ArticleAnnals of surgical oncology2026
Risk of pN2/3 Understaging in Sentinel Node-Positive ER+/HER2- Breast Cancer: A Composite Clinicopathologic Score for Safe RxPONDER and MonarchE Application.
Article in Annals of surgical oncology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundAdjuvant treatment decisions in ER+/HER2- breast cancer depend on accurate distinction between pN1 and pN2/3 disease. As sentinel lymph node biopsy (SLNB) increasingly replaces axillary lymph node dissection (ALND), patients with apparent pN1 disease may be understaged. We evaluated preoperative imaging and developed a composite risk score to identify patients for whom completion ALND might be omitted.
methodsWe retrospectively analyzed 160 ER+/HER2- patients with 1-3 positive sentinel nodes who underwent completion ALND after upfront surgery. Four imaging modalities were assessed for pN2/3 (≥4 positive nodes). A five-item composite score (SLN ≥ 2, lymphovascular invasion, tumor ≥2 cm, Ki-67 ≥20%, multifocality; range 0-5) underwent bootstrap validation and decision curve analysis (DCA).
resultsAll four preoperative imaging modalities failed to predict pN2/3 under-staging (NPV 80-86%; all p ≥ 0.885). Overall, 17.5% harbored true pN2/3 on completion ALND. Low-risk patients (score ≤1; 32% of cohort) had a pN2/3 rate of only 3.9% (NPV 96.1%; sensitivity 92.9%) versus 23.9% in high-risk patients (p = 0.0015). DCA showed net benefit over a treat-all strategy across clinically relevant thresholds, corresponding to ~14 fewer unnecessary ALNDs per 100 patients.
conclusionsPreoperative imaging showed limited sensitivity for pN2/3 under-staging and should not alone guide omission of completion ALND. A five-item composite score identified a low-risk subgroup (NPV 96.1%) in whom completion ALND might be omitted without compromising monarchE or RxPONDER decisions; prospective external validation is required before routine adoption.
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