Abstract P1-01-08: Axillary surgery after neoadjuvant chemotherapy in breast cancer - Survey among Argentinian breast surgeons
Authors: Azar M. Eugenia , Mansilla F. M. Dolores , Cavallero Jorgelina , Sturla Ornella , Ursino Hernan , Berman Gaston , Ipiña Martin , Aguilar Andrea , Caceres Valeria , Gonzalez Eduardo 
Published: March 2022

Abstract
Background: Over the last years, decreasing invasiveness to achieve less morbidity has been the trend for surgical procedure but axillary management after neoadjuvant chemotherapy (NAC) remains controversial. Different authors have shown the efficacy of sentinel lymph node biopsy (SLNB) to assess axillary response in patients who underwent NAC encouraging the use of these techniques instead of axillary lymph node dissection (ALND) in breast cancer patients. Argentinian surgeons don’t have a consensus guideline on the management of the axilla in patients after NAC, therefore the treatment of the axilla widely varies. This survey has been developed to assess the management of the axilla after NAC among argentinian breast surgeons. Methods: Members of the Argentinian Society of Breast Surgeons were invited by e-mail to complete an anonymous online survey between April 1st and May 31th of 2021. The survey consisted in 17 single-answer multiple choice questions (each question having 4 options). The surgeons had the option to write their own custom response on a comment field. Results: Of the 731 members, 263 answered the survey. 71% treated less than 50 neoadjuvant breast cancer patients last year. Axillary ultrasound is considered a standard tool in the initial evaluation of the axilla by 81% of participants and 73% performed core needle biopsy in case of suspicious node before NAC. 78% marked suspicious nodes before NAC (the majority with charcoal). 24% supported that ALND could be omitted only in cN0 patients, 55% in cN0- cN1, 9% in cN0-cN1-cN2 and 15% in any initial stage with a favorable response to NAC. 75% of the respondents evaluated axillary response after NAC using axillary ultrasound prior surgery. 15% performed ALND when there were any suspicious node by ultrasound. Most of the surgeons (76%) considered that double method (blue dye and radioisotope) allows better identification rate. 77% considered that at least three nodes and resection of the marked node is mandatory to reduce the false negative rate of the sentinel lymph node biopsy (SLNB) after NAC. 63% considered that pathologic complete response in the axilla is necessary to omit ALND and 37% omitted the ALND in the presence of positive sentinel node after NAC. 131 of the interviewed work in a public hospital and private practice, 27 of them (20%) can’t manage the axilla in the same way in both places because the lack of technology (gamma detection probe technology for example) at public hospitals. Discussion: The management of the axilla after NAC is a challenge for breast surgeons and forces them to personalize treatments and stay informed regarding changes in the scientific evidence. Axillary ultrasound is a widely-used method by argentine surgeons, it allows them to identify suspicious lymph nodes, perform core needle biopsies, and mark them, but an excessive use can also lead to unnecessary ALND. There is not consensus about the importance of pre- and post-NAC stage in deciding to perform only SLNB or ALND. Twenty percent of the surgeons perform SNLB only in cN0 patients, and on the other hand, 37% will omit the ALND even in the presence of positive sentinel node after NAC, extrapolating results from trials that may not fit in these patients. The high fragmentation and decentralization in the provision of health care services that characterizes Argentina’s health system is an obstacle to manage the complexity of neoadjuvant breast cancer patients. Conclusions: There is no standard management of the axilla in patients that undergo NAC in Argentina. Breast surgeons should gathered together to develop clinical practice guidelines in this matter and design strategies to improve the management of the neoadjuvant breast cancer patients in Argentina.
Citation Format: M. Eugenia Azar, M. Dolores Mansilla F., Jorgelina Cavallero, Ornella Sturla, Hernan Ursino, Gaston Berman, Martin Ipiña, Andrea Aguilar, Valeria Caceres, Eduardo Gonzalez. Axillary surgery after neoadjuvant chemotherapy in breast cancer - Survey among Argentinian breast surgeons [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-01-08.