AGO Recommendations for the Surgical Therapy of Breast Cancer:
Update 2022
AGO-Empfehlungen zur operativenTherapie des Mammakarzinoms:
Update 2022
Authors
Maggie Banys-Paluchowski
1
, Marc Thill
2
, Thorsten Kühn
3
,NinaDitsch
4
,J?rgHeil
5
, Achim W?ckel
6
, Eva Fallenberg
7
,
Michael Friedrich
8
, Sherko Kümmel
9
, Volkmar Müller
10
, Wolfgang Janni
11
,Ute-SusannAlbert
6
,IngoBauerfeind
12
,
Jens-Uwe Blohmer
13
, Wilfried Budach
14
,PeterDall
15
, Peter Fasching
16
, Tanja Fehm
17
, Oleg Gluz
18
, Nadia Harbeck
19
,
Jens Huober
20
, Christian Jackisch
21
, Cornelia Kolberg-Liedtke
22
,HansH.Kreipe
23
,DavidKrug
24
, Sibylle Loibl
25,26
,
Diana Lüftner
27
, Michael Patrick Lux
28
, Nicolai Maass
29
, Christoph Mundhenke
30
,UlrikeNitz
18
,TjoungWonPark-Simon
31
,
Toralf Reimer
32
, Kerstin Rhiem
33
, Achim Rody
1
, Marcus Schmidt
34
, Andreas Schneeweiss
35
, Florian Schütz
36
,
H. Peter Sinn
37
, Christine Solbach
38
, Erich-Franz Solomayer
39
, Elmar Stickeler
40
, Christoph Thomssen
41
, Michael Untch
42
,
Isabell Witzel
10
, Bernd Gerber
32
Affiliations
?1 Klinik für Gyn?kologie und Geburtshilfe, Universit?ts-
klinikum Schleswig-Holstein, Campus Lübeck, Lübeck,
Germany
?2 Klinik für Gyn?kologie und Gyn?kologische Onkologie,
Agaplesion Markus Krankenhaus, Frankfurt am Main,
Germany
?3 Klinik für Frauenheilkunde und Geburtshilfe, Klinikum
Esslingen, Esslingen, Germany
?4 Klinik für Frauenheilkunde und Geburtshilfe, Universit?ts-
klinikum Augsburg, Augsburg, Germany
?5 Klinik für Frauenheilkunde und Geburtshilfe, Sektion
Senologie, Universit?ts-Klinikum Heidelberg, Heidelberg,
Germany
?6 Klinik für Frauenheilkunde und Geburtshilfe, Universit?ts-
klinikum Würzburg, Würzburg, Germany
?7 Institut für Radiologie, Klinikum Rechts der Isar,
Technische Universit?t München, München, Germany
?8 Klinik für Frauenheilkunde und Geburtshilfe,
Helios Klinikum Krefeld, Krefeld, Germany
?9 Klinik für Senologie, Evangelische Kliniken Essen Mitte,
Essen, Germany
10 Klinik und Poliklinik für Gyn?kologie, Universit?tsklinikum
Hamburg-Eppendorf, Hamburg, Germany
11 Klinik für Gyn?kologie und Geburtshilfe, Universit?ts-
klinikum Ulm, Ulm, Germany
12 Frauenklinik, Klinikum Landshut gemeinnützige GmbH,
Landshut, Germany
13 Klinik für Gyn?kologie mit Brustzentrum des Universit?ts-
klinikums der Charite, Berlin, Germany
14 Strahlentherapie, Radiologie Düsseldorf, Universit?ts-
klinikum Düsseldorf, Düsseldorf, Germany
15 Frauenklinik, St?dtisches Klinikum Lüneburg, Lüneburg,
Germany
16 Frauenklinik, Universit?tsklinikum Erlangen, Erlangen,
Germany
17 Klinik für Gyn?kologie und Geburtshilfe, Universit?ts-
klinikum Düsseldorf, Düsseldorf, Germany
18 Brustzentrum, Evang. Krankenhaus Bethesda, M?nchen-
gladbach, Germany
19 Brustzentrum, Klinik für Gyn?kologie und Geburtshilfe,
Klinikum der Ludwig-Maximilians-Universit?t, München,
Germany
20 Brustzentrum, Kantonspital St. Gallen, St. Gallen, Schweiz
21 Klinik für Gyn?kologie und Geburtshilfe, Sana Klinikum
Offenbach GmbH, Offenbach, Germany
22 Klinik für Frauenheilkunde und Geburtshilfe, Universit?ts-
klinikum Essen, Essen, Germany
23 Institut für Pathologie, Medizinische Hochschule
Hannover, Hannover, Germany
24 Klinik für Strahlentherapie, Universit?tsklinikum
Schleswig-Holstein, Campus Kiel, Kiel, Germany
25 German Breast Group c/o GBG Forschungs GmbH,
Neu-Isenburg, Neu-Isenburg, Germany
26 Zentrum für H?matologie und Onkologie Bethanien,
Frankfurt am Main, Goethe Universit?t Frankfurt am Main,
Frankfurt am Main, Germany
27 Medical University of Brandenburg Theodor-Fontane &
Immanuel Hospital M?rkische Schweiz, Buckow, Germany
28 Kooperatives Brustzentrum Paderborn, Klinik für Gyn?ko-
logie und Geburtshilfe, Frauenklinik St. Louise, Paderborn
und St. Josefs-Krankenhaus, Salzkotten, St. Vincenz-
Krankenhaus GmbH, Paderborn, Germany
GebFra Science|Recommendation
1031
Banys-Paluchowski M et al. AGO Recommendations for… Geburtsh Frauenheilk 2022; 82: 1031–1043|? 2022. The author(s).
Article published online: 2022-09-30
29 Klinik für Gyn?kologie und Geburtshilfe, Universit?ts-
klinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
30 Klinik für Gyn?kologie und Geburtshilfe, Klinikum
Bayreuth, Bayreuth, Germany
31 Klinik für Frauenheilkunde und Geburtshilfe, Medizinische
Hochschule Hannover, Hannover, Germany
32 Universit?tsfrauenklinik und Poliklinik am Klinikum
Südstadt, Rostock, Germany
33 Zentrum Famili?rer Brust- und Eierstockkrebs,
Universit?tsklinikum K?ln, K?ln, Germany
34 Klinik undPoliklinik für Geburtshilfe und Frauengesundheit
der Johannes-Gutenberg-Universit?t Mainz, Mainz,
Germany
35 Nationales Centrum für Tumorerkrankungen, Universit?ts-
klinikum und Deutsches Krebsforschungszentrum,
Heidelberg, Germany
36 Klinik für Gyn?kologie und Geburtshilfe, Diakonissen
Krankenhaus Speyer, Speyer, Germany
37 Sektion Gyn?kopathologie, Pathologisches Institut,
Universit?tsklinikum Heidelberg, Heidelberg, Germany
38 Klinik für Frauenheilkunde und Geburtshilfe, Universit?ts-
klinikum Frankfurt, Frankfurt am Main, Germany
39 Klinik für Frauenheilkunde, Geburtshilfe und Reproduk-
tionsmedizin, Universit?tsklinikum des Saarlandes,
Homburg/Saar, Germany
40 Klinik für Gyn?kologie und Geburtsmedizin, Universit?ts-
klinikum Aachen, Aachen, Germany
41 Universit?tsfrauenklinik, Martin-Luther-Universit?t
Halle-Wittenberg, Halle (Saale), Germany
42 Klinik für Gyn?kologie und Geburtshilfe, Helios Klinikum
Berlin-Buch, Berlin, Germany
Key words
breast cancer, breast surgery, surgical therapy, guidelines,
neoadjuvant chemotherapy
Schlüsselw?rter
Mammakarzinom, Brustchirurgie, chirurgische Therapie,
Leitlinien, neoadjuvante Chemotherapie
received 18.6.2022
accepted 18.7.2022
Bibliography
Geburtsh Frauenheilk 2022; 82: 1031–1043
DOI 10.1055/a-1904-6231
ISSN 0016?5751
? 2022. The Author(s).
This is an open access article published by Thieme under the terms of the Creative
Commons Attribution-NonDerivative-NonCommercial-License, permitting copying
and reproduction so long as the original work is given appropriate credit. Contents
may not be used for commercial purposes, or adapted, remixed, transformed or
built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
Georg Thieme Verlag KG, Rüdigerstra?e 14,
70469 Stuttgart, Germany
Correspondence
Priv.-Doz. Dr. med. Maggie Banys-Paluchowski
Klinik für Frauenheilkunde und Geburtshilfe,
Universit?tsklinikum Schleswig-Holstein Campus Lübeck
Ratzeburger Allee 160, 23538 Lübeck, Germany
Maggie.Banys-Paluchowski@uksh.de
Deutsche Version unter:
https://doi.org/10.1055/a-1904-6231
ABSTRACT
The recommendations of the AGO Breast Committee on the
surgical therapy of breast cancer were last updated in March
2022 (www.ago-online.de). Since surgical therapy is one of
several partial steps in the treatment of breast cancer, exten-
sive diagnostic and oncological expertise of a breast surgeon
and good interdisciplinary cooperation with diagnostic radiol-
ogists is of great importance. The most important changes
concern localization techniques, resection margins, axillary
management in the neoadjuvant setting and the evaluation
of the meshes in reconstructive surgery. Based on meta-anal-
yses of randomized studies, the level of recommendation of
an intraoperative breast ultrasound for the localization of
non-palpable lesions was elevated to “++”. Thus, the tech-
nique is considered to be equivalent to wire localization, pro-
vided that it is a lesion which can be well represented by so-
nography, the surgeon has extensive experience in breast ul-
trasoundandhasaccesstoasuitable ultrasounddeviceduring
the operation. In invasive breast cancer, the aim is to reach
negative resection margins (“no tumor on ink”), regardless
of whether an extensive intraductal component is present or
not. Oncoplastic operations can also replace a mastectomy in
selected cases duetothelarge number ofexisting techniques,
and are equivalent to segmental resection in terms of onco-
logical safety at comparable rates of complications. Sentinel
node excision is recommended for patients with cN0 status
receiving neoadjuvant chemotherapy after completion of
chemotherapy. Minimally invasive biopsy is recommended
for initially suspect lymph nodes. After neoadjuvant chemo-
therapy, patients with initially 1–3 suspicious lymph nodes
and a good response (ycN0) can receive the targeted axillary
dissection and the axillary dissection as equivalent options.
ZUSAMMENFASSUNG
Die Empfehlungen der AGO Kommission Mamma zur operati-
ven Therapie des Mammakarzinoms wurden zuletzt im M?rz
2022 aktualisiert (www.ago-online.de). Da die operative The-
rapie einen von mehreren Teilschritten bei der Behandlung
des Mammakarzinoms darstellt, ist eine umfangreiche diag-
nostische und onkologische Expertise eines Brustoperateurs
und gute interdisziplin?re Zusammenarbeit mit den diagnos-
tischen Radiologen von gro?er Bedeutung. Die wichtigsten
?nderungen betreffen die Lokalisationstechniken, die Resek-
tionsr?nder, das axill?re Management im neoadjuvanten Set-
ting und die Bewertung der Netze in der rekonstruktiven Chi-
rurgie. Aufgrund von Metanaanalysen randomisierter Studien
wurde der Empfehlungsgrad der intraoperativen Mamma-
1032
Banys-Paluchowski M et al. AGO Recommendations for… Geburtsh Frauenheilk 2022; 82: 1031–1043|? 2022. The author(s).
GebFra Science|Recommendation
Introduction
into account. Patients who are not receiving neoadjuvant chemo-
therapy should only be recommended to undergo a mastectomy
if the tumor size in relation to the breast size does not permit a
breast-conserving procedure, the negative resection margins are
not reached despite repeated secondary resection, or inflamma-
tory breast cancer is present.
+/? Thisinvestigationor therapeuticinterventionhasnotshown
benefitforpatientsandmaybeperformedonlyinindividual
cases. According to current knowledge,ageneralrecom-
mendation cannot be given.
? This investigation or therapeutic intervention can be
ofdisadvantageto patients and might not be performed.
?? This investigation or therapeutic intervention is ofclear
disadvantage for patients and should beavoidedor omitted
inanycase.
The Breast Committee of the Working Group for Gynecological
Oncology, e.V. (AGO Mamma) last updated the recommenda-
tions for the diagnosis and therapy of breast cancer in March
2022 (www.ago-online.de) [1]. The new study results and current
congress contributions weretaken into account. Two out of a total
of 26 chapters deal with surgical treatment:
? Breast Cancer Surgery – Oncological Aspects
? Oncoplastic and Reconstructive Surgery
This year, both chapters were consulted for the first time with the
AWOgyn (Working Group for Reconstructive Surgery in Oncology-
Gynecology). Prior to the vote, the current evidence was dis-
cussed thoroughly within the Committee. In 2022, the Commit-
tee focused on the following topics: Resection margins, localiza-
tion techniques and axillary surgical management in the neoadju-
vant setting. Since surgical therapy is one of several partial steps
in the treatment of breast cancer, extensive diagnostic and onco-
logical expertise of a breast surgeon and good interdisciplinary
cooperation with diagnostic radiologists is of great importance.
The following article presents the recommendations and current
evidence for surgical and plastic-reconstructive therapy of the
breast.
sonografie zur Lokalisation nicht palpabler Befunde auf ?++“
erh?ht. Somit wird die Technik als gleichwertig zur Drahtloka-
lisation angesehen, vorausgesetzt, es handelt sich um eine
sonografisch gut darstellbare L?sion, der Operateur verfügt
über umfangreiche Kenntnisse in der Mammasonografie und
hat Zugang zu einem geeigneten Ultraschallger?t w?hrend
der Operation. Beim invasiven Mammakarzinom wird das Er-
reichen von negativen Resektionsr?ndern (?no tumor on ink“)
angestrebt, unabh?ngig davon, ob eine extensive intraduktale
Komponente vorliegt oder nicht. Onkoplastische Operationen
k?nnen durch die Vielzahl der existierendenTechniken in aus-
gew?hlten F?llen auch eine Mastektomie ersetzen und sind im
Surgical Therapy of the Breast
Oncological safety of breast-conserving therapy
Breast-conserving therapy (BCT), defined as breast-conserving
surgery (BCS), followed by radiotherapy, became the standard
procedure in the 1990s, after several large randomized studies
wereable to show that overall survival (OS) and breast cancer-spe-
cific survival (BCSS) after BCT and a mastectomy are identical [2,
3]. Meanwhile, results from several prospective registers from dif-
ferent countries are available, suggesting a superiority of BCT [4–
8]. The latest study comes from Sweden. De Boniface et al. from
the Karolinska Institute evaluated clinical courses of 48986 wom-
en [7]. After a median follow-up time of 6.2 years, OS and BCSS
were significantly longer in women receiving BCT than after a
mastectomy with or without radiation therapy. Other possible
confounders, such as age and socio-economic status, were taken
Banys-Paluchowski M et al. AGO Recommendations for… Geburtsh Frauenheilk 2022; 82: 1031
Vergleich zu einer regul?ren Segmentresektion hinsichtlich
der onkologischen Sicherheit bei vergleichbaren Komplika-
tionsraten gleichwertig. Patientinnen mit cN0-Status, die eine
neoadjuvante Chemotherapie erhalten, wird eine Sentinel-
Node-Exzision nach Abschluss der Chemotherapie empfoh-
len. Bei initial suspekten Lymphknoten wird die minimalinva-
sive Sicherung empfohlen. Nach der neoadjuvanten Chemo-
therapie stehen Patientinnen mit initial 1–3suspekten
Lymphknoten und gutem Ansprechen (ycN0) die Targeted
axillary Dissection und die Axilladissektion als gleichwertige
Optionen zur Verfügung.
?Table 1 Recommendation levels of the AGO Breast Committee.
++ This investigation or therapeutic intervention is highly
beneficial for patients,can be recommended without
restriction,andshouldbeperformed.
+ This investigation or therapeutic intervention is of limited
benefit to patients and canbe performed.
Localization of non-palpable breast lesions
70–80% of all breast cancer patients nowadays undergo conserv-
ing surgery [9]. Many of these tumors are non-palpable and their
removal must be supported by imaging. Various techniques are
available for this (?Fig.1). In addition to the wire localization,
which has long been regarded as the gold standard, sonograph-
ically visible lesions can be localized with the aid of intraoperative
sonography (?Fig.2). This option has been awarded a double
plusrecommendation(++)in2022(fordefinitionsof theAGOrec-
ommendation levels, see ?Table 1). The recommendation is
based on meta-analyses of randomized studies, which confirmed
that R0 resection is achieved significantly more frequently with
the use of intraoperative breast ultrasound compared to wire lo-
calization [10,11]. In palpable breast cancer, the advantages of in-
traoperative sonography compared to palpation-guided surgery
have also been demonstrated: the R0 resection rate can be in-
1033
–1043|? 2022. The author(s).
?Fig.1 Current recommendations of the AGO Breast Committee on the localization techniques for non-palpable lesions.
?Fig.2 Practical use of intraoperativebreast ultrasound: a The sonographic linear probe is obtained in asterile manner. There should be sufficient
gel between the probe and the film. b The sterile cover is fixed to the probe. c,d Imaging of the lesion by the surgeon. During the operation,
the lesion is imaged intermittently in order to ensure a sufficient resection distance in all directions. e Immediately after removal of the tissue, the
specimen is examined by ultrasound.
1034
Banys-Paluchowski M et al. AGO Recommendations for… Geburtsh Frauenheilk 2022; 82: 1031–1043|? 2022. The author(s).
GebFra Science|Recommendation
sec?Fig.3 Current recommendations of the AGO Breast Committee on re
creased and the rate of secondary resection can be reduced [11,
12]. Interestingly, resection volumes could be reduced by the use
of intraoperative sonography in some studies [12–14]. Thus, the
technique allows the targeted removal of the tumor and at the
same time spares healthy tissue.
Important prerequisites for the use of intraoperative sonogra-
phy are:
? The lesion must be sonographically visualized by the same
examiner pre- and intraoperatively in its whole extension.
? The surgeon must have adequatetraining in breast ultrasound.
A preoperative sonographic examination by the surgeon is
necessary to assess whether the lesion is suitable for this tech-
nique.
? A high-quality ultrasound device must be available during the
operation.
This year, the modern probe-guided detection methods were
thoroughly discussed. In these techniques, a marker is placed in
the lesion preoperatively and located during the operation using
a special probe (e.g., magnetic, radio-frequency- or radar-based).
With the exception of radioactive techniques (radioactive seeds
and radionuclide labelling), which are widespread abroad but
have not been approved in Germany, these methods have so far
been mainly investigated in single-arm, industry-initiated studies.
For this reason, they are rated +/?. There is an urgent need for in-
dependent studies that will compare these procedures with wire
Banys-Paluchowski M et al. AGO Recommendations for… Geburtsh Frauenheilk 2022; 82: 1031
tion margins in invasive breast cancer.
localization and intraoperative sonography in a real-world setting.
One of the upcoming studies is the Intergroup Trial MELODY
(http://melody.eubreast.com). It must also be kept in mind that
magnetic markers in particular significantly limit the diagnostic
power of MRI in the assessment of the response to therapy due
to susceptibility artifacts. Regardless of the localization tech-
nique, specimen radiography or specimen sonography is manda-
tory (AGO ++).
Resection margins
In the case of invasive breast cancer, no secondary resection has
been recommended for several years when the “no tumor on
ink” situation is reached (i.e., no tumor cell touches the edge of
the specimen). In contrast, a resection margin of 2mm is aimed
for in the case of pure DCIS. One of the most frequently discussed
questions in the tumor boards concerns the optimal resection
margin in invasive breast cancer with a DCIS component
(?Fig.3).Inthis situation,the prognosisandtheadjuvant therapy
decision are determined by the invasive component. The goal
here is also to achieve a “no tumor on ink” situation, even in pa-
tients with an additional extensive intraductal component. Rou-
tine secondary excision should not be performed in case of a neg-
ative, but “close” resection margin. In selected cases, however, an
individualized decision is possible, taking into account the extent
of the invasive and intraductal components and the patient-re-
lated factors such as age.
1035
–1043|? 2022. The author(s).
order to achieve adequate safety margin. The desired free margin
tion in combination with expanders or the autologous reconstruc-
contrast, it was not possible to show a corresponding advantage
GebFra Science|Recommendation
is 2mm for pure DCIS without an invasive component. This ap-
plies to patients receiving adjuvant radiotherapy after the opera-
tion. For patients for whom no radiotherapy is planned, there are
no evidence-based recommendations for optimal resection mar-
gins.
Axillary staging (sentinel lymph node excision, SLNE) is gener-
ally not recommended in patients receiving breast-conserving
surgery. This also applies in the case of an increased risk for the
later detection of an invasive component (extent, grading). In this
case, a secondary SLNE is possible. SLNE is recommended in pa-
Surgical therapy of the breast after
neoadjuvant chemotherapy
In patients receiving neoadjuvant therapy, the tumor should be
marked prior to system therapy. A clip/coil is usually used for this
purpose, but the probe-guided localization methods are also
available. It is important to accurately document the extent and
localization of the lesion(s) at the time of diagnosis, as well as the
position of the marker, in order to enable correct surgical plan-
ning after neoadjuvant therapy. If the tumor responds to therapy,
the lesion is resected within so-called new borders.
Surgical Therapy of Ductal Carcinoma in Situ
The ductal carcinoma in situ (DCIS) corresponds to a heteroge-
neous group of neoplastic lesions in the breast, in which the tu-
mor cells spread within the milk ducts and do not infiltrate the
basement membrane. The DCIS, which occurs alone and without
any further invasive component, is generally detected via mam-
mography screening by suspicious areas of microcalcification,
and accounts for about 25% of all breast cancers. The most impor-
tant treatment objective is to avoid invasive recurrences. An oper-
ation is the most important treatment method. Adjuvant radio-
therapy can reduce non-invasive and invasive recurrence by about
50% in the case of a breast-conserving procedure. Adjuvant endo-
crinetherapycan be offeredasprevention, but does not affect the
local recurrence rate after a DCIS. For this reason, the operation
represents the basic therapy of the DCIS, while adjuvant radiation
or endocrine therapy should be indicated in consideration of risk
reduction and side effects.
In 5–25% of patients, up-staging to an invasive carcinoma is
observedafter breast-conservingsurgery of DCIS confirmed by bi-
opsy. Ipsilateral recurrence occurs after 10 years in about 25% of
women who do not receive adjuvant radiotherapy and in 10% with
radiation. Breast cancer-specific mortality is 3.3%. This means
that women with a DCIS have a 1.8- to 3-fold increased risk of
death compared to the normal population [15].
Preoperative diagnosis by means ofclinical examination, mam-
mography and sonography is necessary to assess the extent and
to exclude an accompanying invasive component. The standard
therapy of the (non-palpable) DCIS, which is dependent on tumor
size in relation to breast size, is primarily the excision after stereo-
tactic marking with intraoperative specimen radiography. If imag-
ing shows that the target lesion has not been completely re-
moved, an immediate re-excision is required. In rare cases and de-
pending on the extent, a mastectomy may also be necessary in
tients undergoing a mastectomy. The reason lies in the fact that
1036
Banys-Paluchowski M et al. AGO Reco
by prolonging intravenous antibiosis compared with antibiotics
for 24 hours (RR=0.80, 95% CI: 0.60–1.08, p=0.13). Therefore,
perioperative antibiotic prophylaxis is only recommended for a
tion with pedicled or free tissue transfer are rated as “+” by the
AGO. The reconstruction can be carried out both as an immediate
reconstruction, especially in the case of skin-sparing or nipple-
sparing mastectomy (SSM/NSM), and as a two-stage procedure
(LoE 3b/B/AGO ++). However, in the case of the latter, the loss of
the skin mantle needs to be taken into account. A delayed recon-
struction is also frequently carried out in the clinical routine, usu-
ally in the case of an autologous reconstruction. In this case, the
implant after an SSM/NSM is inserted only temporarily (as a
“placeholder”) in order to be replaced later by autologous tissue.
The advantage of this strategy is to perform the definitive recon-
struction after receiving the final histology and possibly com-
pleted radiotherapy (LoE 3b/B/AGO +).
Peri-/intraoperative antisepsis/antibiosis
Peri-/intraoperative treatment with local antiseptic and/or antibi-
otic therapy in breast reconstruction is associated with a statisti-
cally significant advantage compared with no such treatment. A
meta-analysis of 11 studies with 15966 mastectomies showed
that the rate of infection of the reconstructed breast could be sig-
nificantly reduced (RR=0.26, 95% CI: 0.12–0.60, p=0.001). In
in the case of a histologically detectable invasion, breast removal
destroys the lymphatic drainage paths, which means that later
SLNE is then no longer possible for technical reasons.
Oncoplastic Operations
An oncoplastic operation is defined as a plastic surgical technique
at the time of tumor removal to achieve safe resection borders
and to preservean aesthetic shape to the breast. Thefocus should
be on favorable scar placement, adequate soft tissue formation,
the choice of a suitable reconstruction method, and a possible
adaptation operation of the contralateral breast in order to
achieve a symmetrical result. A wide variety of techniques can be
considered, such as intramammary or dermoglandular rotation,
the round block or batwing technique, B-plasty or a mastopexy
or reduction mammoplasty adapted to the tumor position, to
name just a few. In order to be able to adequately document the
surgical costs to the payers as well, it is helpful to use one of the
available classifications, for example the classification according
to Hoffmann, which defines different degrees of complexity and
thus reproducibly describes the outlay of the operation [16].
An oncoplastic operation can also replace a mastectomy in se-
lected cases (LoE 2b/B/AGO +) duetothelarge number ofexisting
techniques, and is equivalent to a regular segmental resection in
terms of oncological safety at comparable rates of complications.
Breast Reconstruction
Various options are available for breast reconstruction. Both the
one-stage use of silicone implants or the two-stage reconstruc-
maximum of 24 hours (LoE 2a/B/+) [17,18].
mmendations for… Geburtsh Frauenheilk 2022; 82: 1031–1043|? 2022. The author(s).
? Pain in the arm or numbness/tingling: 31% ALND vs. 11% SLNE
Mesh/ADM-based implant reconstruction
While, until a few years ago, a subpectoral implant position was
still the usual choice in implant reconstruction, the epipectoral
implantation has become increasingly popular. Improved im-
plants, nets/mesh pockets, acellular dermal matrices (ADMs) or
tissue matrices as well as the possibility of a later modelling of
the reconstructed breast by means of lipofilling, today guarantee
cosmetically better and lastingly stable results (?Fig.4). A large
selection of meshes and ADMs is currently commercially available
and has been reviewed in studies [19,20], but a prospectively ran-
domized head-to-head comparison is missing. The question of
subpectoral vs. prepectoral positioning has also not yet been suf-
ficiently clarified [21]. Here, the ongoing prospective randomized
PREPEC study (NCT04293146) may provide additional informa-
tion. A German study currently being planned will also examine
whether mesh- or ADM-supported implant reconstruction and
implant reconstruction without additional material have the same
outcomes.
Due to the limited evidence, the AGO Breast Committee can-
not currently make any recommendation that favors the sub- vs.
the prepectoral implant position (LoE 3b/C/AGO +/?)oramesh-
vs. an ADM-based technique (?Fig.5). The surgeon should tailor
the respective decision individually to the patient.
Although prospectively randomized studies on the important
questions are missing, it iscurrently evident that the complication
rates in ADM-based vs. mesh-based implant reconstruction are
higher [22].
SSM/NSM and reconstruction
Irrespective of the above discussion on implant position and pos-
sible materials, it should, however, now be clear that SSM and
NSM are also oncologically safe (LoE 2b/B/AGO ++) and lead to
an increased quality of life for the patient (LoE 2b/B/AGO ++).
With regard to the different approaches, the AGO Breast Commit-
tee does not differentiate; however, inferolateral access via the in-
framammary fold has the lowest complication rate. However, care
should be taken during surgery to minimize the use of retractors
to avoid skin necrosis.
Prevention of capsular fibrosis
The development of capsular fibrosis depends on the type of op-
eration. In breast augmentation, it is about 2–8%, in reconstruc-
tion after an SSM/NSM, it is about 20%, and after additional radio-
therapy, it is about 40% [23].
Sufficient evidence for the reduction of capsular fibrosis is
available for the use of textured vs. smooth implants (LoE 1a/A/
AGO +) [24]. However, in particular in the case of textured im-
plants, the risk of a breast implant-associated large-cell anaplastic
lymphoma (BIA-ALCL) must be considered, which can occur with
an incidence of 1:3000 to 1:30000. The use of mesh (LoE 3a/C/
AGO +) or an ADM (LoE 2a/B/AGO +) vs. nil can also lead to a re-
duction in capsular fibrosis [25]. The use of an intraoperative local
antibiotic/antiseptic rinse can also cause a reduction in capsular
fibrosis (LoE 2a/B/AGO +) [26], but with limited evidence due to
poor study quality. The use of the leukotriene antagonists monte-
lukast and zafirlukast, which are known from asthma therapy,
should be approached with caution. Data are extremely limited
Banys-Paluchowski M et al. AGO Recommendations for… Geburtsh Frauenheilk 2022; 82: 1031
Ongoingprospectiverandomizedstudies(SOUND,NCT02167490;
INSEMA, NCT02466737; BOOG 2013-08; NCT02271828) inves-
tigate the need for SLNE in clinically nodal-negative breast cancers
and breast-conserving surgery, as SLNE is likely to havelittlethera-
and data on long-term toxicity are not available [27]. A recently
published systematic review could not show any advantage of
massaging the breast tissue, so that everything remains the same
here and a massage has no effect on the development of capsular
fibrosis (LoE 3a/C/AGO ?) [28].
Surgical Management of the Axilla
Nodal status has long been regarded as the most important prog-
nostic factor and decision-making aid for adjuvant systemic and
radiotherapy. With the growing understanding of tumor biology,
systemic therapy is now carried out according to the intrinsic sub-
types. On the other hand, earlier tumor stages with less frequent
axillary metastasis are discovered within the mammography
screening [29]. The sonography of the axillary lymph nodes has
also been improved technically and in terms of personnel to such
an extent that sentinel lymph nodes (SLN) are only rarely affected.
The question thus arises of a de-escalation of axillary surgery [30].
Surgical management of the axilla
in the adjuvant setting
The development of the SLNE at the beginning of the present mil-
lennium was a milestone in the therapy of invasive breast cancer
[31]. Randomized studies have shown that the false negative rate
(FNR) for SLNE is 5–8% and does not affect disease-free survival
and overall survival [32]. Currently, an estimated 50–60% of all
breast cancer patients at initial diagnosis are clinically nodal-neg-
ative (cN0), and patients from mammography screening even at
75% [29].
The lymph node status at the time of diagnosis is examined
clinically and sonographically. For patients with clinically and
sonographically unsuspicious axillary lymph nodes, the SLNE
alone is the standard (LoE 1b/A/AGO ++). The same applies to pa-
tients with breast cancer during pregnancy or breastfeeding.
However, only
99m
technetium colloid should be used here. In any
case,
99m
technetium colloid with LoE1a/GRA/AGO + has the high-
est recommendation level, while all other marking techniques are
rated AGO +/? or AGO ?. Particularly when using magnetic nano-
particles for sentinel marking, it must be taken into account that a
significant limitation of the informative power of MRI imaging can
also occur over several years after injection, if MRI is necessary in
follow-up care, e.g., in high-risk patients. In patients with tumors
>5cm, multifocal or multicenter breast cancer, DCIS with a
planned mastectomy, male breast cancer and after previous tu-
mor removal, SLNE should also be performed (AGO +).
Although SLNE is less radical than the classic axillary dissection
(ALND), it is still an invasive procedure, which can lead to post-
operative complications [33,34]:
? Lymphedema: 10–20% ALND vs. 5–7%SLNE
? Diminished quality of life: 35% ALND vs. 23% SLNE
peutic benefit in these patients. The optimal procedure in the case
1037
–1043|? 2022. The author(s).
?Fig.4 Oncoplastic breast surgery using two examples: a dermoglandular rotation on the right in the case of a large tumor to avoid a change
in height of the nipple-areola complex. b Tumor-adapted reduction mammoplasty on the left with matching surgery on the right in inverse T-in-
cision technique with cranial nipple pedicle.
1038
Banys-Paluchowski M et al. AGO Recommendations for… Geburtsh Frauenheilk 2022; 82: 1031–1043|? 2022. The author(s).
GebFra Science|Recommendation
ty of?Fig.5 Meshes and ADMs with implant reconstruction (endpoint quali
of a mastectomy is currently being researched in further prospec-
tivestudies(POSNOC,NCT02401685;SENOMAC,NCT02240472).
In the INSEMA study – a prospectively randomized study com-
paring SLNE vs. no SLNE in patients with early invasive breast can-
cer (≤5cm, cN0) and breast-conserving therapy – data on pa-
tient-reported outcomes in terms of quality of life were presented
for thefirst timein2021.TheabsenceofSLNEwasassociated with
clinically significant lower arm symptoms (pain in the arm or
shoulder, swelling of the arm or hand and arm mobility) com-
pared to patients with SLNE and even more compared to patients
with ALND [35].
Due to the available evidence, the ASCO recommended as
early as 2021 that any axillary intervention – including SLNE – be
omitted in patients over 70 years of age with favorable tumor bi-
ology (hormone receptor positive HER2-negative, T1 N0), who
would receive endocrine therapy alone [36]. The AGO Breast
Committee also permits refraining from axillary surgery in elderly
patients with cN0 status under certain conditions (>70 years, co-
morbidity, pT1, HR+, HER2-negative). In this case, SLNE is rated
+/?. The indication should be made individually here. Data on the
oncological outcome is expected for the SOUND study (2022) and
for the INSEMA study (end of 2024).
Banys-Paluchowski M et al. AGO Recommendations for… Geburtsh Frauenheilk 2022; 82: 1031
life/complications).
Surgical management of the axilla
in the neoadjuvant setting
Patients with an indication for neoadjuvant chemotherapy (NACT)
and initially clinically negative axillary lymph nodes (cN0) should
not undergo surgical intervention or a core needle biopsy (CNB)
before NACT. For post-NACT ycN0, only SLNE (AGO ++) is recom-
mended. Since the axillary lymph node status is of crucial impor-
tance for the further escalation or de-escalation of post-neoadju-
vant systemic therapy, ALND with different levels of recommen-
dation is advised when tumor cells are detected (?Fig.6) [37,38]:
? ypN0(i+) (sn): AGO +/?
? ypN1mi (sn): AGO +
? ypN1 (sn): AGO ++
A retrospective analysis of the US National Cancer Data Base
(NCDB) was ableto find a histopathological involvementof axillary
lymph nodes in only 1.6% of cases for initially cN0 patients
(N=5377) with HER2-positive or triple-negative (TNBC) breast
cancer and a pathological complete response in the breast (breast
pCR) [39]. If no pCR was found in the breast, the rate of affected
lymph nodes was 27% [39]. In a similar study with 290 cN0 pa-
tients and HER2+/TNBC, all patients with breast pCR (40.4%) had
tumor-free axillary lymph nodes (ypN0), while 6% of patients with
breast non-pCR showed positive lymph nodes (ypN+) [40]. The
authors of both studies no longer consider axillary intervention in
the subpopulation of the initial cN0 HER2+/TNBC and breast PCR
to be necessary. The prerequisite for this, however, is the determi-
1039
–1043|? 2022. The author(s).
rgic
GebFra Science|Recommendation
?Fig.6 Current recommendations of the AGO Breast Committee on su
nation of the breast pCR by means of an operation [41]. Whether
the safe determination of breast pCR will be possible in future
through minimally invasive methods using artificial intelligence
remainstobeseen[42].TheprospectiveEUBREAST-01study
(NCT04101851) examines the absence of any form of axillary in-
tervention in initial cN0 HER2-positive or TNBC and clinically com-
plete remission in the breast.
In patients who have a clinically and/or sonographically posi-
tive axillary lymph node status (cN+) prior to systemic therapy,
this should be confirmed using a minimally invasive core biopsy.
In this context, a marking of the biopsied lymph node is oftencar-
riedoutinGermany.However,thisisnotaninternationalstandard.
There is insufficient evidence for the comparison of individual
markers (clip/coil, coal, magnetic seed, radar reflection, radio fre-
quency markers, etc.), so that participation in the AXSANA study
(NCT04373655) is recommended by the AGO Breast Committee
[10,43]. ALND (AGO ++) is recommended for patients who con-
tinue to have clinically apparent lymph node involvement after
NACT (ycN+). The assessment of the axillary response to NACT by
imaging is of limited accuracy [44,45]. Current research focuses
onoptimal management in patientswhoachieve so-calledaxillary
conversion (cN+ → ycN0). In this group, different techniques are
usedworldwide:ALND, SLNE,andso-called“Targeted Axillary Dis-
section” (TAD). To perform TAD, at least one of the affected
lymph nodes must be marked before the start of NACT. This
lymph node is referred to as the target lymph node. TAD is de-
fined as the removal of the sentinel lymph node and the target
1040
Banys-Paluchowski M et al. AGO Reco
al axillary intervention in the neoadjuvant chemotherapy setting.
lymph node. In patients who initially had a limited nodal involve-
ment (1–3 suspicious lymph nodes before NACT), TAD and ALND
are recommended as equivalent techniques (AGO +). In the case
of higher-grade nodal involvement (4 or more suspicious lymph
nodes), TAD is scored +/?, because the false-negative rate in this
group may be higher (?Fig.7) [46]. Depending on the histopath-
ological findings of the lymph nodes removed during TAD, further
therapy of the axilla may be recommended (?Fig.6). SLNE alone
in the cN+ → ycN0 collective is only rated AGO +/– and is not a
standard in Germany. In contrast, SLNE alone is performed more
frequently abroad. According to observational studies, the local
recurrence rate is very low if three or more negative sentinel
lymph nodes have been removed after NACT and radiotherapy
has been performed [47]. Since “blind” axillary sampling is not in-
dicated in these patients, TAD offers an alternative. Caudle et al.
were able to demonstrate a significant reduction in the false neg-
ativeratefrom10.1%withSLNEaloneand4.2%for the removalof
the target lymph node (TLNE=Targeted Lymph Node Extirpation)
to 1.4% for TAD [48]. If histopathology detects micro- or macro-
metastases at TAD, the ALND should be performed. In the case of
residual isolated tumor cells (ypN0 [i+]), the therapeutic conse-
quences are still unclear and should be investigated further in
studies (e.g., AXSANA) (LoE2b/B/AGO +/?) [43]. Further studies
investigate the optimal radiotherapeutic management in this set-
ting (TAXIS, ALLIANCE A011202).
mmendations for… Geburtsh Frauenheilk 2022; 82: 1031–1043|? 2022. The author(s).
T?Fig.7 Current recommendations of the AGO Breast Committee on the
Summary
The surgical treatment of breast cancer has undergone a change
over thelast two decades. Thefocus of research is on the de-esca-
lation of surgical treatment. Thus, the frequency of radical surgi-
cal procedures, such as mastectomy and axillary dissection, de-
creases. More and more patients are recommended to undergo
(oncoplastic) breast-conserving operations and techniques such
as sentinel lymph node excision or targeted axillary dissection.
The most important innovations in the updated version of the
AGO recommendations include the upgrading of intraoperative
sonography to localize non-palpable lesions and the introduction
of the“notumor on ink” target in invasive breast cancer with DCIS
component, regardless of whether an extensive intraductal com-
ponent is present or not. The prerequisites for a targeted axillary
dissection were also defined more precisely. In particular, in pa-
tients with higher grade nodal involvement (≥4 suspicious lymph
nodes before starting neoadjuvant chemotherapy), the technique
should only be used after careful consideration.
Banys-Paluchowski M et al. AGO Recommendations for… Geburtsh Frauenheilk 2022; 82: 1031
argeted Axillary Dissection.
Conf
–1043
lict of Interest
Maggie Banys-Paluchowski received fees for lectures and consultancy
activities from Roche, Novartis, Pfizer, pfm, Eli Lilly, Onkowissen, Seagen,
AstraZeneca, Eisai, AstraZeneca, Amgen, Samsung, MSD, GSK, Daiichi
Sankyo, Gilead, Sirius Pintuition, Pierre Fabre and study support from
EndoMag, Mammotome, MeritMedical.
Marcus Schmidt reports that he received personal fees for lectures and
consulting activities from AstraZeneca, BioNTech, Daiichi Sankyo, Eisai,
Lilly, MSD, Novartis, Pantarhei Bioscience, Pfizer, Roche and SeaGen,
which are not related to this publication.
Jens Huober: Research support: Celgene, Novartis, Hexal, Lilly. Lecture
activity: Lilly, Novartis, Roche, Pfizer, AstraZeneca, MSD, Celgene; Eisai,
Abbvie, Seagen, Gilead. Consultancy: Lilly, Novartis, Roche, Pfizer, Hexal,
AstraZeneca, MSD, Celgene, Abbvie. Travel expenses: Roche, Pfizer,
Novartis, Celgene, Daiichi Sankyo.
Peter Dall: Lecture fees: Novartis, Pfizer, AstraZeneca, Roche, Lilly.
Ad Boards: Novartis, Seagen, Daiichi Sankyo, AstraZeneca, Roche,
Gilead.
David Krug: honoraria from Merck Sharp & Dohme and Pfizer as well
as research funding from Merck KGaA.
Other authors do not indicate any conflicts of interest.
1041
|? 2022. The author(s).
[18] Yamin F, Nouri A, McAuliffe P et al. Routine Postoperative Antibiotics
GebFra Science|Recommendation
References
[1] Ditsch N, Woeckel A, Untch M et al. AGO Recommendations for the
Diagnosis and Treatment of Patients with Early Breast Cancer (EBC):
Update 2022. Breast Care 2022. doi:10.1159/000524879
[2] Veronesi U, Cascinelli N, Mariani L et al. Twenty-year follow-up of a ran-
domized study comparing breast-conserving surgery with radical mas-
tectomy for early breast cancer. N Engl J Med 2002; 347: 1227–1232
[3] Fisher B, Jeong JH, Anderson S et al. Twenty-five-year follow-up of a ran-
domized trial comparing radical mastectomy, total mastectomy, and
total mastectomy followed by irradiation. N Engl J Med 2002; 347:
567–575
[4] Agarwal S, Pappas L, Neumayer L et al. Effect of breast conservation
therapy vs. mastectomy on disease-specific survival for early-stage
breast cancer. JAMA Surg 2014; 149: 267–274
[5] Hofvind S, Holen A, Aas T et al. Women treated with breast conserving
surgery do better than those with mastectomy independent of detec-
tion mode, prognostic and predictive tumor characteristics. Eur J Surg
Oncol 2015; 41: 1417–1422
[6] van Maaren MC, de Munck L, de Bock GH et al. 10 year survival after
breast-conserving surgery plus radiotherapy compared with mastec-
tomy in early breast cancer in the Netherlands: a population-based
study. Lancet Oncol 2016; 17: 1158–1170
[7] de Boniface J, Szulkin R, Johansson ALV. Survival After Breast Conser-
vation vs. Mastectomy Adjusted for Comorbidity and Socioeconomic
Status: A Swedish National 6-Year Follow-up of 48986 Women. JAMA
Surg 2021; 156: 628–637
[8] Christiansen P, Carstensen SL, Ejlertsen B et al. Breast conserving surgery
versus mastectomy: overall and relative survival-a population based
study by the Danish Breast Cancer Cooperative Group (DBCG). Acta
Oncol 2018; 57: 19–25
[9] [Anonym]. Jahresbericht der zertifizierten Brustkrebszentren: Auditjahr
2019/Kennzahlenjahr 2018. Herausgeber: Deutsche Krebsgesellschaft
(DKG), Berlin in Zusammenarbeit mit OnkoZert, Neu-Ulm. 2020. Ac-
cessed September 2, 2022 at: https://www.onkozert.de/2022/04/20/
jahresberichte-der-zertifizierungssysteme-2022/
[10] Athanasiou C, Mallidis E, Tuffaha H. Comparative effectiveness of differ-
ent localization techniques for non-palpable breast cancer. A systematic
review and network meta-analysis. Eur J Surg Oncol 2022; 48: 53–59
[11] Banys-Paluchowski M, Rubio IT, Karadeniz Cakmak G et al. Intraoperative
Ultrasound-Guided Excision of Non-Palpableand Palpable Breast Cancer:
Systematic Review and Meta-Analysis. Ultraschall Med 2022.
doi:10.1055/a-1821-8559
[12] Volders JH, Haloua MH, Krekel NM et al. Intraoperative ultrasound guid-
ance in breast-conserving surgery shows superiority in oncological out-
come, long-term cosmetic and patient-reported outcomes: Final out-
comes of a randomized controlled trial (COBALT). Eur J Surg Oncol
2017; 43: 649–657
[13] Hoffmann J, Marx M, Hengstmann A et al. Ultrasound-Assisted Tumor
Surgery in Breast Cancer – A Prospective, Randomized, Single-Center
Study (MAC001). Ultraschall Med 2019; 40: 326–332
[14] Krishna KL, Srinath BS, Santosh D et al. A comparative study of perioper-
ative techniques to attain negative margins and spare healthy breast
tissue in breast conserving surgery. Breast Dis 2020; 39: 127–135
[15] Narod SA, Iqbal J, Giannakeas V et al. Breast Cancer Mortality After a
Diagnosis of Ductal Carcinoma In Situ. JAMA Oncol 2015; 1: 888–896
[16] Hoffmann J, Wallwiener D. Classifying breast cancer surgery: a novel,
complexity-based system for oncological, oncoplastic and reconstruc-
tive procedures, and proof of principle by analysis of 1225 operations in
1166 patients. BMC Cancer 2009; 9: 108
[17] Hai Y, Chong W, Lazar MA. Extended Prophylactic Antibiotics for Mastec-
tomy with Immediate Breast Reconstruction: A Meta-analysis. Plast
Reconstr Surg Glob Open 2020; 8: e2613
1042
Banys-Paluchowski M et al. AGO Reco
After Tissue Expander Placement Postmastectomy Does Not Improve
Outcome. Ann Plast Surg 2021; 87: S28–S30
[19] Masià J; iBAG Working Group. The largest multicentre data collection on
prepectoral breast reconstruction: The iBAG study. J Surg Oncol 2020;
122: 848–860
[20] Thill M, Faridi A, Meire A et al. Patient reported outcome and cosmetic
evaluation following implant-based breast-reconstruction with a titan-
ized polypropylene mesh (TiLOOP(R) Bra): A prospective clinical study
in 269 patients. Eur J Surg Oncol 2020; 46: 1484–1490
[21] Saldanha IJ, Cao W, Broyles JM et al. Breast Reconstruction After Mastec-
tomy: A Systematic Review and Meta-Analysis [Internet]. Rockville (MD):
Agency for Healthcare Research and Quality (US); 2021: Report No.: 21-
EHC027
[22] Ganesh Kumar N, Berlin NL, Kim HM et al. Development of an evidence-
based approach to the use of acellular dermal matrix in immediate ex-
pander-implant-based breast reconstruction. J Plast Reconstr Aesthet
Surg 2021; 74: 30–40
[23] Cabalag MS, Rostek M, Miller GS et al. Alloplastic adjuncts in breast re-
construction. Gland Surg 2016; 5: 158–173
[24] Liu X, Zhou L, Pan Fet al. Comparison of the postoperative incidence rate
of capsular contracture among different breast implants: a cumulative
meta-analysis. PLoS One 2015; 10: e0116071
[25] Hallberg H, Rafnsdottir S, Selvaggi G et al. Benefits and risks with acellu-
lar dermal matrix (ADM) and mesh support in immediate breast recon-
struction: a systematic review and meta-analysis. J Plast Surg Hand Surg
2018; 52: 130–147
[26] Samargandi OA, Joukhadar N, Al Youha S et al. Antibiotic Irrigation of
Pocket for Implant-Based Breast Augmentation to Prevent Capsular Con-
tracture: A Systematic Review. Plast Surg (Oakv) 2018; 26: 110–119
[27] Wang Y, Tian J, Liu J. Suppressive Effect of Leukotriene Antagonists on
Capsular Contracture in Patients Who Underwent Breast Surgery with
Prosthesis: A Meta-Analysis. Plast Reconstr Surg 2020; 145: 901–911
[28] Sood A, Xue EY, Sangiovanni C et al. Breast Massage, Implant Displace-
ment, and Prevention of Capsular Contracture After Breast Augmenta-
tion With Implants: A Review of the Literature. Eplasty 2017; 17: e41
[29] Mammographie-Screening-Programm. Gesch?ftsbericht 2021. 2022.
Accessed September 2, 2022 at: https://newsroom.mammo-
programm.de/
[30] Friedrich M, KuhnT, Janni W et al. AGO Recommendations for the Surgi-
cal Therapy of the Axilla After Neoadjuvant Chemotherapy: 2021
Update. Geburtshilfe Frauenheilkd 2021; 81: 1112–1120
[31] Schwartz GF, Guiliano AE, Veronesi U. Proceeding of the consensus con-
ference of the role of sentinel lymph node biopsy in carcinoma or the
breast April 19–22, 2001, Philadelphia, PA, USA. Breast J 2002; 8: 124–
138
[32] Lyman GH, Temin S, Edge SB et al. Sentinel lymph node biopsy for pa-
tients with early-stage breast cancer: American Society of Clinical Oncol-
ogy clinical practice guideline update. J Clin Oncol 2014; 32: 1365–1383
[33] Elfgen C, Güth U, Gruber G et al. Breast-conserving surgery with intraop-
erative radiotherapy in recurrent breast cancer: the patient?sperspec-
tive. Breast Cancer 2020; 27: 1107–1113
[34] Rao R, Euhus D, Mayo HG et al. Axillary node interventions in breast can-
cer: a systematic review. JAMA 2013; 310: 1385–1394
[35] Gerber B, Stachs A, Veselinovic K et al. Patient reported outcomes
(PROS) for the intergroup sentinel mammastudie INSEMA: Persistent im-
pact of axillary surgery on arm and breast. San Antonio Breast Cancer
Symposium 2021, 07-10122021
[36] Brackstone M, Baldassarre FG, Perera FE et al. Management of the Axilla
in Early-Stage Breast Cancer: Ontario Health (Cancer Care Ontario) and
ASCO Guideline. J Clin Oncol 2021; 39: 3056–3082
mmendations for… Geburtsh Frauenheilk 2022; 82: 1031–1043|? 2022. The author(s).
[37] MooTA, Jochelson MS, Zabor EC et al. Is Clinical Exam of the Axilla Suffi-
cient to Select Node-Positive Patients Who Downstage After NAC for
SLNB? A Comparison of the Accuracy of Clinical Exam Versus MRI. Ann
Surg Oncol 2019; 26: 4238–4243
[38] Gerber B, Schneeweiss A, M?bus V et al. Pathological Response in the
Breast and Axillary Lymph Nodes after Neoadjuvant Systemic Treatment
in Patients with Initially Node-Positive Breast Cancer Correlates with
Disease Free Survival: An Exploratory Analysis of the GeparOcto Trial.
Cancers (Basel) 2022; 14: 521
[39] Barron AU, Hoskin TL, Day CN et al. Association of Low Nodal Positiv-
ity Rate Among Patients With ERBB2-Positive or Triple-Negative
Breast Cancer and Breast Pathologic Complete Response to Neoadju-
vant Chemotherapy. JAMA Surg 2018; 153: 1120–1126. doi:10.1001/
jamasurg.2018.2696
[40] Tadros AB, Yang WT, Krishnamurthy S et al. Identification of Patients
With Documented Pathologic Complete Response in the Breast After
Neoadjuvant Chemotherapy for Omission of Axillary Surgery. JAMA Surg
2017; 152: 665–670
[41] Heil J, Pfob A, Sinn HP et al. Diagnosing Pathologic Complete Response
in the Breast After Neoadjuvant Systemic Treatment of Breast Cancer Pa-
tients by Minimal Invasive Biopsy: Oral Presentation at the San Antonio
Breast Cancer Symposium on Friday, December 13, 2019, Program
Number GS5-03. Ann Surg 2022; 275: 576–581
[42] Pfob A, Sidey-Gibbons C, Rauch G et al. Intelligent Vacuum-Assisted
Biopsy to Identify Breast Cancer Patients With Pathologic Complete
Response (ypT0 and ypN0) After Neoadjuvant Systemic Treatment for
Omission of Breast and Axillary Surgery. J Clin Oncol 2022; 40: 1903–
1915. doi:10.1200/jco.21.02439
[43] Banys-Paluchowski M, Gasparri ML, de Boniface J et al.; The Axsana Study
Group. Surgical Management of the Axilla in Clinically Node-Positive
Breast Cancer Patients Converting to Clinical Node Negativity through
Neoadjuvant Chemotherapy: Current Status, Knowledge Gaps, and
Rationale for the EUBREAST?03 AXSANA Study. Cancers (Basel) 2021;
13: 1565
[44] Schwentner L, Helms G, Nekljudova V et al. Using ultrasound and palpa-
tion for predicting axillary lymph node status following neoadjuvant
chemotherapy – Results from the multi-center SENTINA trial. Breast
2017; 31: 202–207
[45] Banys-Paluchowski M, Gruber IV, Hartkopf A et al. Axillary ultrasound for
prediction of response to neoadjuvant therapy in the context of surgical
strategies to axillary dissection in primary breast cancer: a systematic re-
view of the current literature. Arch Gynecol Obstet 2020; 301: 341–353
[46] Kirkilesis G, Constantinidou A, Kontos M. False Negativity of Targeted
Axillary Dissection in Breast Cancer. Breast Care (Basel) 2021; 16: 532–
538
[47] Barrio AV, Montagna G, Mamtani A et al. Nodal Recurrence in Patients
With Node-Positive Breast Cancer Treated With Sentinel Node Biopsy
Alone After Neoadjuvant Chemotherapy-A Rare Event. JAMA Oncol
2021; 7: 1851–1855. doi:10.1001/jamaoncol.2021.4394
[48] Caudle AS, Yang WT, Krishnamurthy S et al. Improved Axillary Evaluation
Following Neoadjuvant Therapy for Patients With Node-Positive Breast
Cancer Using Selective Evaluation of Clipped Nodes: Implementation of
Targeted Axillary Dissection. J Clin Oncol 2016; 34: 1072–1078
Banys-Paluchowski M et al. AGO Recommendations for… Geburtsh Frauenheilk 2022; 82: 1031
1043
–1043|? 2022. The author(s).
|
|
