4
Management
Qualifying Statements for Further Axillary Treatment: SLN(-)
Surgical Interventions
• SLNB is currently the standard of practice for this population.
• The evidence regarding the omission of ALND upon which this
recommendation is based did not include patients who:
▶ had a history of another cancer
▶ had a multicentric breast cancer
▶ had a prior ipsilateral breast cancer surgery or prior ipsilateral axillary surgery
▶ were <18 or >80 years of age
▶ were pregnant or lactating
▶ were allergic to blue dye or radioisotope
▶ had evidence of metastatic disease
▶ had tumors >3 cm in diameter
▶ suffered from chronic life-threatening diseases possibly preventing the use of
adjuvant therapy
▶ had stage T0 tumors (i.e., ductal carcinoma in situ [DCIS]), had multifocal
tumors, and received previous neoadjuvant chemotherapy (NAC)
For these patients, decisions regarding ALND should be made after discussion
between patient and clinicians on a case-by-case basis, depending on the invasive
component of the lesion, other clinical circumstances, and patient preferences.
Radiotherapy Interventions
• Patients with centrally or medially located tumors may modestly benefit (<5%
difference) from LRNI compared with whole-breast irradiation (WBI) only
(post-lumpectomy) or no post-operative radiation (post-mastectomy) in terms
of disease-free survival (DFS), distant DFS, and loco-regional relapse, but not in
terms of overall survival (OS).
• Post-mastectomy patients with node-negative, triple-negative breast cancer who
receive chemotherapy may benefit from chest wall radiotherapy compared with
no radiotherapy in DFS and OS.
• A radiotherapy dose fractionation schedule of 50 Gy in 25 fractions over five
weeks is the current standard used in the relevant clinical trials. However, we
recognize that there are other regimens now considered clinically appropriate
and/or equivalent to this traditional fractionation.
