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Risk of pN2/3 Understaging in Sentinel Node-Positive ER+/HER2- Breast Cancer: A Composite Clinicopathologic Score for
Soong June Bae1, Janghee Lee2, Sung-Im Do3
1Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
Annals of Surgical Oncology
|June 15, 2026
Summary
Accurate staging of ER+/HER2- breast cancer is crucial. A new five-item score effectively identifies low-risk patients, potentially allowing omission of completion axillary lymph node dissection (ALND) and reducing unnecessary procedures.
Area of Science:
- Oncology
- Breast Cancer Research
- Surgical Oncology
Background:
- Adjuvant treatment decisions for ER+/HER2- breast cancer hinge on precise staging of lymph node involvement (pN1 vs. pN2/3).
- Increasing use of sentinel lymph node biopsy (SLNB) may lead to understaging of patients with apparent pN1 disease.
- Accurate identification of patients with more extensive nodal disease is critical for appropriate treatment planning.
Purpose of the Study:
- To evaluate the efficacy of preoperative imaging in predicting advanced nodal disease (pN2/3) in patients with positive SLNB.
- To develop and validate a composite risk score to identify patients with ER+/HER2- breast cancer who may safely omit completion axillary lymph node dissection (ALND).
Main Methods:
- Retrospective analysis of 160 ER+/HER2- patients with 1-3 positive SLNs who underwent completion ALND.
- Assessment of four preoperative imaging modalities for predicting pN2/3 disease (≥4 positive nodes).
- Development and validation of a five-item composite risk score (including SLN status, lymphovascular invasion, tumor size, Ki-67, and multifocality) using bootstrap validation and decision curve analysis (DCA).
Main Results:
- Preoperative imaging modalities demonstrated low sensitivity and failed to reliably predict pN2/3 understaging.
- Overall, 17.5% of patients had true pN2/3 disease upon completion ALND.
- A low-risk subgroup (composite score ≤1) had a pN2/3 rate of only 3.9% (NPV 96.1%), while high-risk patients had a 23.9% rate (p=0.0015).
- DCA indicated that the composite score could reduce unnecessary ALNDs by approximately 14 per 100 patients compared to a treat-all strategy.
Conclusions:
- Preoperative imaging alone is insufficient for guiding the omission of completion ALND due to limited sensitivity for detecting understaged pN2/3 disease.
- A five-item composite risk score effectively identifies a low-risk subgroup (NPV 96.1%) suitable for omitting completion ALND, aligning with monarchE and RxPONDER trial criteria.
- Prospective external validation is necessary before the routine clinical adoption of this composite risk score for guiding ALND decisions.