.A., Parulekar W.R., Ackerman I., Chua B.H., Nabid A., Vallis K.A., White J.R., Rousseau P., Fortin A., Pierce L.J., Manchul L., Chafe S., Nolan M.C., Craighead P., Bowen J., McCready D.R., Pritchard K.I., Gelmon K., Murray Y., Chapman J.A., Chen B.E., Levine M.N.; MA.20 Study Investigators. Regional Nodal Irradiation in Early-Stage Breast Cancer. N Engl J Med. 2015 Jul 23; 373(4): 307–16. doi: 10.1056/NEJMoa1415340.

8. Poortmans P.M., Collette S., Kirkove C., Van Limbergen E., Budach V., Struikmans H., Collette L., Fourquet A., Maingon P., Valli M., De Winter K., Marnitz S., Barillot I., Scandolaro L., Vonk E., Rodenhuis C., Marsiglia H., Weidner N., van Tienhoven G., Glanzmann C., Kuten A., Arriagada R., Bartelink H., Van den Bogaert W.; EORTC Radiation Oncology and Breast Cancer Groups. Internal Mammary and Medial Supraclavicular Irradiation in Breast Cancer. N Engl J Med. 2015 Jul 23; 373(4): 317–27. doi: 10.1056/NEJMoa1415369.

9. Snitkin V.M., Khakurinova N.D., Sholokhov V.N., Berdnikov S.N., Makhotina M.S., Valiev R.K., Sinyukova G.T., Gus A.I. Ultrasound diagnostics in assessing the condition of the parasternal lymph nodes in patients with breast cancer. Obstetrics and gynecology. 2019; 9: 148–52. (in Russian).