Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2021 Oct;81(10):1112-1120.
doi: 10.1055/a-1499-8431. Epub 2021 Oct 6.

AGO Recommendations for the Surgical Therapy of the Axilla After Neoadjuvant Chemotherapy: 2021 Update

Michael Friedrich  1 , Thorsten Kühn  2 , Wolfgang Janni  3 , Volkmar Müller  4 , Maggie Banys-Pachulowski  5   6 , Cornelia Kolberg-Liedtke  7 , Christian Jackisch  8 , David Krug  9 , Ute-Susann Albert  10 , Ingo Bauerfeind  11 , Jens Blohmer  7 , Wilfried Budach  12 , Peter Dall  13 , Eva M Fallenberg  14 , Peter A Fasching  15 , Tanja Fehm  16 , Bernd Gerber  17 , Oleg Gluz  18 , Volker Hanf  19 , Nadia Harbeck  20 , Jörg Heil  21 , Jens Huober  22 , Hans-Heinrich Kreipe  23 , Sherko Kümmel  24 , Sibylle Loibl  25 , Diana Lüftner  26 , Michael Patrick Lux  27 , Nicolai Maass  28 , Volker Möbus  29 , Christoph Mundhenke  28 , Ulrike Nitz  18 , Tjoung-Won Park-Simon  30 , Toralf Reimer  17 , Kerstin Rhiem  31 , Achim Rody  32 , Marcus Schmidt  33 , Andreas Schneeweiss  21 , Florian Schütz  34 , Hans-Peter Sinn  35 , Christine Solbach  36 , Erich-Franz Solomayer  37 , Elmar Stickeler  38 , Christoph Thomssen  39 , Michael Untch  40 , Isabell Witzel  4 , Achim Wöckel  10 , Marc Thill  41 , Nina Ditsch  42
Affiliations

AGO Recommendations for the Surgical Therapy of the Axilla After Neoadjuvant Chemotherapy: 2021 Update

Michael Friedrich et al. Geburtshilfe Frauenheilkd. 2021 Oct.

Erratum in

  • Correction: AGO Recommendations for the Surgical Therapy of the Axilla After Neoadjuvant Chemotherapy: 2021 Update.
    Friedrich M, Kühn T, Janni W, Müller V, Banys-Paluchowski M, Kolberg-Liedtke C, Jackisch C, Krug D, Albert US, Bauerfeind I, Blohmer J, Budach W, Dall P, Fallenberg EM, Fasching PA, Fehm T, Gerber B, Gluz O, Hanf V, Harbeck N, Heil J, Huober J, Kreipe HH, Kümmel S, Loibl S, Lüftner D, Lux MP, Maass N, Möbus V, Mundhenke C, Nitz U, Park-Simon TW, Reimer T, Rhiem K, Rody A, Schmidt M, Schneeweiss A, Schütz F, Sinn HP, Solbach C, Solomayer EF, Stickeler E, Thomssen C, Untch M, Witzel I, Wöckel A, Thill M, Ditsch N. Friedrich M, et al. Geburtshilfe Frauenheilkd. 2021 Oct 22;81(10):e31. doi: 10.1055/a-1674-1114. eCollection 2021 Oct. Geburtshilfe Frauenheilkd. 2021. PMID: 34720743 Free PMC article.

Abstract

For many decades, the standard procedure to treat breast cancer included complete dissection of the axillary lymph nodes. The aim was to determine histological node status, which was then used as the basis for adjuvant therapy, and to ensure locoregional tumour control. In addition to the debate on how to optimise the therapeutic strategies of systemic treatment and radiotherapy, the current discussion focuses on improving surgical procedures to treat breast cancer. As neoadjuvant chemotherapy is becoming increasingly important, the surgical procedures used to treat breast cancer, whether they are breast surgery or axillary dissection, are changing. Based on the currently available data, carrying out SLNE prior to neoadjuvant chemotherapy is not recommended. In contrast, surgical axillary management after neoadjuvant chemotherapy is considered the procedure of choice for axillary staging and can range from SLNE to TAD and ALND. To reduce the rate of false negatives during surgical staging of the axilla in pN+ CNB stage before NACT and ycN0 after NACT, targeted axillary dissection (TAD), the removal of > 2 SLNs (SLNE, no untargeted axillary sampling), immunohistochemistry to detect isolated tumour cells and micro-metastases, and marking positive lymph nodes before NACT should be the standard approach. This most recent update on surgical axillary management describes the significance of isolated tumour cells and micro-metastasis after neoadjuvant chemotherapy and the clinical consequences of low volume residual disease diagnosed using SLNE and TAD and provides an overview of this year's AGO recommendations for surgical management of the axilla during primary surgery and in relation to neoadjuvant chemotherapy.

Keywords: breast cancer; neoadjuvant chemotherapy; sentinel LNE; targeted axillary dissection.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest/Interessenkonflikt PD DR Banys-Paluchowski: Honoraria for lectures and advisory role from Lilly, Pfizer, Roche, Amgen, Eisai, Astra Zeneca, Daiichi Sankyo, Novartis, GSK and study support from Endomag, Merit Medical and Mammotome. Prof. Dr. V. Müller: VM received speaker honoraria from Amgen, Astra Zeneca, Daiichi Sankyo, Eisai, GSK, Pfizer, MSD, Novartis, Roche, Teva, Seagen and consultancy honoraria from Genomic Health, Hexal, Roche, Pierre Fabre, Amgen, ClinSol, Novartis, MSD, Daiichi Sankyo, Eisai, Lilly, Seagen. Institutional research support from Novartis, Roche, Seagen, Genentech. Travel grants: Roche, Pfizer, Daiichi Sankyo./ Vortragshonorare: Amgen, Astra Zeneca, Daiichi Sankyo, Eisai, Pfizer, MSD, Novartis, Roche, Teva, Seattle Genetics, GSK, Seagen. Beratertätigkeit: Genomic Health, Hexal, Roche, Pierre Fabre, Amgen, ClinSol, Novartis, MSD, Daiichi Sankyo, Eisai, Lilly, GSK, Tesaro, Seagen und Nektar. Forschungsuntersützung an den Arbeitgeber: Novartis, Roche, Seattle Genetics, Genentech. Reisekosten: Roche, Pfizer, Daiichi Sankyo.

Figures

Fig. 1
Fig. 1
Algorithm of axillary surgical procedures before and after NACT. [rerif]
Fig. 2
Fig. 2
AXSANA trial flowchart. [rerif]
Abb. 1
Abb. 1
Algorithmus der axillären Interventionen bei NACT. [rerif]
Abb. 2
Abb. 2
Flowchart AXSANA Trial. [rerif]
See this image and copyright information in PMC

References

    1. Ditsch N, Kolberg-Liedtke C, Friedrich M. AGO Recommendations for the Diagnosis and Treatment of Patients with Early Breast Cancer: Update 2021. Breast Care (Basel) 2021;16:214–227. doi: 10.1159/000516419. - DOI - PMC - PubMed
    1. Kühn T, Klauss W, Darsow M. Long-term morbidity following axillary dissection in breast cancer patients – clinical assessment, significance for life quality and the impact of demographic, oncologic and therapeutic factors. Breast Cancer Res Treat. 2000;64:275–286. - PubMed
    1. Krag D N, Anderson S J, Julian T B. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 2010;11:927–933. - PMC - PubMed
    1. Giuliano A E, Ballman K V, McCall L. Effect of Axillary Dissection vs. No Axillary Dissection on 10-Year Overall Survival Among Women With Invasive Breast Cancer and Sentinel Node Metastasis: The ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA. 2017;318:918–926. - PMC - PubMed
    1. Donker M, van Tienhoven G, Straver M E. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981–22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol. 2014;15:1303–1310. - PMC - PubMed