Editor's Note: At the 2024 China Anti-Cancer Association (CACA) Integrated Breast Cancer Conference, Dr. Yongsheng Wang from Shandong Cancer Hospital elaborated on new concepts in regional treatment for breast cancer. He emphasized that local regional treatment for breast cancer patients should comprehensively consider the risk of recurrence and metastasis, the efficacy and adverse effects of systemic treatment, and the efficacy and adverse effects of local regional management. Professor Wang also proposed a new definition for axillary lymph node negativity and discussed individualized adjuvant radiotherapy strategies for patients with positive sentinel lymph node biopsy and new strategies for managing the internal mammary region. Following the conference, Oncology Frontier invited Professor Wang for an in-depth discussion on regional lymph node treatment.01
Oncology Frontier: At the 2024 CACA Integrated Breast Cancer Conference, you presented a report on “New Concepts in Regional Treatment for Breast Cancer.” Could you elaborate on the core content of these new concepts and their clinical application value?
Dr. Yongsheng Wang: My report at the conference mainly covered the following aspects:
- New Concepts in Local Regional Control of Breast Cancer: The “new concepts” should consider three aspects: 1) the risk of recurrence and metastasis (tumor burden); 2) the efficacy and adverse effects of systemic treatment; 3) the efficacy and adverse effects of local regional management, including surgery and radiotherapy. If radiotherapy can replace axillary lymph node dissection while providing the same survival time and lower incidence of adverse effects such as upper limb edema, then radiotherapy should be chosen over traditional axillary lymph node dissection.
- New Definition of Clinically Negative Axillary Lymph Nodes: Two years ago, the China Anti-Cancer Association proposed a definition for axillary lymph node negativity in the “Standardized Operation Guidelines for Sentinel Lymph Node Biopsy in Breast Cancer,” which includes both clinical examination and imaging results being negative. For patients with clinically negative results but abnormal imaging, ultrasound-guided biopsy should be performed to exclude the possibility of metastasis. This definition emphasizes the importance of imaging in regional staging of breast cancer. If imaging is abnormal but clinical examination is negative and biopsy results are positive, the clinical staging should be at least stage II, and such patients can undergo sentinel lymph node biopsy.
- Currently, 40% of patients can be exempt from axillary lymph node dissection, but this should be based on neoadjuvant therapy. For instance, patients with triple-negative and HER2-positive stage II breast cancer should ideally receive neoadjuvant therapy. For HR+/HER2- breast cancer patients, neoadjuvant endocrine therapy should be considered, and short-term neoadjuvant endocrine therapy can provide valuable information for postoperative exemption from adjuvant chemotherapy. Thus, the value of imaging in regional lymph node assessment is more advanced in China compared to other countries.
- Individualized Adjuvant Radiotherapy for Patients with 1-2 Positive Sentinel Lymph Nodes: Traditional radiotherapy indications and target areas are based on tumor burden. The “new concepts” suggest that the selection of adjuvant radiotherapy indications should be guided by physical or biological information for precise adjuvant radiotherapy. Therefore, not all patients with 1-2 positive sentinel lymph nodes require radiotherapy.
- New Strategies for Individualized Internal Mammary Management: Techniques for internal mammary lymph node staging lag far behind those for axillary lymph nodes. We hope to develop individualized internal mammary radiotherapy guided by sentinel lymph node biopsy in the future, reducing the need for lymph node biopsy or axillary staging after neoadjuvant therapy.
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Oncology Frontier: What is the significance of regional lymph node management in the comprehensive treatment system for breast cancer? How will the treatment of regional lymph nodes develop in the future?
Dr. Yongsheng Wang: Currently, lymph node status is crucial for determining adjuvant treatment plans, including systemic and radiotherapy regimens. For axillary lymph node management, in the context of effective systemic treatment, we have reached a consensus that its impact on survival is minimal. In the future, we may use imaging radiomics to identify axillary lymph node metastasis. For early-stage breast cancer patients with no axillary lymph node metastasis confirmed by imaging radiomics, sentinel lymph node biopsy can be exempted during surgery. For patients with biopsy-confirmed axillary lymph node metastasis, if neoadjuvant therapy achieves a significant effect, we can further exempt surgical staging based on the evaluation of the primary breast cancer and axillary lymph nodes through imaging.
Dr. Yongsheng Wang
- Second-level Professor, Doctoral Supervisor, People’s Doctor
- Director of the Department of General Surgery and Breast Disease Center at Shandong Cancer Hospital
- Vice Chairman of the International Medical Exchange Branch of the China Anti-Cancer Association
- Standing Committee Member of the Breast Cancer Professional Committee of the China Anti-Cancer Association
- Standing Committee Member of the Breast Cancer Expert Committee of the Chinese Society of Clinical Oncology (CSCO)
- Deputy Leader of the Breast Cancer Group of the Oncology Branch of the Chinese Medical Doctor Association
- Member of the Breast Cancer Group of the Oncology Branch of the Chinese Medical Association
- Member of the National Health Commission Breast Cancer Diagnosis and Treatment Guidelines Expert Group
- Member of the GBCC International Advisory Expert Committee
