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    The Landmark Series: Axillary Management in Breast Cancer. Fisher Carla S,Margenthaler Julie A,Hunt Kelly K,Schwartz Theresa Annals of surgical oncology The evolution in axillary management for patients with breast cancer has resulted in multiple dramatic changes over the past several decades. The end result has been an overall deescalation of surgery in the axilla. Landmark trials that have formed the basis for the current treatment guidelines are reviewed herein. 10.1245/s10434-019-08154-5
    Evolving imaging techniques for staging axillary lymph nodes in breast cancer. Lowes S,Leaver A,Cox K,Satchithananda K,Cosgrove D,Lim A Clinical radiology The presence and extent of axillary nodal metastases at the time of breast cancer diagnosis is a critical factor in disease prognosis and plays a central role in deciding the best treatment for patients. Accurate assessment of the axilla is therefore an essential component in staging breast cancer. Over the years, axillary staging has evolved from surgical axillary lymph node dissection (ALND), with its numerous associated long-term complications, to the much less-radical surgical sentinel lymph node excision biopsy (SLNB), the current reference standard. In parallel, radiological staging of the axilla has become increasingly more useful as our knowledge and techniques have improved. Preoperative axillary ultrasound is used widely to stage patients with breast cancer, providing an evaluation of node morphology and allowing targeted biopsy of abnormal nodes. This is important in helping stratify which patients should proceed directly to ALND and which should undergo SLNB first. Grey-scale ultrasound on its own is not perfect and can over- and underestimate axillary disease. Newer ultrasound techniques such as elastography may help to improve diagnostic confidence when visually assessing axillary nodes; for example, in more accurately assessing the extent of axillary disease burden or in differentiating benign reactive nodes from malignant nodes in equivocal cases. The use of intradermal "microbubbles" has shown great promise in being able to locate and biopsy the sentinel lymph node under ultrasound guidance, and raises the possibility that in the future such techniques may obviate the need for surgical SLNB in select patient populations. 10.1016/j.crad.2018.01.003
    Axillary surgery in breast cancer: the beginning of the end. Dumitru Dorin,Khan Ayesha,Catanuto Giuseppe,Rocco Nicola,Nava Maurizio B,Benson John R Minerva chirurgica Axillary surgery in breast cancer patients has shifted from more extensive to minimalist approaches with re-evaluation of the risks versus benefits of available treatment options which are increasingly tailored to individual patient characteristics. A radical axillary node dissection is rarely indicated nowadays due to several factors including screening with detection of small node negative cancers, introduction of targeted node sampling, less reliance on information from nodal staging for adjuvant therapy decision making and evidence that non-surgical treatments such as systemic therapies (chemotherapy, hormonal therapy, biological therapy) together with radiotherapy can safely treat low burden axillary disease. Sentinel lymph node biopsy (SLNB) alone with omission of further axillary surgery for nodal macrometastases (>2 mm) might be sufficiently extirpative to achieve local control when combined with adjuvant treatments. There remain unanswered questions on the safety of SLNB post chemotherapy in patients with biopsy-proven nodal disease at presentation and whether omission of axillary node dissection is feasible in selected cases. Emerging evidence suggests that a complete radiological response with removal of at least 3 nodes (including clipped nodes at time of biopsy) can yield false negative rates of <10% and be a safe option. New technologies involving percutaneous biopsy of sentinel nodes under radiological guidance are under investigation and could potentially replace surgical staging of the axilla in the future. Moreover, omission of any type of node biopsy might be a potential option in more favorable tumors and could herald the beginning of the end for histological axillary sampling in selected cases. 10.23736/S0026-4733.18.07728-3
    Management of the axilla in early breast cancer patients in the genomic era. Oliveira M,Cortés J,Bellet M,Balmaña J,De Mattos-Arruda L,Gómez P,Muñoz E,Ortega V,Pérez J,Saura C,Vidal M,Rubio I T,Di Cosimo S Annals of oncology : official journal of the European Society for Medical Oncology Management of the axilla in early breast cancer (EBC) patients has dramatically evolved in recent years from more radical to increasingly conservative approaches. Classically, the EBC patients with a clinically positive axilla are offered axillary lymph node dissection (ALND) and those with a clinically negative axilla (cN0) are offered sentinel lymph node (SLN) biopsy, which obviates the complications related to ALND and provides adequate surgical staging and comparable locoregional control and survival. The need for performing ALND when the SLN is positive and contemporary adjuvant treatment is delivered has been questioned in recent years. On the other hand, ongoing trials are testing whether node-positive patients can be spared chemotherapy, based on intrinsic primary tumor biology. Because the integration of novel surgical management and tumor biology is needed, this article provides an overview of the current challenges that a more detailed knowledge of tumor biology has brought to EBC staging and treatment. We propose that breast cancer oncologists (surgeons, radiation therapists, and medical oncologists) should focus their efforts on offering therapy tailored to each patient's needs in such a way that no matter which treatment is used, no overtreatment occurs. 10.1093/annonc/mds592
    Axillary Management in Breast Cancer Patients: A Comprehensive Review of the Key Trials. Yan Michael,Abdi Mohamed Ahmed,Falkson Conrad Clinical breast cancer Optimal regional management in breast cancer patients has yet to be established. In patients who are clinically node-negative, but sentinel lymph node biopsy (SLNB)-positive, the treatment paradigm has shifted toward the de-escalation of further axillary management. In patients with 2 or fewer positive sentinel nodes, the standard of practice has shifted away from complete axillary lymph node dissection (ALND) as a result of the ACOSOG Z0011 trial. The role of regional nodal irradiation (RNI) to the axilla, supraclavicular and internal mammary regions has also been investigated in the setting of positive SLNB in trials such as the MA20 and EORTC 22922. Having shown evidence of benefit in locoregional control, efforts are now focused on comparing ALND with RNI in patients with limited nodal disease. Results of early trials such as AMAROS suggest noninferiority of radiotherapy. In patients with node-positive or locally advanced disease, neoadjuvant chemotherapy (NAC) is often used to downsize or downstage the disease. The utility of SLNB after NAC has been investigated, with discordant results reported from a number of trials. Current trials in progress seek to validate the noninferiority of RNI compared with ALND in patients with limited nodal disease, or in some trials, the complete omission of further axillary management. There is a global paradigm shift toward de-escalation of axillary management on the basis of recent evidence suggesting lack of benefit from overaggressive treatment. In this review we aim to summarize the seminal trials addressing regional management in breast cancer to illustrate this fact. 10.1016/j.clbc.2018.08.002
    Meta-analysis to determine the clinical impact of axillary lymph node dissection in the treatment of invasive breast cancer. Joyce D P,Manning A,Carter M,Hill A D K,Kell M R,Barry M Breast cancer research and treatment There are divergent opinions regarding the optimum surgical management of the axilla in patients with invasive breast cancer. Guidelines mandate axillary lymph node dissection (ALND) in the setting of positive sentinel lymph nodes. However, recent studies have questioned the true benefits of this procedure. Therefore, a meta-analysis of relevant randomized trials was performed in order to clarify the oncological benefit of axillary lymph node dissection. A comprehensive search of published randomized trials that compared patients with primary operable breast cancer with/without ALND was performed using MEDLINE, and available data were cross-referenced. Reviews of each study were conducted, and data were extracted. Primary outcomes were overall survival and recurrent axillary disease. A total of 7347 patients with operable primary breast cancer were identified from 8 randomised controlled trials comparing axillary recurrence in patients with or without ALND. Six of these trials provided data on overall survival on 6895 patients. Overall survival favours patients having ALND (OR = 1.22 (95% CI 1.03-1.44, p = 0.02). Similarly, patients undergoing ALND had increased recurrence-free survival (OR = 2.25 (95% CI 1.28-3.94, p = 0.0047). ALND appears to positively impact on overall and recurrence-free survival from breast cancer. These data highlight the enduring benefits of ALND in an era where adjuvant therapies are being promoted to manage regionally advanced/metastatic disease. 10.1007/s10549-015-3549-2
    Axillary treatment for operable primary breast cancer. Bromham Nathan,Schmidt-Hansen Mia,Astin Margaret,Hasler Elise,Reed Malcolm W The Cochrane database of systematic reviews BACKGROUND:Axillary surgery is an established part of the management of primary breast cancer. It provides staging information to guide adjuvant therapy and potentially local control of axillary disease. Several alternative approaches to axillary surgery are available, most of which aim to spare a proportion of women the morbidity of complete axillary dissection. OBJECTIVES:To assess the benefits and harms of alternative approaches to axillary surgery (including omitting such surgery altogether) in terms of overall survival; local, regional and distant recurrences; and adverse events. SEARCH METHODS:We searched the Cochrane Breast Cancer Group Specialised Register, MEDLINE, Pre-MEDLINE, Embase, CENTRAL, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov on 12 March 2015 without language restrictions. We also contacted study authors and checked reference lists. SELECTION CRITERIA:Randomised controlled trials (RCTs) including women with clinically defined operable primary breast cancer conducted to compare axillary lymph node dissection (ALND) with no axillary surgery, axillary sampling or sentinel lymph node biopsy (SLNB); RCTs comparing axillary sampling with SLNB or no axillary surgery; RCTs comparing SLNB with no axillary surgery; and RCTs comparing ALND with or without radiotherapy (RT) versus RT alone. DATA COLLECTION AND ANALYSIS:Two review authors independently assessed each potentially relevant trial for inclusion. We independently extracted outcome data, risk of bias information and study characteristics from all included trials. We pooled data according to trial interventions, and we used hazard ratios (HRs) for time-to-event outcomes and odds ratios (OR) for binary outcomes. MAIN RESULTS:We included 26 RCTs in this review. Studies were at low or unclear risk of selection bias. Blinding was not done, but this was only considered a source of bias for outcomes with potential for subjectivity in measurements. We found no RCTs of axillary sampling versus SLNB, axillary sampling versus no axillary surgery or SLNB versus no axillary surgery. No axillary surgery versus ALND Ten trials involving 3849 participants compared no axillary surgery versus ALND. Moderate quality evidence showed no important differences between overall survival of women in the two groups (HR 1.06, 95% confidence interval (CI) 0.96 to 1.17; 3849 participants; 10 studies) although no axillary surgery increased the risk of locoregional recurrence (HR ranging from 1.10 to 3.06; 20,863 person-years of follow-up; four studies). It was uncertain whether no surgery increased the risk of distant metastasis compared with ALND (HR 1.06, 95% CI 0.87 to 1.30; 946 participants; two studies). Low-quality evidence indicated no axillary surgery decreased the risk of lymphoedema compared with ALND (OR 0.31, 95% CI 0.23 to 0.43; 1714 participants; four studies). Axillary sampling versus ALND Six trials involving 1559 participants compared axillary sampling versus ALND. Low-quality evidence indicated similar effectiveness of axillary sampling compared with ALND in terms of overall survival (HR 0.94, 95% CI 0.73 to 1.21; 967 participants; three studies) but it was unclear whether axillary sampling led to increased risk of local recurrence compared with ALND (HR 1.41, 95% CI 0.94 to 2.12; 1404 participants; three studies). The relative effectiveness of axillary sampling and ALND for locoregional recurrence (HR 0.74, 95% CI 0.46 to 1.20; 406 participants; one study) and distant metastasis was uncertain (HR 1.05, 95% CI 0.74 to 1.49; 406 participants; one study). Lymphoedema was less likely after axillary sampling than after ALND (OR 0.32, 95% CI 0.13 to 0.81; 80 participants; one study). SLNB versus ALND Seven trials involving 9426 participants compared SLNB with ALND. Moderate-quality evidence showed similar overall survival following SLNB compared with ALND (HR 1.05, 95% CI 0.89 to 1.25; 6352 participants; three studies; moderate-quality evidence). Differences in local recurrence (HR 0.94, 95% CI 0.24 to 3.77; 516 participants; one study), locoregional recurrence (HR 0.96, 95% CI 0.74 to 1.24; 5611 participants; one study) and distant metastasis (HR 0.80, 95% CI 0.42 to 1.53; 516 participants; one study) were uncertain. However, studies showed little absolute difference in the aforementioned outcomes. Lymphoedema was less likely after SLNB than ALND (OR ranged from 0.04 to 0.60; three studies; 1965 participants; low-quality evidence). Three studies including 1755 participants reported quality of life: Investigators in two studies found quality of life better after SLNB than ALND, and in the other study observed no difference. RT versus ALND Four trials involving 2585 participants compared RT alone with ALND (with or without RT). High-quality evidence indicated that overall survival was reduced among women treated with radiotherapy alone compared with those treated with ALND (HR 1.10, 95% CI 1.00 to 1.21; 2469 participants; four studies), and local recurrence was less likely in women treated with radiotherapy than in those treated with ALND (HR 0.80, 95% CI 0.64 to 0.99; 22,256 person-years of follow-up; four studies). Risk of distant metastasis was similar for radiotherapy alone as for ALND (HR 1.07, 95% CI 0.93 to 1.25; 1313 participants; one study), and whether lymphoedema was less likely after RT alone than ALND remained uncertain (OR 0.47, 95% CI 0.16 to 1.44; 200 participants; one study). Less surgery versus ALND When combining results from all trials, treatment involving less surgery was associated with reduced overall survival compared with ALND (HR 1.08, 95% CI 1.01 to 1.17; 6478 participants; 18 studies). Whether local recurrence was reduced with less axillary surgery when compared with ALND was uncertain (HR 0.90, 95% CI 0.75 to 1.09; 24,176 participant-years of follow up; eight studies). Locoregional recurrence was more likely with less surgery than with ALND (HR 1.53, 95% CI 1.31 to 1.78; 26,880 participant-years of follow-up; seven studies). Whether risk of distant metastasis was increased after less axillary surgery compared with ALND was uncertain (HR 1.07, 95% CI 0.95 to 1.20; 2665 participants; five studies). Lymphoedema was less likely after less axillary surgery than with ALND (OR 0.37, 95% CI 0.29 to 0.46; 3964 participants; nine studies).No studies reported on disease control in the axilla. AUTHORS' CONCLUSIONS:This review confirms the benefit of SLNB and axillary sampling as alternatives to ALND for axillary staging, supporting the view that ALND of the clinically and radiologically uninvolved axilla is no longer acceptable practice in people with breast cancer. 10.1002/14651858.CD004561.pub3
    Refining the Performance of Sentinel Lymph Node Biopsy Post-neoadjuvant Chemotherapy in Patients with Pathologically Proven Pre-treatment Node-positive Breast Cancer: An Update for Clinical Practice. El Hage Chehade Hiba,Headon Hannah,Kasem Abdul,Mokbel Kefah Anticancer research BACKGROUND:Neoadjuvant chemotherapy (NAC) has become the standard treatment regimen for locally advanced breast cancer and has recently been incorporated into the treatment of early breast cancer. It allows down-staging of tumors favoring breast-conservative surgery over mastectomy. Furthermore, NAC results in nodal conversion in about 40% of patients. This favorable outcome has complicated the decision-making regarding the best approach in managing the axilla post-treatment; especially in pathologically proven nodal disease prior to NAC. Axillary lymph node clearance is still the standard-of-care for this group of patients; however, it is clearly an over-treatment in a substantial number of patients. Given the high accuracy of sentinel lymph node biopsy (SLNB) post-NAC in clinically node-negative cases prior to treatment, substantial research has been carried out in order to validate the feasibility of post-NAC SLNB in pathologically proven node-positive cases. The results so far are still inconclusive, yet promising. MATERIALS AND METHODS:We performed a computer-aided review of the literature for relevant articles on the performance of SLNB post-NAC in pathologically proven node-positive patients prior to chemotherapy. We also targeted studies on important factors that can refine the accuracy of SLNB in this group of patients, as well as elements favoring pathological complete response. All studies focusing on post-NAC SLNB in pre-treatment node-positive cases including randomized controlled trials, retrospective and prospective series, review articles, and two meta-analyses were included. RESULTS:The review established a false-negative rate of 14-15.1% and an IR of 89-92.3%. Several technical enhancements, as well as imaging modalities, may be incorporated to improve the performance of SLNB. Furthermore, selected patients with more likelihood of pathological complete response represent the best candidates for this technique. CONCLUSION:SLNB is a valid option after NAC in patients with pathologically proven node-positive breast cancer, given the high node-conversion rate. The literature demonstrated a false-negative rate that is slightly higher than that of patients initially node-negative which although might increase the locoregional recurrence in theory, has no effect on chemotherapy-decision making, and will most probably have no impact on overall survival. We identified several measures to refine its accuracy.
    Management of the Node-Positive Axilla in Breast Cancer in 2017: Selecting the Right Option. Morrow Monica JAMA oncology 10.1001/jamaoncol.2017.3625
    Sentinel lymph node biopsy after neo-adjuvant chemotherapy in patients with breast cancer: Are the current false negative rates acceptable? Patten D K,Zacharioudakis K E,Chauhan H,Cleator S J,Hadjiminas D J Breast (Edinburgh, Scotland) The advent of sentinel lymph node biopsy has revolutionised surgical management of axillary nodal disease in patients with breast cancer. Patients undergoing neo-adjuvant chemotherapy for large breast primary tumours may experience complete pathological response on a previously positive sentinel node whilst not eliminating the tumour from the other lymph nodes. Results from 2 large prospective cohort studies investigating sentinel lymph node biopsy after neo-adjuvant chemotherapy demonstrate a combined false negative rate of 12.6-14.2% and identification rate of 80-89% with the minimal acceptable false negative rate and identification rate being set at 10% and 90%, respectively. A false negative rate of 14% would have been classified as unacceptable when compared to the figures obtained by the pioneers of sentinel lymph node biopsy which was 5% or less. 10.1016/j.breast.2015.02.026
    Sentinel lymph node - historical background and current views on its significance in complex management of breast cancer patients. Kubikova E,Badidova J,Klein M,Beder I,Benus R,Polak S,Varga I Bratislavske lekarske listy Nowadays, breast cancer is the leading oncological diagnosis in women worldwide. On the other hand, breast cancer treatment can be considered one of the most progressive therapeutic approach in the medical field of oncology. The invasive types of breast cancer have a tendency to spread via lymphatic route, what brings in the issue of sentinel lymph node - the first node into which the lymph drains from a given anatomical location. This review paper discusses the historical background of the concept of sentinel lymph node and focuses on clinical significance of the positivity of sentinel lymph node(s) as well. Modern-day conservative therapeutic surgery of breast cancer should be in accordance with diagnostic and preventive interventions in the axilla, whose rate of invasiveness and morbidity must be also attenuated without worsening the patient´s prognosis and survival rate. Formerly, a complete axillary lymph node dissection was routinely performed for prophylactic and cancer staging purposes. The indiscriminate application of this approach was replaced by sentinel lymph node biopsy. Along with common histopathological examination, immunohistochemistry, as well as modern techniques of molecular biology are often employed. These state-of-the-art methods enabled the identification of micrometastases, or even nanometastases, though their real prognostic value is yet to be concluded (Ref. 52). Keywords: sentinel node, breast cancer, biopsy, historical background. 10.4149/BLL_2019_066
    Local management after neoadjuvant treatment for breast cancer. Sakai Takehiko,Ueno Takayuki Chinese clinical oncology Neoadjuvant chemotherapy (NAC) was originally used in patients with locally advanced breast cancer. Then, it is used in operable breast cancer to downstage the primary breast cancer and axillary lymph nodes metastasis, result in improving the cosmetic outcome and decreasing surgical morbidity. However, it is sometimes difficult to assess the extent of residual disease after NAC, as the NAC reduces the lesion and obscure the original images both breast and axilla. Thus, detailed assessment of primary breast cancer and axillary lymph nodes metastasis are required from the time of before NAC until the time of surgery. These assessments include the accurate location, the extent of intraductal component around primary tumor and the axillary nodal status. Multimodality imaging with intervention for cytopathology can help to delineate the size and location of breast cancer and lymph node metastasis and predict the residual tumor burden in primary breast cancer and involved axillary nodes. In the future, with development of new targeted therapy, technologies in medical imaging diagnosis and ongoing trial data will provide further individualized treatment option for patients with breast cancer. This article reviews the current evidence and management recommendations for optimal surgical treatment in this setting. 10.21037/cco-20-164
    A Review of Options for Localization of Axillary Lymph Nodes in the Treatment of Invasive Breast Cancer. Woods Ryan W,Camp Melissa S,Durr Nicholas J,Harvey Susan C Academic radiology Invasive breast cancer is a common disease, and the most common initial site of metastatic disease are the axillary lymph nodes. As the standard of care shifts towards less invasive surgery in the axilla for patients with invasive breast cancer, techniques have been developed for axillary node localization that allow targeted dissection of specific lymph nodes without requiring full axillary lymph node dissection. Many of these techniques have been adapted from technologies developed for localization of lesions within the breast and include marker clip placement with intraoperative ultrasound, carbon-suspension liquids, localization wires, radioactive seeds, magnetic seeds, radar reflectors, and radiofrequency identification devices.The purpose of this article is to summarize these methods and describe benefits and drawbacks of each method for performing localization of lymph nodes in the axilla. 10.1016/j.acra.2018.07.002
    De-escalating and escalating surgery in the management of early breast cancer. Morrow Monica Breast (Edinburgh, Scotland) In the setting of increased awareness regarding the need to address potential overtreatment in the management of breast cancer patients with favorable-prognosis disease, this article reviews three relevant instances in which the extent of surgery has been safely decreased: margin width in patients with ductal carcinoma in situ; axillary management in clinically node-negative women undergoing primary breast-conserving surgery; and the use of neoadjuvant chemotherapy followed by sentinel node biopsy for patients presenting with node-positive breast cancer. The management of the axillary nodes over the past decade highlights the potential to de-escalate surgery in the era of multimodality therapy. Similar opportunities exist for the use of radiotherapy. To fully realize the potential of de-escalating surgery, new communication strategies must be developed to convince patients that bigger is not necessarily better. 10.1016/j.breast.2017.06.018
    Surgical management of the axilla in early breast cancer. Jatoi Ismail,Benson John R Current problems in surgery 10.1067/j.cpsurg.2018.01.003
    Surgical Management of the Axilla in Breast Cancer. Mastrangelo Stephanie,McMasters Kelly,Ajkay Nicolas The American surgeon This article offers a review of the literature on current surgical management of the axilla in breast cancer. This includes the decision-making process involved in clinically node-negative patients versus clinically node-positive patients, with discussion of the indications for sentinel lymph node biopsy versus axillary dissection. It also examines the surgical axillary management of patients who receive neoadjuvant chemotherapy. This article will help update practicing surgeons on the evolving research and guidelines for the management of breast cancer axillary disease.
    De-escalation of Axillary Surgery in the Neoadjuvant Chemotherapy (NACT) Setting for Breast Cancer: Is it Oncologically Safe? Wazir Umar,Mokbel Kefah Anticancer research BACKGROUND/AIM:The treatment of breast cancer has progressed considerably over the years, with a significant de-escalation from radical mastectomies to the current paradigm of breast conserving surgery (BCS) and neoadjuvant chemotherapy (NACT). We aimed to appraise the literature regarding the feasibility of de-escalation of treatment of axillary disease in the context of NACT. MATERIALS AND METHODS:We appraised studies and guidelines published regarding this topic and discussed them in this mini-review. RESULTS AND CONCLUSION:The SNB following NACT is oncologically safe in patients with clinically node negative disease and in patients with biopsy proven axillary node involvement at presentation provided that the dual technique is used and the clipped pathological node is harvested. 10.21873/anticanres.14542
    Neoadjuvant Chemotherapy and Surgical Management of the Axilla in Breast Cancer: A Review of Current Data. Manguso Nicholas,Gangi Alexandra,Giuliano Armando E Oncology (Williston Park, N.Y.) Neoadjuvant chemotherapy has become the standard of care for patients with locally advanced breast cancer, large tumors, certain biologic subtypes of breast cancer, or locally inoperable disease, and for patients who desire breast conservation. It has the advantage of downstaging the tumor, thereby allowing for conversion from mastectomy to breast conservation, and perhaps decreasing the need for axillary lymph node dissection (ALND). In the past, axillary management involved complete ALND for all patients presenting with breast cancer and involved nodes. With neoadjuvant chemotherapy, some patients exhibit a complete clinical axillary response, which may make them candidates for sentinel lymph node biopsy (SNLB) rather than ALND, with its associated morbidities. While there is widespread use of SLNB in the treatment of breast cancer, its use following neoadjuvant chemotherapy remains widely debated.
    Management of axilla in breast cancer - The saga continues. Layeequr Rahman Rakhshanda,Crawford Sybil L,Siwawa Portia Breast (Edinburgh, Scotland) Prospective trials investigating the accuracy of SLNB for cN0 (primary surgical therapy) and cN1 patients (neoadjuvant chemotherapy) have not utilized likelihood ratios (LR) to assess the impact of false negative SLNB. This review evaluates the evidence on accuracy of SLNB using STARD and QUADAS-2 (revised) criteria for patients undergoing primary surgical therapy and primary chemotherapy. It utilizes the: (i) Reported rates for pre-test probabilities of node positive disease from Surveillance, Epidemiology, and End Results (SEER) database for the cN0 patients (primary surgical therapy) for each T stage; calculates the negative LR from cumulative evidence; and uses the Bayesian nomogram to compute the post-test probability of missing the metastatic axillary node based on negative SLNB. (ii) Reported rates of complete axillary response in ACOSOG-Z1071 trial for cN1 patients to calculate the pre-test probabilities of residual nodal disease for each biological tumor sub-type; calculates the negative LR from ACOSOG-Z1071, and SENTINA trial data; and uses the Bayesian nomogram to compute the post-test probability of missing the residual metastatic axillary node based on negative SLNB. For cN0 disease, the odds of missing axillary disease based on negative SLNB for each T stage are: T1a = 0.7%; T1b = 1.5%; T1c = 3%; T2 = 7%; T3 = 18%. For cN1 disease, the odds of missing residual axillary disease based on negative SLNB for each biological subtype are: HER2neu+ = 8%; Triple negative = 15%; ER+/PR+/HER2neu- = 45%. Negative LR is more accurate and superior to false negative rate for determining the clinical utility of SLNB by taking into account the changing pre-test probability of disease. 10.1016/j.breast.2015.03.010
    Standard and controversies in sentinel node in breast cancer patients. Veronesi P,Corso G Breast (Edinburgh, Scotland) Axillary management in breast cancer is still controversial. Recent clinical trials have clearly demonstrated that in breast-conserving surgery, axillary dissection could be an overtreatment when metastases are present in only 1-2 sentinel lymph nodes. Nonetheless, axillary dissection remains the principal treatment in patients undergoing mastectomy with at least one metastatic sentinel lymph node and in patients eligible for breast conserving surgery with three or more positive sentinel lymph nodes. In this analytical review, we discuss the clinical evidence, taking into account recent guidelines, for axillary management. 10.1016/S0960-9776(19)31124-5
    Axillary surgery in breast cancer: An updated historical perspective. Magnoni Francesca,Galimberti Viviana,Corso Giovanni,Intra Mattia,Sacchini Virgilio,Veronesi Paolo Seminars in oncology This historical surgical retrospection focuses on the temporal de-escalation axillary surgery, focusing on the unceasing efforts of researchers toward new challenges, as documented by extensive studies and trials. Axillary surgery has evolved, aiming to offer the best oncologic treatment and improve the quality of life of women. Axillary lymph-node dissection (ALND) has been replaced by sentinel lymph-node biopsy (SLNB) in women with early clinically node-negative breast cancer, providing adequate axillary nodal staging information with minimal morbidity, and becoming the standard of care in the management of breast cancer. However, this is only the beginning. Strategies in defining systemic and radiotherapeutic treatments have gradually been optimized, offering increasingly refined and targeted breast cancer treatment tools. In recent years, the paradigm of completion ALND after a positive SLNB has been questioned, and several studies have led to revolutionary changes in clinical practice. Moreover, the increasingly pivotal role played by neoadjuvant chemotherapy (NAC) has had a profound effect on the extent of axillary surgery, paving the way to a more finite "targeted" procedure in women with node-positive breast cancer who convert to negative nodes clinically after NAC. The utility of SLNB itself and its subsequent omission in women with negative nodes clinically and breast conservative surgery is also under scientific evaluation. The changes over time in the surgical approach to breast cancer have been numerous and significant. The novel emerging perspective characterized by recent advances in biology and genetics, in dedicated axillary ultrasound imaging and chemotherapy regimens, is the present reality that points to the future of axillary node treatment in breast cancer. 10.1053/j.seminoncol.2020.09.001
    Management of the axilla after neo-adjuvant chemotherapy for breast cancer: Sentinel node biopsy and radiotherapy considerations. Currey Adam,Patten Caitlin R,Bergom Carmen,Wilson J Frank,Kong Amanda L The breast journal Preoperative or neo-adjuvant chemotherapy in the management of breast cancer is a treatment approach that has gained in popularity in recent years. However, it is unclear if the treatment paradigms often employed for patients treated with surgery first hold true for those treated with preoperative chemotherapy. The role of sentinel node biopsy and the data supporting its use is different for those with clinically negative and clinically positive nodes prior to chemotherapy. For clinically node-negative patients, sentinel node biopsy after neo-adjuvant chemotherapy may be appropriate. For those node-positive patients whose axillary disease resolves clinically, the false-negative rate of the sentinel node biopsy is high. However, there are measures that can reduce that rate. After surgery, the radiation oncologist is often faced with complicated decisions surrounding the optimal radiotherapy in this setting. Tailoring radiation plans based on chemotherapy response holds promise and is the subject of ongoing clinical trials. In the accompanying article, we review the current literature on both surgery and radiation in axillary management and describe the interplay between these two treatment modalities. This highlights the need for multidisciplinary management in making treatment decisions for patients treated in this manner. 10.1111/tbj.13116
    Treatment of the axilla in patients with primary breast cancer and low burden axillary disease: Limitations of the evidence from randomised controlled trials. Robertson J F R,Herrod P J J,Matthew J,Kilburn L S,Coles C E,Bradbury I Critical reviews in oncology/hematology Invasive breast cancer is the second most common cancer worldwide. It is known to metastasise to the regional axillary lymph nodes but there has been debate over what is the best way to stage and treat the axilla in patients presenting with primary breast cancer. Multiple trials over the last two decades have led to a change in practice from routine axillary lymph node dissection to sentinel lymph node biopsy in patients who are clinically lymph node negative preoperatively. This has resulted in new questions regarding subsequent treatment of some patients. This review will critically appraise the evidence on axillary treatment in patients with low burden axillary disease and highlight limitations of relevant randomised controlled trials. 10.1016/j.critrevonc.2016.11.011
    Management of the Axilla in the Patient with Breast Cancer. Park Ko Un,Caudle Abigail The Surgical clinics of North America Evaluation of the axillary lymph nodes is critical in the management of breast cancer because it is a key predictor of survival outcome. Surgeons must not only be able to perform sentinel lymph node dissection with high accuracy but also understand the implications of the results. Management of clinically node-negative and node-positive cases can vary significantly, as described in this review. With emerging data, management of the axilla in breast cancer will continue to evolve. 10.1016/j.suc.2018.04.001
    Management of the Axilla in Early Breast Cancer. Valero Monica G,Golshan Mehra Cancer treatment and research Management of the axilla in early breast cancer patients has significantly evolved in the last several decades. With the arrival of the sentinel lymph node biopsy, surgical practice for axillary staging in patients with early breast cancer has become gradually less invasive and formal axillary lymph node dissection has been confined to selected patients. Over the last two decades, evidence from randomized clinical trials have allowed for the de-escalation of axillary surgery in the management of early stage breast cancer. Advances in the staging and treatment of the axilla constitute a key component in determining initial surgical planning and therapeutic strategies in the treatment of early breast cancer. This chapter provides an updated review on the history, evolution, and current practices for axillary management in patients with early breast cancer, with particular attention to the surgical recommendations and controversial scenarios of the evolving management of the axilla. 10.1007/978-3-319-70197-4_4
    Contemporary management of the axilla in breast cancer. Nurudeen Suliat,Hunt Kelly K Clinical advances in hematology & oncology : H&O The care of patients with breast cancer in the modern era involves a multimodal approach to treating locoregional and distant disease. Recent studies have demonstrated that the extent of surgical intervention in both the breast and axilla can be minimized through a personalized approach based on breast cancer stage, subtype, and planned adjuvant therapies. The older approach focused on complete removal of the axillary contents for appropriate staging and to determine the need for adjuvant systemic therapy and radiation. This approach has been replaced by sentinel lymph node biopsy, which allows for axillary staging with the removal of only the nodes most likely to contain metastatic disease. Sentinel lymph node biopsy obviates the need for complete axillary lymph node dissection in patients with node-negative disease. Clinical trials have also shown that axillary dissection can be avoided in those patients with low axillary disease burden in the sentinel nodes who are undergoing breast-conserving therapy. Radiation can also be used as an alternative to axillary dissection in patients with positive sentinel nodes, without increasing the risk for regional recurrence. Further studies are needed in patients undergoing mastectomy to determine the optimal strategy for axillary management in the setting of limited disease in the sentinel nodes. The use of neoadjuvant chemotherapy allows the ability to evaluate an individual tumor's response to therapy, thereby increasing the possibility of breast-conserving surgery and reduction in the extent of axillary surgery. This review will explore the evolution of management of the axilla in patients with clinically node-negative and node-positive disease, and will provide insights into future directions in breast cancer care.
    Twenty-five years of change in the management of the axilla in breast cancer. Dixon J Michael,Cartlidge Christopher W J The breast journal Sentinel lymph node (SLN) biopsy is now used worldwide. It has led to many changes in how we manage the axilla in patients with breast cancer. This review covers four areas of management of the axilla in breast cancer: assessing the clinically node-negative axilla, managing the clinically negative axilla found to be involved at SLN biopsy, management of the clinically positive axilla in the context of neo-adjuvant chemotherapy, and treatment of the diseased axilla when radical therapy is required. We suggest that the evidence supports an optimum number of 3 nodes to be removed for accurate SLN biopsy. Breast cancer departments that have not adopted Z0011 patient management cannot continue to avoid change. The evidence is clear: Not all patients with limited axillary nodal disease on sentinel node biopsy need axillary lymph node dissection. For patients who do need axillary treatment, axillary radiotherapy continues to be under-used. Patients undergoing neo-adjuvant chemotherapy can be safely assessed by post-therapy SLN biopsy, with retrieval of any previously biopsied involved nodes by targeted axillary dissection. There is much to support the trend to doing less in the axilla. We are obliged to act based on the available robust clinical trial data in a way that limits morbidity while at the same time does not increase the risk of disease recurrence. 10.1111/tbj.13720