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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

  • Radiotherapy
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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.

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Acknowledgements

We also thank all the members of the EP group for their remarkable contribution (supplementary material D).

Funding

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

Author information

Author notes

  1. Matteo Ghilli and Carlotta Becherini have equally contributed to this work.

Authors and Affiliations

  1. Breast Centre, Breast Surgery, University Hospital of Pisa, Via Roma 67, Pisa, Italy

    Matteo Ghilli & Manuela Roncella

  2. Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy

    Carlotta Becherini & Icro Meattini

  3. Department of Experimental and Clinical Biomedical Sciences “M. Serio”, University of Florence, Florence, Italy

    Icro Meattini

  4. Breast Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, A. Brambilla 3, 50134, Florence, Italy

    Catia Angiolini

  5. Oncology Department, Unit of Medical Oncology, Misericordia Hospital, Grosseto, Italy

    Carmelo Bengala

  6. Breast Oncological and Reconstructive Surgery, S.Luca Hospital- V. G. Lippi Francesconi, 55100, Lucca, Italy

    Aroldo Marconi

  7. Azienda Usl Toscana Centro, Ospedale San Giovanni Di Dio, Via Di Torregalli N 3, 50143, Florence, Italy

    Lorenzo Galli

  8. Radiologia Senologica, Azienda Usl Toscana Sud-Est, Ospedale Arezzo, Giovanni Valdarno, Italy

    Giovanni Angiolucci

  9. Division of Medical Oncology, Livorno Hospital, Department of Oncology, Azienda USL Toscana Nord Ovest, Viale Alfieri 36, Leghorn, Italy

    Luigi Coltelli

  10. Department of Radiation Oncology, Azienda Usl Toscana Sud-Est, Ospedale Arezzo E S., Giovanni Valdarno, Italy

    Simona Borghesi

  11. Department of Radiation Oncology, Livorno Hospital, Azienda USL Toscana Nord Ovest, Viale Alfieri 36, Leghorn, Italy

    Luciana Lastrucci

  12. Breast Centre, Nuclear Medicine, University Hospital of Pisa, Via Roma 67, Pisa, Italy

    Gianpiero Manca

  13. Department of Health Sciences, Division of Pathological Anatomy, University of Florence, Viale Pieraccini 6, Florence, Italy

    Simonetta Bianchi

  14. SOC Anatomia Patologica, Azienda Usl Toscana Centro, Ospedale San Giovanni Di Dio, Via Di Torregalli N° 3, 50143, Florence, Italy

    Morena Doria

  15. Breast Unit AOUS Siena, Siena, Italy

    Donato Casella

  16. European Society of Breast Cancer Specialists, Florence, Italy

    Lorenza Marotti

  17. Azienda Ospedaliero Universitaria Careggi, Florence, Italy

    Gianni Amunni

  18. University Hospital of Pisa, Via Roma 67, Pisa, Italy

    Manuela Roncella

Authors
  1. Matteo Ghilli
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  2. Carlotta Becherini
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  3. Icro Meattini
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  4. Catia Angiolini
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  5. Carmelo Bengala
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  6. Aroldo Marconi
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  7. Lorenzo Galli
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  8. Giovanni Angiolucci
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  9. Luigi Coltelli
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  18. Manuela Roncella
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Icro Meattini, Carlotta Becherini and Matteo Ghilli with the contribution of Catia Angiolini and Carmelo Bengala. The first draft of the manuscript was written by Matteo Ghilli, Carlotta Becherini and Icro Meattini, and all authors commented on the previous versions of the manuscript. All authors read and approved the final manuscript. Manuela Roncella and Gianni Amunni supervised the entire process of the work.

Corresponding author

Correspondence to Matteo Ghilli.

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Conflict of interest

Icro Meattini declares advisory boards supported by Eli Lilly, Novartis, Pfizer, Pierre Fabre, SeaGen, Daiichi Sankyo and AstraZeneca. CB declares honoraria supported by Eli Lilly, Novartis, Pfizer and Amgen. The other authors have no relevant financial or non-financial interest to disclose.

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Supplementary file 1 (DOCX 311 kb)

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Ghilli, M., Becherini, C., Meattini, I. et al. Management of the axilla in breast cancer patients: critical review, regional modified Delphi consensus and implementation in the Tuscan breast network. Radiol med (2024). https://doi.org/10.1007/s11547-024-01818-7

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