Journal Review in Breast Surgery: SOUND and INSEMA Trials - Should Sentinel Lymph Node Biopsy Be Omitted in Select Breast Cancer Patients?

Picture this: a patient with early-stage breast cancer is sitting in front of you in the clinic. You are about to offer your expert management plan. The age-old question arises—should you really perform a sentinel lymph node biopsy, or could omission actually help this patient more? Today, we're tackling one of the hottest debates in modern breast cancer care.

Should we rethink sentinel lymph node biopsy for select patients, and can skipping it actually improve quality of life without sacrificing cancer control? The stakes couldn’t be higher—balancing accurate cancer staging and minimizing harm is the name of the game. Together, we’re breaking down the latest evidence from the SOUND and INSEMA trials. What do these landmark studies mean for your patients, your practice, and the future of axillary management? Ready for a journal review that might just change your next consult?

Hosts:
- Rashmi Kumar, MD, PhD
Resident, University of Michigan General Surgery Residency Program
Twitter/X: @RashmiJKumar
- Melissa Pilewskie, MD
Attending Breast Surgical Oncologist, Co-Director of the Weiser Family Center for Breast Cancer, Michigan Medicine
Twitter/X: @MPilewskie
- Stephanie Downs-Canner, MD
Attending Breast Surgical Oncologist & Physician-Scientist, Memorial Sloan Kettering Cancer Center, Program Director of the Breast Surgical Oncology Fellowship Training Program
Twitter/X: @SDownsCanner

Learning Objectives:
- Understand when and for whom it is safe and beneficial to omit sentinel lymph node biopsy (SLNB) in early-stage breast cancer patients.
- Identify the risks associated with foregoing SLNB, including loss of nodal staging, and analyze how this impacts treatment selection and prognosis.
- Review key findings from the SOUND and INSEMA trials and their influence on axillary management.
- Discuss implications for adjuvant therapy, genomic profiling, and multidisciplinary clinical practice.
- Recognize which patient populations should still receive SLNB, and the importance of individualized, multidisciplinary decision-making.

References:
- Gentilini OD, Botteri E, Sangalli C, et al. 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(11):1557–1564. doi:10.1001/jamaoncol.2023.3759 https://pubmed.ncbi.nlm.nih.gov/37733364/
- Reimer T, Stachs A, Veselinovic K, et al. Axillary surgery in breast cancer – primary results of the INSEMA trial. N Eng J Med. 2024. doi:10.1056/NEJMoa2412063.
https://pubmed.ncbi.nlm.nih.gov/39665649/
- Sparano JA, Gray RJ, Makower DF, Albain KS, Saphner TJ, Badve SS, Wagner LI, Kaklamani VG, Keane MM, Gomez HL, Reddy PS, Goggins TF, Mayer IA, Toppmeyer DL, Brufsky AM, Goetz MP, Berenberg JL, Mahalcioiu C, Desbiens C, Hayes DF, Dees EC, Geyer CE Jr, Olson JA Jr, Wood WC, Lively T, Paik S, Ellis MJ, Abrams J, Sledge GW Jr. Clinical Outcomes in Early Breast Cancer With a High 21-Gene Recurrence Score of 26 to 100 Assigned to Adjuvant Chemotherapy Plus Endocrine Therapy: A Secondary Analysis of the TAILORx Randomized Clinical Trial. JAMA Oncol. 2020 Mar 1;6(3):367-374. doi: 10.1001/jamaoncol.2019.4794. PMID: 31566680; PMCID: PMC6777230. https://pubmed.ncbi.nlm.nih.gov/31566680/
- Slamon DJ, Fasching PA, Hurvitz S, Chia S, Crown J, Martín M, Barrios CH, Bardia A, Im SA, Yardley DA, Untch M, Huang CS, Stroyakovskiy D, Xu B, Moroose RL, Loi S, Visco F, Bee-Munteanu V, Afenjar K, Fresco R, Taran T, Chakravartty A, Zarate JP, Lteif A, Hortobagyi GN. Rationale and trial design of NATALEE: a Phase III trial of adjuvant ribociclib + endocrine therapy versus endocrine therapy alone in patients with HR+/HER2- early breast cancer. Ther Adv Med Oncol. 2023 May 29;15:17588359231178125. doi: 10.1177/17588359231178125. Erratum in: Ther Adv Med Oncol. 2023 Sep 29;15:17588359231201818. doi: 10.1177/17588359231201818. PMID: 37275963; PMCID: PMC10233570. https://pubmed.ncbi.nlm.nih.gov/37275963/

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