Axillary dissection is avoidable in most cT1N0 triple-negative & HER2+ breast cancers treated with upfront surgery

The use of neoadjuvant chemotherapy (NAC) in cT1N0 patients with triple-negative (TN) or HER2-positive (HER2+) breast cancer has been controversial. It is unclear whether NAC or upfront surgery minimizes axillary dissection (ALND) risk in the contemporary cT1N0 TN/HER2+ patient population.

Consecutive cT1N0 TN/HER2+ patients who received NAC or underwent upfront surgery at our institution between 01/2020-12/2022 were examined. ALND was indicated for any positive sentinel nodes (+SLNs) after NAC, ≥ 3 positive SLNs after upfront surgery, or 1-2 positive SLNs after upfront mastectomy not requiring radiotherapy (RT). Clinicopathologic features, nodal burden, and ALND rates were compared between NAC versus upfront surgery cohorts.

Among 506 patients, 43% (N = 218) were TN and 57% (N = 288) were HER2+; 9% (N = 47) received NAC before surgery; 68%( N = 343) underwent upfront breast-conserving surgery (BCS); 23% (N = 116) underwent upfront mastectomy. Axillary ultrasound was performed in 23% of patients who received NAC versus 26% of patients who underwent upfront BCS versus 33% of patients who underwent upfront mastectomy. ALND was performed in 6.4% (N = 3) of patients with any positive SLN after NAC, 1.7% (N = 6) who underwent upfront BCS, and 1.7% (N = 2) who underwent upfront mastectomy with ≥ 3 positive SLNs or 1-2 positive SLNs not meeting RT criteria (p = 0.13). No factors were associated with ALND, including T stage, upfront versus NAC approach, or tumor subtype.

Nodal disease burden is low among cT1N0 TN/HER2+ patients even in the absence of routine axillary ultrasound. ALND was performed in < 2% of patients with cT1N0 TN/HER2+ disease who had upfront surgery, and adjuvant systemic therapy was de-escalated among many pathologically node-negative patients following surgery.