Completely dissected.

Top Line: Who doesn’t love talking about axilla management? 

The Study: Here’s a new guideline From ASCO and Cancer Care Ontario for managing the axilla in patients with early stage breast cancer complete with a 4-page “bottom line” and a vertical algorithm (for those of us tired of horizontal algorithms). We’ll hit the highlights here. First off, who needs to skip the sentinel lymph node biopsy (SLNB) and go straight to axillary lymph node dissection (ALND)? Those who are clinically node-positive who 1) don’t get neoadjuvant chemo or 2) get neoadjuvant chemo without complete clinical response. Regional nodal irradiation (RNI) is recommended in addition to ALND for these patients. Now, let’s talk about the 1-2 positive nodes group. Z11 still guides us to omit ALND in those with 1-2 SLN+ who have breast conservation and will receive adjuvant breast radiation. What if they had a mastectomy? Radiation to the axilla (in some form) is recommended. This brings us to an important point. There are obviously many case-by-case nuances to these recommendations, but the guidelines typically favor using axilla-directed radiation over ALND when there are high risk features that nudge one towards treating the axilla beyond SLNB. Next, who should get completion ALND after SLNB? Those with 1) 3 or more positive SLN or 2) clinical node involvement with persistent SLN+ disease. For these patients, RNI is recommended in addition to ALND. Finally, how should you manage clinical node involvement that converts to cN0 after neoadjuvant chemo? SLNB is recommended, but it’s very important that the clinically involved nodes are markes prior to chemo. Also, it’s recommended to sample at least 3 sentinel nodes in this setting. And to reiterate, completion ALND is recommended for those who have positive SLN. Off trial, RNI is recommended for anyone with clinically involved nodes regardless of response. 

TBL: Managing the axilla is complicated, and it’s best that surgeons, medical oncologists, and radiation oncologists are all on the same page (or algorithm). | Brackstone, J Clin Oncol 2021

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