Contralateral axillary lymph node and chest wall skin recurrence 2 years after radical mastectomy for breast cancer: a case report and literature review
Case Report

Contralateral axillary lymph node and chest wall skin recurrence 2 years after radical mastectomy for breast cancer: a case report and literature review

Zhi-Yong Liu, Ran Chen

Breast Diagnosis and Treatment Center, Huangjin Branch, First Affiliated Hospital of Gannan Medical University, Ganzhou, China

Contributions: (I) Conception and design: Both authors; (II) Administrative support: None; (III) Provision of study materials or patients: ZY Liu; (IV) Collection and assembly of data: Both authors; (V) Data analysis and interpretation: Both authors; (VI) Manuscript writing: Both authors; (VII) Final approval of manuscript: Both authors.

Correspondence to: Zhi-Yong Liu, MD. Breast Diagnosis and Treatment Center, Huangjin Branch, First Affiliated Hospital of Gannan Medical University, No. 128 Jinling Road, Huangjin Technology Development Zone, Ganzhou 341000, China. Email: barton123321@163.com.

Background: Contralateral axillary lymph node metastasis (CAM) following radical mastectomy for breast cancer is a rare and clinically challenging event, with a reported incidence of approximately 1.9% to 6.0%. Its pathogenesis, often attributed to altered lymphatic drainage after primary breast surgery, is not fully elucidated. The classification of CAM remains controversial, as current American Joint Committee on Cancer (AJCC) staging guidelines categorize it as distant metastasis (M1), while emerging clinical evidence suggests its biological behavior and prognosis may align more closely with advanced regional (stage III) disease. This ambiguity complicates management, as standardized treatment guidelines are lacking. Accurate diagnosis is imperative and requires thorough investigation to exclude a new occult primary malignancy or metastases from other tumors.

Case Description: We report a detailed case of a 39-year-old female who developed synchronous CAM and extensive contralateral chest wall skin involvement, presenting as nodules and ulceration, 2 years after undergoing a right modified radical mastectomy for triple-negative breast cancer. Despite undergoing multiple lines of systemic therapy over several years, the disease progressed locally at these contralateral sites without evidence of other distant metastases. After comprehensive imaging and histopathological evaluation confirmed the metastatic origin from her primary breast cancer, the patient underwent aggressive local surgical resection. This included a left radical mastectomy with nipple-areola complex preservation, wide resection of the chest wall tumor, and immediate reconstruction using a pedicled latissimus dorsi flap. The patient tolerated the procedure well, achieved clear margins, and had a satisfactory postoperative recovery.

Conclusions: CAM represents a complex clinical scenario that necessitates meticulous differential diagnosis and multimodal evaluation. The outcome of this case, alongside a review of the literature, suggests that in selected patients without concomitant distant metastases, CAM may behave as a locoregional progression rather than systemic dissemination. Therefore, a blanket classification as stage IV disease may lead to the undertreatment of potentially curable local recurrences. Current evidence supports considering an aggressive local therapeutic approach, including surgery and/or radiotherapy, combined with systemic therapy to enhance local control and improve prognosis. An individualized, comprehensive treatment strategy is strongly recommended to optimize survival outcomes in such rare cases.

Keywords: Breast cancer; contralateral lateral chest wall recurrence; contralateral axillary lymph metastasis; individualized treatment; case report

Received: 09 November 2025; Accepted: 09 January 2026; Published online: 26 February 2026.

doi: 10.21037/acr-2025-317

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Key findings

• This case reports a rare instance of simultaneous contralateral axillary lymph node metastasis (CAM) and chest wall skin recurrence 2 years after right breast cancer mastectomy. Despite multiline systemic therapy, the disease progressed locally at these sites without distant metastases. Aggressive surgical resection, including left radical mastectomy and chest wall reconstruction, resulted in successful local control and good recovery.

What is known and what is new?

• CAM is a rare event often linked to altered lymphatic drainage post-surgery. Its staging is controversial: the American Joint Committee on Cancer system classifies it as stage IV (M1), while some evidence suggests a prognosis more akin to stage III regional disease.

• This case presents a unique, scarcely reported pattern of combined CAM and contiguous chest wall recurrence. It demonstrates that aggressive local therapy can achieve excellent control and a favorable outcome even after multiline chemotherapy failure, supporting the argument that CAM may represent regional progression rather than systemic dissemination in selected patients.

What is the implication, and what should change now?

• CAM may represent a locally advanced state rather than widespread metastasis in some patients. A blanket M1 classification might undertreat potentially curable local recurrences. The staging of CAM should be reconsidered. For isolated CAM, an individualized strategy centered on aggressive local therapy (surgery/radiotherapy) combined with systemic treatment should be strongly considered to improve survival outcomes.

Introduction

Breast cancer is the most common malignancy in women worldwide. Contralateral axillary lymph node metastasis (CAM) in breast cancer patients refers to the metastasis of breast cancer to the contralateral axillary lymph nodes, with a reported incidence that is low, ranging from approximately 1.9% to 6.0% depending on clinical context (1). CAM and breast cancer can occur simultaneously or asynchronously. Reports of contralateral lateral chest wall skin recurrence in association with CAM are exceedingly rare. This article presents a case report of a patient admitted to First Affiliated Hospital of Gannan Medical University who developed contralateral axillary lymph node and contralateral lateral chest wall skin recurrence and metastasis 2 years after breast cancer surgery, and conducts a retrospective analysis of relevant literature. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-317/rc).

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Current medical history and timeline

The patient, aged 39 years, was initially diagnosed with a malignant tumor in the right breast through color Doppler ultrasound, mammography, and magnetic resonance imaging (MRI) in November 2021. Subsequently, she underwent coarse needle aspiration of the right breast mass and coarse needle aspiration of the right supraclavicular lymph nodes. Postoperative pathological results showed that the specimen from the coarse needle aspiration of the right breast mass was invasive ductal carcinoma, non-specific type, with histological grade II. Immunohistochemical results were as follows: estrogen receptor (ER) (positive cell count <1%), progesterone receptor (PR) (positive cell count <1%), human epidermal growth factor receptor 2 (HER2) (0%), Ki-67 (35%+). The specimen from the coarse needle aspiration of the right supraclavicular lymph nodes showed cancer metastasis. The tumor staging is: cT2N3M0. A summary of the patient’s diagnosis, treatments, and disease progression is provided in Table 1.

Table 1

Timeline of patient’s diagnosis, treatment, and disease progression

Date Event Details
Nov 2021 Initial diagnosis Right breast invasive ductal carcinoma, grade II. ER−/PR−/HER2− (triple-negative). Right supraclavicular lymph node metastasis confirmed
Nov 2021 to 2022 Neoadjuvant & surgical therapy 6 courses of TAC chemotherapy. Right modified radical mastectomy [2022]. Post-op pathology: Miller-Payne grade 4 response; 12/29 axillary LNs positive. Adjuvant radiotherapy (25 sessions). Adjuvant capecitabine (5 months)
Oct 2022 First recurrence Enlarged left axillary lymph nodes. Biopsy confirmed metastatic breast cancer
2022 to 2023 Systemic therapy 1 8 courses of vinorelbine + cisplatin chemotherapy
Apr 2023 to Mar 2024 Systemic therapy 2 Oral vinorelbine capsules (stable disease), then switched to vinorelbine + capecitabine (4 courses)
Jun 2024 to Feb 2025 Systemic therapy 3 7 sessions of paclitaxel (albumin-bound) + carboplatin. Disease progression noted in left axilla (Jan 2025)
Jan to Mar 2025 Systemic therapy 4 & complication 4 sessions of carboplatin + gemcitabine + bevacizumab. Left axillary abscess (Mar 2025)
Apr 2025 Progression & new therapy MRI confirmed left chest wall skin recurrence/ulceration. Started eribulin + durvalumab (11 sessions)
Sep 2025 Definitive local therapy Left radical mastectomy with nipple preservation, chest wall tumor resection, and latissimus dorsi flap reconstruction
Post-op Outcome Good postoperative recovery. Final pathology: chest wall invasive carcinoma (grade III); 12/18 left axillary LNs positive

ER, estrogen receptor; HER2, human epidermal growth factor receptor 2; LN, lymph node; MRI, magnetic resonance imaging; PR, progesterone receptor; TAC, docetaxel, doxorubicin and cyclophosphamide.

On April 15, 2025, subcutaneous nodules were observed in the left breast, with uneven thickening of the skin in the left breast, left chest wall, and anterior axillary area, accompanied by multiple nodules and local ulcers, indicating tumor recurrence and surface skin ulcers (see Figure 1A). On September 15, 2025, a physical examination revealed that subcutaneous nodules were gradually becoming larger (see Figure 1B).

  • Physical examination (at time of definitive surgery planning): the right breast was absent. Multiple ulcers and excrescences were present on the skin of the left axillary region and left lateral chest/back. A localized induration was palpable on the left breast.
  • Auxiliary examination: enhanced computed tomography (CT) scans of the neck, upper abdomen (including liver, gallbladder, spleen, and pancreas), and chest show multiple lymph node shadows in the left anterior axillary region; uneven thickening of the skin in the left breast, left chest wall, and anterior axillary area, accompanied by multiple nodules; no obvious abnormalities were found in the neck and upper abdomen (see Figure 2). Breast ultrasound examination combined with axillary and supraclavicular regions showed multiple hypoechoic areas in the left axilla, with a maximum area of 37 mm × 16 mm and relatively clear boundaries. Color Doppler flow imaging (CDFI) showed abundant internal blood flow signals (see Figure 3). The detection of tumor markers [carcinoembryonic antigen (CEA), carbohydrate antigen 125 (CA125), carbohydrate antigen 153 (CA153)] did not show significant abnormalities. Various blood biochemical tests did not find any obvious abnormalities. Breast MRI shows no significant abnormalities in the left mammary gland; whole body bone emission computed tomography (ECT) imaging showed no significant abnormalities; enhanced MRI of the head showed no significant abnormalities.
  • Surgical treatment: due to local progression refractory to multiline chemotherapy, the patient underwent a left radical mastectomy with nipple-areola complex preservation, resection of the chest wall tumor, and immediate reconstruction with a pedicled latissimus dorsi flap and V-Y advancement flaps on September 19, 2025. Postoperative healing was good (see Figure 4). Postoperative pathology: left breast tissue: a piece of breast tissue measuring 13.5112.7 cm in size, cut in a book-like shape, with no obvious tumor mass observed. The cut surface was grayish-white and grayish-yellow, with a soft texture. Left chest wall malignant tumor tissue: a piece of tissue with skin, measuring 21,153.2 cm in size, with a skin area of 21 cm × 15 cm. Several nodular protrusions were observed in the center of the skin, with diameters ranging from 0.5 to 5 cm and protruding 0.3 to 2.5 cm above the skin surface. Left breast tissue mammary adenosis with partial ductal epithelial ordinary hyperplasia. Left chest wall tissue consistent with invasive breast cancer, non-specific type, grade III, with intravascular cancer thrombus visible, negative margins around the tumor and at the base (see Figure 5). Cancer metastasis was observed in the left axillary lymph nodes (12/18). Immunohistochemistry: 2513057-B9#: P120 (membrane+), E-Cad (partially+), P63 (−), GATA-3 (+), CK5/6 (+), Calponin (−), PR (−), Ki-67 (70%+), HER2 (1%+), ER (<3%, weakly+). Postoperative recovery was good. Final pathology confirmed invasive breast cancer (grade III) in the chest wall specimen with negative margins, and metastasis in 12 of 18 left axillary lymph nodes.
Figure 2 Chest enhanced CT (A: transverse section; B: longitudinal section). CT, computed tomography.
Figure 3 Breast color Doppler ultrasound results.
Figure 4 Postoperative wound images (A: front view; B: side view; C: back view). This image is published with the patient’s written informed consent.
Figure 5 Postoperative pathological images (hematoxylin and eosin stain). (A) Normal breast tissue (×200); (B) chest wall cancer tissue (×200).
Figure 1 Appearance of the recurrent area in the patient (A: April 15, 2025; B: September 15, 2025).

Discussion

Breast cancer is one of the common malignant tumors in women, and its incidence rate is increasing year by year. Breast cancer often metastasizes to lymph nodes, with ipsilateral axillary lymph node metastasis being the most common, while CAM is relatively rare (2).

Research has shown that the occurrence of CAM is related to alterations and abnormal pathways in lymphatic drainage. The primary metastatic pathway may be lymphatic dissemination rather than hematogenous dissemination (3). Morcos et al. (4) investigated the lymphatic drainage pathways in recurrent breast cancer and found that 43.2% of patients exhibited abnormal lymphatic drainage. Maseki et al. (5) used lymphoscintigraphy and fluorescence imaging to confirm that breast cancer can direct lymphatic fluid to the contralateral axillary lymph nodes via the subcutaneous lymphatic network. Currently, alterations in lymphatic drainage pathways are considered the primary cause of CAM. In an earlier study (6), Estourgie et al. enrolled a total of 700 patients who did not have lymph node metastasis upon preoperative examination and underwent breast sentinel lymph node biopsy using a dual-tracer method involving methylene blue and radioactive isotopes. The results revealed that 92.3% of patients drained to the ipsilateral axillary lymph nodes, 21.8% to the internal mammary lymph nodes, 2.7% to the subclavian lymph nodes, and 0.5% to the supraclavicular lymph nodes, with no observed drainage to the contralateral lymph nodes. van der Ploeg et al. (7) explored the lymphatic drainage patterns after breast cancer surgery, yielding significantly different results. Among 12 patients who underwent axillary lymph node dissection, only 25% (3/12) drained to the ipsilateral axillary lymph nodes, while 33% (4/12) drained to the contralateral axillary lymph nodes. This indicates that breast cancer surgery may alter the breast-related lymphatic drainage pathways, subsequently leading to the occurrence of CAM. Factors such as lymphatic obstruction, skin invasion, lymph node invasion, history of breast surgery, history of axillary surgery, and radiotherapy due to breast cancer can all cause alterations in lymphatic drainage pathways, leading to the occurrence of CAM. The findings of this study align with this scenario. The high-risk factors for CAM in the cases studied include: previous modified radical mastectomy on the right side; detection of 29 lymph nodes in the right axilla, with up to 12 lymph nodes showing cancer metastasis (12/29); and a history of radiotherapy.

When diagnosing CAM, it is important to exclude the following conditions: (I) occult breast cancer (8-10); (II) axillary tail cancer or accessory breast cancer (11); (III) lymph node metastasis of other malignancies (12). Imaging examinations such as breast MRI should be combined to exclude the possibility of contralateral primary cancer, and suspicious lymph nodes should undergo needle biopsy and immunohistochemical testing to determine the source of the metastatic lesion. In this case, the immunohistochemical results of the left axillary lymph nodes were consistent with the primary cancer of the right breast, leading to the diagnosis of CAM.

Currently, there is controversy surrounding the staging of CAM. The American Joint Committee on Cancer (AJCC) staging guidelines classify CAM as M1 (stage IV) (13). However, studies by Coopey et al. (2) have found that the progression-free survival and overall survival of patients with CAM are similar to those of patients with stage III breast cancer, and significantly better than those of patients with other distant metastases (liver, lung, brain). Given that ipsilateral supraclavicular lymph node metastasis (ISLM) and CAM are both classified as distant metastases in the 7th edition of the AJCC staging criteria and previous versions, there is reference value between the two in terms of treatment approaches. Research by Lv et al. (14) has shown that combining local control with systemic therapy for patients with supraclavicular lymph node metastasis can significantly improve prognosis. Jing et al.’s (15) study also indicates that local treatment of the neck in patients with ISLM can significantly improve survival prognosis. Several studies have shown improved survival with aggressive local treatment. However, these observations are largely based on case reports and may not reflect the entire population. Currently, most studies support aggressive surgical treatment for CAM combined with systemic therapy, which can significantly improve patient prognosis (16-19). Magnoni et al. (20) conducted a retrospective analysis of 47 patients with CAM and found that the overall 5-year survival rate after comprehensive treatment reached 72%, supporting the view that CAM should be considered as a regional disease. Pan et al. (21) compared the prognosis of distant lymph node metastasis (DLNM) and ISLM and found that the survival outcomes of the two were similar, further suggesting that some distant lymph node metastases may actually be regional lesions. Moossdorff et al.’s (22) systematic review also pointed out that patients with metachronous CAM who underwent surgical treatment had a good prognosis, supporting the use of local radical treatment for them. In summary, surgical treatment may be considered for CAM.

This case presented with CAM accompanied by chest wall skin recurrence 2 years after radical mastectomy for breast cancer. Despite undergoing multiline chemotherapy, local progression was observed, but no distant metastasis was found. After comprehensive evaluation, a left radical mastectomy preserving nipple and areola, combined with chest wall tumor resection and skin flap repair, was performed, and the patient recovered well postoperatively. This treatment strategy embodies the concept of individualized comprehensive treatment.

In summary, the diagnosis of CAM requires imaging and pathological examinations to clarify the tumor origin and exclude the possibility of contralateral primary cancer and other metastases. Current evidence supports the adoption of a comprehensive treatment strategy primarily based on surgery for CAM, which is conducive to improving patient prognosis. In the future, it is necessary to further explore its biological characteristics and staging criteria to guide clinical practice.

Conclusions

CAM represents a challenging clinical scenario that necessitates careful differential diagnosis to rule out a new primary malignancy or other metastases. Multimodal evaluation, including detailed imaging and histopathological disease, growing evidence including the outcome of this case suggests that for selected patients without other distant metastases, CAM may, in selected patients, display locoregional behavior. In this context, current evidence supports an aggressive local surgical approach combined with systemic therapy to achieve local control and improve outcomes. Therefore, an individualized comprehensive treatment strategy, rather than a blanket classification as stage IV, is recommended to optimize survival for patients with this rare pattern of recurrence.

Acknowledgments

We express our gratitude to the First Affiliated Hospital of Gannan Medical University for support.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-317/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-317/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-317/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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doi: 10.21037/acr-2025-317
Cite this article as: Liu ZY, Chen R. Contralateral axillary lymph node and chest wall skin recurrence 2 years after radical mastectomy for breast cancer: a case report and literature review. AME Case Rep 2026;10:74.

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