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Axillary management in patients with cN + breast cancer undergoing neoadjuvant chemotherapy: pattern of practice in
Fiorenza De Rose1,2, Sara Lucidi1,2, Elisabetta Bonzano3,4
1Radiation Oncology, Azienda Sanitaria Universitaria Integrata del Trentino (ASUIT), Trento, Italy.
Purpose:
To assess the current practices concerning the axillary management of clinically node-positive (cN +) breast cancer (BC) patients undergoing neoadjuvant chemotherapy (NAC), among radiation oncologists (ROs) practicing in Italy.
Methods:
An online 24-question survey was distributed via SurveyMonkey to ROs between December 2024 and February 2025. This survey was developed through a multistep process by the Clinical Oncology Breast Cancer Group (COBCG) and AIRO Breast Cancer study groups' experts, focusing on axillary lymph node dissection (ALND) omission after pathological complete response (pCR) and its implications for regional nodal irradiation (RNI). The survey followed the CHERRIES statement and ESTRO guidelines and was revised and approved by the scientific committee of AIRO (Nr. 21/2024).
Results:
119/195 (61%) Italian Radiotherapy Centers, mostly public hospitals, completed the survey. Regarding cN + disease at diagnosis and node-negative disease (ypN0) on sentinel lymph node biopsy (SLNB) after NAC, ALND was omitted a) always, b) when three sentinel nodes were removed, c) never, and d) only in selected cases, in 26.05%, 45.38%, 2.52% and 26.05%, respectively. Most respondents (80%) said ALND omission was a multidisciplinary decision. According to 48.60%, ALND was omitted in cN1 disease. RNI indications varied in patients not undergoing ALND. Among 70 respondents defining RNI target volumes in cN2-3 patients without ALND, 62.86% treated all nodal levels (I-IV). Key factors influencing RNI included pre-NAC lymph node burden (56.72%), extracapsular nodal extension (43.94%), and tumor size (40.63%).
Conclusions:
Axillary management of BC patients undergoing NAC in Italy is moving toward treatment de-escalation, with relevant variability, supporting the need for multidisciplinary harmonization.