Axillary surgery in clinically node-positive patients
tumor, breast cancers, cancer, cM0 breast cancer, AJCC/UICC stage II-III, imaging-positive nodal disease
RECURRENCES, TUMOR, RECURRENCE, BREAST CANCER, CANCER, RESIDUAL DISEASE
The only way to spare clinically node-positive patients ALND today is neoadjuvant systemic treatment and confirmed nodal pCR after selective LN removal as a diagnostic surgical procedure. The exception are patients with imaging-positive nodal disease that is non palpable, as almost half of these patients can undergo the SLN procedure without ALND according to the Z0011 protocol [Retrospectively, real-life data from the national cancer database showed controversial results. In a series from 2006 to 2014, with patients showing cT1-3, cN1, cM0 breast cancer, who underwent NST and had residual disease in at least one of ≤4 removed LN (defined as SLNB) two matched cohorts were formed, one having received adjuvant RNI (n = 304), and a second having received ALND and RNI (n = 1313). Estimated 5-year OS results showed a significant benefit for patients with ALND (77%) over SLNB (71%), with a HR of 1.7 (95%CI 1.3–2.2). Interestingly, the analysis did not show an OS difference in patients with luminal A or B tumor, and only one affected LN (HR 1.03, 95%CI 0.59–1.8) [Currently, three trials are addressing the question regarding de-escalation of axillary surgery in clinically node-positive patients. Firstly, the Alliance A011202 trial (NCT01901094) includes patients with cT1-3, cN1 breast cancer, undergoing NST followed by breast conserving surgery or mastectomy with SLNB. Patients with positive SLN are thereafter randomly assigned to undergo either ALND and extended nodal radiotherapy sparing the dissected axilla or extended nodal irradiation including the full axilla. So far, no results have been published.The before-mentioned MARI trial, also includes patients with cALN <4 and positive ypMARI LN, undergoing adjuvant axillary radiotherapy, and patients with cALN ≥4 + ypMARI positive receiving ALND. The reported 3-year axillary recurrence-free interval was 98.2%. However, the 5 reported axillary recurrences all occurred in cALN <4 patients, whereas four occurred in ypMARI positive patients (3-year axillary recurrence rate 3.4%), which all had triple negative breast cancers [Furthermore, two registry based trials AXSANA (NCT04373655) [And finally, the TAXIS trial (NCT03513614), investigating patients with AJCC/UICC stage II-III and histologically confirmed node-positivity [