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The internal mammary lymph node (IMLN) chain is a pathway through which breast lymphatic drainage flows. The internal mammary lymphatic vessel runs around the internal mammary artery and veins with IMLN in the parasternal intercostal spaces. IMLN metastasis, which forms a part of clinical TNM staging, may negatively affect the prognosis of primary breast cancer patients. IMLN metastasis is clinically detected using ultrasound, computed tomography, magnetic resonance imaging, and F-deoxyglucose positron emission tomography computed tomography. The uptake of radioactive tracers in IMLN with clinically negative axillary lymph nodes is often identified using sentinel lymph node mapping (SLNM) in primary breast cancer patients. The indication for IMLN biopsy or resection that is clinically detected or visualized using SLNM is controversial. The clinically suspicious IMLN may be considered for ultrasound-guided fine-needle aspiration. First IMLN recurrence needs to be biopsied. Irradiation of the breast, chest wall, and/or regional nodal irradiation, including IMLN, following lumpectomy or postmastectomy is recommended. Although radiation therapy for IMLN recurrence may improve clinical outcomes, it is also associated with pulmonary and cardiac toxicities. This review covers the local anatomy of IMLN, lymph drainage and image findings of IMLN with a discussion.

Extramedullary plasmacytoma of the breast (EPB), a manifestation of multiple myeloma (MM), is very rare. It is important to recognize the imaging findings of EPB because it may be the first manifestation of relapsed MM. An 85-year-old woman presented with a lump in her right breast 4 years after the complete remission of MM. She underwent mammography and ultrasonography, which showed an oval circumscribed mass and an irregular circumscribed heterogeneous solid mass, respectively. Following ultrasound-guided vacuum-assisted breast biopsy, this lesion was confirmed to be EPB. Whole-body computed tomography showed multiple new osteolytic lesions and other multiple extramedullary lesions in addition to EPB in the right breast. The final diagnosis was relapsed MM with multiple extramedullary plasmacytoma.

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