6
Management
D) Radiotherapy Compared with No Treatment
➤ In patients with unilateral invasive cancer of small size (i.e., T1a),
favorable tumor features (e.g., ER+ undergoing hormonal therapy),
clear margins, and one to three positive nodes, treated with
chemotherapy or hormonal therapy, clinicians might offer the option
of omitting LRNI. (Weak Recommendation; EB-B-I)
Qualifying Statements for Further Axillary Treatment: SLN(+)
A) No Further Axillary Surgery Beyond SLNB Compared with ALND
• The evidence upon which this recommendation is based did not include patients
who:
▶ were pregnant or breastfeeding
▶ had a history of another malignancy in the previous 5 years
▶ have bilateral breast cancer
▶ have multicentric disease
▶ have three or more positive sentinel lymph nodes
▶ have a concomitant malignancy
▶ previously received systemic therapy for breast cancer
▶ received chemoprevention in the preceding year
▶ have distant metastases or macrometastatic disease
▶ have palpable axillary nodes
▶ were <18 or >75 years old
For these patients, as well as for patients who are treated with mastectomy,
decisions regarding completion of 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,
taking into account the limited data specific to mastectomy and considering
that these recommendations represent an extrapolation, on the basis of expert
opinion, from trials designed for patients undergoing breast conserving surgery.
• The management of the axilla for patients with four or more positive lymph
nodes (N2, N3 disease) falls outside the scope of this guideline. Please refer to
Brackstone, et al. Curr Oncol. 2015 Mar; 22(Suppl 1): S54–S66 .
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4381791/]
• For exactly three positive lymph nodes, there is not enough evidence to make a
recommendation, and therefore, we recommend proceeding with ALND and
considering LRNI.
