Axillary Management Trends and Survival in Men Undergoing Mastectomy with Positive Sentinel Nodes

Men are often diagnosed with node-positive breast cancer and treated with mastectomy because of a lack of screening and an unfavorable tumor-to-breast ratio. The AMAROS trial showed no difference in outcomes between axillary lymph node dissection (ALND) and axillary radiation in women with cT1-2N0 breast cancer with positive sentinel lymph nodes (+SLNs). Axillary management in men remains unstandardized, so we assessed current trends and outcomes.

Males with cT1-2N0M0 breast cancer undergoing mastectomy with one to two +SLNs were identified from the National Cancer Database (2018-2021). Patients were stratified by axillary management. Postmastectomy radiotherapy (PMRT) included chest wall and axillary fields. Management strategies and overall survival were analyzed.

Among 445 patients, 25% had no further axillary treatment, 22% underwent ALND, 29% PMRT, and 24% ALND+PMRT. Patients with two +SLNs more often underwent ALND+PMRT (43% vs. 19%, p < 0.001). The use of PMRT rose over time (23-36%), whereas ALND alone declined (27-12%). Additional positive nodes were found in 31% of ALND cases, with no difference between ALND and ALND+PMRT. Performance of ALND delayed PMRT (194 vs. 133 days from diagnosis, p < 0.001). On multivariable analysis, two +SLNs predicted ALND+PMRT (odds ratio 2.5, p = 0.006). Older age (p < 0.001) and two +SLNs (p = 0.03) were linked to worse overall survival, whereas axillary management was not (p = 0.23).

Although axillary strategies are proven safe and effective in women, their extrapolation to men is inconsistent. Half of men undergoing mastectomy are undertreated or overtreated, underscoring the need for multidisciplinary consensus and prospective male-specific data to guide care and reduce morbidity.