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BCC 2021 | Axillary surgery de-escalation in node-positive breast cancer

Walter Weber, MD, University Hospital Basel, Basel, Switzerland, provides a summary on the changes in the use of axillary surgery in node-positive breast cancer based on results of the IBCSG 23-01 study (NCT00072293) and other long-term trials where the omission of axillary lymph node dissection in node-negative breast cancer does not increase risk of regional recurrence. Prof. Weber also highlights the ongoing TAXIS trial (NCT03513614), evaluating the de-escalation of surgery in clinically node-positive breast cancer patients. This interview took place during the 17th St. Gallen International Breast Cancer Conference.

Transcript (edited for clarity)

There are several key messages involved here. The first one is that based on long-term follow-up of several randomized trials, axillary dissection can no longer be considered standard care in all node-positive patients. We have now 10-year results of IBCSG 23-01, ACOSOG Z0011, and EORTC AMAROS trial, all showing that the omission of axillary dissection in clinically node-negative patients with positive sentinel nodes does not increase the risk of regional recurrence...

There are several key messages involved here. The first one is that based on long-term follow-up of several randomized trials, axillary dissection can no longer be considered standard care in all node-positive patients. We have now 10-year results of IBCSG 23-01, ACOSOG Z0011, and EORTC AMAROS trial, all showing that the omission of axillary dissection in clinically node-negative patients with positive sentinel nodes does not increase the risk of regional recurrence. And none of these trials found any differences in disease-free or overall survival. So that is pretty clear now that many patients do not need axillary dissection even if there is cancer in the sentinel nodes.

Most of the efforts in clinical research in this field of axillary surgery de-escalation, our focus is on ways to determine that there is nodal pathologic complete response after neoadjuvant chemotherapy without removing all nodes. So limited concepts of axillary surgery, and these involve mostly the sentinel node procedure, but also similar concepts that use clipping of the sampled nodes and selective localization on the imaging guidance, in combination with the sentinel node, that’s called targeted dissection to reliably show with a low false negative rate that the nodes are clear and the patient can then be spared axillary dissection. And now we have oncologic follow-up of the first series showing that these concepts most probably work just fine.

And then we wait for the data answering the question, if we can omit axillary dissection in case of residual disease. There’s the Alliance trial that reopened now that recruits very well, and there is the TAXIS trial that tries a new concept of tailored axillary surgery in clinically node-positive breast cancer. So axillary surgery de-escalation will go on in the next few years.

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