Key debates in surgical management of breast cancer_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

ZHANG Xi ,  GENG Cuizhi

The Breast Center of the Fourth Hospital of Hebei Medical University, Shijiazhuang 050035, P. R. China;

Corresponding author：

GENG Cuizhi, Email: 46300349@hebmu.edu.cn

Keywords：

breast cancer; breast-conserving surgery margin prediction model; axillary surgery de-escalation; BRCA1/2 mutation; intraoperative radiotherapy

DOI：

10.7507/1007-9424.202508051

Video：

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Objective To synthesize recent advances in surgical management of breast cancer, focusing on five key issues: axillary surgery de-escalation, margin control in breast-conserving surgery (BCS), prophylactic surgery for BRCA1/2 gene mutation carriers, local therapy for oligometastasis, and intraoperative radiotherapy (IORT), aiming to guide individualized clinical decisions. Methods A comprehensive analysis of high-quality evidence (RCTs, prospective cohorts and multicenter studies) was conducted, comparing efficacy and safety across strategies. Results For patients with positive sentinel lymph nodes (SLN) undergoing BCS, axillary lymph node dissection (ALND) can be safely omitted if they present with clinical stage cT1–2, cN0 disease, have not received preoperative chemotherapy, exhibit 1–2 positive SLNs, and are planned for whole-breast radiotherapy. The Memorial Sloan Kettering Cancer Center nomogram quantitatively predicts non-SLN metastasis risk by integrating features like tumor size and SLN metastatic burden. Omission of ALND is particularly safe for SLN micrometastasis (≤2 mm), demonstrating a 5-year overall survival rate of approximately 97.5%. In patients achieving clinically node-negative (ycN0) status post-neoadjuvant therapy, techniques such as dual-tracer mapping or pre-treatment marking of suspicious nodes reduce the false negative rate of SLN biopsy. Treatment decisions for elderly patients require multidisciplinary assessment of surgical risks versus benefits. The integration of multiparametric MRI, artificial intelligence with intraoperative ultrasound significantly reduces positive margin rates in BCS from 25% to 8%–15%, markedly decreasing reoperation rates. For BRCA1/2 mutation carriers, prophylactic mastectomy reduces breast cancer risk by 90%–95%, while prophylactic bilateral salpingo-oophorectomy (PBSO) reduces ovarian cancer risk by 80%–90%; the timing of PBSO is stratified by genotype (BRCA1: 35–40 years; BRCA2: 40–45 years) and integrated with fertility plans and psychological assessment. Local therapy provides clear survival benefits for oligometastatic breast cancer patients with hormone receptor positive disease and bone/soft tissue metastases, with stereotactic body radiotherapy being preferred for low-burden metastases. IORT for early breast cancer is strictly limited to low-risk patients, achieving long-term survival rates equivalent to conventional radiotherapy but necessitating stringent patient selection. Conclusions Precision surgery is evolving through axillary de-escalation, real-time margin assessment, risk-adapted prophylactic surgery, selected local therapy for oligometastasis, and strict patient selection for IORT. Multidisciplinary integration is essential for future optimization.

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1. Mactier M, Mansell J, Arthur L, et al. Survival after standard or oncoplastic breast-conserving surgery versus mastectomy for breast cancer. BJS Open, 2025, 9(2): zraf002. doi: 10.1093/bjsopen/zraf002.
2. Knerr S, Guo B, Mittendorf KF, et al. Risk-reducing surgery in unaffected individuals receiving cancer genetic testing in an integrated health care system. Cancer, 2022, 128(16): 3090-3098.
3. Giuliano AE, Ballman KV, McCall L, et al. Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: the ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA, 2017, 318(10): 918-926.
4. 刘岩松, 张丽莎, 马菲, 等. 浅谈乳腺癌手术中腋窝淋巴结的处理. 中华外科杂志, 2024, 62(8): 731-736.
5. Huang Z, Wu Z, Zou QQ, et al. Risk factors of non-sentinel lymph node metastasis in breast cancer with 1-2 sentinel lymph node macrometastases underwent total mastectomy: a case-control study. World J Surg Oncol, 2023, 21(1): 125. doi: 10.1186/s12957-023-02888-z.
6. van la Parra RF, Ernst MF, Bevilacqua JL, et al. Validation of a nomogram to predict the risk of nonsentinel lymph node metastases in breast cancer patients with a positive sentinel node biopsy: validation of the MSKCC breast nomogram. Ann Surg Oncol, 2009, 16(5): 1128-1135.
7. Syed YY. Oncotype DX breast recurrence score^®: a review of its use in early-stage breast cancer. Mol Diagn Ther, 2020, 24(5): 621-632.
8. Nica A, Gien LT, Ferguson SE, et al. Does small volume metastatic lymph node disease affect long-term prognosis in early cervical cancer?. Int J Gynecol Cancer, 2020, 30(3): 285-290.
9. Galimberti V, Cole BF, Viale G, et al. Axillary dissection versus no axillary dissection in patients with breast cancer and sentinel-node micrometastases (IBCSG 23-01): 10-year follow-up of a randomised, controlled phase 3 trial. Lancet Oncol, 2018, 19(10): 1385-1393.
10. Andersson Y, Bergkvist L, Rydén L, et al. Omitting completion axillary lymph node dissection in breast cancer patients with sentinel lymph node micrometastases undergoing mastectomy: results from the prospective SENOMIC trial. Br J Surg, 2025, 112(6): znaf111. doi: 10.1093/bjs/znaf111.
11. Solá M, Alberro JA, Fraile M, et al. Complete axillary lymph node dissection versus clinical follow-up in breast cancer patients with sentinel node micrometastasis: final results from the multicenter clinical trial AATRM 048/13/2000. Ann Surg Oncol, 2013, 20(1): 120-127.
12. Houvenaeghel G, Cohen M, Raro P, et al. Overview of the pathological results and treatment characteristics in the first 1 000 patients randomized in the SERC trial: axillary dissection versus no axillary dissection in patients with involved sentinel node. BMC Cancer, 2018, 18(1): 1153. doi: 10.1186/s12885-018-5053-7.
13. Gentilini OD, Botteri E, Sangalli C, et al. Sentinel lymph node biopsy vs no axillary surgery in patients with small breast cancer and negative results on ultrasonography of axillary lymph nodes: the SOUND randomized clinical trial. JAMA Oncol, 2023, 9(11): 1557-1564.
14. Reimer T, Stachs A, Veselinovic K, et al. Axillary surgery in breast cancer - primary results of the INSEMA trial. N Engl J Med, 2025, 392(11): 1051-1064.
15. Zheng X, Yao Z, Huang Y, et al. Deep learning radiomics can predict axillary lymph node status in early-stage breast cancer. Nat Commun, 2020, 11(1): 1236. doi: 10.1038/s41467-020-15027-z.
16. Boughey JC, Suman VJ, Mittendorf EA, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA, 2013, 310(14): 1455-1461.
17. de Boniface J, Frisell J, Andersson Y, et al. Survival and axillary recurrence following sentinel node-positive breast cancer without completion axillary lymph node dissection: the randomized controlled SENOMAC trial. BMC Cancer, 2017, 17(1): 379. doi: 10.1186/s12885-017-3361-y.
18. Breslin TM, Cohen L, Sahin A, et al. Sentinel lymph node biopsy is accurate after neoadjuvant chemotherapy for breast cancer. J Clin Oncol, 2000, 18(20): 3480-3486.
19. Jung SY, Han JH, Park SJ, et al. The sentinel lymph node biopsy using indocyanine green fluorescence plus radioisotope method compared with the radioisotope-only method for breast cancer patients after neoadjuvant chemotherapy: a prospective, randomized, open-label, single-center phase 2 trial. Ann Surg Oncol, 2019, 26(8): 2409-2416.
20. Sun X, Wang XE, Zhang ZP, et al. Neoadjuvant therapy and sentinel lymph node biopsy in HER2-positive breast cancer patients: results from the PEONY trial. Breast Cancer Res Treat, 2020, 180(2): 423-428.
21. Zetterlund LH, Frisell J, Zouzos A, et al. Swedish prospective multicenter trial evaluating sentinel lymph node biopsy after neoadjuvant systemic therapy in clinically node-positive breast cancer. Breast Cancer Res Treat, 2017, 163(1): 103-110.
22. Rebollo-Aguirre AC, Gallego-Peinado M, Menjón-Beltrán S, et al. Sentinel lymph node biopsy in patients with operable breast cancer treated with neoadjuvant chemotherapy. Rev Esp Med Nucl Imagen Mol, 2012, 31(3): 117-123.
23. Classe JM, Loaec C, Gimbergues P, et al. Sentinel lymph node biopsy without axillary lymphadenectomy after neoadjuvant chemotherapy is accurate and safe for selected patients: the GANEA 2 study. Breast Cancer Res Treat, 2019, 173(2): 343-352.
24. Chen X, Lu Z, Wang C, et al. Targeted axillary dissection after neoadjuvant chemotherapy for highly selective patients with initial cN1 breast cancer: a single-center prospective trial. Chin Med J (Engl), 2024, 137(12): 1421-1430.
25. Zhang X, Zeng Y, Wang Z, et al. Associations of clinicopathological factors with local treatment and survival outcome in elderly patients with ductal carcinoma in situ. Front Surg, 2023, 10: 1074980. doi: 10.3389/fsurg.2023.1074980.
26. Wang Y, Wang R, Lu D, et al. Predictive factors for axillary pathological complete response to neoadjuvant therapy in elderly breast cancer patients. BMC Cancer, 2025, 25(1): 156. doi: 10.1186/s12885-025-13571-9.
27. Zhao X, Bai JW, Jiang S, et al. Multiparametric MRI and transfer learning for predicting positive margins in breast-conserving surgery: a multi-center study. Int J Surg, 2025, 111(4): 3123-3128.
28. Ma J, Chen K, Li S, et al. MRI-based radiomic models to predict surgical margin status and infer tumor immune microenvironment in breast cancer patients with breast-conserving surgery: a multicenter validation study. Eur Radiol, 2024, 34(3): 1774-1789.
29. Balbaloglu H, Tekin H, Yorgancioglu I, et al. A comparative study of learning curves among general surgery residents for intraoperative ultrasound-guided breast-conserving surgery. Sci Rep, 2024, 14(1): 18881. doi: 10.1038/s41598-024-70040-2.
30. Alves-Ribeiro L, Osório F, Amendoeira I, et al. Positive margins prediction in breast cancer conservative surgery: assessment of a preoperative web-based nomogram. Breast, 2016, 28: 167-173.
31. Zhao R, Xing J, Gao J. Development and validation of a prediction model for positive margins in breast-conserving surgery. Front Oncol, 2022, 12: 875665. doi: 10.3389/fonc.2022.875665.
32. Liu P, Zhao Y, Rong DD, et al. Diagnostic value of preoperative examination for evaluating margin status in breast cancer. World J Clin Cases, 2023, 11(20): 4852-4864.
33. Barth RJ Jr, Krishnaswamy V, Paulsen KD, et al. A patient-specific 3D-printed form accurately transfers supine MRI-derived tumor localization information to guide breast-conserving surgery. Ann Surg Oncol, 2017, 24(10): 2950-2956.
34. Barth RJ Jr, Krishnaswamy V, Rooney TB, et al. A pilot multi-institutional study to evaluate the accuracy of a supine MRI based guidance system, the Breast Cancer Locator^TM in patients with palpable breast cancer. Surg Oncol, 2022, 44: 101843. doi: 10.1016/j.suronc.2022.101843.
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