5
III. Further Axillary Treatment: SLN(+)
A) No Further Axillary Surgery Beyond SLNB Compared with ALND
➤ Clinicians should NOT recommend ALND for women with early-stage
breast cancer who have one or two sentinel lymph node metastases
and will receive breast-conserving surgery with conventionally
fractionated whole-breast radiotherapy.*
(Strong Recommendation; EB-B-H for those who received breast
conserving surgery. Weak Recommendation; EB-B-Ins for patients
who had mastectomy as well as for those excluded from the trials.)
B) Radiotherapy of the Axilla (LRNI) Compared with No LRNI
➤ It is reasonable to offer the option of treating the axilla with
radiotherapy in addition to breast or chest wall irradiation following
surgery, particularly in patients with medial or central tumors, and
in patients with high-risk features. Discussion of pros and cons with
patients needs to occur, and the decision should be made on a case-
by-case basis. (Weak Recommendation; EB-B-L)
C) Radiotherapy to the Axilla Compared with Further Surgery
(ALND)
➤ We recommend radiotherapy of the axilla in lieu of ALND in patients
who are clinically node-negative and pathologically sentinel lymph
node-positive with tumors of up to 5 cm and unifocal or multifocal
disease restricted to one quadrant.
• In patients who receive breast-conserving surgery, we recommend no ALND
if one or two sentinel lymph nodes are positive. LRNI is a reasonable option,
especially when there are high-risk features as in (B).
• ALND and LRNI to the axilla is recommended if ≥3 sentinel lymph nodes are
positive. In patients who receive mastectomy and have one to two positive nodes,
post-mastectomy radiation (PMRT) to the chest wall and axilla is recommended
and ALND can be safely omitted. In patients declining PMRT (i.e., patients with
immediate reconstruction), either radiation to the axilla without the chest wall or
completion ALND can be offered.
• In patients who receive mastectomy and have ≥3 positive nodes, ALND followed
by LRNI can be considered.
(Weak Recommendation; IC-B (in the short term)-L)
* Endorsed from Lyman GH, et al. J Clin Oncol. 2017;5:561-4, Recommendation 2.1
