8
Management
➤ Post-mastectomy patients who are node-positive on surgical
pathology after NAC can be offered PMRT after a completion ALND.
➤ We recommend LRNI for the post-mastectomy node-positive cohort
after NAC while awaiting data from ongoing trials (i.e., the MAC19
study).
➤ We recommend LRNI after ALND for patients clinically and biopsy
proven node-positive at breast-conserving surgery who remain
pathologically node-positive after NAC.
➤ Shared decision-making processes should be put in place while
we await mature clinical trial data, to enable patient value-based
decision making. (Weak Recommendation; EB-B-L)
C) SLNB Timing: Before or After NAC
➤ We recommend against performing lymph node sampling twice,
before and after NAC. We recommend to time the SLNB after NAC and
not before in clinically node-negative patients who will receive NAC.
(Strong Recommendation; IC-B-L)
Qualifying Statements for When NAC is Used
B) Initially Clinically Positive and Biopsy-proven Node-positive
Patients
• To date, the clinical standard of care for node-positive patients who fail to
respond clinically in the axilla to NAC require maximal therapy to the axilla,
which includes ALND followed by LRNI.
V. Identifying Sentinel Nodes
A) Single versus Dual Tracer
➤ For patients having primary surgery, we recommend using a sentinel
node tracer (e.g., it is not necessary to add blue dye on a regular
basis for SLNB if the radiocolloid signal successfully identifies the
sentinel node(s) in the axilla). In cases of non-identification, blue dye
can be added.
• Screening for radiocolloid signal prior to incision is recommended, and blue dye
can be added prior to making the incision.
• In patients who receive NAC, we recommend either placing a biopsy clip into
the positive node at diagnosis and localizing it at the time of surgery or using dual
tracer (radiocolloid plus blue dye). (Moderate Recommendation; EB-B-I)
