Multicenter Study

. 2025 Sep 2;112(9):znaf180.

doi: 10.1093/bjs/znaf180.

Axillary dissection for low-volume nodal involvement after neoadjuvant therapy in breast cancer: multicentre AXSANA cohort study

Thorsten Kühn^{1

2}, Maggie Banys-Paluchowski³, Nina Ditsch⁴, Elmar Stickeler⁵, Michael Hauptmann⁶, Jennifer Schroth⁶, Guldeniz Karadeniz Cakmak⁷, Markus Hahn⁸, Marc Thill⁹, Toralf Reimer¹⁰, Sarah Fröhlich¹⁰, Esther Schmidt¹⁰, Kristina Wihlfahrt¹¹, Tomasz Berger¹², Timo Basali¹³, Franziska Ruf³, Angelika Rief¹⁴, Michael Patrick Lux^{15

16}, Hans-Christian Kolberg¹⁷, Isabel Teresa Rubio¹⁸, Maria Luisa Gasparri^{19

20}, Michalis Kontos²¹, Eduard-Alexandru Bonci^{22

23}, Laura Niinikoski²⁴, Dawid Murawa^{25

26}, David Pinto²⁷, Florentia Peintinger^{14

28}, Ellen Schlichting²⁹, Helidon Nina³⁰, Hagigat Valiyeva Qanimat³¹, Marian Vanhoeij³², Lia Pamela Rebaza³³, Bilge Aktas Sezen³⁴, Katharina Jursik³⁴, Geeta Kadayaprath³⁵, Lukas Dostalek³⁶, Ashutosh Kothari³⁷, Andraz Perhavec³⁸, Tsvetomir Ivanov³⁹, Douglas Zippel⁴⁰, Sarun Thongvitokomarn⁴¹, Meryem Gunay Gurleyik⁴², Dirk Watermann⁴³, Mauro Porpiglia⁴⁴, Annette Lebeau^{45

46}, Rosa Di Micco⁴⁷, Oreste Davide Gentilini^{47

48}, Jana de Boniface^{49

50}, Steffi Hartmann¹⁰; AXSANA Study Group

Collaborators, Affiliations

Collaborators

AXSANA Study Group:
A Kolacinska-Wow, A Fancellu, A Hein, A Miller, A Thodas, A Isabel Cruz, A Musina, A Fleuster, A Stefek, A Putz, A Lorek, A Kleine-Tebbe, A Smeets, A Madej-Mierzwa, A Bachmann, A Lebrecht, A Nixdorf, A Grasso, A Calvo Cordoba, A Marano, A Pinero Madrona, A Kumar Goel, A Sezer, A Gatzweiler, B Costa Leite, B Schlesinger, B Adamczyk, B Janke, B Lex, B Königs-El-Amrawy, C Cipolla, C Paschold, C Schulte-Tiwisinia, C Nestle-Krämling, C M Ugur, C Yilmaz, C Schindlbeck, C Ankel, C Solbach, C Zeder-Goess, C Anthuber, C Großmann, C Scholz, C Uras, C Maurer, C Müller, C Neumann, C Meisel, C Fuhljahn, C Kühn, D Langanke, D De Tullio, D Dieterle, D Rezek, D Bolla, D J Müller, D Mink, D Fischer, E Simon, E von Abel, E Ignatiadou, E Shaari, E Thiemann, E Faust, E Keil, E Buch Villa, E Esposito, E Klein, F Corsi, F Bacelar, F Ebner, F Guerini, F Beldermann, F Bilow, F Thele, F F Fromm, F Klaassen Federspiel, F Wärnberg, G Bonatz, G Feisel-Schwickardi, G Kaltenecker, G Stalzer, G Franceschini, G Tazzioli, G Armatura, G Xepapadakis, H Huschman Nia, H Strittmatter, H Karanlik, H Graf, H Ikonomidis Sackey, H Eichler, H Heidegger, I Bekes, I Bauerfeind, I Thalmann, I Buck, I Natasiopoulos, I Cebrecos Lerena, I Utz-Billing, I Himsl, J Palatty, J Kosse, J Schnabel, J Seldte, J Kruse, J Blohmer, J Leitsmann, J Wagner, J Rom, J Czihak, J Lecht, J Lermann, J I Sanchez-Mendez, J Lui Fougo, J Farthmann, J Schuster, J Lefarth, K Wimmer-Freys, K Chrobak-Kasprzyk, K Engelken, K Roth, K Hilmer, K Ramaker, K Pankert, K Unterrieder, K Ahsberg, K Freese, K Scheerer, L Bauer, L Johnsen, L Adwall, L Zetterlund, L Steinhilper, L Melnichuk, L Lahuerta Lorente, L Dogan, M Umit Ugurlu, M T Sanchez Barron, M Hofmann, M Hufnagel, M Sciamannini, M Santos, M Mangold, M Taffurelli, M Paul, M H Hansen, M Höing, M Keller, M D'Aiuto, M Busani, M Frank, M A Gülcelik, M Berghorn, M Burkhardt, M Eichbaum, M Schrauder, M Untch, M Weigel, N Kühn, N Ruyssers, N Krawczyk, N Deuerling, N Cabioglu, N Rocco, N Stahl, N Biglia, N Bangemann, N Argudo, O Behrens, O Tomé, O Agcaoglu, P Diem, P Dall, P Diebold, P Fehr, P Bolkenius, P Pluta, R Völker, R Ruderfors Malterling, R Buss-Steidle, R Felberbaum, R Berger, R Rodriguez, R Iosifidou, R Oom, S Lemster, S Riemer, S Schmatloch, S Rauen, S Wetzig, S Gunay, S Majid, S Ozkan Gurdal, S Perez, S Mattes, S Michieletto, S Cáradenas Ovalle, S Kommos, S Renner, S Liebers, S Hasmüller, S Seitz, S Perdigão Ribeiro, S Albrecht, S Barrot, S Bucher, S Kraudelt, S Peschel, S Grasshoff, T Lantzsch, T Hadar, T Abraham, T Durpektova Leuf, T Wanik, T Chiang Salazar, T Pursche, T Erber, T Hildebrandt, T Noesselt, T Papathemelis, T Nowikiewicz, U Denison, U Makowiec, U Scholz, U Fenske, U Felten, U Albert, V Venizelos, V Vural, V Bjelic-Radisic, V Hagan, V Soos, V Hanf, W Ruhwedel, W Heyl, W Seifert, Z Sidiropoulou, Z I Nowecki

Affiliations

¹ Department of Gynaecology and Obstetrics, University of Ulm, Ulm, Germany.
² Breast Centre, Die Filderklinik gGmbH, Filderstadt, Germany.
³ Department of Obstetrics and Gynaecology, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany.
⁴ Department of Gynaecology and Obstetrics, University Hospital Augsburg, Augsburg, Germany.
⁵ Department of Gynaecology and Obstetrics, University Hospital Aachen, Aachen, Germany.
⁶ Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany.
⁷ Breast and Endocrine Unit, General Surgery Department, The School of Medicine, Zonguldak BEUN, Zonguldak, Turkey.
⁸ Department of Gynaecology and Obstetrics, University Hospital Tübingen, Tübingen, Germany.
⁹ Department of Gynaecology and Gynaecological Oncology, Agaplesion Markus Hospital, Frankfurt, Germany.
¹⁰ Department of Gynaecology and Obstetrics, University Hospital Rostock, Rostock, Germany.
¹¹ Department for Gynaecology and Obstetrics, Practice Wihlfahrt, Kiel, Germany.
¹² Department of Gynaecology and Obstetrics, Müritz-Klinikum Waren, Waren, Germany.
¹³ Department of Gynaecology and Obstetrics, Hospital Esslingen, Esslingen, Germany.
¹⁴ Department of Gynaecology and Obstetrics, Medical University of Graz, Graz, Austria.
¹⁵ Department of Gynaecology and Obstetrics, Frauenklinik St Louise, Paderborn, Germany.
¹⁶ Frauenklinik St Josefs-Krankenhaus, Salzkotten, St Vincenz Kliniken, Paderborn, Germany.
¹⁷ Department of Gynaecology and Obstetrics, Marienhospital Bottrop, Bottrop, Germany.
¹⁸ Breast Surgical Unit, Clínica Universidad de Navarra, Madrid, Spain.
¹⁹ Department of Gynaecology and Obstetrics, Ente Ospedaliero Cantonale, Ospedale Regionale di Lugano, Lugano, Switzerland.
²⁰ Faculty of Biomedicine, University of Italian-Speaking Switzerland (USI), Lugano, Switzerland.
²¹ Department of Surgery, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece.
²² Department of Surgical Oncology, 'Prof. Dr. Ion Chiricuță' Institute of Oncology, Cluj-Napoca, Romania.
²³ Department of Oncological Surgery and Gynaecological Oncology, 'Iuliu Hațieganu' University of Medicine and Pharmacy, Cluj-Napoca, Romania.
²⁴ Breast Surgery Unit, Comprehensive Cancer Centre, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
²⁵ Surgery and Oncology Collegium Medicum, University of Zielona Góra, Zielona Góra, Poland.
²⁶ Department of General Surgery and Surgical Oncology, The Regional Hospital in Poznan-The Greater Poland Specialist Centre, Poznan, Poland.
²⁷ Breast Unit, Champalimaud Clinical Centre, Champalimaud Foundation, Lisboa, Portugal.
²⁸ Institute of Pathology, Medical University of Graz, Graz, Austria.
²⁹ Department of Oncology, Oslo University Hospital, Oslo, Norway.
³⁰ Department of Surgery, Oncology Hospital, Tirana, Albania.
³¹ Oncological Clinic, Azerbaijan Medical University, Baku, Azerbaijan.
³² Breast Clinic, Universitair Ziekenhuis Brussel, Brussel, Belgium.
³³ Breast Surgery, Oncosalud, Lima, Peru.
³⁴ EUBREAST e.V., Esslingen, Germany.
³⁵ Breast Surgical Oncology and Oncoplastic Surgery, MAX Hospital, Patparganj, New Delhi, India.
³⁶ Gynaecological Oncology Centre, Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University, General University Hospital, Prague, Czech Republic.
³⁷ Breast Unit, Guy's & St Thomas' NHS Foundation Trust, London, UK.
³⁸ Department of Surgical Oncology, Center for Breast Diseases, Institute of Oncology Ljubljana, Ljubljana, Slovenia.
³⁹ Department of General Surgery, Heart and Brain Hospital, Pleven, Bulgaria.
⁴⁰ Surgical Oncology Unit, Chaim Sheba Medical Centre, Ramat Gan, Israel.
⁴¹ Queen Sirikit Centre for Breast Cancer, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.
⁴² Department of General Surgery, Istanbul Haydarpasa Numune Training and Research Hospital, University of Health Sciences Turkey, İstanbul, Turkey.
⁴³ Department of Gynaecology and Obstetrics, Ev. Diakoniekrankenhaus, Freiburg, Germany.
⁴⁴ Breast Unit, S. Anna Hospital, Turin, Italy.
⁴⁵ Private Group Practice for Pathology, Lübeck, Germany.
⁴⁶ Institute of Pathology, University Hamburg-Eppendorf, Hamburg, Germany.
⁴⁷ Breast Surgery Unit, IRCCS Ospedale San Raffaele, Milan, Italy.
⁴⁸ Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy.
⁴⁹ Department of Surgery, Breast Centre, Capio St Göran's Hospital, Stockholm, Sweden.
⁵⁰ Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.

PMID: 40966675
DOI: 10.1093/bjs/znaf180

Multicenter Study

Axillary dissection for low-volume nodal involvement after neoadjuvant therapy in breast cancer: multicentre AXSANA cohort study

Thorsten Kühn et al. Br J Surg. 2025.

. 2025 Sep 2;112(9):znaf180.

doi: 10.1093/bjs/znaf180.

Authors

Collaborators

AXSANA Study Group:
A Kolacinska-Wow, A Fancellu, A Hein, A Miller, A Thodas, A Isabel Cruz, A Musina, A Fleuster, A Stefek, A Putz, A Lorek, A Kleine-Tebbe, A Smeets, A Madej-Mierzwa, A Bachmann, A Lebrecht, A Nixdorf, A Grasso, A Calvo Cordoba, A Marano, A Pinero Madrona, A Kumar Goel, A Sezer, A Gatzweiler, B Costa Leite, B Schlesinger, B Adamczyk, B Janke, B Lex, B Königs-El-Amrawy, C Cipolla, C Paschold, C Schulte-Tiwisinia, C Nestle-Krämling, C M Ugur, C Yilmaz, C Schindlbeck, C Ankel, C Solbach, C Zeder-Goess, C Anthuber, C Großmann, C Scholz, C Uras, C Maurer, C Müller, C Neumann, C Meisel, C Fuhljahn, C Kühn, D Langanke, D De Tullio, D Dieterle, D Rezek, D Bolla, D J Müller, D Mink, D Fischer, E Simon, E von Abel, E Ignatiadou, E Shaari, E Thiemann, E Faust, E Keil, E Buch Villa, E Esposito, E Klein, F Corsi, F Bacelar, F Ebner, F Guerini, F Beldermann, F Bilow, F Thele, F F Fromm, F Klaassen Federspiel, F Wärnberg, G Bonatz, G Feisel-Schwickardi, G Kaltenecker, G Stalzer, G Franceschini, G Tazzioli, G Armatura, G Xepapadakis, H Huschman Nia, H Strittmatter, H Karanlik, H Graf, H Ikonomidis Sackey, H Eichler, H Heidegger, I Bekes, I Bauerfeind, I Thalmann, I Buck, I Natasiopoulos, I Cebrecos Lerena, I Utz-Billing, I Himsl, J Palatty, J Kosse, J Schnabel, J Seldte, J Kruse, J Blohmer, J Leitsmann, J Wagner, J Rom, J Czihak, J Lecht, J Lermann, J I Sanchez-Mendez, J Lui Fougo, J Farthmann, J Schuster, J Lefarth, K Wimmer-Freys, K Chrobak-Kasprzyk, K Engelken, K Roth, K Hilmer, K Ramaker, K Pankert, K Unterrieder, K Ahsberg, K Freese, K Scheerer, L Bauer, L Johnsen, L Adwall, L Zetterlund, L Steinhilper, L Melnichuk, L Lahuerta Lorente, L Dogan, M Umit Ugurlu, M T Sanchez Barron, M Hofmann, M Hufnagel, M Sciamannini, M Santos, M Mangold, M Taffurelli, M Paul, M H Hansen, M Höing, M Keller, M D'Aiuto, M Busani, M Frank, M A Gülcelik, M Berghorn, M Burkhardt, M Eichbaum, M Schrauder, M Untch, M Weigel, N Kühn, N Ruyssers, N Krawczyk, N Deuerling, N Cabioglu, N Rocco, N Stahl, N Biglia, N Bangemann, N Argudo, O Behrens, O Tomé, O Agcaoglu, P Diem, P Dall, P Diebold, P Fehr, P Bolkenius, P Pluta, R Völker, R Ruderfors Malterling, R Buss-Steidle, R Felberbaum, R Berger, R Rodriguez, R Iosifidou, R Oom, S Lemster, S Riemer, S Schmatloch, S Rauen, S Wetzig, S Gunay, S Majid, S Ozkan Gurdal, S Perez, S Mattes, S Michieletto, S Cáradenas Ovalle, S Kommos, S Renner, S Liebers, S Hasmüller, S Seitz, S Perdigão Ribeiro, S Albrecht, S Barrot, S Bucher, S Kraudelt, S Peschel, S Grasshoff, T Lantzsch, T Hadar, T Abraham, T Durpektova Leuf, T Wanik, T Chiang Salazar, T Pursche, T Erber, T Hildebrandt, T Noesselt, T Papathemelis, T Nowikiewicz, U Denison, U Makowiec, U Scholz, U Fenske, U Felten, U Albert, V Venizelos, V Vural, V Bjelic-Radisic, V Hagan, V Soos, V Hanf, W Ruhwedel, W Heyl, W Seifert, Z Sidiropoulou, Z I Nowecki

Affiliations

¹ Department of Gynaecology and Obstetrics, University of Ulm, Ulm, Germany.
² Breast Centre, Die Filderklinik gGmbH, Filderstadt, Germany.
³ Department of Obstetrics and Gynaecology, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany.
⁴ Department of Gynaecology and Obstetrics, University Hospital Augsburg, Augsburg, Germany.
⁵ Department of Gynaecology and Obstetrics, University Hospital Aachen, Aachen, Germany.
⁶ Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany.
⁷ Breast and Endocrine Unit, General Surgery Department, The School of Medicine, Zonguldak BEUN, Zonguldak, Turkey.
⁸ Department of Gynaecology and Obstetrics, University Hospital Tübingen, Tübingen, Germany.
⁹ Department of Gynaecology and Gynaecological Oncology, Agaplesion Markus Hospital, Frankfurt, Germany.
¹⁰ Department of Gynaecology and Obstetrics, University Hospital Rostock, Rostock, Germany.
¹¹ Department for Gynaecology and Obstetrics, Practice Wihlfahrt, Kiel, Germany.
¹² Department of Gynaecology and Obstetrics, Müritz-Klinikum Waren, Waren, Germany.
¹³ Department of Gynaecology and Obstetrics, Hospital Esslingen, Esslingen, Germany.
¹⁴ Department of Gynaecology and Obstetrics, Medical University of Graz, Graz, Austria.
¹⁵ Department of Gynaecology and Obstetrics, Frauenklinik St Louise, Paderborn, Germany.
¹⁶ Frauenklinik St Josefs-Krankenhaus, Salzkotten, St Vincenz Kliniken, Paderborn, Germany.
¹⁷ Department of Gynaecology and Obstetrics, Marienhospital Bottrop, Bottrop, Germany.
¹⁸ Breast Surgical Unit, Clínica Universidad de Navarra, Madrid, Spain.
¹⁹ Department of Gynaecology and Obstetrics, Ente Ospedaliero Cantonale, Ospedale Regionale di Lugano, Lugano, Switzerland.
²⁰ Faculty of Biomedicine, University of Italian-Speaking Switzerland (USI), Lugano, Switzerland.
²¹ Department of Surgery, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece.
²² Department of Surgical Oncology, 'Prof. Dr. Ion Chiricuță' Institute of Oncology, Cluj-Napoca, Romania.
²³ Department of Oncological Surgery and Gynaecological Oncology, 'Iuliu Hațieganu' University of Medicine and Pharmacy, Cluj-Napoca, Romania.
²⁴ Breast Surgery Unit, Comprehensive Cancer Centre, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
²⁵ Surgery and Oncology Collegium Medicum, University of Zielona Góra, Zielona Góra, Poland.
²⁶ Department of General Surgery and Surgical Oncology, The Regional Hospital in Poznan-The Greater Poland Specialist Centre, Poznan, Poland.
²⁷ Breast Unit, Champalimaud Clinical Centre, Champalimaud Foundation, Lisboa, Portugal.
²⁸ Institute of Pathology, Medical University of Graz, Graz, Austria.
²⁹ Department of Oncology, Oslo University Hospital, Oslo, Norway.
³⁰ Department of Surgery, Oncology Hospital, Tirana, Albania.
³¹ Oncological Clinic, Azerbaijan Medical University, Baku, Azerbaijan.
³² Breast Clinic, Universitair Ziekenhuis Brussel, Brussel, Belgium.
³³ Breast Surgery, Oncosalud, Lima, Peru.
³⁴ EUBREAST e.V., Esslingen, Germany.
³⁵ Breast Surgical Oncology and Oncoplastic Surgery, MAX Hospital, Patparganj, New Delhi, India.
³⁶ Gynaecological Oncology Centre, Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University, General University Hospital, Prague, Czech Republic.
³⁷ Breast Unit, Guy's & St Thomas' NHS Foundation Trust, London, UK.
³⁸ Department of Surgical Oncology, Center for Breast Diseases, Institute of Oncology Ljubljana, Ljubljana, Slovenia.
³⁹ Department of General Surgery, Heart and Brain Hospital, Pleven, Bulgaria.
⁴⁰ Surgical Oncology Unit, Chaim Sheba Medical Centre, Ramat Gan, Israel.
⁴¹ Queen Sirikit Centre for Breast Cancer, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.
⁴² Department of General Surgery, Istanbul Haydarpasa Numune Training and Research Hospital, University of Health Sciences Turkey, İstanbul, Turkey.
⁴³ Department of Gynaecology and Obstetrics, Ev. Diakoniekrankenhaus, Freiburg, Germany.
⁴⁴ Breast Unit, S. Anna Hospital, Turin, Italy.
⁴⁵ Private Group Practice for Pathology, Lübeck, Germany.
⁴⁶ Institute of Pathology, University Hamburg-Eppendorf, Hamburg, Germany.
⁴⁷ Breast Surgery Unit, IRCCS Ospedale San Raffaele, Milan, Italy.
⁴⁸ Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy.
⁴⁹ Department of Surgery, Breast Centre, Capio St Göran's Hospital, Stockholm, Sweden.
⁵⁰ Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.

PMID: 40966675
DOI: 10.1093/bjs/znaf180

Abstract

Background: Completion axillary lymph node dissection (cALND) is often recommended for patients with isolated tumour cells (ITCs) or micrometastases in the sentinel lymph node (SLN) or target lymph node (TLN) to assess the definite nodal tumour burden after neoadjuvant chemotherapy (NACT). The aim of this study was to investigate the upgrade of N stage by cALND in patients with low-volume metastases in the SLN/TLN after NACT from the prospective, international, multicentre AXSANA cohort study.

Methods: NACT-treated patients that converted from a positive to a negative clinical lymph node status and underwent cALND based on low-volume SLN/TLN involvement were included. The association between the final N stage, the pathological tumour response in the breast, and the clinical impact of cALND on post-NACT treatment decisions was determined.

Results: Among 5329 patients recruited between June 2020 and March 2024, 2194 were scheduled for SLN biopsy (SLNB), targeted axillary dissection (TAD), or TLN biopsy (TLNB). Among 16 patients with ypN0i+(SLN/TLN), one patient was upgraded to ypN1a by cALND, while five of the 71 patients with ypN1mi(SLN/TLN) were upstaged to ypN2 and one of the 71 patients with ypN1mi(SLN/TLN) was upstaged to ypN3. None of these patients had a pCR in the breast and thus nodal upstaging had no impact on post-NACT treatment decisions.

Conclusion: Despite substantial additional nodal involvement in low-volume SLN/TLN disease, cALND does not provide clinically meaningful information for post-NACT systemic treatment modifications and should not be encouraged for diagnostic purposes alone.

© The Author(s) 2025. Published by Oxford University Press on behalf of BJS Foundation Ltd. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.

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Axillary dissection for low-volume nodal involvement after neoadjuvant therapy in breast cancer: multicentre AXSANA cohort study

Collaborators

Affiliations

Axillary dissection for low-volume nodal involvement after neoadjuvant therapy in breast cancer: multicentre AXSANA cohort study

Authors

Collaborators

Affiliations

Abstract

Publication types

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Medical

Miscellaneous