Axillary lymph node dissection is not required for breast cancer patients with minimal axillary residual disease after neoadjuvant chemotherapy

Axillary lymph node dissection is not required for breast cancer patients with minimal axillary residual disease after neoadjuvant chemotherapy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Axillary lymph node dissection is not required for breast cancer patients with minimal axillary residual disease after neoadjuvant chemotherapy Mahmut Muslumanoglu, Baran Mollavelioglu, Neslihan Cabioglu, Selman Emiroglu, and 13 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4712847/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 31 Oct, 2024 Read the published version in World Journal of Surgical Oncology → Version 1 posted 9 You are reading this latest preprint version Abstract Background Sentinel lymph node biopsy(SLNB) is widely used in patients who receive neoadjuvant chemotherapy(NAC). Still, axillary lymph node dissection(ALND) is recommended for patients with any axillary residual disease after NAC. The necessity of ALND in patients with minimal axillary disease is unclear. We aim to investigate regional recurrence rates in patients with limited axillary residual disease after NAC underwent SLNB + image-tailored axillary surgery and adjuvant radiotherapy (RT). Methods Patients with clinical stages were T1-3 and N1 at the time of diagnosis, clinically good or complete axillary response after NAC, and limited axillary residue (≤ 3 pathological lymph nodes) with favorable response to NAC in the final pathological examination were included in the study. All patients underwent SLNB + image-tailored axillary surgery. Peripheral lymphatic radiotherapy was applied, and no further surgery was performed in patients with compatible radiology and pathology results. Results Our study, which evaluated 139 patients with a median age of 47 years, found that the median number of excised lymph nodes was 4. Notably, 46% of patients had between 1 and 3 lymph nodes excised, while 45% had between 4 and 6. Only 9% of patients had ≥ 7 lymph nodes. 83(60%) of the patients underwent breast-conserving surgery (BCS), and 56(40%) underwent mastectomy. The study's median follow-up period was 44 months. During this duration, one breast recurrence (0.7%), one supraclavicular recurrence (0.7%), and six systemic recurrences (4.3%) were observed. No axillary recurrence occurred within the follow-up period. Conclusions Patients presenting with pathological-suspicious ≤ 3 lymph nodes on imaging and showing a good response to NAC can be considered suitable candidates for SLNB + image-tailored axillary surgery, followed by adjuvant RT instead of ALND. Breast Cancer Breast surgery Neoadjuvant chemotherapy axillary lymph node dissection sentinel lymph node biopsy Figures Figure 1 Figure 2 INTRODUCTION In recent decades, there has been a shift towards personalized treatment approaches for breast cancer patients. The traditional one-size-fits-all surgical methods are being reconsidered, and more tailored minimally invasive interventions are being developed. In the 1990s, Giuliano et al. first described sentinel lymph node biopsy (SLNB), demonstrating that axillary lymph node dissection (ALND) is unnecessary for SLNB-negative breast cancer patients ( 1 ). Landmark trials such as NSABP B-04 and NSABP B-32 have shown that the extent of axillary surgery does not improve survival for clinically node-negative patients ( 2 )( 3 ). The evidence overwhelmingly supports SLNB as the preferred treatment for axillary surgery in early breast cancer, considering its proven benefits in terms of morbidity, quality of life, and oncological safety ( 4 ). Notably, clinical studies like ACOSOG Z0011 and AMAROS have shown that even in cases of limited axillary involvement with a positive SLNB, axillary dissection does not offer lower axillary recurrence and survival benefit when axillary radiotherapy (RT) is applied ( 5 , 6 ). The extensive use of neoadjuvant chemotherapy (NAC) in locally advanced breast cancer and the remarkable rates of pathological complete response (pCR) have sparked a new debate on how to approach the axilla after NAC. While SLNB is commonly used in patients who initially present with no signs of cancer in the lymph nodes and are treated with NAC, its use in patients with positive axillary nodes before NAC is controversial ( 7 ). Prospective studies have been conducted to resolve this controversy. With current chemotherapy treatments, axillary pCR rates have reached 50%, making ALND unnecessary in almost half of the patients. Consequently, the option of SLNB has become more prominent in patients with a positive axillary status before NAC ( 8 , 9 ). In light of current guidelines, ALND is recommended for axillary residual disease after NAC, irrespective of disease burden, due to insufficient evidence. Nonetheless, there is growing scrutiny around the necessity of ALND, particularly in cases of limited axillary residue ( 10 ). Magnetic resonance imaging (MRI) and ultrasound (USG) are widely used to evaluate response to neoadjuvant therapy, with an approximately 60% success rate in predicting complete pathological response. However, the accuracy improves when comparing the presence of axillary response (shrinking) to baseline images ( 11 , 12 ). Our study sought to evaluate the efficacy and the safety of image-tailored axillary surgery in combination with SLNB as a substitute for ALND in patients exhibiting limited axillary involvement and demonstrating favorable responses to NAC. METHODS In this prospectively designed study, we evaluated patients with clinical stages of T1-3 and N1 at the time of diagnosis, who showed good or complete response to NAC for both the breast and axilla and exhibited favorable changes (> 50% fibrotic) in the final pathological examination. The study was conducted at the Breast Surgery Unit, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, between January 2011 and December 2023. Patients with T4, cN2-3, and M1 stages at admission, no clinical axillary response to NAC, more than three pathological lymph nodes on imaging, and complete axillary pathological response as per the final pathology report were excluded from the study. All patients underwent evaluation by a multidisciplinary team before and after NAC. The tumor stage, NAC response, and the number of pathological lymph nodes with their location were determined using USG, mammography (MMG), MRI, and positron emission tomography-computed tomography (PET-CT) by a breast specialist radiologist. Patients who showed a significant or complete response in their axillary lymph nodes after NAC were included in the study, while those who showed progression or no regression were excluded (Fig. 1 ). Before surgery, it is important to identify the locations of pathological lymph nodes. For instance, level 1 in the inferior axilla can be close to the breast tail or lateral to the pectoralis minor muscle. In the superior axilla, level 1 can be lateral to the pectoralis major muscle, close to the axillary vein, or near the latissimus dorsi muscle. This information helps surgeons to target and remove these nodes more effectively during the operation, which is referred to as image-tailored surgery. All patients underwent neoadjuvant chemotherapy, including anthracycline and taxane. Patients with HER2-neu-positive disease received additional trastuzumab therapy. Adjuvant hormonal therapy was administered to all hormone-positive patients. Patients with triple-negative disease had capecitabine after surgery, and those with HER-2-positive disease had trastuzumab or trastuzumab emtansine. Patients underwent SLNB in conjunction with image-tailored lymph node excision performed by dedicated breast specialist surgeons. In a minority of cases, dual mapping (lymphoscintigraphy + blue dye) was employed (17%) and targeted axillary dissection (TAD) was carried out as per surgeon preference (7%). Lymph nodes were meticulously dissected from the excision material by an experienced pathologist. The presence of blue dye was noted during macroscopic evaluation. At least four sections were obtained from each lymph node block at 250-m intervals and stained with hematoxylin and eosin (H&E). Sentinel lymph nodes containing tumor cells detected by H&E or cytokeratin immunohistochemistry staining were considered positive, according to the AJCC 8th edition. Pathologic findings regarding chemotherapy response were also recorded, including regressional fibrosis, fibrohyalinization, and reactive changes. The study investigated the relationship between the number of radiologically suspicious or positive lymph nodes and the number of lymph nodes removed. The number of lymph nodes removed was at least equal to the number found to be suspicious or pathologic. The multidisciplinary council reviewed patients' final pathology results. Evaluation encompassed assessing the number of lymph nodes removed, the number of pathological lymph nodes identified radiologically before NAC, and the number of nodes with residual disease pathologically. No further axillary intervention was scheduled for patients with consistent radiology and pathology results. Patients who had breast-conserving surgery (BCS) received RT to the entire breast, while those who had a mastectomy received RT to the chest wall. All patients also received RT to the axilla (level I-II-III), which includes the supraclavicular lymph node regions with or without the internal mammary lymph node region. Patients with high-load axillary residual disease, unable to undergo adjuvant RT, and having inconsistent radiologic and pathological findings regarding the number of positive nodes underwent ALND. This group of patients was also excluded from the study (Fig. 1 ). Demographic, clinicopathological, and radiological data of the patients were analyzed. According to the current guidelines, patients were regularly examined and evaluated for local recurrence or systemic disease. Statistical analysis The assumption of normality of continuous variables was tested with the Shapiro-Wilk test. Categorical variables were presented as frequency(%), continuous variables as mean ± SD, median (IQR: P25-P75), and range. Comparisons between groups in continuous variables were made with the Mann-Whitney U test, and comparisons between groups in categorical variables were made with Chi-Square tests (Pearson Chi-Square Test, Continuity Correction Test, and Fisher's Exact Test). Diagnostic tests (sensitivity, specificity, PPV, NPV, and accuracy) were used to compare clinical findings and pathological results. Statistical analyses were made with SPSS software version 25 (IBM Corp., Armonk, NY, USA). Results were evaluated in the 95% confidence interval, and p < 0.05 was considered significant. RESULTS Out of the 308 patients assessed for eligibility, 28 patients with four or more pathological lymph nodes in the preoperative evaluation were excluded. Additionally, three patients declined to participate, and nine patients were excluded due to disease progression during treatment. Breast surgery with SLNB + image tailored axillary surgery was performed on the remaining patients. Furthermore, 85 patients with pathological complete response, three with incompatible pathology and radiology results, 28 with high-load axillary residual disease (four or more metastatic lymph nodes) in pathological evaluation, and one with contraindication for adjuvant radiotherapy were also excluded from the study (Fig. 2 ). A total of 139 patients with a median age of 47 years (IQR, 39–54; range, 21–73) were included in the study. Of these, 128 patients had T1-2 stage tumors, while 11 had T3 stage tumors. Breast-conserving surgery was performed on 83 patients (59.7%), while 56 patients (40.3%) underwent mastectomy. Non-luminal subtype was found in 30 patients (21.6%), whereas 109 patients (78.4%) had luminal subtype. Prior to neoadjuvant chemotherapy (NAC), MRI and USG imaging of all patients were examined by a breast radiologist. The imaging revealed a single pathological lymph node in 76 patients, 2 in 41 patients, and 3 in 22 patients. Pathological features of the lymph nodes were confirmed through fine-needle aspiration biopsy (FNAB). During the study, sentinel lymph node biopsy (SLNB) was carried out using blue dye in 115 cases (82.7%) and with the combined method of blue dye and lymphoscintigraphy in 24 cases (17.3%) (Table 1 ). The identification rate of SLNB was 97.3% when using the single tracer (blue dye) and 100% when using the dual tracer. In only three patients, no blue dye was observed in the axilla. In these cases, lymph node excision was conducted based on palpation findings and radiological imaging. Table 1 Patient characteristics Characteristics(N = 139) Category n(%) Median age(IQR) All 47(39–54) Age, minimum-maximum All 21–73 Age ≤ 50 89(64) > 50 50(36) Clinical T stage cT1/2 128(92.1) cT3 11(7.9) Type of Breast Surgery BCS 83(59.7) Mastectomy 56(40.3) Histopathology of core biopsy and surgical specimen Invasive ductal carcinoma 123(88.5) Invasive Lobular carcinoma 2(1.4) Invasive ductal&lobular carcinoma 11(7.9) Other 3(2.2) pCR (breast) Complete 28(20.1) Near complete(> 90%) 30(21.6) 80–90% 24(17.3) 50–80% 34(24.5) < 50% 23(16.5) HER2- neu Negative 108(77.4) Positive 31(22.3) Tumor Subtype (IHC) Luminal A 13(9.4) Luminal B/HER2(-) 76(55.1) Luminal B/HER2(+) 19(13.8) Non luminal B/HER2(+) 12(8.7) Triple-negative 18( 13 ) Tumor Subtype (IHC) Luminal 109(78.4) Non-luminal 30(21.6) Sentinel Lymph Node Methodology Blue Dye 115(82.7) Combined (Blue dye and radioisotope) 24(17.3) Radiologic lymph node involvement # 1ln 77(55.4) 2ln 40(28.8) 3ln 22(15.8) TAD Yes 10(7.2) No 129(92.8) Number of sentinel lymph nodes 1–3 92(66.2) ≥ 4 47(33.8) Number of metastatic sentinel lymph nodes 1 112(80.6) ≥ 2 27(19.4) Number of total LN (Median:4, range:1–9) 1–3 64(46) ≥ 4 75(54) Number of total metastatic LN 1 101(72.7) ≥ 2 38(27.3) Characteristics of metastatic lymph nodes (LNs) removed Macrometastasis 80(57.6) Micrometastasis 43(30.9) Isolated tumor cells 16(11.5) Presence of extracapsular extension Yes 23(16.5) No 116(83.5) Non sentinel lymph node positivity (n = 52)* Yes 12(23.1) No 40(76.9) Lymph Node Ratio(LNR) ≤ 0.33 91(65.5) > 0.33 48(34.5) IQR : Interquartile Range(P 25 - P 75 ), BCS: Breast breast-conserving surgery # It refers to the number of lymph nodes that appear suspicious or pathological in radiological evaluation before NAC. * It refers to lymph nodes that are considered suspicious with intraoperative palpation findings and lymph nodes removed through image-tailored axillary surgery except for SLNB A total of 64 patients (46%) had 1–3 excised lymph nodes, while 62 patients (45%) had 4–6 excised lymph nodes. Thirteen patients (9%) had seven or more lymph nodes removed (Table 2 ). The median number of excised lymph nodes was 4 (IQR, 3–5). Five patients had only one lymph node excised, as radiological findings suggested only one pathological node and no other palpable or suspicious node was found during the operation. Pathological examination revealed that 101 patients had a single metastatic lymph node, 32 patients had 2 metastatic lymph nodes, and 6 patients had 3 metastatic lymph nodes. Macrometastasis was observed in 80 nodes, micrometastasis in 43, and isolated tumor cells in 16. pCR was detected in the breast in 26 patients (18.7%). Table 2 Comparison of radiological lymph node involvement with the number of excised lymph nodes Radiologic lymph node involvement 1LN(n = 77) 2LN(n = 40) 3LN(n = 22) Total(n = 139) Quantitative variables Median(IQR)/ Range Median(IQR)/ Range Median(IQR)/ Range Median(IQR)/ Range Number of total LN 4( 3 – 5 )/1–9 3( 3 – 5 )/2–9 5( 3 – 6 )/3–9 4( 3 – 5 )/1–9 Number of total metastatic LN 1( 1 – 1 )/1–1 2( 1 – 2 )/1–3 2( 1 – 2 )/1–3 1( 1 – 2 )/1–3 Total excised LN n(%) n(%) n(%) n(%) 1–3 37(48) 21(52.5) 6(27.3) 64(46) 4–6 36(46.8) 14(35) 12(54.5) 62(44.6) ≥ 7 4(5.2) 5(12.5) 4(18.2) 13(9.4) N/A: Not available The study compared the number of radiologically positive lymph nodes, pathologically positive lymph nodes, and positive sentinel lymph nodes, as shown in Table 2 . All patients with one radiologically positive lymph node were found to have one metastatic lymph node. In this group, all patients had metastasis in the sentinel nodes and no metastasis was detected in non-sentinel lymph nodes. Among 41 patients with two radiologically positive lymph nodes, 17 (41%) had one metastatic lymph node, 22 (53%) had two metastatic lymph nodes, and 2 (5%) had three metastatic lymph nodes. Two patients with inconsistent pathology and radiology results were re-evaluated in a multidisciplinary council, and it was determined that axillary lymph node dissection (ALND) was not necessary. Radiology revealed three positive lymph nodes in 22 patients, of which 8 (36%) had one metastatic lymph node, 10 (45%) had two metastatic lymph nodes, and 4 (18%) had three metastatic lymph nodes (Additional file 1). The median follow-up period was 44 months (IQR, 29–56). One patient experienced breast recurrence in the 31st month, and another patient had lymphatic recurrence in the supraclavicular area in the 39th month (Table 3 ). Systemic recurrence was observed in 6 (4.3%) patients. No axillary recurrence occurred during the follow-up period (Additional file 2). Table 3 Characteristics of patients with local or regional recurrence Age cT/N ypSLN LN ratio pCR (breast) Molecular subtype Extracapsular invasion LVI Breast Surgery Recurrence time(month) Site of recurrence Case 1 31 2/1 macromet 3/5 no TN yes no BCT 31 breast Case 2 54 2/1 macromet 1/5 no Lum-B yes no mastectomy 39 supra LN : lymph node, LVI : lymphovascular invasion DISCUSSION The efficacy of chemotherapeutic agents in the treatment of breast cancer is progressively on the rise. Following NAC, the incidence of axillary pCR may escalate to 50%. Notably, rates of pCR are even more pronounced in HER-2-positive and triple-negative patients ( 13 ). The notable efficacy of NAC warrants deliberation on the necessity of ALND in cases of limited axillary residual disease, thereby advocating for the adoption of less invasive techniques in axillary surgery. Particularly, SLNB is the preferred approach for patients who are converted from cN + to cN0 post-NAC. Although SLNB is often performed in patients who have converted to cN0 after NAC, some surgeons are concerned about the potential for false-negative results of SLNB. Caudle et al. suggested targeted axillary dissection for this concern ( 14 ). Boughey et al. also showed that the false negative rate (FNR) can be reduced to less than 10% with TAD( 15 ). In clinically node-positive (cN+) patients who were converted to clinically node-negative (cN0), various prospective studies have demonstrated that FNR of the SLNB was higher than 10%, and if the dual mapping is used and ≥ 3 Lymph nodes are excised, and FNR can be reduced to acceptable rates of < 10% (4.9%-9.1%) regardless of TAD ( 16 – 18 ). In the SENTINA trial, the FNR was 24.3% for patients with one sentinel node removed and 18.5% for patients with two sentinel nodes removed ( 17 ). Three or more lymph node excisions and dual methods are recommended to reduce FNR ( 19 ). In contrast, Galimberti et al. published 10-year follow-up results of patients who were initially cN + and became cN0 after NAC. Inclusion criteria were SLNB alone (one node is enough) without TAD, single tracer (no dual mapping), and nodal radiotherapy was not mandatory. Axillary failure occurred in 1.8% of the initially cN1/2 patients and 1.5% of the initially cN0 patients ( 20 ). Although there is a risk of false negativity of SLNB, nodal recurrence rates are not increased in patients with negative SLNB who do not undergo ALND ( 21 , 22 ). Despite the lack of evidence regarding the negative impact of FNR on axillary recurrence and survival, the surgical community is actively pursuing strategies such as dual mapping and targeted axillary dissection to reduce FNR. It is recognized that despite diligent efforts, the FNR of SLNB cannot be reduced to zero, resulting in the presence of minimal residue in the axilla of a subset of patients. For patients undergoing upfront surgery, we have substantial evidence from prospective trials with 10 years of follow-up, such as ACOSOG Z0011 and AMAROS ( 5 , 23 ). It is established that even if there is a limited residual disease in the axilla, ALND does not decrease axillary recurrence rates or extend overall survival as long as adjuvant RT is administered. Now is the time to discuss avoiding ALND for N + disease following NAC. Reports of ongoing prospective trials, such as Alliance 11202 and NSABP B-51/RTOG 1304, are expected to clarify this topic ( 24 , 25 ). A trial including SLNB + patients after NAC was presented in ASCO 2023. The study evaluated cN1 breast cancer that became ycN0 but remained node positive following NAC, according to findings from a retrospective analysis of patients treated in phase 3 prospective NSABP B-40 and B-41 trials. Results showed that more intense axillary surgery (ALND) was not associated with better cancer outcomes when compared with SLNB. 5-year loco-regional recurrence was 9% in the ALND group, compared with 12% for those who underwent SLNB (p = 0.790) in unselected patients. 5-year risk of metastasis was 31% and 26%, respectively, and 5-year risk of any recurrence was 33% and 32%, respectively ( 26 ). Similarly, in a few recently published studies, the superiority of ALND in oncological terms could not be demonstrated for neoadjuvant breast cancer patients with limited axillary residual disease ( 27 – 29 ). In a multicentric registry trial, Cabioglu et al. showed that ALND could be avoided in selected cN (+) patients who underwent SLNB after NAC having low-volume residual nodal disease with luminal pathology, as long as axillary radiotherapy is provided ( 29 ). Almaharic et al. analyzed a total of 1617 patients from the National Cancer Database to compare survival following SLND and ALND in breast cancer patients with residual LN disease. Subgroup analysis demonstrated that SLNB was comparable with ALND in patients with luminal A or B tumors with a single metastatic lymph node ( 28 ). Unlike these studies, Our study showed no difference in local recurrence rates between luminal and non-luminal subtypes. In the database study of Kantor et al., 6554 HR+/her- cN0 patients receiving neoadjuvant endocrine therapy were evaluated, and > 90% of patients had less than three positive lymph nodes. No survival difference was found between SLNB and ALND in these patients ( 30 ). Axillary involvement is generally defined as N0 and N + without considering the volume of nodal disease (number and size of pathological nodes). The absence of image-tailored localization of suspicious lymph nodes places all N + patients in the same category and prevents individual decision-making (one size fits all). Our aim should be to determine precise, tailored surgical (need for ALND) and medical treatment (need for additional systemic treatment) approaches for every patient. To achieve this, we need to determine the extent of axillary involvement before NAC and assess the response after NAC using imaging to identify cases with minimal axillary residual disease. In our study, we observed no axillary recurrences in 4 years of follow-up, despite expecting a high recurrence rate in patients with axillary residual disease after NAC. This suggests that minimal axillary residual disease may not necessitate ALND as long as radiological and pathological findings are consistent. It's worth noting that current guidelines recommend ALND for patients with any axillary residual disease, regardless of tumor burden and NAC response ( 10 ). Our practice is based on multidisciplinary councils where we evaluate the clinicopathological features of patients, pre- and post-neoadjuvant imaging, and pathological examination results. Based on this evaluation, we devise a personalized treatment plan that goes beyond the current guidelines. It's important to note that we focus on the compatibility of imaging findings and pathological examination results. This approach allows us to initiate a personalized treatment for patients with limited axillary involvement without compromising oncological safety. Most patients had an average of 6 or fewer lymph nodes removed (95% of patients with one pathological lymph node, 87% with two, and 82% with three). The number of lymph nodes removed in our study appears to be higher than standard SLNB. This is because we also removed palpable and suspicious lymph nodes guided by imaging. Excising more lymph nodes helps obtain a better correlation between imaging and final pathology, leading to safer decisions to avoid ALND. The number of excised lymph nodes could be decreased, but this may cause an increase in second axillary surgery rates. Radiological evaluation of post-neoadjuvant axilla can be challenging. While imaging techniques are effective in identifying axillary involvement, they may be insufficient, particularly in assessing the complete response to NAC ( 31 , 32 ). Our study focused on differentiating between high-volume axillary disease and limited disease (< 3 lymph nodes). Our objective in evaluating post-neoadjuvant response was not to discern complete response, and we included patients with a good partial response, so the constraints of imaging methods did not impact our study. The study's main limitation was the absence of a comparison group. Additionally, interpreting the palpation findings requires experience. Our team consists of breast specialist surgeons and radiologists, and our center deals with a high volume of breast cancer cases. A comprehensive multidisciplinary tumor board evaluated all patients and determined individualized treatments. Therefore, conducting this prospective study in a tertiary referral center is feasible. CONCLUSİON In patients with minimal axillary residual disease, SLNB + image-tailored axillary surgery and adjuvant radiotherapy may be sufficient for local control of the axilla as long as radiological and pathological correlation is ensured. ALND may be considered in patients suspected of having a high-volume residual disease. This study also confirmed that the belief that “chemo-resistance is equal to radio-resistance” is not valid in patients with minimal axillary residual disease (3 or fewer nodes) who exhibit a favorable response to NAC. Abbreviations SLNB Sentinel lymph node biopsy NAC neoadjuvant chemotherapy ALND axillary lymph node dissection pCR pathological complete response MRI Magnetic resonance imaging USG ultrasound MMG mammography PET CT -positron emission tomography-computed tomography TAD targeted axillary dissection H&E hematoxylin and eosin BCS breast-conserving surgery FNR false negative rate Declarations Ethics approval and consent to participate The study was approved by the ethical committee of Istanbul University, Istanbul Faculty of Medicine (08.08.2023-1981986), by the ethical standards of the institutional and national research committee, and with the 1964 Helsinki Declaration. Informed consent was obtained from all individual participants included in the study. Consent for publication The authors have approved the publication of the final version of the manuscript. Availability of data and materials The datasets analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Funding No funding was received for this study. Authors' contributions Design of the work: Muslumanoglu M., Cabioglu N., Tukenmez M., Emiroglu S., Mollavelioglu B. Acquisition of data: Karanlık H., Ozmen T., Muslumanoglu M., Cabioglu N., Tukenmez M., Emiroglu S., Mollavelioglu B., Ibis K. Analysis and interpretation of data: Yılmaz R., Gunoz Comert R., Onder S., Bayram A., Oflas M., Has Simsek D., Drafting: Yılmaz R., Gunoz Comert R., Onder S., Bayram A., Oflas M., Has Simsek D., Ibis K., Mollavelioglu B. Important intellectual content: Karanlık H., Ozmen T., Aydiner A., Ozmen V., Igci A., Muslumanoglu M., Cabioglu N., Tukenmez M. 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Ann Surg. 2016;263(4):802. Boughey JC, Suman VJ, Mittendorf EA, Ahrendt GM, Wilke LG, Taback B, Leitch AM, Kuerer HM, Bowling M, Flippo-Morton TS, Byrd DR. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 2013;310(14):1455–61. Kuehn T, Bauerfeind I, Fehm T, Fleige B, Hausschild M, Helms G, Lebeau A, Liedtke C, von Minckwitz G, Nekljudova V, Schmatloch S. Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study. Lancet Oncol. 2013;14(7):609–18. Boileau JF, Poirier B, Basik M, Holloway CM, Gaboury L, Sideris L, Meterissian S, Arnaout A, Brackstone M, McCready DR, Karp SE. Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study. J Clin Oncol. 2015;33(3):258–64. Yan M, Abdi MA, Falkson C. Axillary management in breast cancer patients: a comprehensive review of the key trials. Clin Breast Cancer. 2018;18(6):e1251–9. Galimberti V, Fontana SK, Vicini E, Morigi C, Sargenti M, Corso G, Magnoni F, Intra M, Veronesi P. This house believes that: Sentinel node biopsy alone is better than TAD after NACT for cN + patients. Breast. 2023;67:21–5. Wong SM, Basik M, Florianova L, Margolese R, Dumitra S, Muanza T, Carbonneau A, Ferrario C, Boileau JF. Oncologic safety of sentinel lymph node biopsy alone after neoadjuvant chemotherapy for breast cancer. Ann Surg Oncol. 2021;28:2621–9. Barrio AV, Montagna G, Mamtani A, Sevilimedu V, Edelweiss M, Capko D, Cody HS, El-Tamer M, Gemignani ML, Heerdt A, Kirstein L. Nodal recurrence in patients with node-positive breast cancer treated with sentinel node biopsy alone after neoadjuvant chemotherapy—a rare event. JAMA Oncol. 2021;7(12):1851–5. Bartels SAL, Donker M, Poncet C, Sauvé N, Straver ME, van de Velde CJH, Mansel RE, Blanken C, Orzalesi L, Klinkenbijl JHG, van der Mijle HCJ, Nieuwenhuijzen GAP, Veltkamp SC, van Dalen T, Marinelli A, Rijna H, Snoj M, Bundred NJ, Merkus JWS, Belkacemi Y, Rutgers EJT. Radiotherapy or Surgery of the Axilla After a Positive Sentinel Node in Breast Cancer: 10-Year Results of the Randomized Controlled EORTC 10981–22023 AMAROS Trial. J Clin oncology: official J Am Soc Clin Oncol. 2023;41(12):2159–65. https://doi.org/10.1200/JCO.22.01565 . Mamounas EP, Bandos H, White JR, Julian TB, Khan AJ, Shaitelman SF, Torres MA, Vicini F, Ganz PA, McCloskey SA, Paik S. NRG Oncology/NSABP B-51/RTOG 1304: Phase III trial to determine if chest wall and regional nodal radiotherapy (CWRNRT) post mastectomy (Mx) or the addition of RNRT to whole breast RT post breast-conserving surgery (BCS) reduces invasive breast cancer recurrence-free interval (IBCR-FI) in patients (pts) with pathologically positive axillary (PPAx) nodes who are ypN0 after neoadjuvant chemotherapy (NC). Comparison of Axillary Lymph Node Dissection With Axillary Radiation for Patients With. Node-Positive Breast Cancer Treated With Chemotherapy | ClinicalTrials.gov. https://clinicaltrials.gov/study/NCT01901094 . Mailhot Vega R, Deladisma AM, Mobley EM, Wang S, Morris CG, Oladeru OT, Brooks E, Gharia BM, Spiguel LR, MacDonald SM, Mamounas EP. Axillary surgery efficacy for patients with breast cancer receiving neoadjuvant chemotherapy on NSABP B40 and B41. van Loevezijn AA, van der Noordaa ME, Stokkel MP, van Werkhoven ED, Groen EJ, Loo CE, Elkhuizen PH, Sonke GS, Russell NS, van Duijnhoven FH, Vrancken Peeters MJ. Three-year follow-up of de-escalated axillary treatment after neoadjuvant systemic therapy in clinically node-positive breast cancer: the MARI-protocol. Breast Cancer Res Treat. 2022;193(1):37–48. Almahariq MF, Levitin R, Quinn TJ, Chen PY, Dekhne N, Kiran S, Desai A, Benitez P, Jawad MS, Gustafson GS, Dilworth JT. Omission of axillary lymph node dissection is associated with inferior survival in breast cancer patients with residual N1 nodal disease following neoadjuvant chemotherapy. Ann Surg Oncol. 2021;28:930–40. Cabıoğlu N, Karanlık H, Yıldırım N, Müslümanoğlu M, Karadeniz GÇ, Can DT, Tükenmez M, Ersoy YE, Uras C, Zengel B, Emiroğlu S. Favorable outcome with sentinel lymph node biopsy alone after neoadjuvant chemotherapy in clinically node positive breast cancer at diagnosis: Turkish Multicentric NEOSENTI-TURK MF-18-02-study. Eur J Surg Oncol. 2021;47(10):2506–14. Kantor O, Wakeman M, Weiss A, Wong S, Laws A, Grossmith S, Mittendorf EA, King TA. Axillary management after neoadjuvant endocrine therapy for hormone receptor-positive breast cancer. Ann Surg Oncol. 2021;28:1358–67. Ahmed M, Jozsa F, Baker R, Rubio IT, Benson J, Douek M. Meta-analysis of tumour burden in pre-operative axillary ultrasound positive and negative breast cancer patients. Breast Cancer Res Treat. 2017;166(2):329–336. 10.1007/s10549-017-4405-3 . Epub 2017 Jul 28. Erratum in: Breast Cancer Res Treat. 2017;166(2):337. PMID: 28755147; PMCID: PMC5668351. Kim R, Chang JM, Lee HB, Lee SH, Kim SY, Kim ES, Cho N, Moon WK. Predicting Axillary Response to Neoadjuvant Chemotherapy: Breast MRI and US in Patients with Node-Positive Breast Cancer. Radiology. 2019;293(1):49–57. 10.1148/radiol.2019190014 . Epub 2019 Aug 13. PMID: 31407967. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1.docx Additionalfile2.docx Cite Share Download PDF Status: Published Journal Publication published 31 Oct, 2024 Read the published version in World Journal of Surgical Oncology → Version 1 posted Editorial decision: Revision requested 31 Aug, 2024 Reviews received at journal 18 Aug, 2024 Reviewers agreed at journal 06 Aug, 2024 Reviews received at journal 29 Jul, 2024 Reviewers agreed at journal 27 Jul, 2024 Reviewers invited by journal 25 Jul, 2024 Editor assigned by journal 11 Jul, 2024 Submission checks completed at journal 09 Jul, 2024 First submitted to journal 09 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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11:33:43","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":475909,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow chart of study inclusion and exclusion criteria\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4712847/v1/313fe9d8f550ca39e12da44b.jpeg"},{"id":68207144,"identity":"6e41f522-4a1b-45e2-a0ce-8fae96f5fc80","added_by":"auto","created_at":"2024-11-04 16:35:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1924446,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4712847/v1/2d94fb6a-9e2b-47ba-bbeb-cb7fa9fae124.pdf"},{"id":62183169,"identity":"6ec016fe-2e0c-4b9a-8952-ddb1f39227d7","added_by":"auto","created_at":"2024-08-10 11:33:43","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17597,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4712847/v1/ef9736bd24fcb062975f6a22.docx"},{"id":62183170,"identity":"78784eb3-a9df-4860-82ee-8c22b10b5845","added_by":"auto","created_at":"2024-08-10 11:33:44","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":15794,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-4712847/v1/e903f7bcd198cb20c746b156.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Axillary lymph node dissection is not required for breast cancer patients with minimal axillary residual disease after neoadjuvant chemotherapy","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eIn recent decades, there has been a shift towards personalized treatment approaches for breast cancer patients. The traditional one-size-fits-all surgical methods are being reconsidered, and more tailored minimally invasive interventions are being developed. In the 1990s, Giuliano et al. first described sentinel lymph node biopsy (SLNB), demonstrating that axillary lymph node dissection (ALND) is unnecessary for SLNB-negative breast cancer patients (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Landmark trials such as NSABP B-04 and NSABP B-32 have shown that the extent of axillary surgery does not improve survival for clinically node-negative patients (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe evidence overwhelmingly supports SLNB as the preferred treatment for axillary surgery in early breast cancer, considering its proven benefits in terms of morbidity, quality of life, and oncological safety (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Notably, clinical studies like ACOSOG Z0011 and AMAROS have shown that even in cases of limited axillary involvement with a positive SLNB, axillary dissection does not offer lower axillary recurrence and survival benefit when axillary radiotherapy (RT) is applied (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe extensive use of neoadjuvant chemotherapy (NAC) in locally advanced breast cancer and the remarkable rates of pathological complete response (pCR) have sparked a new debate on how to approach the axilla after NAC. While SLNB is commonly used in patients who initially present with no signs of cancer in the lymph nodes and are treated with NAC, its use in patients with positive axillary nodes before NAC is controversial (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Prospective studies have been conducted to resolve this controversy. With current chemotherapy treatments, axillary pCR rates have reached 50%, making ALND unnecessary in almost half of the patients. Consequently, the option of SLNB has become more prominent in patients with a positive axillary status before NAC (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e In light of current guidelines, ALND is recommended for axillary residual disease after NAC, irrespective of disease burden, due to insufficient evidence. Nonetheless, there is growing scrutiny around the necessity of ALND, particularly in cases of limited axillary residue (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Magnetic resonance imaging (MRI) and ultrasound (USG) are widely used to evaluate response to neoadjuvant therapy, with an approximately 60% success rate in predicting complete pathological response. However, the accuracy improves when comparing the presence of axillary response (shrinking) to baseline images (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur study sought to evaluate the efficacy and the safety of image-tailored axillary surgery in combination with SLNB as a substitute for ALND in patients exhibiting limited axillary involvement and demonstrating favorable responses to NAC.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eIn this prospectively designed study, we evaluated patients with clinical stages of T1-3 and N1 at the time of diagnosis, who showed good or complete response to NAC for both the breast and axilla and exhibited favorable changes (\u0026gt;\u0026thinsp;50% fibrotic) in the final pathological examination. The study was conducted at the Breast Surgery Unit, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, between January 2011 and December 2023.\u003c/p\u003e \u003cp\u003ePatients with T4, cN2-3, and M1 stages at admission, no clinical axillary response to NAC, more than three pathological lymph nodes on imaging, and complete axillary pathological response as per the final pathology report were excluded from the study.\u003c/p\u003e \u003cp\u003eAll patients underwent evaluation by a multidisciplinary team before and after NAC. The tumor stage, NAC response, and the number of pathological lymph nodes with their location were determined using USG, mammography (MMG), MRI, and positron emission tomography-computed tomography (PET-CT) by a breast specialist radiologist. Patients who showed a significant or complete response in their axillary lymph nodes after NAC were included in the study, while those who showed progression or no regression were excluded (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Before surgery, it is important to identify the locations of pathological lymph nodes. For instance, level 1 in the inferior axilla can be close to the breast tail or lateral to the pectoralis minor muscle. In the superior axilla, level 1 can be lateral to the pectoralis major muscle, close to the axillary vein, or near the latissimus dorsi muscle. This information helps surgeons to target and remove these nodes more effectively during the operation, which is referred to as image-tailored surgery.\u003c/p\u003e \u003cp\u003eAll patients underwent neoadjuvant chemotherapy, including anthracycline and taxane. Patients with HER2-neu-positive disease received additional trastuzumab therapy. Adjuvant hormonal therapy was administered to all hormone-positive patients. Patients with triple-negative disease had capecitabine after surgery, and those with HER-2-positive disease had trastuzumab or trastuzumab emtansine.\u003c/p\u003e \u003cp\u003ePatients underwent SLNB in conjunction with image-tailored lymph node excision performed by dedicated breast specialist surgeons. In a minority of cases, dual mapping (lymphoscintigraphy\u0026thinsp;+\u0026thinsp;blue dye) was employed (17%) and targeted axillary dissection (TAD) was carried out as per surgeon preference (7%). Lymph nodes were meticulously dissected from the excision material by an experienced pathologist. The presence of blue dye was noted during macroscopic evaluation. At least four sections were obtained from each lymph node block at 250-m intervals and stained with hematoxylin and eosin (H\u0026amp;E). Sentinel lymph nodes containing tumor cells detected by H\u0026amp;E or cytokeratin immunohistochemistry staining were considered positive, according to the AJCC 8th edition. Pathologic findings regarding chemotherapy response were also recorded, including regressional fibrosis, fibrohyalinization, and reactive changes.\u003c/p\u003e \u003cp\u003eThe study investigated the relationship between the number of radiologically suspicious or positive lymph nodes and the number of lymph nodes removed. The number of lymph nodes removed was at least equal to the number found to be suspicious or pathologic. The multidisciplinary council reviewed patients' final pathology results. Evaluation encompassed assessing the number of lymph nodes removed, the number of pathological lymph nodes identified radiologically before NAC, and the number of nodes with residual disease pathologically. No further axillary intervention was scheduled for patients with consistent radiology and pathology results.\u003c/p\u003e \u003cp\u003ePatients who had breast-conserving surgery (BCS) received RT to the entire breast, while those who had a mastectomy received RT to the chest wall. All patients also received RT to the axilla (level I-II-III), which includes the supraclavicular lymph node regions with or without the internal mammary lymph node region.\u003c/p\u003e \u003cp\u003ePatients with high-load axillary residual disease, unable to undergo adjuvant RT, and having inconsistent radiologic and pathological findings regarding the number of positive nodes underwent ALND. This group of patients was also excluded from the study (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDemographic, clinicopathological, and radiological data of the patients were analyzed. According to the current guidelines, patients were regularly examined and evaluated for local recurrence or systemic disease.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe assumption of normality of continuous variables was tested with the Shapiro-Wilk test. Categorical variables were presented as frequency(%), continuous variables as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, median (IQR: P25-P75), and range. Comparisons between groups in continuous variables were made with the Mann-Whitney U test, and comparisons between groups in categorical variables were made with Chi-Square tests (Pearson Chi-Square Test, Continuity Correction Test, and Fisher's Exact Test). Diagnostic tests (sensitivity, specificity, PPV, NPV, and accuracy) were used to compare clinical findings and pathological results. Statistical analyses were made with SPSS software version 25 (IBM Corp., Armonk, NY, USA). Results were evaluated in the 95% confidence interval, and p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eOut of the 308 patients assessed for eligibility, 28 patients with four or more pathological lymph nodes in the preoperative evaluation were excluded. Additionally, three patients declined to participate, and nine patients were excluded due to disease progression during treatment. Breast surgery with SLNB\u0026thinsp;+\u0026thinsp;image tailored axillary surgery was performed on the remaining patients. Furthermore, 85 patients with pathological complete response, three with incompatible pathology and radiology results, 28 with high-load axillary residual disease (four or more metastatic lymph nodes) in pathological evaluation, and one with contraindication for adjuvant radiotherapy were also excluded from the study (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A total of 139 patients with a median age of 47 years (IQR, 39\u0026ndash;54; range, 21\u0026ndash;73) were included in the study. Of these, 128 patients had T1-2 stage tumors, while 11 had T3 stage tumors. Breast-conserving surgery was performed on 83 patients (59.7%), while 56 patients (40.3%) underwent mastectomy. Non-luminal subtype was found in 30 patients (21.6%), whereas 109 patients (78.4%) had luminal subtype. Prior to neoadjuvant chemotherapy (NAC), MRI and USG imaging of all patients were examined by a breast radiologist. The imaging revealed a single pathological lymph node in 76 patients, 2 in 41 patients, and 3 in 22 patients. Pathological features of the lymph nodes were confirmed through fine-needle aspiration biopsy (FNAB).\u003c/p\u003e \u003cp\u003eDuring the study, sentinel lymph node biopsy (SLNB) was carried out using blue dye in 115 cases (82.7%) and with the combined method of blue dye and lymphoscintigraphy in 24 cases (17.3%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The identification rate of SLNB was 97.3% when using the single tracer (blue dye) and 100% when using the dual tracer. In only three patients, no blue dye was observed in the axilla. In these cases, lymph node excision was conducted based on palpation findings and radiological imaging.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTable 1 Patient characteristics\u003c/p\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003e\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e\u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics(N\u0026thinsp;=\u0026thinsp;139)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedian age(IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47(39\u0026ndash;54)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, minimum-maximum\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u0026ndash;73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89(64)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50(36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical T stage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecT1/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e128(92.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(7.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of Breast Surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83(59.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMastectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56(40.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistopathology of core biopsy and surgical specimen\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvasive ductal carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e123(88.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvasive Lobular carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvasive ductal\u0026amp;lobular carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(7.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(2.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003epCR (breast)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28(20.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNear complete(\u0026gt;\u0026thinsp;90%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30(21.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80\u0026ndash;90%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24(17.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u0026ndash;80%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34(24.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23(16.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHER2- neu\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e108(77.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31(22.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTumor Subtype (IHC)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLuminal A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13(9.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLuminal B/HER2(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76(55.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLuminal B/HER2(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19(13.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon luminal B/HER2(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(8.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTriple-negative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTumor Subtype (IHC)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLuminal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e109(78.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-luminal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30(21.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSentinel Lymph Node Methodology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlue Dye\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e115(82.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombined (Blue dye and radioisotope)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24(17.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRadiologic lymph node involvement\u003c/b\u003e\u003csup\u003e\u003cb\u003e#\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1ln\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77(55.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2ln\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40(28.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3ln\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22(15.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTAD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(7.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e129(92.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of sentinel lymph nodes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92(66.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47(33.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of metastatic sentinel lymph nodes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e112(80.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(19.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of total LN\u003c/b\u003e (Median:4, range:1\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64(46)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75(54)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of total metastatic LN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e101(72.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38(27.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCharacteristics of metastatic lymph nodes (LNs) removed\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMacrometastasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80(57.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicrometastasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43(30.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIsolated tumor cells\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(11.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePresence of extracapsular extension\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23(16.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e116(83.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNon sentinel lymph node positivity (n\u0026thinsp;=\u0026thinsp;52)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(23.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40(76.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLymph Node Ratio(LNR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91(65.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48(34.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eIQR : Interquartile Range(P\u003csub\u003e25\u003c/sub\u003e- P\u003csub\u003e75\u003c/sub\u003e), BCS: Breast breast-conserving surgery\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e#\u003c/sup\u003e It refers to the number of lymph nodes that appear suspicious or pathological in radiological evaluation before NAC.\u003c/p\u003e \u003cp\u003e* It refers to lymph nodes that are considered suspicious with intraoperative palpation findings and lymph nodes removed through image-tailored axillary surgery except for SLNB\u003c/p\u003e \u003cp\u003eA total of 64 patients (46%) had 1\u0026ndash;3 excised lymph nodes, while 62 patients (45%) had 4\u0026ndash;6 excised lymph nodes. Thirteen patients (9%) had seven or more lymph nodes removed (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The median number of excised lymph nodes was 4 (IQR, 3\u0026ndash;5). Five patients had only one lymph node excised, as radiological findings suggested only one pathological node and no other palpable or suspicious node was found during the operation. Pathological examination revealed that 101 patients had a single metastatic lymph node, 32 patients had 2 metastatic lymph nodes, and 6 patients had 3 metastatic lymph nodes. Macrometastasis was observed in 80 nodes, micrometastasis in 43, and isolated tumor cells in 16. pCR was detected in the breast in 26 patients (18.7%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of radiological lymph node involvement with the number of excised lymph nodes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eRadiologic lymph node involvement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1LN(n\u0026thinsp;=\u0026thinsp;77)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2LN(n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3LN(n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal(n\u0026thinsp;=\u0026thinsp;139)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuantitative variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian(IQR)/\u003c/p\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian(IQR)/\u003c/p\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian(IQR)/\u003c/p\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedian(IQR)/\u003c/p\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of total LN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)/1\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)/2\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5(\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)/3\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4(\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)/1\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of total metastatic LN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)/1\u0026ndash;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)/1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)/1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)/1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal excised LN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003en(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003en(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003en(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37(48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(52.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6(27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e64(46)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36(46.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14(35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12(54.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e62(44.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13(9.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eN/A: Not available\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe study compared the number of radiologically positive lymph nodes, pathologically positive lymph nodes, and positive sentinel lymph nodes, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. All patients with one radiologically positive lymph node were found to have one metastatic lymph node. In this group, all patients had metastasis in the sentinel nodes and no metastasis was detected in non-sentinel lymph nodes. Among 41 patients with two radiologically positive lymph nodes, 17 (41%) had one metastatic lymph node, 22 (53%) had two metastatic lymph nodes, and 2 (5%) had three metastatic lymph nodes. Two patients with inconsistent pathology and radiology results were re-evaluated in a multidisciplinary council, and it was determined that axillary lymph node dissection (ALND) was not necessary. Radiology revealed three positive lymph nodes in 22 patients, of which 8 (36%) had one metastatic lymph node, 10 (45%) had two metastatic lymph nodes, and 4 (18%) had three metastatic lymph nodes (Additional file 1).\u003c/p\u003e \u003cp\u003eThe median follow-up period was 44 months (IQR, 29\u0026ndash;56). One patient experienced breast recurrence in the 31st month, and another patient had lymphatic recurrence in the supraclavicular area in the 39th month (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Systemic recurrence was observed in 6 (4.3%) patients. No axillary recurrence occurred during the follow-up period (Additional file 2).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients with local or regional recurrence\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecT/N\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eypSLN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLN\u003c/p\u003e \u003cp\u003eratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003epCR\u003c/p\u003e \u003cp\u003e(breast)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMolecular\u003c/p\u003e \u003cp\u003esubtype\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eExtracapsular invasion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLVI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eBreast Surgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eRecurrence time(month)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eSite of\u003c/p\u003e \u003cp\u003erecurrence\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCase 1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003emacromet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eBCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003ebreast\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCase 2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003emacromet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLum-B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003emastectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003esupra\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003e\u003cb\u003eLN\u003c/b\u003e: lymph node, \u003cb\u003eLVI\u003c/b\u003e: lymphovascular invasion\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe efficacy of chemotherapeutic agents in the treatment of breast cancer is progressively on the rise. Following NAC, the incidence of axillary pCR may escalate to 50%. Notably, rates of pCR are even more pronounced in HER-2-positive and triple-negative patients (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The notable efficacy of NAC warrants deliberation on the necessity of ALND in cases of limited axillary residual disease, thereby advocating for the adoption of less invasive techniques in axillary surgery. Particularly, SLNB is the preferred approach for patients who are converted from cN\u0026thinsp;+\u0026thinsp;to cN0 post-NAC.\u003c/p\u003e \u003cp\u003eAlthough SLNB is often performed in patients who have converted to cN0 after NAC, some surgeons are concerned about the potential for false-negative results of SLNB. Caudle et al. suggested targeted axillary dissection for this concern (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Boughey et al. also showed that the false negative rate (FNR) can be reduced to less than 10% with TAD(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In clinically node-positive (cN+) patients who were converted to clinically node-negative (cN0), various prospective studies have demonstrated that FNR of the SLNB was higher than 10%, and if the dual mapping is used and \u0026ge;\u0026thinsp;3 Lymph nodes are excised, and FNR can be reduced to acceptable rates of \u0026lt;\u0026thinsp;10% (4.9%-9.1%) regardless of TAD (\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In the SENTINA trial, the FNR was 24.3% for patients with one sentinel node removed and 18.5% for patients with two sentinel nodes removed (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Three or more lymph node excisions and dual methods are recommended to reduce FNR (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn contrast, Galimberti et al. published 10-year follow-up results of patients who were initially cN\u0026thinsp;+\u0026thinsp;and became cN0 after NAC. Inclusion criteria were SLNB alone (one node is enough) without TAD, single tracer (no dual mapping), and nodal radiotherapy was not mandatory. Axillary failure occurred in 1.8% of the initially cN1/2 patients and 1.5% of the initially cN0 patients (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Although there is a risk of false negativity of SLNB, nodal recurrence rates are not increased in patients with negative SLNB who do not undergo ALND (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Despite the lack of evidence regarding the negative impact of FNR on axillary recurrence and survival, the surgical community is actively pursuing strategies such as dual mapping and targeted axillary dissection to reduce FNR. It is recognized that despite diligent efforts, the FNR of SLNB cannot be reduced to zero, resulting in the presence of minimal residue in the axilla of a subset of patients. For patients undergoing upfront surgery, we have substantial evidence from prospective trials with 10 years of follow-up, such as ACOSOG Z0011 and AMAROS (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). It is established that even if there is a limited residual disease in the axilla, ALND does not decrease axillary recurrence rates or extend overall survival as long as adjuvant RT is administered.\u003c/p\u003e \u003cp\u003eNow is the time to discuss avoiding ALND for N\u0026thinsp;+\u0026thinsp;disease following NAC. Reports of ongoing prospective trials, such as Alliance 11202 and NSABP B-51/RTOG 1304, are expected to clarify this topic (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). A trial including SLNB\u0026thinsp;+\u0026thinsp;patients after NAC was presented in ASCO 2023. The study evaluated cN1 breast cancer that became ycN0 but remained node positive following NAC, according to findings from a retrospective analysis of patients treated in phase 3 prospective NSABP B-40 and B-41 trials. Results showed that more intense axillary surgery (ALND) was not associated with better cancer outcomes when compared with SLNB. 5-year loco-regional recurrence was 9% in the ALND group, compared with 12% for those who underwent SLNB (p\u0026thinsp;=\u0026thinsp;0.790) in unselected patients. 5-year risk of metastasis was 31% and 26%, respectively, and 5-year risk of any recurrence was 33% and 32%, respectively (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Similarly, in a few recently published studies, the superiority of ALND in oncological terms could not be demonstrated for neoadjuvant breast cancer patients with limited axillary residual disease (\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In a multicentric registry trial, Cabioglu et al. showed that ALND could be avoided in selected cN (+) patients who underwent SLNB after NAC having low-volume residual nodal disease with luminal pathology, as long as axillary radiotherapy is provided (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Almaharic et al. analyzed a total of 1617 patients from the National Cancer Database to compare survival following SLND and ALND in breast cancer patients with residual LN disease. Subgroup analysis demonstrated that SLNB was comparable with ALND in patients with luminal A or B tumors with a single metastatic lymph node (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Unlike these studies, Our study showed no difference in local recurrence rates between luminal and non-luminal subtypes. In the database study of Kantor et al., 6554 HR+/her- cN0 patients receiving neoadjuvant endocrine therapy were evaluated, and \u0026gt;\u0026thinsp;90% of patients had less than three positive lymph nodes. No survival difference was found between SLNB and ALND in these patients (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAxillary involvement is generally defined as N0 and N\u0026thinsp;+\u0026thinsp;without considering the volume of nodal disease (number and size of pathological nodes). The absence of image-tailored localization of suspicious lymph nodes places all N\u0026thinsp;+\u0026thinsp;patients in the same category and prevents individual decision-making (one size fits all). Our aim should be to determine precise, tailored surgical (need for ALND) and medical treatment (need for additional systemic treatment) approaches for every patient. To achieve this, we need to determine the extent of axillary involvement before NAC and assess the response after NAC using imaging to identify cases with minimal axillary residual disease.\u003c/p\u003e \u003cp\u003eIn our study, we observed no axillary recurrences in 4 years of follow-up, despite expecting a high recurrence rate in patients with axillary residual disease after NAC. This suggests that minimal axillary residual disease may not necessitate ALND as long as radiological and pathological findings are consistent. It's worth noting that current guidelines recommend ALND for patients with any axillary residual disease, regardless of tumor burden and NAC response (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur practice is based on multidisciplinary councils where we evaluate the clinicopathological features of patients, pre- and post-neoadjuvant imaging, and pathological examination results. Based on this evaluation, we devise a personalized treatment plan that goes beyond the current guidelines. It's important to note that we focus on the compatibility of imaging findings and pathological examination results. This approach allows us to initiate a personalized treatment for patients with limited axillary involvement without compromising oncological safety.\u003c/p\u003e \u003cp\u003eMost patients had an average of 6 or fewer lymph nodes removed (95% of patients with one pathological lymph node, 87% with two, and 82% with three). The number of lymph nodes removed in our study appears to be higher than standard SLNB. This is because we also removed palpable and suspicious lymph nodes guided by imaging. Excising more lymph nodes helps obtain a better correlation between imaging and final pathology, leading to safer decisions to avoid ALND. The number of excised lymph nodes could be decreased, but this may cause an increase in second axillary surgery rates.\u003c/p\u003e \u003cp\u003eRadiological evaluation of post-neoadjuvant axilla can be challenging. While imaging techniques are effective in identifying axillary involvement, they may be insufficient, particularly in assessing the complete response to NAC (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Our study focused on differentiating between high-volume axillary disease and limited disease (\u0026lt;\u0026thinsp;3 lymph nodes). Our objective in evaluating post-neoadjuvant response was not to discern complete response, and we included patients with a good partial response, so the constraints of imaging methods did not impact our study.\u003c/p\u003e \u003cp\u003eThe study's main limitation was the absence of a comparison group. Additionally, interpreting the palpation findings requires experience. Our team consists of breast specialist surgeons and radiologists, and our center deals with a high volume of breast cancer cases. A comprehensive multidisciplinary tumor board evaluated all patients and determined individualized treatments. Therefore, conducting this prospective study in a tertiary referral center is feasible.\u003c/p\u003e"},{"header":"CONCLUSİON","content":"\u003cp\u003eIn patients with minimal axillary residual disease, SLNB\u0026thinsp;+\u0026thinsp;image-tailored axillary surgery and adjuvant radiotherapy may be sufficient for local control of the axilla as long as radiological and pathological correlation is ensured. ALND may be considered in patients suspected of having a high-volume residual disease. This study also confirmed that the belief that \u0026ldquo;chemo-resistance is equal to radio-resistance\u0026rdquo; is not valid in patients with minimal axillary residual disease (3 or fewer nodes) who exhibit a favorable response to NAC.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSLNB\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSentinel lymph node biopsy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eNAC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eneoadjuvant chemotherapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eALND\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eaxillary lymph node dissection\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003epCR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epathological complete response\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMRI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic resonance imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eUSG\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eultrasound\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMMG\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emammography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePET\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cb\u003eCT\u003c/b\u003e-positron emission tomography-computed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eTAD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etargeted axillary dissection\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eH\u0026amp;E\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehematoxylin and eosin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBCS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebreast-conserving surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eFNR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003efalse negative rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the ethical committee of Istanbul University, Istanbul Faculty of Medicine (08.08.2023-1981986), by the ethical standards of the institutional and national research committee, and with the 1964 Helsinki Declaration. Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have approved the publication of the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDesign of the work: Muslumanoglu M.,\u0026nbsp;Cabioglu N., Tukenmez M., Emiroglu S., Mollavelioglu B.\u003c/p\u003e\n\u003cp\u003eAcquisition of data: Karanlık H., Ozmen T., Muslumanoglu M.,\u0026nbsp;Cabioglu N., Tukenmez M., Emiroglu S., Mollavelioglu B., Ibis K.\u003c/p\u003e\n\u003cp\u003eAnalysis and interpretation of data:\u0026nbsp;Yılmaz\u0026nbsp;R., Gunoz Comert R., Onder S., Bayram A., Oflas M., Has Simsek D.,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDrafting:\u0026nbsp;Yılmaz\u0026nbsp;R., Gunoz Comert R., Onder S., Bayram A., Oflas M., Has Simsek D., Ibis K.,\u0026nbsp;Mollavelioglu B.\u003c/p\u003e\n\u003cp\u003eImportant intellectual content: Karanlık H., Ozmen T., Aydiner A., Ozmen V., Igci A., Muslumanoglu M., Cabioglu N., Tukenmez M.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are grateful to Atilla Bozdogan, MSc, who helped with the preparation of the\u003c/p\u003e\n\u003cp\u003estatistical analysis\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eVeronesi U, Viale G, Paganelli G, Zurrida S, Luini A, Galimberti V, Veronesi P, Intra M, Maisonneuve P, Zucca F, Gatti G. 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J Clin Oncol. 2015;33(3):258\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYan M, Abdi MA, Falkson C. Axillary management in breast cancer patients: a comprehensive review of the key trials. Clin Breast Cancer. 2018;18(6):e1251\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGalimberti V, Fontana SK, Vicini E, Morigi C, Sargenti M, Corso G, Magnoni F, Intra M, Veronesi P. This house believes that: Sentinel node biopsy alone is better than TAD after NACT for cN\u0026thinsp;+\u0026thinsp;patients. Breast. 2023;67:21\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong SM, Basik M, Florianova L, Margolese R, Dumitra S, Muanza T, Carbonneau A, Ferrario C, Boileau JF. Oncologic safety of sentinel lymph node biopsy alone after neoadjuvant chemotherapy for breast cancer. 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J Clin oncology: official J Am Soc Clin Oncol. 2023;41(12):2159\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1200/JCO.22.01565\u003c/span\u003e\u003cspan address=\"10.1200/JCO.22.01565\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMamounas EP, Bandos H, White JR, Julian TB, Khan AJ, Shaitelman SF, Torres MA, Vicini F, Ganz PA, McCloskey SA, Paik S. NRG Oncology/NSABP B-51/RTOG 1304: Phase III trial to determine if chest wall and regional nodal radiotherapy (CWRNRT) post mastectomy (Mx) or the addition of RNRT to whole breast RT post breast-conserving surgery (BCS) reduces invasive breast cancer recurrence-free interval (IBCR-FI) in patients (pts) with pathologically positive axillary (PPAx) nodes who are ypN0 after neoadjuvant chemotherapy (NC).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eComparison of Axillary Lymph Node Dissection With Axillary Radiation for Patients With. Node-Positive Breast Cancer Treated With Chemotherapy | ClinicalTrials.gov. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://clinicaltrials.gov/study/NCT01901094\u003c/span\u003e\u003cspan address=\"https://clinicaltrials.gov/study/NCT01901094\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMailhot Vega R, Deladisma AM, Mobley EM, Wang S, Morris CG, Oladeru OT, Brooks E, Gharia BM, Spiguel LR, MacDonald SM, Mamounas EP. Axillary surgery efficacy for patients with breast cancer receiving neoadjuvant chemotherapy on NSABP B40 and B41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Loevezijn AA, van der Noordaa ME, Stokkel MP, van Werkhoven ED, Groen EJ, Loo CE, Elkhuizen PH, Sonke GS, Russell NS, van Duijnhoven FH, Vrancken Peeters MJ. Three-year follow-up of de-escalated axillary treatment after neoadjuvant systemic therapy in clinically node-positive breast cancer: the MARI-protocol. Breast Cancer Res Treat. 2022;193(1):37\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlmahariq MF, Levitin R, Quinn TJ, Chen PY, Dekhne N, Kiran S, Desai A, Benitez P, Jawad MS, Gustafson GS, Dilworth JT. Omission of axillary lymph node dissection is associated with inferior survival in breast cancer patients with residual N1 nodal disease following neoadjuvant chemotherapy. Ann Surg Oncol. 2021;28:930\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCabıoğlu N, Karanlık H, Yıldırım N, M\u0026uuml;sl\u0026uuml;manoğlu M, Karadeniz G\u0026Ccedil;, Can DT, T\u0026uuml;kenmez M, Ersoy YE, Uras C, Zengel B, Emiroğlu S. 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Breast Cancer Res Treat. 2017;166(2):329\u0026ndash;336. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10549-017-4405-3\u003c/span\u003e\u003cspan address=\"10.1007/s10549-017-4405-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2017 Jul 28. Erratum in: Breast Cancer Res Treat. 2017;166(2):337. PMID: 28755147; PMCID: PMC5668351.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim R, Chang JM, Lee HB, Lee SH, Kim SY, Kim ES, Cho N, Moon WK. Predicting Axillary Response to Neoadjuvant Chemotherapy: Breast MRI and US in Patients with Node-Positive Breast Cancer. Radiology. 2019;293(1):49\u0026ndash;57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1148/radiol.2019190014\u003c/span\u003e\u003cspan address=\"10.1148/radiol.2019190014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2019 Aug 13. PMID: 31407967.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-surgical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjso","sideBox":"Learn more about [World Journal of Surgical Oncology](http://wjso.biomedcentral.com)","snPcode":"12957","submissionUrl":"https://submission.nature.com/new-submission/12957/3","title":"World Journal of Surgical Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Breast Cancer, Breast surgery, Neoadjuvant chemotherapy, axillary lymph node dissection, sentinel lymph node biopsy","lastPublishedDoi":"10.21203/rs.3.rs-4712847/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4712847/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSentinel lymph node biopsy(SLNB) is widely used in patients who receive neoadjuvant chemotherapy(NAC). Still, axillary lymph node dissection(ALND) is recommended for patients with any axillary residual disease after NAC. The necessity of ALND in patients with minimal axillary disease is unclear. We aim to investigate regional recurrence rates in patients with limited axillary residual disease after NAC underwent SLNB\u0026thinsp;+\u0026thinsp;image-tailored axillary surgery and adjuvant radiotherapy (RT).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients with clinical stages were T1-3 and N1 at the time of diagnosis, clinically good or complete axillary response after NAC, and limited axillary residue (\u0026le;\u0026thinsp;3 pathological lymph nodes) with favorable response to NAC in the final pathological examination were included in the study. All patients underwent SLNB\u0026thinsp;+\u0026thinsp;image-tailored axillary surgery. Peripheral lymphatic radiotherapy was applied, and no further surgery was performed in patients with compatible radiology and pathology results.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOur study, which evaluated 139 patients with a median age of 47 years, found that the median number of excised lymph nodes was 4. Notably, 46% of patients had between 1 and 3 lymph nodes excised, while 45% had between 4 and 6. Only 9% of patients had\u0026thinsp;\u0026ge;\u0026thinsp;7 lymph nodes. 83(60%) of the patients underwent breast-conserving surgery (BCS), and 56(40%) underwent mastectomy. The study's median follow-up period was 44 months. During this duration, one breast recurrence (0.7%), one supraclavicular recurrence (0.7%), and six systemic recurrences (4.3%) were observed. No axillary recurrence occurred within the follow-up period.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePatients presenting with pathological-suspicious\u0026thinsp;\u0026le;\u0026thinsp;3 lymph nodes on imaging and showing a good response to NAC can be considered suitable candidates for SLNB\u0026thinsp;+\u0026thinsp;image-tailored axillary surgery, followed by adjuvant RT instead of ALND.\u003c/p\u003e","manuscriptTitle":"Axillary lymph node dissection is not required for breast cancer patients with minimal axillary residual disease after neoadjuvant chemotherapy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-10 11:33:38","doi":"10.21203/rs.3.rs-4712847/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-01T03:41:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-18T23:32:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"326142130368116925474057167401756179775","date":"2024-08-06T16:47:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-29T17:39:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"113218995263547026687677125932676189857","date":"2024-07-27T10:03:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-25T06:10:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-11T17:05:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-09T23:20:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Surgical Oncology","date":"2024-07-09T14:35:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-surgical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjso","sideBox":"Learn more about [World Journal of Surgical Oncology](http://wjso.biomedcentral.com)","snPcode":"12957","submissionUrl":"https://submission.nature.com/new-submission/12957/3","title":"World Journal of Surgical Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"72cfd1eb-1d47-49f3-b4b8-901751cf33dd","owner":[],"postedDate":"August 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-04T16:26:15+00:00","versionOfRecord":{"articleIdentity":"rs-4712847","link":"https://doi.org/10.1186/s12957-024-03547-7","journal":{"identity":"world-journal-of-surgical-oncology","isVorOnly":false,"title":"World Journal of Surgical Oncology"},"publishedOn":"2024-10-31 16:20:12","publishedOnDateReadable":"October 31st, 2024"},"versionCreatedAt":"2024-08-10 11:33:38","video":"","vorDoi":"10.1186/s12957-024-03547-7","vorDoiUrl":"https://doi.org/10.1186/s12957-024-03547-7","workflowStages":[]},"version":"v1","identity":"rs-4712847","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4712847","identity":"rs-4712847","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}