7
B) LRNI Compared with No LRNI
• Patients with estrogen receptor negative (ER–) and progesterone receptor
negative (PR–) status may have a more favorable DFS when treated with LRNI in
addition to surgery.
C) Radiotherapy to the Axilla Compared with Further Surgery (ALND)
• The ongoing MA39 (NCT00005957) study addresses the incremental benefit of
LRNI of the axilla in lower-risk, node-positive patients. At this time, no studies
comparing SLNB alone without LRNI have been identified in the mastectomy or
lumpectomy setting.
D) Radiotherapy Compared with No Treatment
• Patients ≥65 years of age may benefit less from the addition of radiotherapy.
• Receptor-negative patients may benefit more from radiotherapy treatment.
IV. When NAC is Used
A) Initially Node-negative Patients
➤ Patients who are initially clinically node-negative on physical
examination, and those who had clinically suspicious nodes on
physical examination but deemed to be pathologically negative at fine
needle aspiration/core needle biopsy, and were treated with NAC,
should receive SLNB at the time of surgery as their axillary staging
procedure. (Strong Recommendation; IC-B-Ins)
B) Initially Node-positive Patients
➤ For patients who were initially clinically and biopsy-proven node-
positive, and who remained clinically node-positive after NAC, we
recommend ALND.
➤ For patients who were initially clinically and biopsy-proven node-
positive, and became node-negative after NAC, we recommend SLNB
to restage the axilla. Restaging can be achieved by placing a biopsy
clip into the biopsied positive node at diagnosis and localizing it at
surgery along with sentinel node biopsy, or, in institutions where the
use of biopsy clips for nodes is not available, by performing sentinel
node biopsy with dual tracer and excising at least three sentinel
nodes in order to minimize the false negative rate and optimize
accuracy of the procedure. At this time, we also recommend LRNI
for these patients, regardless of pathologic status of sentinel lymph
nodes.
