45-year-old patient, right-axillary lymph node suggestive of metastasis detected in sonography

Dr. S. Metz, Institute for Diagnostic and Interventional Radiology at the Technical University of Munich, Klinikum Rechts der Isar. Munich, Germany.

Case description

Right-axillary lymph node suggestive of metastasis detected in sonography. Initially ultrasound-guided punch biopsy of lymph node cancer cells. PET-CT and breast MRI for staging followed.

Second-look ultrasound and sono-biopsy of breast inside right: NST, G3, HR negative, HER2-immunohistochemistry: 3+

Course of treatment

Primary tumor and right-axillary lymph node clip marked with Tumark Vision. -> Primary systemic therapy initiated, consisting of 4 x EC followed by 12 x trastuzumab + pertuzumab weekly. 

Following  Primary Systemic Therapy (PST) complete remission (CR) shown in imaging.

Conclusion

A treatment option analogous to the course of action suggested in the SenTa study would be a suitable option for the presented case. The hospitals Kliniken Essen-Mitte (Kümmel S. et al.) have initiated this study, which is a prospective, multi-centric registry on usage frequency and feasibility of targeted axillary dissection in patients with primary breast cancer and PST in whom initially a punch biopsy is performed and the clinically suspicious lymph node is clip marked.   

The primary study goal defined is identifying the surgical detection rate of the clip-marked target lymph node (TLNB). In this context, sonographic distinguishing of the clip for pre-operative marking is of crucial importance.  

Pictures

primary lymph node metastasis

Image 1
Shows the primary lymph node metastasis (arrow).

Following primary systemic therapy (PST), images show complete remission (CR) of the metastasis, the lymph node’s inconspicuous morphology, the clip (Tumark Vision, arrow) in a regular position, highly visible in sonography.

Image 2
Following primary systemic therapy (PST), images show complete remission (CR) of the metastasis, the lymph node’s inconspicuous morphology, the clip (Tumark Vision, arrow) in a regular position, highly visible in sonography.

MRI corT1-w native to the right axilla; following PST.

Image 3
MRI corT1-w native to the right axilla; following PST.

Sonography of the (former) inside right breast tumor, the clip (Tumark Vision, arrow) clearly delimited. 5 months after initiation of PST.

Image 4
Sonography of the (former) inside right breast tumor, the clip (Tumark Vision, arrow) clearly delimited. 5 months after initiation of primary systemic therapy (PST).

MRI axialT1-w of right breast shows susceptibility artefact inside due to clip (Tumark Vision, arrow).

Image 5
MRI axialT1-w of right breast shows susceptibility artefact inside due to clip (Tumark Vision, arrow).

MRT als axiale Maximum-Intensitätsprojektion (MIP) der ersten Subtraktion.  Vor PST mit dem bis dahin okkulten Primarius rechts innen (Pfeil).

Image 6
MRI as axial Maximum Intensity Projection (MIP) of the first substraction
Prior to PST with the until then occult primary tumor inside right (arrow).

MRI as axial MIP of the first subtraction. Image shows CR after PST.

Image 7
MRI as axial MIP of the first subtraction.
Image shows CR after PST.