Axillary surgery after neoadjuvant therapy in initially node-positive breast cancer: international EUBREAST survey

Abstract

Background There is no consensus on axillary management after neoadjuvant therapy (NAT) in patients with clinically node-positive (cN+) breast cancer. To investigate current clinical practice, an international survey was conducted among breast surgeons and radiation oncologists. The aim of the first part of the survey was to provide a snapshot of international discrepancies regarding axillary surgery in this context. Methods The European Breast Cancer Research Association of Surgical Trialists (EUBREAST) developed a web-based survey containing 39 questions describing clinical scenarios in the setting of axillary management in patients with cN1 disease converting to ycN0 after NAT. The survey was then distributed to breast surgeons and radiation oncologists via 14 breast cancer societies between April and October 2021. Results Responses from 349 physicians in 45 countries were recorded. The most common post-NAT axillary surgery in patients with cN1 disease converting to ycN0 was targeted axillary dissection (54.2 per cent), followed by sentinel lymph node biopsy (SLNB) alone (20.9 per cent), level 1–2 axillary lymph node dissection (ALND) (18.4 per cent), level 1–3 ALND (4 per cent), and targeted lymph node biopsy (2.5 per cent). For SLNB alone, dual tracers were most commonly used (62.3 per cent). Management varied widely in patients with ambiguous axillary status before initiation of treatment or a residual metastatic burden in the axilla after NAT. In patients with ycN+ tumours, ALND was the preferred surgical approach for 66.8 per cent of respondents. Conclusion These results highlight the wide heterogeneity in surgical approaches to the axilla after NAT. To standardize the guidelines, further data from clinical research are urgently needed, which underlines the importance of the ongoing AXSANA (EUBREAST-3) study.

Low neutrophil-to-lymphocyte ratio and pan-immune-inflammation-value predict nodal pathologic complete response in 1274 breast cancer patients treated with neoadjuvant chemotherapy: a multicenter analysis

“…For this reason, axillary involvement is usually considered an indication to NAC in most T1-T2 operable BC presenting nodal involvement at diagnosis. Unfortunately, when cN + does not convert to cN0 after NAC, ALND is recommended 14 . Therefore, the identi cation of pre-NAC markers that are predictive of axillary response might be useful in selecting those patients who may bene t from chemotherapy in terms of lymph node downstaging.…”

“…A large meta-analysis on 13 studies including over 1900 women documented a false negative rate exceeding 10% for SLNB technique in this setting 13 . A recent international EUBREAST survey among 349 international breast units demonstrated that standard ALND or target ALND are still the preferred approach in these patients 14 . In 2021, our group developed and validated a post-NAC predictive nomogram to select cN + BC patients with a low risk of residual axillary disease after NAC in whom axillary surgery could be minimized 15 .…”

Real de-escalation or escalation in disguise?

“…Recently, the results of the international EUBREAST survey on surgical management of the axilla were reported [66]. 349 physicians from 45 countries completed a detailed online questionnaire on their approach to specific clinical scenarios.…”

Regional radiotherapy after primary systemic treatment for cN+ breast cancer patients

“…Nevertheless, all authors justifiably warn that the above-mentioned data do not comprise level 1 evidence, and that the ongoing RCTs will have to be awaited before firm conclusions can be drawn. From a recent survey by the European Breast Cancer Research Association of Surgical Trialists (EUBREAST) it is clear that this lack of level 1 evidence leads to a wide heterogeneity in surgical approaches to the axilla after PST [ 66 ]. To overcome the current problem that in many (surgical) studies important radiation details are lacking, the Breast Cancer subcommittee of ESTRO guidelines is currently developing Quality Assurance guidelines regarding the reporting of radiation details in trials.…”