Optimal management of breast cancer with physical exam negative/radiological abnormal axilla.

For breast cancer patients with physical exam node negative but radiological finding node abnormal (cN0/rNa), the NCCN and ASCO guidelines recommend sentinel lymph node biopsy (SLNB) as the first-line axillary staging. However, patients who undergo surgery firstly may be upstaged to pathological II-III status, and these patients happen to be the adaptive population of neoadjuvant therapy (NAT). There is no consensus on the optimal management of cN0/rNa patients. The aim is to explore the optimal management strategy of these patients. We performed a retrospective real-world study of 1414 cN0/rNa patients from June 2014 to October 2022. There were 1003 patients underwent surgery first and 411 patients underwent surgery after NAT. We analyzed the real-world conditions of these patients, compared axilla tumor burden between these two groups. In addition, we compared benefit ratio of axillary surgery and regional nodal irradiation (RNI) de-escalation under the two strategies. Among 1003 patients underwent surgery first, the positive and negative rates of fine needle aspiration (FNA) were 18.5% and 81.5%, respectively. There were 66.1% had ≤ 2 lymph nodes+. There were 40.8% of FNA+ patients could be exempted from ALND underwent surgery first. In 411 patients underwent surgery after NAT, the FNA positive and negative rates were 60.8% and 49.2%, respectively. There were 54.4% of FNA+ patients achieved axilla pathologic complete response (apCR) and could omit ALND after NAT. The apCR was 67.3% in HER2+/TNBC subtypes. According to the NSABP-B51 trial, there were 0 and 54.4% of FNA+ patients could omit RNI among surgery first and after NAT, respectively. Among 1-2 sentinel lymph node (SLN)-positive patients underwent surgery first, with a median follow-up 49 months, there was no difference of survival benefit between SLNB-only and SLNB-ALND. Compared with 1-2 SLN+ patients without RNI, RNI could bring better invasive disease-free survival (97.38% vs. 89.36%, P = 0.046) and breast cancer special survival (100% vs. 94.68%, P = 0.020). It is safe to perform SLNB omitting ALND when detected 1-2 positive SLNs in cN0/rNa patients. Patients with HER2+/TNBC subtypes underwent surgery after NAT had more chance to benefit from dual de-escalation, including axillary surgery and RNI de-escalation.

The feasibility of targeted axillary dissection for breast cancer axillary surgery de-escalation after neoadjuvant therapy: A prospective cohort study.

PURPOSE: Targeted axillary dissection (TAD) after neoadjuvant therapy (NAT) includes removing of marked and sentinel lymph nodes (SLNs). The aim was to investigate the optimization of TAD localization techniques after NAT among breast cancer patients. METHODS: From November 2020 to 2022, we prospectively enrolled 107 lymph node-positive breast cancer patients in XX Hospital and received complete cycles of NAT. Patients were randomly divided into the following 3 groups before treatment: group A, marked node with clip (n=34); group B, marked node with 125I seed (n=32); and group C, marked node with clip and 125I seed (n=41). Dual tracers were used to search for SLNs after NAT. The main endpoint was the detection rate of marked nodes and false-negative rate (FNR). RESULTS: The detection rates using the TAD localization technique were 82.6% (28/34), 100% (32/32), and 100% (41/41) for groups A, B, and C, respectively (P>0.05). The FNR rates were 15.8%, 5.9%, and 5.6% among group A, B, and C, respectively (P>0.05). The FNR rates in cN1 patients were 5.1%, 2.7%, and 2.6%, among these three groups, respectively (P>0.05). The change in distance between 125I seeds and clips in axillary lymph nodes was <3 mm. The FNR rates of TAD guided by dye tracer, radiolabeled tracer, and dual tracers were 5.4%, 5.2%, and 3.4%, respectively (P>0.05). The negative predictive values were 93.0%, 93.0%, and 95.2%, respectively (P>0.05). CONCLUSION: Considering inexpensive and detect rate of 125I seeds, it is recommended that placement of 125I seeds to localize metastatic nodes in neoadjuvant setting. The TAD guided by dye tracer is also feasible for axillary de-escalation surgery after NAT in countries or regions without radiolabeled colloid.

A Dual-Responsive Liquid Crystal Elastomer for Multi-Level Encryption and Transient Information Display.

Information security has gained increasing attention in the past decade, leading to the development of advanced materials for anti-counterfeiting, encryption and instantaneous information display. However, it remains challenging to achieve high information security with simple encryption procedures and low-energy stimuli. Herein, a series of strain/temperature-responsive liquid crystal elastomers (LCEs) are developed to achieve dual-modal, multi-level information encryption and real-time, rewritable transient information display. The as-prepared polydomain LCEs can change from an opaque state to a transparent state under strain or temperature stimuli, with the transition strains or temperatures highly dependent on the concentration of long-chain flexible spacers. Information encrypted by different LCE inks can be decrypted under specific strains or temperatures, leading to multi-level protection of information security. Furthermore, with the combination of the phase transition of polydomain LCEs and the photothermal effect of multi-walled carbon nanotubes (MWCNTs), we achieved a repeatable transient information display by using near-infrared (NIR) light as a pen for writing. This study provides new insight into the development of advanced encryption materials with versatility and high security for broad applications.

Development and validation of a nomogram for predicting internal mammary sentinel node metastasis in breast cancer patients.

OBJECTIVE: Internal mammary nodes are important in breast cancer prognosis, but their diagnosis is often missed in clinical practice, leading to inaccurate staging and treatment. We developed a validated nomogram to predict the presence of internal mammary sentinel nodes (IMSN) metastasis. METHODS: A total of 864 sequential IMSN biopsy procedures from a prospective studies database of 1505 cases were used for model development and validation. Multivariable logistic regression was performed on 519 sequential IMSN biopsy procedures from multi-center data between August 2018 and July 2022 to predict the presence of IMSN metastasis. A nomogram was developed based on the logistic regression model and subsequently applied to 345 sequential IMSN biopsy procedures from single-center data between November 2011 and July 2018. The model's discrimination was assessed using the area under the receiver operating characteristic curve. RESULTS: The overall frequency of IMSN metastasis was 17.0% in our study. A predictive model for IMSN metastasis was constructed using tumor size, tumor location, lymphovascular invasion, the number of positive axillary nodes (P < 0.05 for all variables in multivariate analysis), and histological grade (P < 0.05 only in univariate analysis). The nomogram was accurate, with a concordance index of 0.84 in the bootstrapping analysis and an area under the receiver operating characteristic curve of 0.80 in the validation population. CONCLUSION: Our nomogram provides an accurate and validated multivariable predictive model for estimating the individual likelihood of having IMSN metastasis. This may be useful for personalized treatment decisions regarding internal mammary radiotherapy in breast cancer patients.

The modified shrinkage classification modes could help to guide breast conserving surgery after neoadjuvant therapy in breast cancer.

Purpose: The traditional shrinkage classification modes might not suitable for guiding breast conserving surgery (BCS) after neoadjuvant therapy (NAT). Aim was to explore the modified shrinkage classification modes to guide BCS after NAT. Methods: From April 2010 to 2018, 104 patients were included. All patients underwent MRI examinations before and after NAT. Residual tumors were removed and divided into more than 30 tissue blocks at 5-mm intervals. After performing routine procedures for paraffin-embedded histology, we made semiserial sections (6-µm thick). The MRI and pathology 3D models were reconstructed with 3D-DOCTOR software. Combined with traditional shrinkage modes and efficacy of NAT, we derived modified shrinkage classification modes which oriented by BCS purpose: modified concentric shrinkage modes (MCSM) and modified non concentric shrinkage modes (MNCSM). The MCSM means the longest diameter of residual tumor was less than 50% and ≤2cm in comparison with the primary tumor before NAT. Other shrinkage modes were classified as MNCSM. Results: According to traditional shrinkage modes, 50 (48.1%) cases were suitable for BCS;while 70 (67.3%) cases were suitable for BCS according to the modified shrinkage modes (p=0.007). The consistency of MRI 3D reconstruction in assessing modified shrinkage classification modes was 93.2%, while it was 61.5% when assessing traditional shrinkage modes. Multivariate analysis showed that primary tumor stage, mammographic malignant calcification, molecular subtypes and nodal down-staging after NAT were independent predictors of modified shrinkage modes (all p<0.05). A nomogram was created based on these four predictors. With a median follow-up time of 77 months, the recurrence/metastasis rate in the MCSM and MNCSM group was 7.1% and 29.4%, respectively. Conclusion: Modified shrinkage classification modes could help to guide the individualized selection of BCS candidates and scope of resection after NAT. MRI 3D reconstruction after NAT could accurately predict modified shrinkage modes and extent of residual tumor.

A Fully Flexible Intelligent Thermal Touch Panel Based on Intrinsically Plastic Ag2 S Semiconductor.

Wearable touch panels, a typical flexible electronic device, can recognize and feed back the information of finger touch and movement. Excellent wearable touch panels are required to accurately and quickly monitor the signals of finger movement as well as the capacity of bearing various types of deformation. High-performance thermistor materials are one of the key functional components, but to date, a long-standing bottleneck is that inorganic semiconductors are typically brittle while the electrical properties of organic semiconductors are quite low. Herein, a high-performance flexible temperature sensor is reported by using plastic Ag2 S with ultrahigh temperature coefficient of resistance of -4.7% K-1 and resolution of 0.05 K, and rapid response/recovery time of 0.11/0.11 s. Moreover, the temperature sensor shows excellent durability without performance damage or loss during force stimuli tests. In addition, a fully flexible intelligent touch panel composed of a 16 × 10 Ag2 S-film-based temperature sensor array, as well as a flexible printed circuit board and a deep-learning algorithm is designed for perceiving finger touch signals in real-time, and intelligent feedback of Chinese characters and letters on an app. These results strongly show that high-performance flexible inorganic semiconductors can be widely used in flexible electronics.

A Three lncRNA Set: AC009975.1, POTEH-AS1 and AL390243.1 as Nodal Efficacy Biomarker of Neoadjuvant Therapy for HER-2 Positive Breast Cancer.

PURPOSE: The study aimed to explore whether the expression of lncRNAs in primary tumors could predict nodal efficacy after neoadjuvant therapy (NAT) for HER2+ breast cancer. METHODS: Total RNA was extracted from HER2+ breast cancer tissues before NAT (n=103) and from 48 pairs of cancers and para-cancers tissues that did not receive NAT. Different lncRNAs were selected by microarray, validated by qPCR, and analyzed to illuminate their potential as nodal efficacy biomarkers after NAT. RESULTS: Our results demonstrated that three lncRNA sets, lncRNA-AL390243.1, POTEH-AS1, and lncRNA-AC009975.1, were up-regulated in non-apCR tissues. The AUC value was 0.789 (95%CI: 0.703-0.876). The multivariate logistic regression analysis identified the expression of lncRNA-AL390243.1 (OR 5.143; 95% CI: 1.570-16.847), tumor type (OR 0.144; 95% CI: 0.024-0.855), and nodal stage (OR 0.507; 95% CI: 0.289-0.888) as independent predictors for apCR after NAT in HER2+ patients (all p<0.05). Then the three predictors were used to create a predictive nomogram. The AUC value was 0.859 (95%CI: 0.790-0.929). The calibration curve showed a satisfactory fit between predictive and actual observation based on internal validation with a bootstrap resampling frequency of 1000. Patients with higher expression of lncRNA-AL390243.1 had worse survival. LncRNA-AL390243.1 was up-regulated more in the nodal positive subgroup than in the nodal negative subgroup (p=0.0271). CONCLUSION: The lncRNA-AL390243.1, POTEH-AS1, and lncRNA-AC009975.1 were upregulated in non-apCR breast cancer tissues. These three lncRNAs might have the potential to be used as predictive biomarkers of nodal efficacy of HER2+ breast cancer. Further studies are required to illuminate the underlying molecular mechanisms further.

Candidates of Genomic Tests in HR+/HER2- Breast Cancer Patients With 1-2 Positive Sentinel Lymph Node Without Axillary Lymph Node Dissection: Analysis From Multicentric Cohorts.

BACKGROUND: The genomic tests such as the MammaPrint and Oncotype DX test are being gradually applied for hormone receptor positive/HER-2 negative (HR+/HER2-) breast cancer patients with up to three positive axillary lymph nodes (ALNs). The first results from RxPONDER trial suggested that Oncotype DX could be applied to patients with 1-2 positive sentinel lymph nodes (SLNs) without axillary lymph node dissection (ALND), which constituted 37.4% of the intent-to-treat population. However, there was no distinctive research on how to apply genomic tests precisely to HR+/HER2- patients with 1-2 positive SLNs without ALND. The purpose was to construct a nomogram using the multi-center retrospective data to predict precisely which HR+/HER2- candidates with 1-2 positive SLNs could be subjected to genomic tests (≤ 3 positive lymph nodes). METHODS: We conducted a retrospective analysis of 18,600 patients with stage I-III breast cancer patients treated with sentinel lymph node biopsy (SLNB) in Shandong Cancer Hospital, Fudan University Shanghai Cancer Center, and West China Hospital. The univariate and multivariate logistic regression analysis was conducted to identify the independent predictive factors of having ≤ 3 positive nodes among patients with 1-2 positive SLNs. A nomogram was developed based on variables in the final model with p<0.05. Calibration of the nomogram was carried out by internal validation using the bootstrap resampling approach and was displayed using a calibration curve. The discrimination of the model was evaluated using the ROC curve. RESULTS: Based on the database of the three institutions, a total of 18,600 breast cancer patients were identified undergoing SLNB between May 2010 and 2020. Among the 1817 HR+/HER2- patients with 1-2 positive SLNs undergoing ALND, 84.2% harbored ≤ 3 totals metastatic ALNs. The multivariate logistic regression analysis identified imaging abnormal nodes (OR=0.197, 95%CI: 0.082-0.472), the number of positive SLNs (OR=0.351, 95%CI: 0.266-0.464), the number of negative SLNs (OR=1.639, 95%CI: 1.465-1.833), pathological tumor stage (OR=0.730, 95%CI: 0.552-0.964), and lympho-vascular invasion (OR=0.287, 95%CI: 0.222-0.398) as independent predictors for the proportion of patients with ≤ 3 total metastatic ALNs (all p<0.05). These five predictors were used to create a predictive nomogram. The AUC value was 0.804 (95%CI: 0.681-0.812, p<0.001). The calibration curve showed a satisfactory fit between the predictive and actual observation based on internal validation with a bootstrap resampling frequency of 1000. CONCLUSION: The nomogram based on the multi-centric database showed a good accuracy and could assist the oncologist in determining precisely which HR+/HER2- candidates with 1-2 positive SLNs without ALND could perform genomic tests. In the era of SLNB and precision medicine, the combined application of genomic tests and SLNB could provide patients with a better strategy of dual de-escalation management, including the de-escalation of both surgery and systemic treatment.

Correction to: Internal Mammary Sentinel Lymph Node Biopsy in Clinically Axillary Lymph Node-Positive Breast Cancer: Diagnosis and Implications for Patient Management.

The authors' affiliations are corrected as reflected here.

Internal Mammary Sentinel Lymph Node Biopsy in Clinically Axillary Lymph Node-Positive Breast Cancer: Diagnosis and Implications for Patient Management.

BACKGROUND: Routine performance of internal mammary sentinel lymph node biopsy (IM-SLNB) remains a subject of debate due to no clinical relevance in breast cancer, because it was performed only in clinically axillary lymph node (ALN)-negative patients. In this study, IM-SLNB was performed in clinically ALN-positive patients, and its impact on nodal staging and therapeutic strategy were subsequently analyzed. METHODS: Clinically ALN-positive patients who underwent IM-SLNB were enrolled in this prospective study. Statistical analysis was performed using Chi square test, Mann-Whitney U and logistic regression models with a significance level of 0.05. RESULTS: Among the 352 recruited patients, the internal mammary sentinel lymph node (IMSLN) visualization rate of patients who received initial surgery and neoadjuvant systemic therapy (NST) was 71.9% (123/171) and 33.1% (60/181), respectively. The 183 patients who underwent IM-SLNB successfully had the average time duration of 7 min and the median IMSLN number of 2. There were 87 positive IMSLNs in all the 347 removed IMSLNs, which were mainly concentrated in the second (50.6%) and third (34.5%) intercostal space. The IMSLN metastasis rate was 39.8% (initial surgery) and 13.3% (NST), respectively. All of the 183 IM-SLNB patients received more accurate nodal staging, 57 of whom had stage elevated, which might have prompted modifications to the therapeutic strategy. CONCLUSIONS: IM-SLNB should be routinely performed in clinically ALN-positive patients, and thus more accurate nodal staging and perfect pathologic complete response definition could be put forward. The identification of IMLN metastases by IM-SLNB might potentially influence therapeutic strategies.

Neo-adjuvant chemotherapy and axillary de-escalation management for patients with clinically node-negative breast cancer.

This study aimed to explore the optimal time of sentinel lymph node biopsy (SLNB) and neo-adjuvant chemotherapy (NAC) and to assess the feasibility of selective elimination of axillary surgery after NAC in clinically node-negative (cN0) patients. From April 2010 to August 2018, 845 patients undergoing surgery after NAC were included in this retrospective study to analyze the correlation between different clinicopathological characteristics of cN0 patients and negative axillary lymph node after NAC (ypN0). Among the 148 cN0 patients, 83.1% (123/148) were ypN0. The rates of ypN0 in patients with hormone receptor positive (HR+)/HER2-, HR+/HER2+, HR-/HER2+, and triple-negative (TN) breast cancer were 75.4% (46/61), 82.6% (19/23), 85.2% (23/27), and 94.6% (35/37), respectively (P < 0.001). The rates of ypN0 in TN and HER2+ patients were 94.6% and 95.5%, which were significantly higher than that in HR+/HER2- patients (P < 0.05). Molecular subtypes, clinical stage, radiologic complete response, and pathologic complete response (bpCR) of the breast tumor correlated with ypN0 after full-course NAC (P < 0.05). Molecular subtypes (OR = 2.374, P = 0.033), clinical stage (OR = 0.320, P = 0.029), and bpCR (OR = 0.454, P = 0.012) were independent predictors for ypN0. The optimal time of SLNB and NAC in cN0 patients might be different among different molecular subtypes: it would be preferable to perform SLNB prior to NAC for HR+/HER2- patients, and SLNB after NAC for TN and HER2+ patients to reduce the risk of axillary lymph node dissection. In view of the high ypN0 rate in cN0 patients, axillary surgical staging might be selectively eliminated, especially for HER2+ and TN patients.

The Lymphatic Drainage Pattern of Internal Mammary Sentinel Lymph Node Identified by Small Particle Radiotracer (99mTc-Dextran 40) in Breast.

PURPOSE: The purpose of this study was to detect the lymphatic drainage pattern of internal mammary area and verify the concept of internal mammary sentinel lymph node (IM-SLN) in breast. MATERIALS AND METHODS: A small particle radiotracer (99mTc-Dextran 40) was prepared and tested. 99mTc-Dextran 40 was injected into intraparenchyma at the sound breast by a modified radiotracer injection technique. Subsequently, dynamic single-photon emission computed tomography (SPECT), computed tomography (CT), and SPECT/CT combination images were performed to identify the radioactive lymph vessels and internal mammary lymph nodes (IMLNs). The direction of lymph drainage and the location of the IMLNs were identified in the SPECT/CT imaging. RESULTS: The radiochemical purity of 99mTc-Dextran 40 was > 95%. 99mTc-Dextran 40 could drainage into first, second, and third lymph node and the radioactive lymph node could be detected by the γ detector in the animal experiment. After 99mTc-Dextran 40 injecting into intraparenchyma, 50.0% cases (15/30) were identified the drainage lymphatic vessels and radioactive IMLNs by SPECT. The drainage lymphatic vessel was found from injection point to the first IMLN (IM-SLN) after 10.5±0.35 minutes radiotracer injection, and then 99mTc-Dextran 40 was accumulated into the IM-SLN. The combination imaging of SPECT/CT showed the second IMLN received the lymph drainage from the IM-SLN. The lymphatic drainage was step by step in the internal mammary area. CONCLUSION: The lymph was identified to drain from different regions of the breast to IM-SLN, and then outward from IM-SLN to other IMLN consecutively. It demonstrated the concept of the IM-SLN and provided more evidences for the application of internal mammary sentinel lymph node biopsy.

Definition of Internal Mammary Node Target Volume Based on the Position of the Internal Mammary Sentinel Lymph Nodes Presented on SPECT/CT Fusion Images.

Purpose: Mapping the distribution of internal mammary sentinel lymph nodes (IM-SLNs) presented on single photon emission computed tomography in conjunction with computed tomography (SPECT/CT) images to explore the value of IM-SLN to guide tailored clinical target volume (CTV) delineation of postoperative prophylactic IMNI. Materials and methods: Ninety-seven patients who underwent preoperative lymphoscintigraphy by SPECT/CT and had imaging of IM-SLN were selected in this study. The imaging IM-SLNs on SPECT/CT of eligible patients were projected onto corresponding anatomical positions of a representative axial CT image. The IMN CTVs were delineated on the representative axial CT images according to the Radiation Therapy Oncology Group (RTOG) and Danish Breast Cancer Cooperative Group (DBCG) guideline, and defined as CTVRTOG and CTVDBCG. The location of the IM-SLNs was compared with the RTOG and DBCG guidelines of IMN target volume delineations, respectively. The intercostal space distribution of IM-SLNs was recorded. The distances from the CTVRTOG and CTVDBCG to the IM-SLNs were measured, respectively. Results: The total number of imaging IM-SLNs was 136. IM-SLNs were mostly found in the first intercostal space (40.4%), with 30.2, 24.3, 4.4, and 0.7% of IM-SLNs in the second, third, fourth, and fifth intercostal space, respectively. The average distance from the edge of the CTVRTOG and the edge of CTVDBCG to the central points of the IM-SLNs was 4.10 mm (SD, 3.3 mm) and 1.60 mm (SD, 2.6 mm), respectively (t = 16.640, P = 0.000). The average distance from the edge of CTVRTOG and the edge of CTVDBCG to the lateral border IM-SLN was 6.40 mm (SD, 3.5 mm) and 3.34 mm (SD, 3.3 mm), respectively (t = 19.815, P = 0.000). Only 18.4% of IM-SLN central points were included in the CTVRTOG, and 60.3% of IM-SLN central points were included in the CTVDBCG. When covering 90 and 100% of the IM-SLN center points, the CTVRTOG needs to expand 8 and 15 mm, respectively, and the CTVDBCG needs to expand 5 and 13 mm, respectively. Conclusion: Neither the RTOG nor DBCG consensus guideline about the delineation of IMN CTV was sufficient to cover 90% of IM-SLNs. For 90% coverage of IM-SLN central points, CTVRTOG needed to be expanded by 8 mm, and CTVDBCG needed to be expanded by 5 mm.

Internal mammary sentinel lymph node biopsy with modified injection technique: A case report.

RATIONALE: In addition to axillary lymph node (ALN), internal mammary lymph node (IMLN) is also the first-echelon drainage nodes reached by metastasising cancer cells from breast cancer, which can provide important prognostic information. PATIENT CONCERNS: In this paper, we will introduce a case of breast cancer patient whose postoperative pathology result showed that she had internal mammary sentinel lymph node (IMSLN) metastases but no axillary sentinel lymph node (ASLN) metastases. DIAGNOSES: She was diagnosed as pT1cN1bM0 breast cancer based on the positive IMSLN but negative ASLN. INTERVENTIONS: She received axillary-sentinel lymph node biopsy (A-SLNB) and internal mammary-sentinel lymph node biopsy (IM-SLNB) guided by modified injection technique. In the choice of chemotherapy, she received dose-dense AC × 4 times followed P × 4 times for chemotherapy. As to irradiation therapy, she received irradiation therapy include chest wall, superclavicular region, and internal mammary nodes. OUTCOMES: After performing IM-SLNB, the nodal staging of this patient increased (from N0 to N1b). And she received additional chemotherapy and irradiation therapy. LESSONS: With the guidance of modified injection technique, the preoperative visualization rate of IMLN has been improved. IM-SLNB could be a minimally invasive technique for effective evaluation of the status of IMLN to provide information for staging and guide the adjuvant treatment.

Axillary and internal mammary sentinel lymph node biopsy in breast cancer after neoadjuvant chemotherapy.

With the improvement of neoadjuvant chemotherapy (NAC), the proportion of pathological complete response (pCR) in the breast and axillary lymph node (ALN) is increasing. The evaluation of pCR does not include the status of internal mammary lymph node (IMLN). This study is to evaluate the roles of both axillary sentinel lymph node biopsy (ASLNB) and internal mammary sentinel lymph node biopsy (IM-SLNB) in breast cancer patients after NAC. There were 74 patients enrolled into this study. IM-SLNB was performed on patients with radioactive internal mammary sentinel lymph node (IM-SLN). Patients (n = 8) with cN0 and ycN0 received ASLNB, and axillary lymph node dissection (ALND) in cases of positive axillary sentinel lymph node (ASLN). Patients (n = 48) with cN+ but ycN0 received ASLNB and ALND. Patients (n = 18) with ycN+ received ALND without ASLNB. The visualization rate of IM-SLN was 56.8% (42/74). The success rate of IM-SLNB was 97.6% (41/42) and the metastasis rate of IM-SLN was 7.3% (3/41). The success rate of ASLNB was 100% (56/56). The false negative rate (FNR) of ASLNB was 17.2% (5/29). The FNR in patients with 1, 2 and ≥ 3ASLNs examined was 27.3% (3/11), 20.0% (2/10) and 0% (0/8) respectively. ASLNB could be performed on ycN0 after NAC, and ALND should be performed on initially ALN-positive patients. IM-SLNB should be considered after NAC, especially for patients with clinically positive axillary nodes before NAC, which might help make clear of the pathological nodal staging of both ALN and IMLN, improve the definition of nodal pCR, and guide the individual adjuvant regional and systemic therapy.