Article Details

Opportunistic biopsy of internal mammary lymph nodes (IMLNs) during free-flap breast reconstruction can reveal otherwise occult nodal disease that directly alters staging and adjuvant therapy in selected breast cancer patients. This report describes a 42-year-old woman with pT1aN0, hormone receptor–positive, HER2-negative breast cancer who underwent delayed deep inferior epigastric perforator flap reconstruction two years after mastectomy and negative axillary sentinel node biopsy; an incidental IMLN harvested during internal mammary vessel preparation demonstrated isolated metastatic carcinoma, prompting tumor board–directed escalation to anthracycline- and taxane-based chemotherapy without post-mastectomy radiation to preserve flap integrity. Review of contemporary series shows that routine or opportunistic IMLN sampling during microsurgical breast reconstruction yields metastatic involvement in a minority of patients, including those with negative axillae, and frequently leads to nodal upstaging and modification of systemic therapy and regional nodal irradiation fields. These data support incorporating selective IMLN biopsy into reconstructive algorithms to refine N1b/N1c classification and individualize post-mastectomy radiation decisions.

Keywords: Breast cancer; Lymph nodes; Radiation; Mammoplasty; Mastectomy