Would you recommend ALND or sentinel node re-mapping in a patient with recurrent breast cancer of the areola complex who had previous nipple-sparing mastectomy and SLNB and no previous radiation?

The extent of axillary surgery in general, and also in the setting of locally recurrent disease with a clinically-negative axilla, has lessened over time, largely to try to mitigate arm morbidity. In the past, if a patient had a prior SLNB at the time of the original diagnosis, it was not uncommon to ask for an ALND at the time of local recurrence (the thought being that the accuracy of repeat SLNB after prior mastectomy was not sufficient to warrant re-mapping). Given the overall philosophy of trying to limit the use of ALND (and/or substitute RT) as we have seen in recent trials for initial breast cancer diagnoses, we have moved away from insisting on a completion dissection in the setting of a chest wall recurrence after mastectomy. A th...

I typically have a discussion with patient and surgeon with factors including the features of the recurrence (receptor, grade, LVSI), patient factors, and technical factors as well as discussion of risk of lymphedema. Additionally, I like to have complete axillary imaging as well to guide the discussion and decision making.

In patients at low risk of axillary disease, negative imaging, I have treated without either ALND/SLN mapping and included regional nodes in my treatment fields.

Otherwise, patient usually gets ALND and then RT including regional nodes

Remapping can be attempted but likelihood of finding node is low in practical world (although some series could be close to 60 to 70 percent)

If imaging negative favor RT as part of regional node RT