Management of the axilla in breast cancer patients: critical review, regional modified Delphi consensus and implementation in the Tuscan breast network

Matteo Ghilli^#¹, Carlotta Becherini^#², Icro Meattini^{2

3}, Catia Angiolini⁴, Carmelo Bengala⁵, Aroldo Marconi⁶, Lorenzo Galli⁷, Giovanni Angiolucci⁸, Luigi Coltelli⁹, Simona Borghesi¹⁰, Luciana Lastrucci¹¹, Gianpiero Manca¹², Simonetta Bianchi¹³, Morena Doria¹⁴, Donato Casella¹⁵, Lorenza Marotti¹⁶, Gianni Amunni¹⁷, Manuela Roncella^{18

19}

Affiliations

¹ Breast Centre, Breast Surgery, University Hospital of Pisa, Via Roma 67, Pisa, Italy. m.ghilli@ao-pisa.toscana.it.
² Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
³ Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy.
⁴ Breast Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, A. Brambilla 3, 50134, Florence, Italy.
⁵ Oncology Department, Unit of Medical Oncology, Misericordia Hospital, Grosseto, Italy.
⁶ Breast Oncological and Reconstructive Surgery, S.Luca Hospital- V. G. Lippi Francesconi, 55100, Lucca, Italy.
⁷ Azienda Usl Toscana Centro, Ospedale San Giovanni Di Dio, Via Di Torregalli N 3, 50143, Florence, Italy.
⁸ Radiologia Senologica, Azienda Usl Toscana Sud-Est, Ospedale Arezzo, Giovanni Valdarno, Italy.
⁹ Division of Medical Oncology, Livorno Hospital, Department of Oncology, Azienda USL Toscana Nord Ovest, Viale Alfieri 36, Leghorn, Italy.
¹⁰ Department of Radiation Oncology, Azienda Usl Toscana Sud-Est, Ospedale Arezzo E S., Giovanni Valdarno, Italy.
¹¹ Department of Radiation Oncology, Livorno Hospital, Azienda USL Toscana Nord Ovest, Viale Alfieri 36, Leghorn, Italy.
¹² Breast Centre, Nuclear Medicine, University Hospital of Pisa, Via Roma 67, Pisa, Italy.
¹³ Department of Health Sciences, Division of Pathological Anatomy, University of Florence, Viale Pieraccini 6, Florence, Italy.
¹⁴ SOC Anatomia Patologica, Azienda Usl Toscana Centro, Ospedale San Giovanni Di Dio, Via Di Torregalli N° 3, 50143, Florence, Italy.
¹⁵ Breast Unit AOUS Siena, Siena, Italy.
¹⁶ European Society of Breast Cancer Specialists, Florence, Italy.
¹⁷ Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
¹⁸ Breast Centre, Breast Surgery, University Hospital of Pisa, Via Roma 67, Pisa, Italy.
¹⁹ University Hospital of Pisa, Via Roma 67, Pisa, Italy.

^# Contributed equally.

PMID: 38683499
DOI: 10.1007/s11547-024-01818-7

Review

Management of the axilla in breast cancer patients: critical review, regional modified Delphi consensus and implementation in the Tuscan breast network

Matteo Ghilli et al. Radiol Med. 2024 Jun.

. 2024 Jun;129(6):945-954.

doi: 10.1007/s11547-024-01818-7. Epub 2024 Apr 29.

Authors

Affiliations

¹ Breast Centre, Breast Surgery, University Hospital of Pisa, Via Roma 67, Pisa, Italy. m.ghilli@ao-pisa.toscana.it.
² Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
³ Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy.
⁴ Breast Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, A. Brambilla 3, 50134, Florence, Italy.
⁵ Oncology Department, Unit of Medical Oncology, Misericordia Hospital, Grosseto, Italy.
⁶ Breast Oncological and Reconstructive Surgery, S.Luca Hospital- V. G. Lippi Francesconi, 55100, Lucca, Italy.
⁷ Azienda Usl Toscana Centro, Ospedale San Giovanni Di Dio, Via Di Torregalli N 3, 50143, Florence, Italy.
⁸ Radiologia Senologica, Azienda Usl Toscana Sud-Est, Ospedale Arezzo, Giovanni Valdarno, Italy.
⁹ Division of Medical Oncology, Livorno Hospital, Department of Oncology, Azienda USL Toscana Nord Ovest, Viale Alfieri 36, Leghorn, Italy.
¹⁰ Department of Radiation Oncology, Azienda Usl Toscana Sud-Est, Ospedale Arezzo E S., Giovanni Valdarno, Italy.
¹¹ Department of Radiation Oncology, Livorno Hospital, Azienda USL Toscana Nord Ovest, Viale Alfieri 36, Leghorn, Italy.
¹² Breast Centre, Nuclear Medicine, University Hospital of Pisa, Via Roma 67, Pisa, Italy.
¹³ Department of Health Sciences, Division of Pathological Anatomy, University of Florence, Viale Pieraccini 6, Florence, Italy.
¹⁴ SOC Anatomia Patologica, Azienda Usl Toscana Centro, Ospedale San Giovanni Di Dio, Via Di Torregalli N° 3, 50143, Florence, Italy.
¹⁵ Breast Unit AOUS Siena, Siena, Italy.
¹⁶ European Society of Breast Cancer Specialists, Florence, Italy.
¹⁷ Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
¹⁸ Breast Centre, Breast Surgery, University Hospital of Pisa, Via Roma 67, Pisa, Italy.
¹⁹ University Hospital of Pisa, Via Roma 67, Pisa, Italy.

^# Contributed equally.

PMID: 38683499
DOI: 10.1007/s11547-024-01818-7

Abstract

Purpose: Data from recently trials have provided practice-changing recommendations in management of the axilla in early breast cancer (eBC). However, further controversies have been raised, resulting in heterogeneous diffusion of these recommendations. Our purpose was to obtain a better homogeneity.

Material and methods: In 2021, the Tuscan Breast Network (TBN) established a consensus with the aim to update recommendations in this area. We performed a literature review on axillary management in eBC patients which led to an expert Delphi consensus aiming to explore the gray areas, build consensus and propose evidence-based suggestions for an appropriate management. Thereafter, we investigate their implementation in clinical practice.

Results: (1) DCIS patients should have SLN biopsy only in case of mastectomy or in conservative surgery if tumor is in a location that would preclude future nodal sampling or in case of a mass; (2) ALND may be omitted for 1-2 positive SLN patients undergoing BCS in T1-2 tumors with 1-2 SLN positive, eligible for whole-breast irradiation and adjuvant systemic therapies; (3) consider the option of RNI in patients with 1-3 positive lymph nodes and one or more high-risk characteristics; (4) the population identified in 2) should NOT undergo lymph node irradiation as an alternative to axillary surgery and (5) patients with clinically (pre-operatively) positive axilla, or undergoing primary systemic therapy, or outside the criteria reported in 2) must receive additional ALND and/or RT as per local policy.

Conclusion: This consensus provided a practical tool to stimulate local and national breast surgical and radiotherapy protocols.

Keywords: Axillary management; Breast cancer; Breast cancer surgery; Delphi consensus; Guidelines; Positive sentinel node.

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References

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1. Giuliano AE, Ballman KV, McCall L, Beitsch PD, Brennan MB, Kelemen PR et al (2017) Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis. JAMA 318:918. https://doi.org/10.1001/jama.2017.11470 - DOI - PubMed - PMC
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Management of the axilla in breast cancer patients: critical review, regional modified Delphi consensus and implementation in the Tuscan breast network

Affiliations

Management of the axilla in breast cancer patients: critical review, regional modified Delphi consensus and implementation in the Tuscan breast network

Authors

Affiliations

Abstract

References

Publication types

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LinkOut - more resources

Full Text Sources

Medical