What is your treatment approach in patients with early breast cancer with axillary soft tissue involvement, with or without concurrent lymph node involvement?

We are fortunate that Mass General has recently published an excellent paper on this topic that helps give guidance (Naoum et al., PMID 37967296). As expected, axillary soft tissue involvement is a high-risk feature, and these patients are at high risk for metastatic disease. For example, if there is LN involvement, axillary soft tissue involvement, and extracapsular extension, the 10-year distant metastasis incidence would be 42%. If it's only LN and axillary soft tissue involvement, these patients still have a distant metastasis incidence of 23%.

From a medical oncology perspective, I would consider any patient with axillary soft tissue involvement as high risk. In my opinion, there is "bad biology" present. I think of these patients akin ...

Thank you for your kind comment Dr. @Dr. First Last … I would like to add few points in terms of local therapies that we found during this analysis:

1. The role of a separate nodal radiation field (RLNR) in the setting of ECE or AXT is not well defined, we found that RLNR improved tumor outcomes across different strata and the entire cohort as well. The dose has to be 50 Gy at least in the setting of those aggressive tumor features. RLNR dosage can be 45-50.4 Gy in conventional fractionation according to NCCN. So 50 Gy at least is recommended for those at higher risk.
2. For surgery de-escalation, we found on a multivariable level that there is no significant difference between SLNB and ALND as long as RLNR is accounted for …which reinforces po...