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Internal mammary (IM) lymph nodes can be seen on sonograms. It is important to recognize the sonographic features that make IM nodes worrisome for metastatic disease. Breast cancer, especially when located in the medial breast, can have IM node involvement without axillary lymphadenopathy. Prognosis, staging, and treatment will be altered based on lymph node involvement found with breast cancer. Breast sonography has been warranted following mammographically detectable densities and/or palpable abnormalities.