Management of the Axilla in Early-Stage Breast Cancer: Ontario Health (Cancer Care Ontario) and ASCO Guideline

Abstract

PURPOSE To provide recommendations on the best strategies for the management and on the best timing and treatment (surgical and radiotherapeutic) of the axilla for patients with early-stage breast cancer. METHODS Ontario Health (Cancer Care Ontario) and ASCO convened a Working Group and Expert Panel to develop evidence-based recommendations informed by a systematic review of the literature. RESULTS This guideline endorsed two recommendations of the ASCO 2017 guideline for the use of sentinel lymph node biopsy in patients with early-stage breast cancer and expanded on that guideline with recommendations for radiotherapy interventions, timing of staging after neoadjuvant chemotherapy (NAC), and mapping modalities. Overall, the ASCO 2017 guideline, seven high-quality systematic reviews, 54 unique studies, and 65 corollary trials formed the evidentiary basis of this guideline. RECOMMENDATIONS Recommendations are issued for each of the objectives of this guideline: (1) To determine which patients with early-stage breast cancer require axillary staging, (2) to determine whether any further axillary treatment is indicated for women with early-stage breast cancer who did not receive NAC and are sentinel lymph node–negative at diagnosis, (3) to determine which axillary strategy is indicated for women with early-stage breast cancer who did not receive NAC and are pathologically sentinel lymph node–positive at diagnosis (after a clinically node-negative presentation), (4) to determine what axillary treatment is indicated and what the best timing of axillary treatment for women with early-stage breast cancer is when NAC is used, and (5) to determine which are the best methods for identifying sentinel nodes. Additional information is available at www.asco.org/breast-cancer-guidelines .

Male Breast Cancer: Treatment Trends, Reported Outcomes, and Suggested Recommendations

“…Based on the results of this study, authors believe that SLNB should be the initial treatment of choice in MBC patients with clinically negative lymph nodes [ 24 ]. The American Society of Clinical Oncology (ASCO) also states that SLNB leads to fewer complications than an ALND including, the postoperative development of lymphedema, shoulder discomfort, sensory deficits, infections, and arm-related morbidity [ 15 ].…”

“…Based on available data collected from 2007-16, 4.6% of men reported postsurgical complications within 30 days following any surgical breast cancer management, with 3.2% of those being wound complications (superficial surgical site infection (SSI) 2.4%, deep SSI 0.5%, organ space SSI 0.2%, wound disruption 0.1%) [ 14 ]. As a result, less invasive surgical treatment approaches have been implemented in breast cancer treatment [ 14 , 15 ]. Yet, men are still treated with mastectomy 86% of the time, while 50% of women have a less invasive breast conservative surgery (BCS), suggesting that men with MBC are not always treated in accordance with the FBC treatment guidelines [ 16 ].…”

Clinical Significance of Peritumoral Adipose Tissue PET/CT Imaging Features for Predicting Axillary Lymph Node Metastasis in Patients with Breast Cancer

“…Breast cancer is the primary cause of the incidence of and death from female cancer globally [ 1 ]. In patients with breast cancer, axillary lymph node metastasis is one of the most significant clinical factors dictating the treatment strategy and predicting survival [ 2 , 3 ]. Axillary lymph node dissection is recommended for breast cancer patients involving clinically and biopsy-proven positive axillary lymph nodes [ 2 ].…”

“…In patients with breast cancer, axillary lymph node metastasis is one of the most significant clinical factors dictating the treatment strategy and predicting survival [ 2 , 3 ]. Axillary lymph node dissection is recommended for breast cancer patients involving clinically and biopsy-proven positive axillary lymph nodes [ 2 ]. Meanwhile, sentinel lymph node biopsy is suggested as the gold standard for axillary lymph node staging of patients with clinically negative or suspicious lymph nodes but negative biopsy results [ 2 , 4 ].…”

“…Axillary lymph node dissection is recommended for breast cancer patients involving clinically and biopsy-proven positive axillary lymph nodes [ 2 ]. Meanwhile, sentinel lymph node biopsy is suggested as the gold standard for axillary lymph node staging of patients with clinically negative or suspicious lymph nodes but negative biopsy results [ 2 , 4 ]. However, sentinel lymph node biopsy showed a 9.8% false-negative rate in a previous clinical trial and, despite a lower morbidity than that of axillary lymph node dissection, surgical complications such as lymphedema were reported in 3.7–6.9% of patients undergoing sentinel lymph node sampling [ 5 , 6 , 7 ].…”