Sentinel node biopsy was omitted in 97% of eligible older women after SOUND and INSEMA

Design

Prospective single-institution cohort applying trial criteria

Population

437 postmenopausal women aged 50 to 70 with cT1–2N0, grade 1–2, HR+/HER2− cancer and normal axillary ultrasound

Primary outcome

Proportion in whom sentinel node biopsy was omitted

Effect

Omitted in 97%; 3.2% had later biopsy; no axillary recurrence at 7.7 months

A prospective single-institution series in Annals of Surgery, published on 12 October, applied the results of the SOUND, INSEMA and BOOG 13-08 trials to routine care. Women aged 50 to 70, postmenopausal, with clinical stage 1, grade 1 or 2, hormone receptor-positive, HER2-negative cancers and a normal axillary ultrasound, having breast-conserving surgery, did not have sentinel node biopsy. Tumours up to 2.5 cm were included once INSEMA reported.

Of 437 women, 34 (8%) had higher-risk features on final pathology — grade 3, larger tumour or HER2-positive — and after multidisciplinary review 14 (3.2%) went on to sentinel node biopsy, of whom 2 had nodal metastases. Ninety-five per cent received endocrine therapy and 96% radiotherapy. At a median follow-up of 7.7 months, there were no axillary recurrences.

The value is in feasibility: when patients are selected tightly, almost all can avoid axillary surgery, and the small group upgraded on final pathology can be handled by a defined review step. The follow-up is far too short to say anything about recurrence; that safety evidence comes from the trials themselves.

• Consider omitting sentinel node biopsy in postmenopausal women with small, grade 1–2, HR-positive, HER2-negative cancers and a normal axillary ultrasound having breast conservation.
• Make a good-quality axillary ultrasound a precondition, not an optional extra.
• Set a rule in advance for review if final pathology shows grade 3, a larger tumour or HER2 positivity.
• Confirm radiotherapy and endocrine therapy plans, which were near-universal in this cohort.
• Discuss with oncology colleagues; this depends on local multidisciplinary agreement.

Why it matters

It shows that trial-based de-escalation of the axilla works in routine practice, with only 3% needing a return to the axilla.

Don't overread it

With 7.7 months of follow-up, the absence of axillary recurrence says nothing yet about long-term safety.

The statistics, in plain English

This is a feasibility series without a comparison group. The 97% figure describes how often the approach could be applied, not how safe it is; recurrence and survival data come from the randomised trials.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.