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Gentilini OD, Botteri E, Sangalli C, Galimberti V, Porpiglia M, Agresti R, Luini A, Viale G, Cassano E, Peradze N, Toesca A, Massari G, Sacchini V, Munzone E, Leonardi MC, Cattadori F, Di Micco R, Esposito E, Sgarella A, Cattaneo S, Busani M, Dessena M, Bianchi A, Cretella E, Ripoll Orts F, Mueller M, Tinterri C, Chahuan Manzur BJ, Benedetto C, Veronesi P. Sentinel Lymph Node Biopsy vs No Axillary Surgery in Patients With Small Breast Cancer and Negative Results on Ultrasonography of Axillary Lymph Nodes: The SOUND Randomized Clinical Trial. JAMA Oncol 2023; 9:1557-1564. [PMID: 37733364 PMCID: PMC10514873 DOI: 10.1001/jamaoncol.2023.3759] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/29/2023] [Indexed: 09/22/2023]
Abstract
Importance Sentinel lymph node biopsy (SLNB) is the standard of care for axillary node staging of patients with early breast cancer (BC), but its necessity can be questioned since surgery for examination of axillary nodes is not performed with curative intent. Objective To determine whether the omission of axillary surgery is noninferior to SLNB in patients with small BC and a negative result on preoperative axillary lymph node ultrasonography. Design, Setting, and Participants The SOUND (Sentinel Node vs Observation After Axillary Ultra-Sound) trial was a prospective noninferiority phase 3 randomized clinical trial conducted in Italy, Switzerland, Spain, and Chile. A total of 1463 women of any age with BC up to 2 cm and a negative preoperative axillary ultrasonography result were enrolled and randomized between February 6, 2012, and June 30, 2017. Of those, 1405 were included in the intention-to-treat analysis. Data were analyzed from October 10, 2022, to January 13, 2023. Intervention Eligible patients were randomized on a 1:1 ratio to receive SLNB (SLNB group) or no axillary surgery (no axillary surgery group). Main Outcomes and Measures The primary end point of the study was distant disease-free survival (DDFS) at 5 years, analyzed as intention to treat. Secondary end points were the cumulative incidence of distant recurrences, the cumulative incidence of axillary recurrences, DFS, overall survival (OS), and the adjuvant treatment recommendations. Results Among 1405 women (median [IQR] age, 60 [52-68] years) included in the intention-to-treat analysis, 708 were randomized to the SLNB group, and 697 were randomized to the no axillary surgery group. Overall, the median (IQR) tumor size was 1.1 (0.8-1.5) cm, and 1234 patients (87.8%) had estrogen receptor-positive ERBB2 (formerly HER2 or HER2/neu), nonoverexpressing BC. In the SLNB group, 97 patients (13.7%) had positive axillary nodes. The median (IQR) follow-up for disease assessment was 5.7 (5.0-6.8) years in the SLNB group and 5.7 (5.0-6.6) years in the no axillary surgery group. Five-year distant DDFS was 97.7% in the SLNB group and 98.0% in the no axillary surgery group (log-rank P = .67; hazard ratio, 0.84; 90% CI, 0.45-1.54; noninferiority P = .02). A total of 12 (1.7%) locoregional relapses, 13 (1.8%) distant metastases, and 21 (3.0%) deaths were observed in the SLNB group, and 11 (1.6%) locoregional relapses, 14 (2.0%) distant metastases, and 18 (2.6%) deaths were observed in the no axillary surgery group. Conclusions and Relevance In this randomized clinical trial, omission of axillary surgery was noninferior to SLNB in patients with small BC and a negative result on ultrasonography of the axillary lymph nodes. These results suggest that patients with these features can be safely spared any axillary surgery whenever the lack of pathological information does not affect the postoperative treatment plan. Trial Registration ClinicalTrials.gov Identifier: NCT02167490.
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Affiliation(s)
- Oreste Davide Gentilini
- Division of Breast Surgery, European Institute of Oncology Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Breast Surgery Unit, San Raffaele Scientific and Research Hospital, Milan, Italy
| | - Edoardo Botteri
- Division of Epidemiology and Biostatistics, European Institute of Oncology IRCCS, Milan, Italy
- Department of Research, Cancer Registry of Norway, Oslo, Norway
| | - Claudia Sangalli
- Clinical Trial Office, European Institute of Oncology IRCCS, Milan, Italy
| | - Viviana Galimberti
- Division of Breast Surgery, European Institute of Oncology Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Mauro Porpiglia
- Department of Surgical Sciences Gynecology and Obstetrics, City of Health and Science of Turin, Sant’Anna Hospital, University of Turin, Turin, Italy
| | - Roberto Agresti
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Alberto Luini
- Division of Breast Surgery, European Institute of Oncology Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Giuseppe Viale
- Division of Pathology and Laboratory Medicine, European Institute of Oncology IRCCS, Milan, Italy
- Oncology and Oncohematology Department, University of Milan, Milan, Italy
| | - Enrico Cassano
- Division of Breast Imaging, European Institute of Oncology IRCCS, Milan, Italy
| | - Nickolas Peradze
- Division of Breast Surgery, European Institute of Oncology Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Antonio Toesca
- Division of Breast Surgery, European Institute of Oncology Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Giulia Massari
- Division of Breast Surgery, European Institute of Oncology Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Virgilio Sacchini
- Division of Breast Surgery, European Institute of Oncology Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Oncology and Oncohematology Department, University of Milan, Milan, Italy
| | - Elisabetta Munzone
- Division of Medical Oncology, European Institute of Oncology IRCCS, Milan, Italy
| | | | | | - Rosa Di Micco
- Breast Surgery Unit, San Raffaele Scientific and Research Hospital, Milan, Italy
| | - Emanuela Esposito
- Struttura Complessa (SC) di Chirurgia Oncologica di Senologia, Istituto Nazionale Tumori Napoli, IRCCS, Fondazione Pascale, Naples, Italy
| | - Adele Sgarella
- Breast Center, Department of Surgical Sciences, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Silvia Cattaneo
- Department of General Surgery, Sant’Anna Hospital, Como, Italy
| | - Massimo Busani
- Struttura Semplice Dipartimentale di Chirurgia Senologica Azienda Socio-Sanitaria Territoriale (ASST), Mantova, Italy
| | - Massimo Dessena
- SC di Chirurgia Oncologica e Senologia, Ospedale Oncologico, Azienda Ospedaliera Brotzu, Selargius, Cagliari, Italy
| | - Anna Bianchi
- Breast Unit, Spedali Civili di Brescia, Brescia, Italy
| | - Elisabetta Cretella
- Medical Oncology Division, Azienda Sanitaria dell’Alto Adige, Bolzano, Italy
| | | | - Michael Mueller
- Frauenklinik Inselpital Hospital, Theodor-Kocher-Haus, Bern, Switzerland
| | - Corrado Tinterri
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | | | - Chiara Benedetto
- Department of Surgical Sciences Gynecology and Obstetrics, City of Health and Science of Turin, Sant’Anna Hospital, University of Turin, Turin, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, European Institute of Oncology Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Oncology and Oncohematology Department, University of Milan, Milan, Italy
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