Table 8 Summary of main recommendations and how can practice change if they are applied

Avoid ALND for patients undergoing upfront surgery who had a positive SLNB (cT1-2).

- Decreased unnecessary ALND and surgery-related morbidity (eg, lymphedema).

- Locoregional control through radiotherapy and adjuvant systemic therapy.

Consider ALND for patients who had positive SLNB after NAT.

- More appropriate axillary staging and prognostic information about the disease.

- Reduction of locoregional and distant recurrences.

Avoid the unrestricted indication of bilateral mastectomy.

- Reduction of morbidity and financial costs related to bilateral mastectomy.

- Prioritize patients with pathogenic mutations, especially if < 60 years of age.

Consider “no ink on tumor” as being indicative of adequate surgical margins.

- Decreased re-operations and mastectomies by close margins.

Avoid the evaluation of flap thickness using imaging methods.

- Avoid unnecessary RT in women with T1-2 N0 tumors submitted to mastectomy.

Add platinum agents to NAT regimens (irrespective of BRCA mutations).

- Increase in pCR rate and event-free survival.

- Slight increase in toxicity.

Add immune checkpoint inhibitors to NAT (irrespective of PD-L1 expression).

- Use of pembrolizumab as indicated in the KEYNOTE-522 study.

- Increase in pCR rate and event-free survival.

- Slight increase in toxicity and immune-mediated events.

Consider adjuvant capecitabine to patients undergoing NAT with residual disease.

- Increased disease-free survival and overall survival.

- Slight increase in toxicity.