Lu C, Xu H, Chen X, Tong Z, Liu X, Jia Y. Irradiation after surgery for breast cancer patients with primary tumours and one to three positive axillary lymph nodes: yes or no? Lymph node micrometastases (LNMM) was defined as the presence of metastases no larger than 2mm in the lymph nodes, which was firstly proposed by Huvos et al. I think that the fact I was determed to not let cancer steel any part of my life was the big factor in my well being. The number of different axillary surgery types reversed between 2010 and 2011. Cancer in lymph nodes: What happens and treatment - Medical News Today Breast cancers with 10 or more positive lymph nodes at the time of diagnosis are staged as pathological N3a (pN3a) and they have poor prognosis. Primary study endpoints were: LRR, defined as time from date of surgery to date of LRR after diagnosis regardless of incidence of other event types, including distant metastasis (DM), that were coincident, before or after the LRR or last follow-up date; RFS, defined as date of surgery to LRR or distant disease, whichever came first; last date of follow-up; and OS, defined as time from surgical intervention to date of death from any cause or last follow-up. Median tumor size was 1.8cm (range 0.15.0cm). FitzSullivan E, Bassett RL, Kuerer HM, et al. N Engl J Med. Overall, the proportion of pN1mi patients receiving SLNB is increasing year by year(P for trend<0.001). Impact of Number of Positive Lymph Nodes and Lymph Node Ratio on While a recent multi-center cohort study from Sweden [6] showed that lymph node micrometastases were associated with significantly lower 10-year breast cancer-specific survival (BCSS) and overall survival (OS) rates compared with lymph node-negative cases, while outcomes were similar to those of lymph node macrometastases, which may be associated with inadequate systemic treatment. Ann Surg Oncol. 2017;43(4):6729. Ann Surg. It is shown that in the T1-2N1miM0 population, patients older than 60 were more likely to receive SLNB, and patients younger than 40 were more likely to undergo ALND. Univariate and multivariate analyses of overall survival (OS) in T1-2N1miM0 patients. Clinical significance of extranodal extension in sentinel lymph node positive breast cancer. https://doi.org/10.1200/JCO.2002.02.026. Your surgeon may remove some or all the lymph nodes in your armpit to check for cancer cells. Weiser R, Polychronopoulou E, Haque W, et al. the contents by NLM or the National Institutes of Health. Andersson M, Kamby C, Jensen MB, Mouridsen H, Ejlertsen B, Dombernowsky P, Rose C, et al. By using this website, you agree to our Among them, the patients with one LNMM are the most significant (Supplemental TableS3). Patients-, tumor-, and treatment- level characteristics are presented as frequencies (N) and percentages, and compared using chi-square tests as appropriate. Ann. According to the survival analysis (Fig. A total of 27,032 patients with T1-2N1miM0 breast cancer were included in this study, of which 22,463 (83.1%) were involved in one LNMM, 3,089 (11.4%) in two, and 1,480 (5.5%) in three or more lymph nodes. Median follow-up was 10.8 years (range 021) for the entire cohort; 10.8 (range .1021.4) and 10.7 (range .9720.9) for the no-PMRT and PMRT groups, respectively. From the 6th edition of AJCC manual [2] for staging to the latest 8th edition [14], no matter how many number of micrometastasis lymph nodes were detected, they were all divided into the same pN1mi staging, and the difference in prognosis caused by the inconsistent number was not distinguished. Wu SP, Tam M, Shaikh F, et al. Most were localized to the chest wall (32/63 [51%]) and the supraclavicular nodes (17/63 [27%]). We excluded all patients who had T3 or T4 tumors, received neoadjuvant chemotherapy (NAC), or in whom the axillary node metastases were isolated tumor cells only. Weiser R, Haque W, Polychronopoulou E, et al. Donker M, van Tienhoven G, Straver ME, et al. Er, Her2 positive also. Patients who received PMRT were more likely younger (age 50 years [p=0.0011]), to have larger tumor size (p=0.0013), higher histologic grade (p=0.029), and to have LVI (p<.0001). However, it's impossible to remove and examine every lymph node and organ in the body to check for small cancer cells. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Univariate and unadjusted comparison of (A) locoregional recurrence, (B) recurrence-free survival, and (C) overall survival in postmastectomy radiotherapy versus no postmastectomy radiotherapy groups. The pathologist will determine if the biopsied lymph node is infected with cancer cells. And it is also unfortunate that cases receiving neoadjuvant chemotherapy (NAC) could not be identified in the SEER database, so axillary management cannot be discussed in patients receiving NAC. Cancer. Targeted cancer drugs for breast cancer | Cancer Research UK Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 1 Axillary lymph node dissection, however, is associated with significant morbidity, including long-term complications such as limitation of shoulder movements, paresthesias and arm numbness, and lymphedema, which can have a s. In Fig. In the analysis of axillary surgery and radiotherapy, we adopted the method of 1:1 nearest propensity score matching (PSM) with matching tolerance 0.02, in order to balance the characteristic differences between the two compared axillary surgery groups, covariables included in propensity score matching were age, race, marital status, grade, T stage, nodal status, estrogen receptor (ER) status, progesterone receptor (PR) status, HER2 status, type of breast surgery, radiation and chemotherapy. 2009;114(3):393402. There were 6838 breast cancer patients with LNMM, of which 2240 received SLNB and 4598 received ALND, and post-surgery relevant systemic therapy and local radiation therapy. However, it was felt this benefit may be outweighed by side effects in low LRR-risk patients.14. Ann Surg Oncol. The NSABP B-32 trial [11, 22] enrolled 3795 breast cancer patients who underwent BCS and received postoperative whole-breast radiotherapy(WBRT) and systemic adjuvant therapy. Another two large, single-institution studies separately from Memorial Sloan Kettering Cancer Center and MD Anderson Cancer Center [29, 30] demonstrated no difference in local recurrence rates(LRR) for patients with N1mi disease post-mastectomy and SLNB, regardless of further radiation or ALND. Characteristics of DNA macro-alterations in breast cancer with liver https://doi.org/10.1093/bjs/znab141. Moreover, after 2004, anti-HER2 therapy became standard at our institution due to its survival benefit.2123 Anti-HER2 therapy has also been shown to significantly improve local control.24 Furthermore, endocrine therapy used in the 1970s/1980s was limited to tamoxifen compared to the modern era, in which aromatase inhibitors are favored in postmenopausal women.25 In our patient population, 60% of patients receiving endocrine therapy had an aromatase inhibitor included. If cancer is found in the sentinel nodes (lymph node-positive), however, more lymph nodes may be removed with a procedure called axillary dissection. We designed this study to compare the prognosis and local treatment recommendations of N1mi breast cancer patients with different numbers of micrometastatic lymph nodes. Cancer. The results of the pathology exam help physicians determine the stage of breast cancer and create a treatment plan. Do not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Mamtani A, Patil S, Stempel M, Morrow M. Axillary micrometastases and isolated tumor cells are not an indication for post-mastectomy radiotherapy in stage 1 and 2 breast cancer [published correction appears in Ann Surg Oncol. So arm yourself and fight. Springer Nature. Roi Weiser et al. 2, it can be clearly seen that before 2010, most of the patients with pN1mi received ALND. However, in the overall population, ALND was associated with better overall survival than SLNB (adjusted HR 0.932, 95%CI 0.8740.994; P=0.033) (Supplemental TableS1), this trend was also the same in the Nmi=1 subgroup (adjusted HR: 0.926, 95%CI 0.8590.990; P=0.026) and the Nmi=2 subgroup(adjusted HR 0.828, 95%CI 0.6910.993; P=0.042) (Fig. The patients basic characteristics are shown in Table1. Significance of axillary macrometastases and micrometastases in mammary cancer. DF After propensity score matching. Swollen lymph nodes ( lymphadenopathy ) can be associated with breast cancer. Kaplan-Meier and Cox regression analysis were used to determine rates of LRR, recurrence-free survival (RFS), and overall survival (OS). 1989;63(1):1817. CS Lymph Nodes: Breast Cancer. Here, we present data of patients with more than 3 positive axillary lymph nodes (+aLN) receiving dd chemotherapy after a median follow-up period of 12.3 years. This data can be found here: Surveillance, Epidemiology, and End Results (SEER) database (https://seer.cancer.gov/). The management of the axilla in patients with LNMM has a long history. Breast Cancer and Lymph Nodes: Cancer Stage and Treatments - Healthgrades Further stratified analysis showed that in the SLNB subgroup, radiotherapy was associated with a significant survival benefit (HR 1.695, 95%CI 1.5341.874; P<0.001), whereas in the ALND subgroup, there was no significant prognostic difference with or without radiotherapy (HR 1.029, 95%CI 0.9331.136; P=0.564). 2009;361(7):65363. Use of this online service is subject to the disclaimer and the terms and conditions. 1980;45(12):291724. We previously reported LRR risk in patients with T1-2N1 breast cancer who underwent total mastectomy with or without PMRT and received modern adjuvant systemic therapy at a median follow-up of 6.8 years.15 Here we sought to update results beyond 10 years follow-up, as 95% of LRRs occur within 10 years after surgical intervention.3 Here we also evaluated relapse-free survival (RFS), overall survival (OS), and predictors of LRR when PMRT was omitted. Go to: INTRODUCTION AATRM trial [24] is a prospective and randomized clinical trial specifically targeting the early breast cancer patients with sentinel lymph node micrometastases, it randomized patients to ALND or clinical follow-up and showed no significant difference in DFS between two groups. Treating Breast Cancer Surgery for Breast Cancer Download Section as PDF Lymph Node Surgery for Breast Cancer On this page [ show] If breast cancer spreads, it typically goes first to nearby lymph nodes under the arm. The axillary. Gradishar WJ, Anderson BO, Abraham J, et al. We designed this study to distinguish the prognosis and local treatment recommendations of N1mi breast cancer patients with different numbers of micrometastatic lymph nodes involved. 8600 Rockville Pike Most of the time, swollen lymph nodes are a symptom of an infection. Furthermore, with 10.8 years median follow-up, we believe we have captured the overwhelming majority of LRR, as these events are infrequent beyond the first 10 years follow-up.3 The difference in LRR rates between the trials in the meta-analysis and our study may be partially attributed to two factors: more modern chemotherapy and endocrine treatment, and axillary clearance completeness. Staging of the Axilla in Breast Cancer and the Evolving Role of During an axillary lymph node dissection, anywhere from 10 to 40 lymph nodes are removed and examined. Yi M, Giordano SH, Meric-Bernstam F, et al. We designed this study to compare the prognosis and local treatment recommendations of N1mi breast cancer patients with different numbers of micrometastatic lymph nodes. The SEER*Stat version 8.4.0 was utilized to extract 32,032 pN1mi breast cancer patients information, diagnosed between January 2004 and December 2019 (Nov 2021 Submission). The .gov means its official. We find that age <40 years and presence of lymphovascular invasion are significant predictors of locoregional recurrence in those not receiving postmastectomy radiation. 2021;39(27):305682. It is a pill typically given for 2 years twice a day. This is referred to as lymph node status. Breast cancer-specific survival in patients with lymph node-positive The survival curves of different axillary surgery types. https://doi.org/10.1016/S1470-2045(10)70207-2. Stages of Breast Cancer | Understand Breast Cancer Staging Only 14% had three. Stage 2 Breast Cancer: 2A, 2B Symptoms & Treatment Baseline characteristics of before and after matching in patients, stratified by receive radiation or not. government site. https://doi.org/10.1016/S1470-2045(18)30380-2. Lymph node status and tumor size If cancer is found in the lymph nodes chemotherapy drugs that kill cancer, hormonal therapy medications that block the production of hormones or block the binding of a hormone to its receptor on the breast tumor and prevent the tumor from growing, and targeted therapy such as Herceptin which blocks a gene which has been turned on and promotes cancer growth and spread, may be required in addition to surgery, which removes the cancer. Lancet Oncol. The 10-year LRR rate in the age <40 years with LVI group was 28%; such a high rate warrants PMRT. Overgaard M, Jensen MB, Overgaard J, Hansen PS, Rose C, Andersson M, Kamby C, et al. Hence, if the EORTCs analysis had been limited to the 955 patients who underwent a mastectomy, it is unclear if the same conclusion could be reached. Finally, a total of 27,032 female breast cancer patients, with a stage of T1-2N1miM0, were included in our retrospective study. 2017;24(3):6529. This is known as regional spread or locally advanced breast cancer. Google Scholar. Bethesda, Maryland, USA. Lancet Oncol. Katz A, Strom EA, Buchholz TA, Thames HD, Smith CD, Jhingran A, Hortobagyi G, et al. Although the 10-year follow-up results of IBCSG 2301 [8] and the American College of Surgeons Oncology Group(ACOSOG) Z0011 trial [9] both support the avoidance of ALND in breast cancer patients with LNMM, most of these patients underwent breast-conserving surgery (BCS) plus whole breast radiation therapy (WBRT). Front Oncol. The ACOSOG Z0011 trial randomized women with clinical T1-T2 N0 breast cancer and 1-2 positive sentinel lymph nodes at the time of SLNB to no further axillary surgery or completion ALND. Cumulative incidence was estimated by calculating 1 minus the Kaplan-Meier estimate. Sci Rep, 10 (2020), p. 14684. . Distant nodes are coded in the field Mets at DX. Changing Views on Breast Cancer Metastasis The axillary lymph nodes run from the breast tissue into the armpit. Long-term outcomes of high-risk HR-positive and HER2-negative early The tumor is less than 20 mm (2 cm) in size and there is no spread to lymph nodes. Finally, 77% of our studys patients had an ER positive tumor, all of whom received hormonal therapy; in EORTC 22922, 78% of patients with known ER status had an ER positive tumor; only 59% of these patients received hormonal treatment.35 As previously stated, we believe modern chemotherapy and adequate hormonal treatment were important in lowering the LRR rate and improving survival in those without PMRT. Nonetheless, our study found discrepant results with different numbers of LNMM involved. Chapter Lymph node-positive means at least one axillary lymph node contains cancer. 4). Patients with LNMM are also treated in the light of the guidelines recommendation for patients with positive lymph nodes. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The spread of cancer to a new. Krag DN, Anderson SJ, Julian TB, et al. In addition, patients underwent breast-conserving surgery (BCS) were more likely to receive SLNB, while ALND was more common in patients with mastectomy. Background Lymph node micrometastasis is an important prognostic factor in breast cancer, but patients with different numbers of involved lymph nodes are all divided into the same N1mi stage without distinction. Remember one step at a time. Frasier LL, Holden S, Holden T, Schumacher JR, Leverson G, Anderson B, Greenberg CC, et al. Radiotherapy and tamoxifen after mastectomy in postmenopausal women -- 20 year follow-up of the South Sweden Breast Cancer Group randomised trial SSBCG II:I. Overgaard M, Nielsen HM, Overgaard J. Breast Cancer Res Treat. Recht A, Gray R, Davidson NE, Fowble BL, Solin LJ, Cummings FJ, Falkson G, et al. The survival curves of receiving radiotherapy or not, adjusted by other prognostic factors. And after 2011, the number of patients has gradually decreased. Itchy Nipple. If the findings show no cancer in the sentinel nodes (lymph node-negative), then it is unlikely that other lymph nodes have cancer so surgery to remove more lymph nodes is not necessary. We screened the Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute to identify eligible breast cancer patients in this retrospective study. Impact of postmastectomy radiation on locoregional recurrence in breast cancer patients with 1-3 positive lymph nodes treated with modern systemic therapy. Giuliano AE, Ballman KV, McCall L, et al. These two trials included 29% and 25% of patients with microscopic nodal disease respectively. Recent ASCO/ASTRO/SSO guidelines on PMRT in women with T1-T2 disease and 1-3 positive LNs strongly recommend a multidisciplinary decision to use PMRT and that the PMRT-use decision be made in a multidisciplinary manner. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. https://doi.org/10.1245/s10434-010-1253-3. 8th ed. After adjustment for other prognostic factors, the overall death risk of Nmi=2 increased by 1.145 times (95%CI 1.0471.251, P=0.003) compared with Nmi=1, and the risk of Nmi3 group increased by 1.697 times (95%CI 1.531.882, P<0.001) (Fig. McBride A, Allen P, Woodward W, Kim M, Kuerer HM, Drinka EK, Sahin A, et al. It isn't easy and I know that your mother will try and shield you because she is scared and doesn't want to hurt those she loves as well.One can just be there to listen and be there for them and that is the best one can do.Your already there and your mother should be proudTara, Ima a positive tooStage 3c with 18/20 positive nodes. It can also sometimes spread to lymph nodes near the collarbone or near the breastbone (the front center of the chest). We explored the characteristics and survival outcomes of the population receiving different local treatments, including different axillary surgery types and whether receiving radiotherapy or not. Galimberti V, Cole BF, Viale G, et al. volume21, Articlenumber:202 (2023) We designed this study to compare the prognosis and local treatment recommendations of N1mi breast cancer patients with different numbers of micrometastatic lymph nodes. https://doi.org/10.1016/S1470-2045(13)70035-4. Accordingly, National Comprehensive Cancer Network(NCCN) guideline [12] and American Society of Clinical Oncology(ASCO) guideline [13] recommend radiotherapy of the axilla in lieu of ALND in patients with pathological SLN-positive and low tumor burden. PubMed Central Effective in 2019 edition of ICD-10-CM, starting October 1, 2018. Patterns and risk factors of locoregional recurrence in T1-T2 node negative breast cancer patients treated with mastectomy: implications for postmastectomy radiotherapy. Federal government websites often end in .gov or .mil. We identified 1331 patients who had a mastectomy with 1-3 positive nodes. 2018 Jul; 25(7): 19121920. The axillary and internal mammary nodes were the recurrence site in 5 (8%) and 3 (5%) patients, respectively. The lymph nodes most likely to be affected are in the armpit (called axillary lymph nodes). 94% of our patients received an ALND; the median number of nodes removed was 18 versus <10 in some of the EBCTCG meta-analysis trials. [15] used National Cancer Database (NCDB) data to analyze the prognosis of lymph nodes status, and concluded all nodal status had a positive effect on survival compared with Nmic>1 status, with HRs of 0.68, 0.88, and 0.93 for N0, Nmi=1, and N1.1 disease respectively, with only N0 reaching statistical significance. A systematic review of morbidity associated with autologous breast reconstruction before and after exposure to radiotherapy: are current practics ideal? Blue indicates that the normalised inferred weight of the indicated signature is 0, and red indicates . AJCC cancer staging manual. Donker M, van Tienhoven G, Straver ME, Meijnen P, van de Velde CJ, Mansel RE, Cataliotti L, et al. While in the Nmi=2 subgroup, the proportion of receiving SLNB decreased to 38.1%, and the remaining 61.9% of patients received ALND. The type of cancer, the size, whether it has spread to distant sites--all these factors also affect prognosis. Quality assurance in breast cancer: EORTC experiences in the phase III trial on irradiation of the internal mammary nodes. After adjustment for other factors, receiving radiotherapy resulted in some improvement in prognosis (HR 1.107, 95%CI 1.0301.190; P=0.006) (Fig. Oncologists assume tiny, undetectable metastases may exist outside of the breast (s) and lymph nodes when: A tumor is of a particular size. Pathologic correlates of prognosis in lymph node-positive breast carcinomas. Trends in and outcomes from sentinel lymph node biopsy (SLNB) alone vs. SLNB with axillary lymph node dissection for node-positive breast cancer patients: experience from the SEER database. mmartin@geicam.org. Impact of evidence-based clinical guidelines on the adoption of postmastectomy radiation in older women. Baseline characteristics for different types of axillary surgery are presented in Supplemental TableS2. Clinical significance of extranodal extension in sentinel lymph node This decrease translated to a significant reduction in breast cancer mortality (rate ratio [RR] 0.84, 95% confidence interval [CI] 0.760.94, p=0.001). The survival curves of different local treatments combinations, including axillary surgery types and local radiotherapy. All electronic medical records were reviewed to update the follow-up status for each patient. Univariate and multivariate Cox regression analysis indicated that nodal status was an independent prognostic factor. During an axillary lymph node dissection . To investigate the prognostic significance of axillary lymph node micrometastases, the MIRROR trial [21] was the first retrospective cohort study of patients with LNMM and ITC, which confirmed that for patients who did not receive adjuvant therapy, both pN0(i+) and pN1mi stages are independent prognostic indicators. Hilliges C, Hsu M, Gallagher M, Stempel M, El-Tamer M, Brogi E. Morphologic features and prognostic value of lymphovascular invasion in lymph node positive breast carcinoma. It then ranges from stage I (1) through IV (4). Pathologic Evaluation of Lymph Nodes in Breast Cancer - ScienceDirect Stage 2 breast cancers typically spread to up to three lymph nodes. After a median follow-up of 95months, there was no significant difference in disease-free survival (DFS), OS and distant metastasis-free survival between pN1mi and pN0 stage patients. Second primary cancers after adjuvant radiotherapy in early breast cancer patients: a national population based study under the Danish Breast Cancer Cooperative Group (DBCG). CS Lymph Nodes: Breast Cancer In the SLNB subgroup, radiotherapy was associated with a significant survival benefit (adjusted HR 1.197, 95%CI 1.0761.331, P=0.001), whereas in the ALND subgroup, there was no significant prognostic difference with or without radiotherapy (HR 1.029, 95%CI 0.9331.136; P=0.564) (Supplemental FigureS2). Furthermore, complete ALND lowers the chance of residual nodal disease that may contribute to a higher axillary nodal recurrence. Tender, Swollen Breasts. https://doi.org/10.1245/s10434-016-5605-5. A recurrence outside those regions was considered distant metastatic disease. Chemotherapy was delivered to 952 patients (88%); in 76%, the regimen were anthracycline- and/or taxane-based. Measurement of extracapsular extension in sentinel lymph node as a There are also discussions on the prognostic significance of the involved lymph node number in patients with pNmi stage. Breast Cancer and Lymph Node Involvement: Treatment, Outlook - Healthline The authors declare no competing interests. "If you're going through hell, keep walking." The objective of the pathology evaluation of lymph nodes in breast cancer is the detection of all macrometastases larger than 2.0 mm using systematic gross and microscopic evaluation protocols. The median length of follow-up was 115 months. The number of patients with T1-2N1miM0 breast cancer undergoing different types of axillary surgery between 2004 and 2019. Google Scholar. T2 tumors approached significance in predicting LRR compared to T1 tumors (p=0.085) (Table 3). In 2018, Wu SP et al. hbspt.cta.load(4456983, '3c0f8c80-d3d6-4dc7-a40b-7c3bffd36c1c', {}); Virginia Oncology Associates 2023 All rights reserved. Copyright 2000-2023 Cancer Survivors Network, My mother is done with mascetomy,now the doc is telling that her 12 lymph nodes are positive, http://ww5.komen.org/BreastCancer/LymphNodeStatus.html. There was no significant difference in survival outcomes between SLNB and ALND with radiotherapy (P=0.121), nor between the two groups without radiotherapy (P=0.113). SEER is a publically available anonymous data source, so this study was not reviewed by a Human Subjects Committee. Therefore, the conclusions of these two studies can only be applied to the clinical practice of relevant populations that meet the inclusion criteria and cannot be extrapolated to all pN1mi patients. Terms and Conditions, Right from the beginning, I tried to have a positive out look. Arguably, in patients with clinically negative axillas and <40 years who have T1-2 tumors with LVI, a positive sentinel node may not dictate a completion ALND, as the axilla may be equally controlled with radiation therapy with lower rate of lymphedema. https://doi.org/10.1097/00000658-197101000-00006. 2007;14(12):337884. The presence of ECE was related to a higher mean of positive sentinel lymph nodes, 3.9 ( 4.8) vs. 2.0 ( 2.1), p = 0.001. Although only whether received radiotherapy or not achieved significant benefit, it still suggested that when the number of lymph node involved is different, the treatment mode should be focused and cannot be static. Recurrence in the axilla and chest wall developed in 5 patients; 1 had recurrence in the supraclavicular and internal mammary nodes (Table 2). Patients were divided into three groups for prognosis comparison according to the number of LNMM: N1mi with 1 (Nmi=1), 2 (Nmi=2), or more (Nmi3) involved lymph nodes. Supraclavicular nodal fields were included in 137/163 (84%) patients, axillary field in 7 (4%), and the internal mammary chain was added in 6 (4%).