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Targeted axillary dissection: worldwide variations in clinical practice

  • Epidemiology
  • Published:
Breast Cancer Research and Treatment Aims and scope Submit manuscript

Abstract

Purpose

Targeted axillary dissection (TAD) for the axillary staging of clinically node-positive (cN +) breast cancer patients converting to clinically node negative post neoadjuvant chemotherapy (NAC), has gained popularity due to its minimal false negative rate and low arm morbidity. The aim of this study is to shed more light on the variation in the clinical practice globally in terms of indications and perceived limitations of TAD.

Methods

A panel of expert breast surgeons constructed a structured questionnaire comprising of 18 questions and asked surgeons worldwide for their opinions and routine practice on TAD. The questionnaire was electronically distributed and answers were collected between May 1st and August 1st 2022.

Results

Responses included 137 entries from 36 countries. Of them, 73.7% consider TAD for cN + patients planned to receive NAC. Among them, the greatest number of respondents (45%) perform the procedure for tumours up to T3, whereas 27% regardless of T-stage. The majority (42%) perform TAD on patients with 1–3 positive nodes and only 30% consider TAD when matted nodes are present. HER2 positive and Triple Negative subtypes are more likely to undergo TAD than Luminal A and B (86%, 79.1%, 39.5%, and 62.8%, respectively). Maximum acceptable lymph node burden is median 3 nodes for any subtype with a tendency to accept more positive nodes for Triple Negative.

Conclusion

This study demonstrates the differences in current practice regarding TAD as well as the fact that the biology of the tumour heavily affects the method of axillary staging.

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Data availability

The datasets generated during and/or analysed during the current study are not publicly available due to personally identifiable information included, but are available from the corresponding author on reasonable request.

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Acknowledgements

Collaborators of TAD Study Group: Argentina: Eduardo Gonzalez (Instituto de Oncología Ángel H. Roffo). Australia: Melanie Walker (Alfred Health), AJ Collins (ANU), MT Nano (Australia), Kim Heron (Barwon Health), Beth Penington (Bendigo hospital), Mike He (Calvary Health Care ACT), Norman Janu (Concord Hospital), Katrina Read (Dr Katrina Read), Jose Cid Fernandez (Fiona Stanley Hospital, Western Australia), Belinda Brown (Frankston Hospital), Aashit Shah (LH), Kylie Snook (Mater Sydney), Sarah Forsyth (Prince of Wales Hospital), Janne Bingham (Royal Adelaide Hospital), Jocelyn Lippey (St. Vincent’s Hospital, Melbourne), Joel Symonds (Strathfield Private Hospital), Alec Winder (Townsville hospital), Nita Bartlett (Townsville University Hospital and Mater private), Petar Vujovic (Wesley Breast & Endocrine Centre), Jenny Gough (Wesley Hospital), Sarah Birks (Alfred Health), Farid Meybodi (BCU), Saud Hamza (Fiona Stanley Hospital), Elisabeth Elder (Westmead Breast Cancer Institute). Austria: Heidi Stranzl (Medical University of Graz). Azerbaijan: Tahmina Kosayeva (Azerbaijan Medical University). Belgium: Glenn Vergauwen (Ghent University Hospital). Chile: Jaime Letzkus (San Borja Arriaran Clinical hospital). Colombia: Gilberto Benitez (Clínica Oncológica Aurora), Eduardo Cabrera (Hospital San Juan de Dios). Cyprus: Evros Kitiris (The Breast Center of Cyprus), Michalis Kailides (The Breast Center of Cyprus). Ecuador: Patricio Corral (Centro Integral de Patología Mamaria (CIPAM)). Egypt: Khaled Mohamed Abdelwahab Ali (Mansoura oncology center – Mansoura university). Finland: Laura Niinikoski (Helsinki University Hospital, Department of Breast Surgery). Germany: Kerstin Weinand (Evangelisches Diakoniekrankenhaus Freiburg), Stephan Hasmüller (Kreisklinik Ebersberg), Conny Kurz (Klinikum Esslingen), Hans-Christian Kolberg (Marienhospital Bottrop GmbH), Ingo Thalmann (Siloah St. Trudpert Klinikum Pforzheim), Maggie Banys-Paluchowski (UKSH Lübeck). Greece: Aikaterini Manika (Athinaiki Mediclinic), Vasileios Venizelos (Breast Unit Metropolitan Hospital), Georgios Metaxas (Elena Venizelou Hospital), Lazaros Papadopoulos (Iaso B Breast Unit ), Ioannis Natsiopoulos (Interbalkan Medical Center), Eleftheria Ignatiadou (Metaxa Memorial Hospital), Rodoniki Iosifidou (Theagenio Anticancer Hospital), Ioannis Askoksilakis (University Hospital Heraklion ), Nikolaos Michalopoulos (University of Athens), Grigorios Xepapadakis (Breast Clinic, REA Hospital, Piraeus). Hong Kong: Serena Yu Yan Wong (Queen Elizabeth Hospital). India: Karishma Kirti (DY Patil Hospital). Iran: Roghieh Nooripour (Alzahra University). Italy: Alessandra invento (AOUI VERONA chirurgia senologica), Lea Regolo (Asst-Melegnano-Martesana, Vizzolo Hospital), Corrado Chiappa (ASST-settelaghi – Ospedale di Circolo Fondazione Macchi di Varese), Maria-Grazia Lazzaretti (AUSL Modena), Andrea Sibilio (AUSL Romagna), Viviana-Enrica Galimberti (Istituto Europeo di Oncologia IEO), Denise Mattar (Istituto Europeo di Oncologia IEO), Silvia Michieletto (Istituto Oncologico Veneto), Rosa Di Micco (San Raffaele University and Research Hospital), Teresa Di Palma (Santa Maria Goretti Latina), Oreste D. Gentilini (San Raffaele University and Research Hospital), Nicola Rocco (University of Naples Federico II), Mauro Porpiglia (Breast Unit S. Anna Hospital – Torino). Kuwait: Mervat Alsaleh (Kuwait university), Ibtisam Albader (Mubarak H). Mexico: Sergio Aguilar-Villanueva (Instituto Nacional de Cancerologia). Netherlands: Emiel Rutges (Netherlands Cancer Institute). New Zealand: Eva Juhasz (North Shore Hospital, Auckland), Nicola Davis (Tauranga Hospital), Stan Govender (St Marks Breast Centre). Palestine: Khaled Sharaf (Augusta Victoria Hospital). Peru: Lia Pamela Rebaza Vasquez (Oncosalud). Philippines: Aldine Basa (The Medical city). Poland: Dawid Murawa (General Surgery and Surgical Oncology Clinic; University Hospita Zielona Gora). Portugal: David Pinto (Champalimaud Foundation). Romania: Bonci Eduard-Alexandru (“Prof. Dr. Ion Chiricuta” Institute of Oncology), Florin Bobirca (Dr I Cantacuzino Clinical Hospital), Elena Adelina Toma (Elias Emergency Hospital), Bogdan Diaconescu (Emergency Clinical Hospital Bucharest), Radu Mihail Mirica (Emergency Hospital Saint John, Bucharest), Adrian Udrea (Medisprof cancer center), Silvia Brotea-Mosoiu (Oncology institute of aidrest), Gabriel Dimofte (Regional Institute of Oncology Iasi), Lunca Sorinel (Regional Institute of Oncology Iasi), Octav Ginghina (Emergency Hospital Saint John, Bucharest), Gata Vlad Alexandru (The Institute of Oncology Cluj), Mihai-Stefan Muresan (Iuliu Hatieganu University of Medicine and Pharmacy, Medicover Hospital), Ana-Maria Musina (Regional Institute of Oncology). Saudi Arabia: Lolwah Alriyees (KAMC). Singapore: Chi Wei Mok (Changi General Hospital). Slovenia: Andraz Perhavec (Institute of Oncology Ljubljana). Spain: Laura Comin (Hospital general de Teruel Obispo Polanco), José Ignacio Sánchez-Méndez (HospitalUniversitario La Paz), Gloria Ortega-Perez (MD Anderson Cancer Center. Madrid). Sweden: Jana De Boniface (Capio St Goran’s Hospital), Ira Oikonomou (Karolinska), Andreas Karakatsanis (Uppsala University Hospital). Switzerland: Christoph Tausch (Breast Center Zurich), Walter Weber (University Hospital Basel), Maria-Luisa Gasparri (Ente Ospedaliero Cantonale, Lugano). Turkey: Ahmet Necati Sanli (Abdulkadir Yuksel State Hospital), Seymur Abdullayev (Bakırköy Dr. aid Konuk REC), Melek Gokova (Izmir Ataturk Researge and Training Hospital), Abut Kebudi (Okan University Medical Faculty), Gultekin Ozan Kucuk (Samsun Training and Research Hospital), Baha Zengel (University of Health Sciences, Izmir Bozyaka Research and Training Hospital), Tolga Kalayci (Erzurum City Hospital), Lutfi Dogan (Oncology hospital), Betul Bozkurt (Private office), Semra Gunay (Prof. Dr. Cemil Taşcıoğlu Şehir Hastanesi Istanbul). United Kingdom: Elina Shaari (Guy’s Hospital, London), Ashutosh Kothari (Guys & St Thomas NHS Trust), Manas Dube (Kings Mill Hospital), Chloe Constantinou (Kingston), Teresa Fernandez Cuadrafo (NHS LOTHIAN, Edinburgh Breast Unit), Jane Macaskill (NHS Tayside), Hazem Khout (Nottingham breast institute), Anupama Nagarajakumar (PRUH, KCH), Rob Milligan (Queen Elizabeth Hospital, Gateshead), Laura Arthur (Royal Alexandra Hospital, Paisley), Ricardo Pardo (Royal Bolton Hospital NHS Foundation Trust), Peter Barry (Royal Marsden hospital), Emanuele Garreffa (University Hospitals of Derby and Burton). USA: Jill Dietz (Allegheny Health Network), Shawna Willey (INOVA Schar Cancer Institute), Judy Boughey (Mayo clinic), Susan Boolbol (Nuvance Health), Anne Peled (Sutter Health CPMC)

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Author information

Author notes

  1. Michalis Kontos and Prodromos Kanavidis contributed equally to this work.

Authors and Affiliations

  1. National and Kapodistrian University of Athens, Athens, Greece

    Michalis Kontos & Prodromos Kanavidis

  2. University of Ulm, Ulm, Germany

    Thorsten Kühn

  3. Broomfield Hospital, Mid and South Essex NHS Trust, Chelmsford, UK, Broomfield, UK

    Yazan Masannat

  4. University of Aberdeen, School of Medicine, Medical Science and Nutrition, Aberdeen, UK

    Yazan Masannat

  5. Marmara University School of Medicine, Istanbul, Turkey

    Bahadir Gulluoglu

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  1. Michalis Kontos
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  2. Prodromos Kanavidis
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  3. Thorsten Kühn
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  4. Yazan Masannat
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  5. Bahadir Gulluoglu
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Consortia

TAD Study Group

  • Eduardo Gonzalez
  • , Melanie Walker
  • , A. J. Collins
  • , M. T. Nano
  • , Kim Heron
  • , Beth Penington
  • , Mike He
  • , Norman Janu
  • , Katrina Read
  • , Jose Cid Fernandez
  • , Belinda Brown
  • , Aashit Shah
  • , Kylie Snook
  • , Sarah Forsyth
  • , Janne Bingham
  • , Jocelyn Lippey
  • , Joel Symonds
  • , Alec Winder
  • , Nita Bartlett
  • , Petar Vujovic
  • , Jenny Gough
  • , Sarah Birks
  • , Farid Meybodi
  • , Saud Hamza
  • , Elisabeth Elder
  • , Heidi Stranzl
  • , Tahmina Kosayeva
  • , Glenn Vergauwen
  • , Jaime Letzkus
  • , Gilberto Benitez
  • , Eduardo Cabrera
  • , Evros Kitiris
  • , Michalis Kailides
  • , Patricio Corral
  • , Khaled Mohamed Abdelwahab Ali
  • , Laura Niinikoski
  • , Kerstin Weinand
  • , Stephan Hasmüller
  • , Conny Kurz
  • , Hans-Christian Kolberg
  • , Ingo Thalmann
  • , Maggie Banys-Paluchowski
  • , Aikaterini Manika
  • , Vasileios Venizelos
  • , Georgios Metaxas
  • , Lazaros Papadopoulos
  • , Ioannis Natsiopoulos
  • , Eleftheria Ignatiadou
  • , Rodoniki Iosifidou
  • , Ioannis Askoksilakis
  • , Nikolaos Michalopoulos
  • , Grigorios Xepapadakis
  • , Serena Yu Yan Wong
  • , Karishma Kirti
  • , Roghieh Nooripour
  • , Alessandra Invento
  • , Lea Regolo
  • , Corrado Chiappa
  • , Maria-Grazia Lazzaretti
  • , Andrea Sibilio
  • , Viviana-Enrica Galimberti
  • , Denise Mattar
  • , Silvia Michieletto
  • , Rosa Di Micco
  • , Teresa Di Palma
  • , Oreste D. Gentilini
  • , Nicola Rocco
  • , Mauro Porpiglia
  • , Mervat Alsaleh
  • , Ibtisam Albader
  • , Sergio Aguilar-Villanueva
  • , Emiel Rutges
  • , Eva Juhasz
  • , Nicola Davis
  • , Stan Govender
  • , Khaled Sharaf
  • , Lia Pamela Rebaza Vasquez
  • , Aldine Basa
  • , Dawid Murawa
  • , David Pinto
  • , Bonci Eduard-Alexandru
  • , Florin Bobirca
  • , Elena Adelina Toma
  • , Bogdan Diaconescu
  • , Radu Mihail Mirica
  • , Adrian Udrea
  • , Silvia Brotea-Mosoiu
  • , Gabriel Dimofte
  • , Lunca Sorinel
  • , Octav Ginghina
  • , Gata Vlad Alexandru
  • , Mihai-Stefan Muresan
  • , Ana-Maria Musina
  • , Lolwah Alriyees
  • , Chi Wei Mok
  • , Andraz Perhavec
  • , Laura Comin
  • , José Ignacio Sánchez-Méndez
  • , Gloria Ortega-Perez
  • , Jana De Boniface
  • , Ira Oikonomou
  • , Andreas Karakatsanis
  • , Christoph Tausch
  • , Walter Weber
  • , Maria-Luisa Gasparri
  • , Ahmet Necati Sanli
  • , Seymur Abdullayev
  • , Melek Gokova
  • , Abut Kebudi
  • , Gultekin Ozan Kucuk
  • , Baha Zengel
  • , Tolga Kalayci
  • , Lutfi Dogan
  • , Betul Bozkurt
  • , Semra Gunay
  • , Elina Shaari
  • , Ashutosh Kothari
  • , Manas Dube
  • , Chloe Constantinou
  • , Teresa Fernandez Cuadrafo
  • , Jane Macaskill
  • , Hazem Khout
  • , Anupama Nagarajakumar
  • , Rob Milligan
  • , Laura Arthur
  • , Ricardo Pardo
  • , Peter Barry
  • , Emanuele Garreffa
  • , Jill Dietz
  • , Shawna Willey
  • , Judy Boughey
  • , Susan Boolbol
  •  & Anne Peled

Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by PK and MK. The first draft of the manuscript was written by MK and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Prodromos Kanavidis.

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Kontos, M., Kanavidis, P., Kühn, T. et al. Targeted axillary dissection: worldwide variations in clinical practice. Breast Cancer Res Treat 204, 389–396 (2024). https://doi.org/10.1007/s10549-023-07204-7

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