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In addition to axillary lymph node (ALN), internal mammary lymph node (IMLN) could also provide important prognostic information. In this paper, we will introduce a case of breast cancer patient whose preoperative lymphoscintigraphy revealed that there were "hot-spots" in bilateral intercostal space. The bilateral IMLN found by preoperative lymphoscintigraphy is a rare phenomenon. She received ipsilateral internal mammary sentinel lymph node biopsy (IM-SLNB) and IMLN dissection and contralateral IM-SLNB. She was diagnosed as pT2N3bM1 breast cancer based on the positive IMLN and positive ALN. After performing surgery, the pathology indicated: (left breast) invasive ductal carcinoma (3.0×3.0 cm 2 ), ALN (3/30), ipsilateral internal mammary sentinel lymph node (IMSLN) (1/2), IMLN (0/2); contralateral IMSLN (1/1). After performing IMLN surgery, the pathology staging increased from pT2N1aM0 to pT2N3bM1. And the irradiation therapy choice had been changed, she received irradiation therapy include chest wall, supraclavicular region, ipsilateral IMLN and contralateral IMLN. The treatment benefit had been increased. When the ipsilateral internal mammary lymphatic vessels were obstructed, deep lymphatic system might drain from ipsilateral IMLN to contralateral IMLN. The contralateral IMLN metastasis belongs to distant metastasis. The IMLN irradiation therapy should be tailored and balanced based on the statues of IMLN. With effective application of systemic therapy, the localized treatment advantage benefited from IMLN surgery might be transferred to survival benefit.

The study of internal mammary lymph node dissection guided by modified radiotracer injection technique in breast cancer-a case report and review