At the 2024 SIBCS conference, Dr. Li Ma from The Fourth Hospital of Hebei Medical University presented on the topic “Advances and Controversies in Breast Surgery and Pathology.” He addressed various hot topics, including: “Can axillary dissection be completely avoided in patients with 1–2 positive sentinel lymph nodes? Can axillary dissection be omitted after downstaging lymph nodes with neoadjuvant therapy? Does bilateral mastectomy lower the risk of contralateral cancer but not improve mortality rates? Is screening necessary for HER2-ultra-low expression? What factors influence the accurate diagnosis of HER2-negative and HER2-ultra-low expression?” Following the presentation, Oncology Frontier interviewed Dr. Ma to discuss these advancements and controversies and invited him to share his insights on potential updates in the breast surgery and pathology sections of the 2025 “Little Red Book.”Q1. Oncology Frontier: Breast cancer management has entered the era of chronic disease management. Could you share how you implement individualized and precision treatment concepts in surgical practice for breast cancer?
Dr. Li Ma: Individualized and precision treatment are two fundamental principles in breast surgery. Individualized treatment means tailoring the treatment plan according to the patient’s unique characteristics, while precision treatment involves utilizing gene testing to categorize patients based on their molecular subtypes and formulating corresponding treatment strategies. In clinical practice, we must consider both the patient’s individual traits and molecular subtypes to select the most suitable treatment approach. Additionally, in the context of chronic disease management, it is crucial to adopt a multidisciplinary approach to patient education, manage complications, and ensure regular follow-ups.
Q2. Oncology Frontier: In your presentation on “Advances and Controversies in Breast Surgery and Pathology,” could you briefly discuss the major advances in these fields in recent years and the controversies that still exist?
Dr. Li Ma: During this conference, I highlighted key advancements in breast surgery and pathology since the conclusion of the 2023 SIBCS meeting (in December 2023). Given the 10-minute time constraint, I couldn’t cover everything in depth, but I focused on five main topics (see figure), three of which pertain to breast surgery.
First Topic: There is growing evidence that patients with 1–2 sentinel lymph node metastases may no longer need axillary lymph node dissection. Previously, our focus was mainly on patients undergoing breast-conserving surgery. The SENOMAC study, published in NEJM in April, included a higher proportion of patients who underwent total mastectomy, suggesting that axillary lymph node dissection may be avoided not only in breast-conserving patients but also in those undergoing mastectomy.
Second Topic: The feasibility of omitting axillary dissection in patients who receive neoadjuvant therapy and have negative sentinel lymph node biopsies is also improving. A large clinical cohort study published in JAMA Oncology this year showed that traditional sentinel lymph node biopsy and targeted axillary lymph node dissection (TAD) have similar efficacy in detecting lymph nodes, suggesting that either method can be chosen.
Third Topic: A study published in JAMA this year, based on the SEER database, followed 661,270 patients diagnosed with unilateral breast cancer between 2000 and 2019 for 20 years. The main conclusion was that prophylactic contralateral mastectomy lowers the risk of contralateral breast cancer but has no significant impact on overall survival. This finding calls for a cautious approach when considering prophylactic contralateral mastectomy in clinical practice.
Following the release of the DB-06 study results, the concept of HER2-ultra-low expression has gained considerable attention in pathology. In this context, I addressed two topics related to HER2-ultra-low expression. Despite ongoing debates around this concept, I believe it’s necessary to screen and identify these cases. However, how to properly reflect these findings in pathology reports remains unresolved. Additionally, several factors—both subjective and objective—affect the accurate diagnosis of HER2-ultra-low expression, highlighting the need for clinicians to stay updated on diagnostic developments while focusing on the treatment outcomes of these patients.
Q3. Oncology Frontier: Based on the advancements and controversies you discussed, what changes do you foresee for the 2025 “Little Red Book” in the breast surgery and pathology sections?
Dr. Li Ma: Despite the many advancements in breast surgery and pathology, I believe we still need to carefully consider some content through repeated discussions and exchanges before integrating it into clinical practice. In my opinion, two of the five topics I discussed have a good chance of being included in the 2025 “Little Red Book” updates:
- For patients with 1–2 positive sentinel lymph nodes (even those undergoing mastectomy), axillary lymph node dissection may no longer be necessary. I anticipate that the updated “Little Red Book” will provide detailed guidance on axillary management for these patients.
- In the pathology section, updates on HER2-ultra-low expression detection details will likely be included based on recent advancements.
Dr. Li Ma
- Chief Physician, Professor, PhD, Postdoctoral Fellow at the Third Military Medical University
- PhD Supervisor
- Director of the Breast Center, Fourth Hospital of Hebei Medical University
- Member of the Breast Cancer Committee of the Chinese Anti-Cancer Association
- Member of the Breast Cancer Expert Committee of the Chinese Society of Clinical Oncology (CSCO)
- Standing Member of the Breast Disease Committee of the Chinese Medical Education Association
- Deputy Secretary-General of the Hebei Cancer Prevention and Treatment Alliance
- Chair-Elect of the Breast Cancer Committee of the Hebei Cancer Prevention and Treatment Alliance
- Chair-Elect of the Breast Cancer Expert Committee of the Hebei Clinical Oncology Society
- Standing Member of the Breast Cancer Committee of the Hebei Anti-Cancer Association
- Chair of the Youth Committee of the Breast Cancer Committee of the Hebei Anti-Cancer Association
