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BACKGROUND: Sentinel lymph node biopsy (SLNB) for axillary staging in patients with ductal carcinoma in situ (DCIS) undergoing mastectomy is debated due to low nodal positivity rate and risk of morbidity. Standard SLNB entails removing all lymph nodes (LN) that have a radioactive count > 10% of the most radioactive node, contain blue dye or are palpably suspicious. In this study, we hypothesize that judicious SLNB with attempt to remove only the node with the highest radioactive count provides sufficient pathologic information while minimizing morbidity. METHOD: A single institution prospective database was retrospectively reviewed to identify women with DCIS who underwent mastectomy and SLNB between 2010 and 2022. Patient characteristics, number of SLNs retrieved, pathologic results and long-term upper extremity complications were analyzed. RESULTS: A total of 743 LNs were removed in 324 pts. Median (IQR) age was 62 (51-70) years. Dual tracer technique, with technetium-99m labeled radiocolloid and blue dye, was used in 311 (96%) pts, whereas single agent (radioisotope or blue dye alone) was utilized in 9 (2.8%) and 4 (1.2%) patients, respectively. Median (IQR) number of SLN removed was 2 (1-3) (range 1-9). In 99% of cases, the SLN with the highest radioactive count was identified among the first 3 dissected LNs. Final pathology revealed upstaging to invasive cancer in 27.5% (n = 89) of the breasts and nodal positivity in 1.9% (n = 6) of the patients. In all 6 cases, metastatic disease was identified in the LN with highest radioactive count among the LNs retrieved. No additional metastatic nodes were identified after > 3 SLN had been removed. At median follow-up of 57 (range 28-87) months, 8.3% (n = 27) of pts complained of long-term upper extremity symptoms. 7.1% (23 pts) were referred to physical therapy for symptoms such as swelling, fullness, heaviness, stiffness, or sensory discomfort in the upper extremity and/or axillary cording. Long-term upper extremity complications were higher when > 3 SLNs compared to ≤ 3 SLNs were removed (10.4% vs. 6.5%, P = .005). CONCLUSION: In this cohort of patients with DCIS undergoing mastectomy who were upstaged on final pathology to node positive invasive cancers, the SLN with the highest radioactive count provided sufficient information for axillary staging. Acknowledging that the "hottest" LN is not always the first 1 removed, these data support an increased likelihood of developing long-term complications when more than 3 SLNs are removed. Rather than comprehensive removal of all SLNs meeting the standard "10% rule," prioritizing the sequence of removal to the highest count provides the same prognostic information with reduced morbidity.

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Background: Previous clinical trials have diminished the significance of lymph node (LN) metastasis and axillary surgery in breast cancer, particularly in cN0, postmenopausal estrogen receptor (ER)-positive/human epidermal growth factor receptor 2 (HER2)-negative patients undergoing breast-conserving treatment (BCT). We assessed the replacement of axillary surgery with preoperative imaging modalities by analyzing the proportion of high nodal burden (HNB) patients with ≥3 LN metastases in these patients. Methods: We retrospectively identified 333 cN0, postmenopausal ER-positive/HER2-negative breast cancer patients who underwent BCT in two hospitals between January 2003 and December 2017. The proportion of LN metastasis patients and the number of metastatic LN were investigated. Risk factors of LN metastasis were analyzed and recurrence-free survival (RFS) was compared. Results: Axillary surgery confirmed LN metastasis in 81 (24.3%) of the cN0 patients. The clinical tumor size (cT) and age were factors associated with LN metastasis [cT: odds ratio (OR), 2.92, 95% confidence interval (CI): 1.69-5.05, P<0.001; age: OR, 0.33, 95% CI: 0.11-0.99, P=0.048]. However, HNB patients with ≥3 LN metastases were 15 (4.5%) of all the patients. There was statistically significant difference in the incidence of HNB between patients with cT1 tumors (3.6%) and those with cT2 tumors (7.4%) (P<0.001). Conclusions: In cN0, postmenopausal ER-positive/HER2-negative patients who underwent BCT, patients with cT1 tumors had lower rate of LN metastasis, and there were fewer instances of HNB. Therefore, in these patients, omission of axillary surgery including SLNB can be carefully considered.

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BACKGROUND: The population aged ≥90 years is increasing worldwide, yet nearly 50% of elderly breast cancer (BC) patients receive suboptimal treatments, resulting in high rates of BC-related mortality. We analyzed clinical and survival outcomes of nonagenarian BC patients to identify effective treatment strategies. METHODS: This single-institution retrospective cohort study analyzed patients aged ≥90 years diagnosed with stage I-III BC between 2007 and 2018. Patients were categorized into three treatment groups: traditional surgery (TS), performed according to local guidelines; current-standard surgery (CS), defined as breast surgery without axillary surgery (in concordance with 2016 Choosing Wisely guidelines) and/or cavity shaving; and non-surgical treatment (NS). Clinicopathological features were recorded and recurrence rates and survival outcomes were analyzed. RESULTS: We collected data from 113 nonagenarians with a median age of 93 years (range 90-99). Among these patients, 43/113 (38.1%) underwent TS, 34/113 (30.1%) underwent CS, and 36/113 (31.9%) underwent NS. The overall recurrence rate among surgical patients was 10.4%, while the disease progression rate in the NS group was 22.2%. Overall survival was significantly longer in surgical patients compared with NS patients (p = 0.04). BC-related mortality was significantly higher in the NS group than in the TS and CS groups (25.0% vs. 0% vs. 7.1%, respectively; p = 0.01). There were no significant differences in overall survival and disease-free survival between the TS and CS groups (p = 0.6 and p = 0.8, respectively), although the TS group experienced a significantly higher overall postoperative complication rate (p < 0.001). CONCLUSIONS: Individualized treatment planning is essential for nonagenarian BC patients. Surgery, whenever feasible, remains the treatment of choice, with CS emerging as the best option for the majority of patients.

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BACKGROUND: Current guidelines do not recommend routine sentinel node biopsy (SLNB) for ductal carcinoma in situ (DCIS), except in the setting of mastectomy or microinvasive disease. This study aimed to evaluate national SLNB utilization in women undergoing upfront mastectomy for DCIS, identify predictors of SLNB utilization, and determine the percentage with a positive SLNB. METHODS: A retrospective cohort analysis was performed using the NCDB of women with clinical DCIS who underwent upfront mastectomy between 2012 and 2017. Demographic and clinicopathologic variables were compared between patients who underwent SLNB and those who did not. Multivariate logistic regression models were used to identify factors associated with SLNB utilization and positive SLNB. RESULTS: About 38,973 patients met inclusion criteria: 34,231 (88%) underwent SLNB and 4742 (12%) had no surgical axillary staging. Most patients were age 50-69 (51%), non-Hispanic White (71%), with private insurance (66%). On multivariate analysis, older patients were less likely to receive SLNB (P < .01), while patients with higher grade DCIS were more likely to undergo SLNB (P < .01). In those who underwent SLNB (n = 34,231), only 1,149 (3.4%) had nodal involvement. Non-Hispanic Black patients had increased odds of a positive SLNB (P < .01), while those with estrogen receptor positive disease were less likely to be node positive (OR 0.68, P < .001). CONCLUSIONS: While 88% of patients had a SLNB, only 3.4% were found to be node positive. Given this low rate, it is reasonable to consider SLNB omission in select patients with low grade, hormone receptor positive DCIS undergoing upfront mastectomy.

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Background: The SOUND study demonstrated that an axillary de-escalation may be sufficient in locoregional and distant disease control in selected early breast cancer (EBC) patients. To establish any preoperative variables that may drive sentinel lymph node biopsy (SLNB) omission, a study named sentinel omission risk factor (SOFT) 1.23 was planned. Methods: A single-center retrospective study from a prospectively maintained database was designed, aiming at underlying preoperative prognostic factors involved in sentinel lymph node (SLN) metastasis (lymph node involvement (LN+) vs. negative lymph node (LN-) group). Secondary outcomes included surgical room occupancy analysis for SLNB in patients fulfilling the SOUND study inclusion criteria. The institutional ethical committee Area Territoriale Lazio 2 approved the study (n° 122/23). Results: Between 1 January 2022 and 30 June 2023, 160 patients were included in the study and 26 (%) were included in the LN+ group. Multifocality, higher cT stage, and larger tumor diameter were reported in the LN+ group (p = 0.020, p = 0.014, and 0.016, respectively). Tumor biology, including estrogen and progesterone receptors, and molecular subtypes showed association with the LN+ group (p < 0.001; p = 0.001; and p = 0.001, respectively). A total of 117 (73.6%) patients were eligible for the SOUND study and the potential operating room time saved was 2696.81 min. Conclusions: De-escalating strategies may rationalize healthcare activities. Multifactorial risk stratification may further refine the selection of patients who could benefit from SLNB omission.

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BACKGROUND: Low false negative rates can be achieved with sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NAC) in breast cancer (BC) patients with clinical N1 (cN1) disease. We examined changes in axillary management and oncologic outcomes in BC patients with cN1 disease receiving NAC. METHODS: BC patients with biopsy proven cN1 disease treated with NAC were selected from our institutional cancer registry (2014-2017). Patients were grouped by axillary management, axillary lymph node dissection (ALND), SLNB followed by ALND, or SLNB alone. Univariable and multivariable survival analysis for recurrence-free survival (RFS) and overall survival (OS) were performed. RESULTS: 81 patients met inclusion criteria: 31 (38%) underwent ALND, 25 (31%) SLNB + ALND, and 25 (31%) SLNB alone. A SLN was identified in 45/50 (90%) patients who had SLNB. ALND was performed in 25/50 (50%) patients who had SLNB: 18 for a + SLNB, 5 failed SLNB, and 2 insufficient SLNs. 25 patients had SLNB alone, 17 were SLN- and 8 SLN+. In the SLNB alone group, 23/25 (92%) patients received adjuvant radiation (RT). 20 (25%) patients developed BC recurrence: 14 distant (70%), 3 local (15%), 2 regional + distant (10%), and 1 contralateral (5%). In the SLNB alone group, there was 1 axillary recurrence in a patient with a negative SLNB who did not receive RT. Univariable survival analysis showed significant differences in RFS and OS between axillary management groups, ALND/SLNB + ALND vs. SLNB alone (RFS: p = 0.006, OS: p = 0.021). On multivariable survival analysis, worse RFS and OS were observed in patients with TNBC (RFS: HR 3.77, 95% CI 1.70-11.90, p = 0.023; OS: HR 8.10, 95% CI 1.84-35.60, p = 0.006). CONCLUSIONS: SLNB alone and RT after NAC in BC patients with cN1 disease who have negative SLNs at surgery provides long-term regional disease control. This analysis provides support for the practice of axillary downstaging with NAC and SLNB alone.

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With new investigations and clinical trials in breast oncology reported every year, it is critical that surgeons be aware of advances and insights into the evolving care paradigms and treatments available to their patients. This article highlights five publications found to be particularly impactful this past year. These articles report on efforts to select the minimal effective dose of tamoxifen for prevention, to challenge the existing age-based screening guidelines as they relate to race and ethnicity, to refine axillary management treatment standards, to optimize systemic therapy in multidisciplinary care settings, and to reduce the burden of breast cancer-related lymphedema after treatment. Taken together, these efforts have an impact on all facets of the continuum of care from prevention and screening through treatment and survivorship.

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Axillary surgery for patients with breast cancer (BC) in 2024 is becoming increasingly specific, moving away from the previous 'one size fits all' radical approach. The goal is to spare morbidity whilst maintaining oncologic safety. In the upfront surgery setting, a first landmark randomized controlled trial (RCT) on the omission of any surgical axillary staging in patients with unremarkable clinical examination and axillary ultrasound showed non-inferiority to sentinel lymph node (SLN) biopsy (SLNB). The study population consisted of 87.8% postmenopausal patients with estrogen receptor-positive, human epidermal growth factor receptor 2-negative BC. Patients with clinically node-negative breast cancer and up to two positive SLNs can safely be spared axillary dissection (ALND) even in the context of mastectomy or extranodal extension. In patients enrolled in the TAXIS trial, adjuvant systemic treatment was shown to be similar with or without ALND despite the loss of staging information. After neoadjuvant chemotherapy (NACT), targeted lymph node removal with or without SLNB showed a lower false-negative rate to determine nodal pathological complete response (pCR) compared to SLNB alone. However, oncologic outcomes do not appear to differ in patients with nodal pCR determined by either one of the two concepts, according to a recently published global, retrospective, real-world study. Real-world studies generally have a lower level of evidence than RCTs, but they are feasible quickly and with a large sample size. Another global real-world study provides evidence that even patients with residual isolated tumor cells can be safely spared from ALND. In general, few indications for ALND remain. Three randomized controlled trials are ongoing for patients with clinically node-positive BC in the upfront surgery setting and residual disease after NACT. Pending the results of these trials, ALND remains indicated in these patients.

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INTRODUCTION: Neoadjuvant chemotherapy (NAC) has a profound impact on surgical management of breast cancer. For this reason, the Italian Association of Breast Surgeons (ANISC) promoted the third national Consensus Conference on this subject, open to multidisciplinary specialists. MATERIALS AND METHODS: The Consensus Conference was held on-line in November 2022, and after an introductory session with five core-team experts, participants were asked to vote on eleven controversial issues, while results were collected in real-time with a polling system. RESULTS: A total of 164 dedicated specialists from 74 Breast Centers participated. Consensus was reached for only three of the eleven issues, including: 1) the indication to assess the response with Magnetic Resonance Imaging (79 %); 2) the need to re-assess the biological factors of the residual tumor if present (96 %); 3) the possibility of omitting a formal axillary node dissection for cN1 patients if a pathologic Complete Response (pCR) was confirmed with analysis of one or more sentinel lymph nodes (82 %). The majority voted in favor of mapping both the breast and nodal lesions pre-NAC (59 %), and against the omission of sentinel lymph node biopsy in cN0 patients in the case of pathologic or clinical Complete Response (69 %). In cases of cT3/cN1+ tumors with pCR, only 8 % of participants considered appropriate the omission of Post-Mastectomy Radiation Therapy. CONCLUSION: There is still a wide variability in surgical approaches after NAC in the "real world". As NAC is increasingly used, multidisciplinary teams should be attuned to conforming their procedures to the rapid advances in this field.

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This article provides a brief account of the recent evolution of the highly controversial surgical management of the positive axilla in patients with breast cancer, an issue still open to disparate surgical procedures. This short review highlights the reports that supply the rationale for current trends in reducing the aggressiveness of this surgery and discusses the course of the trials still in progress pointing in the same direction, thus supporting the principle of not performing axillary lymph node dissection for staging purposes alone.(AU)

Este artículo es un breve resumen de la reciente evolución del controvertido tratamiento quirúrgico de la axila en pacientes con cáncer de mama, que sigue estando abierto a procedimientos quirúrgicos demasiado dispares. Esta corta revisión destaca las publicaciones que constituyen la base lógica de las tendencias actuales hacia la reducción de la agresividad quirúrgica y recalca los ensayos clínicos aún en progreso apuntando en esta misma dirección, apoyando así el principio de evitar la linfadenectomía axilar solo por razones de estadiaje.(AU)

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Neoadjuvant systemic treatment (NST) is the standard treatment for HER2+, triple-negative (TN), and highly proliferative luminal HER2- early breast cancer. Pathologic complete response (pCR) after NST is associated with improved outcomes. We evaluated the predictive factors for axillary-pCR (AXpCR) and its impact on the extent of axillary node surgery. This retrospective study included 92 patients (median age of 50.4 years) with an initially node-positive disease. Patients were treated with molecular subtype-specific NST (4.3% were luminal A-like, 28.3% luminal HER2-, 26.1% luminal HER2+, 18.5% HER2+ non-luminal, and 22.8% TN). Axillary-, breast- and total-pCR were achieved in 52.2%, 48.9%, and 38% of patients, respectively. In a binary logistic regression model for the whole population, the only independent factor significantly associated with AXpCR was breast-pCR (OR 7.4; 95% CI 2.6-20.9; p < 0.001). In patients who achieved breast-pCR, aggressive subtypes (HER2+ and TN; OR 11.24) and clinical tumor stage (OR 0.10) had a significant impact on achieving AXpCR. Axillary lymph node dissection was avoided in 53.3% of patients. In conclusion, in node-positive patients with HER2+ and TN subtypes, who achieved breast-pCR after NST, de-escalation of axillary surgery could be considered in most cases.

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Natural language understanding (NLU) may be particularly well-equipped for enhanced data capture from the electronic health record (EHR) given its examination of both content- and context-driven extraction. We developed and applied a NLU model to examine rates of pathological node positivity (pN+) and rates of lymphedema to determine if omission of routine axillary staging could be extended to younger patients with ER+/cN0 disease. We found that rates of pN+ and arm lymphedema were similar between patients 55-69yo and ≥70yo, with rates of lymphedema exceeding rates of pN+ for clinical stage T1c and smaller disease. Data from our NLU model suggest that omission of SLNB might be extended beyond Choosing Wisely recommendations, limited to those over 70 years old, to all postmenopausal women with early-stage ER+/cN0 disease. These data support the recently-reported SOUND trial results and provide additional granularity to facilitate surgical de-escalation.

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BACKGROUND: Lymphedema (LE) is the most notable complication of axillary surgery. The axillary reverse mapping (ARM) technique was created to decrease LE. This study aims to evaluate a single surgeon's experience with ARM in patients undergoing sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) for breast cancer. METHODS: We retrospectively analyzed patients who underwent SLNB or ALND. Tumor characteristics and treatments received were evaluated. Surgical intervention and use of ARM were compared to assess LE rates. A subgroup analysis was also performed of patients who underwent NAC. RESULTS: LE was initially reported in 7.1% (n = 10) of patients; 3.3% (n = 4) with SLNB and 35% (n = 6) with ALND. At initial follow-up, LE was reported 16.4% more often in patients who underwent ALND with no ARM, and 38.8% more often in patients who underwent ALND plus ARM. An increased risk of LE was found in patients treated with ALND (OR = 16.0, P < .001). All patients who underwent ARM were 12.75% more likely to develop LE if they received NAC (P < .05). Patients in the ALND group who also received NAC were more likely to undergo ARM as compared with patients in the SLNB group (P < .01). DISCUSSION: Our study showed that ARM failed to decrease the incidence of LE. Until better surgical outcomes are shown for the prevention of LE using ARM, other approaches should be utilized. However, larger prospective studies are needed to evaluate ARM.

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PURPOSE: Up to 40% of the 56,000 women diagnosed with breast cancer each year in the UK undergo mastectomy. Seroma formation following surgery is common, may delay wound healing, and be uncomfortable or delay the start of adjuvant treatment. Multiple strategies to reduce seroma formation include surgical drains, flap fixation and external compression exist but evidence to support best practice is lacking. We aimed to survey UK breast surgeons to determine current practice to inform the feasibility of undertaking a future trial. METHODS: An online survey was developed and circulated to UK breast surgeons via professional and trainee associations and social media to explore current attitudes to drain use and management of post-operative seroma. Simple descriptive statistics were used to summarise the results. RESULTS: The majority of surgeons (82/97, 85%) reported using drains either routinely (38, 39%) or in certain circumstances (44, 45%). Other methods for reducing seroma such as flap fixation were less commonly used. Wide variation was reported in the assessment and management of post-operative seromas. Over half (47/91, 52%) of respondents felt there was some uncertainty about drain use after mastectomy and axillary surgery and two-thirds (59/91, 65%) felt that a trial evaluating the use of drains vs no drains after simple breast cancer surgery was needed. CONCLUSIONS: There is a need for a large-scale UK-based RCT to determine if, when and in whom drains are necessary following mastectomy and axillary surgery. This work will inform the design and conduct of a future trial.

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This article provides a brief account of the recent evolution of the highly controversial surgical management of the positive axilla in patients with breast cancer, an issue still open to disparate surgical procedures. This short review highlights the reports that supply the rationale for current trends in reducing the aggressiveness of this surgery and discusses the course of the trials still in progress pointing in the same direction, thus supporting the principle of not performing axillary lymph node dissection for staging purposes alone.

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Axillary lymph node dissection (ALND) has been associated with postoperative morbidities, including arm lymphedema, shoulder dysfunction, and paresthesia. Sentinel lymph node (SLN) biopsy emerged as a method to assess axillary nodal status and possibly obviate the need for ALND in patients with clinically node-negative (cN0) breast cancer. The majority of breast cancer patients are eligible for SLN biopsy only, so ALND can be avoided. However, there are subsets of patients in whom ALND cannot be eliminated. ALND is still needed in patients with three or more positive SLNs or those with gross extranodal or matted nodal disease. Moreover, ALND has conventionally been performed to establish local control in clinically node-positive (cN+) patients with a heavy axillary tumor burden. The sole method to avoid ALND is through neoadjuvant chemotherapy (NAC). Recently, various forms of conservative axillary surgery have been developed in order to minimize arm lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, conventional ALND may not be necessary in either cN0 or cN+ patients. Further studies with a longer follow-up period are needed to determine the safety of conservative axillary surgery.

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Introduction: Increasing evidence suggests that de-escalation of axillary surgery is safe, without significantly impacting patient outcome. Obtaining positive lymph nodes at a sentinel lymph node biopsy (SNB) can guide decisions toward the requirement of axillary nodal clearance (ANC). However, methods to predict how many further nodes will be positive are not available. This study investigates the feasibility of predicting the likelihood of a negative ANC based on the ratio between positive nodes and the total number of lymph nodes excised at SNB. Methods: Retrospective data from January 2017 to March 2022 was collected from electronic medical records. Patients with oestrogen receptor (ER) positive and HER2 negative receptor disease were included in the study. ER-negative and HER2-positive disease was excluded, alongside patients who had chemotherapy before ANC. Results: Of 102 patients, 58.8% (n=60) had no macrometastasis at ANC. On average, 2.76 lymph nodes were removed at SNB. A higher SNB ratio of positive to total nodes [OR 11.09 (CI 95% 2.33-52.72), P=0.002] had a significant association with positive nodes during ANC. SNB ratio less than or equal to 0.33 (1/3) had a specificity of 79.2% in identifying cases that later had a negative completion ANC, with a 95.8% specificity of no further upgrade of nodal staging. Conclusion: A low SNB ratio of less than 0.33 (1/3) has a high specificity in excluding the upgradation of nodal staging on completion of ANC, with a false-negative rate of less than 5%. This may be used to identify patients with a low risk of axillary metastasis, who can avoid ANC.

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While upper limb lymphoedema following breast and axillary surgery is well established in the literature, breast lymphoedema is rarely documented. Our primary objective was to identify risk factors of breast lymphoedema, and our secondary aim was to assess the possibility of using a breast ultrasound scan to assess breast lymphoedema. This study was a case series analysis, including patients who had wide local excision for primary breast cancer treatment between January 2013 and January 2018. Patients' demographics, including age, weight, body mass index (BMI), breast volume, tumour characteristics, and histological findings, were noted. All patients had a clinical assessment and ultrasound scan 6 months and 12 months after surgery, comparing ipsilateral to the contralateral breast skin, subcutaneous thickness, as well as parenchymal changes. We have included two hundred eighty-six breast cancer; the mean age was 54.7 years SD 17.3, the mean weight was 76.5 kg SD 12.6, the mean BMI was 31.5 SD 5.2, and the mean breast volume was 1223 ml SD 179. This study identified breast lymphoedema in patients with clinically detected skin oedema in the absence of radiotherapy skin changes; skin and subcutaneous 5 mm added thickness more than the contralateral side, and based on that, 22 patients (7.7%) were found to have breast lymphoedema. We have also found that patients with high BMI, larger breast volume, upper outer quadrant tumours, and patients who had axillary lymph node clearance had an increased incidence of breast lymphoedema. The incidence of breast lymphoedema in this cohort was 7.7%. We suggest that breast lymphoedema should be considered if skin and subcutaneous thickness are 5 mm more than the contralateral side in the absence of severe radiotherapy skin changes. Also, we have found that high body mass index (BMI), larger breast volume, upper outer quadrant tumours, and patients who had axillary lymph node clearance are associated with an increased incidence of breast lymphoedema.

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Objective: Sentinel lymph node biopsy (SLNB) represents the gold standard for axillary surgical staging. The aim of this study was to assess the proportion of axillary lymph node dissection (ALND) that could be avoided after retrospective application of the ACOSOG Z0011 criteria and to evaluate the shortterm complications associated with axillary surgery. Materials and Methods: We reviewed breast cancer (BC) patients treated by primary breast-conserving surgery from 2012 to 2015. The percentage of SLNB vs ALND performed before and after the application of the ACOSOG Z0011 criteria was calculated. Complications were analyzed using crosstabs, with p<0.05 considered significant. Results: Two hundred fifty one patients with a median age of 59.3 years were included. BC tumors had a median size of 13 mm and were mostly unifocal (83.9%). There were 30.3% with 1-2 metastatic lymph nodes (MLN). ALND was performed in 44.2%. The patients with 1-2 MLN, had only SLNB in 14.5% of cases. By applying the ACOSOG Z0011 criteria, ALND would have been avoided in 40.2% of patients. At least one postoperative complication was reported after SLNB or ALND for 45.7% and 74.7% of patients respectively. Seroma was the most frequent complication, and occurred in 29.3% of cases after SLNB and in 59.5% after ALND. Conclusion: SNLB is the most commonly used axillary surgical staging procedure in this series (55.8%). With a retrospective application of the ACOSOG Z0011 criteria in our population, ALND could have been avoided for 40.2% patients. Post-operative complications rate was higher after ALND, with a seroma rate at 59.5%.

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Background: Systemic inflammatory markers draw great interest as potential blood-based prognostic factors in several oncological settings. Objectives: The aim of this study is to evaluate whether neutrophil-to-lymphocyte ratio (NLR) and pan-immune-inflammation value (PIV) predict nodal pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) in node-positive (cN+) breast cancer (BC) patients. Design: Clinically, cN+ BC patients undergoing NAC followed by breast and axillary surgery were enrolled in a multicentric study from 11 Breast Units. Methods: Pretreatment blood counts were collected for the analysis and used to calculate NLR and PIV. Logistic regression analyses were performed to evaluate independent predictors of nodal pCR. Results: A total of 1274 cN+ BC patients were included. Nodal pCR was achieved in 586 (46%) patients. At multivariate analysis, low NLR [odds ratio (OR) = 0.71; 95% CI, 0.51-0.98; p = 0.04] and low PIV (OR = 0.63; 95% CI, 0.44-0.90; p = 0.01) were independently predictive of increased likelihood of nodal pCR. A sub-analysis on cN1 patients (n = 1075) confirmed the statistical significance of these variables. PIV was significantly associated with axillary pCR in estrogen receptor (ER)-/human epidermal growth factor receptor 2 (HER2)+ (OR = 0.31; 95% CI, 0.12-0.83; p = 0.02) and ER-/HER2- (OR = 0.41; 95% CI, 0.17-0.97; p = 0.04) BC patients. Conclusion: This study found that low NLR and PIV levels predict axillary pCR in patients with BC undergoing NAC. Registration: Eudract number NCT05798806.