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Bin-Bin Cong, Yong-Sheng Wang Breast Cancer Center, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, People’s Republic of ChinaCorrespondence: Yong-Sheng Wang, Email wangysh2008@aliyun.comAbstract: The opinion of “all pCRs are the same” in St. Gallen International Consensus Guidelines 2021 attracted the attention from clinical doctors. But this opinion is not consistent with the current clinical practice guidelines. The evidence-based medical evidence supported that the survival benefit of pCR was associated with treatment regimes, initial staging, and tumor biomarkers. To compare with the different status, the survival prognosis of pCRs is not the same. Furthermore, the pretreatment clinical stage, pathological stage, tissue grade, and subtype still influence on the survival prognosis of pCR. The pCR should be stratified according to histological factors and to guide the identification of individualized treatment after neoadjuvant therapy. In the future, a de-escalation treatment might be detected by the clinical trials of neoadjuvant therapy which would approach “all pCRs are the same”.Keywords: breast cancer, neoadjuvant therapy, prognosis, pathologic complete response, St. Gallen International Consensus Guidelines

Bin-Bin Cong,1–4 Jin-Ming Yu,3,4,* Yong-Sheng Wang2,4,* 1School of Medicine and Life Sciences, University of Jinan and Shandong Academy of Medical Sciences, Jinan, Shandong, China; 2Breast Cancer Center, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, Shandong, China; 3Department of Radiotherapy, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, Shandong, China; 4Shandong Academy of Medical Sciences, Jinan, Shandong, China *These authors contributed equally to this work Abstract: More attention has been paid to the axillary management over the past 50 years, and clinical practice has been changed as results of the random controlled trials. The American College of Surgeons Oncology Group Z0011 and International Breast Cancer Study Group (IBCSG) 23-01 trials provided high-level evidence to support the omission of axillary lymph nodes dissection (ALND) in sentinel lymph node (SLN)-positive patients receiving breast-conserving surgery (BCS) and adjuvant systemic treatment. In patients treated with BCS, whole breast irradiation (WBI) with tangential fields could lead to substantial axillary irradiation and control the residual tumor burden in axilla, whereas (intraoperative) partial breast irradiation has no therapeutic effect on these residual axillary metastases. In the observation group of the IBCSG 23-01 trial, 425 patients received BCS and 80 (18.8%) of them just underwent intraoperative radiotherapy. While the 10-year axillary recurrence rate was acceptable low (1.7%, 8/467) in the no ALND group, it was 4.5% (6/134) in patients without axillary management, which was significantly higher than that of 0.6% (2/333) in patients with axillary management (P=0.0024). Should we accept an axillary recurrence rate as high as 4.5% in patients with only SLNs micrometastases? What is the best way to control the residual tumor burden in the axilla and decrease the recurrence rate if there is no ALND? The evidence showed that both WBI after BCS (Z0011, AATRM [Agència d’Avaluació de Tecnologia i Recerca Mèdiques]) and axillary regional nodal irradiation after mastectomy/BCS OTOASOR (Optimal Treatment Of the Axilla - Surgery Or Radiotherapy), AMAROS (After Mapping of the Axilla: Radiotherapy Or Surgery) could control the regional residual tumor burden when the SLN is positive and an ALND is omitted. In the modern era, systemic therapy could further decrease the risk of local/regional recurrences. After the subanalysis of the POSNOC (POsitive Sentinel NOde: adjuvant therapy alone versus adjuvant therapy plus Clearance or axillary radiotherapy), SERC (Sentinelle Envahiet Randomisation du Curage), and Dutch BOOG (BOrstkanker Onderzoek Groep) trials, a prediction model might be established to identify those patients who could beneft from no axillary management as a guide to clinical practice. At present, axillary management should still be required for patients with SLN micrometastases. Keywords: breast cancer, sentinel lymph node biopsy, micrometastasis, axillary treatment