Triple-negative breast cancer: 2025 consensus guidelines
DOI:
https://doi.org/10.29289/2594539420250026Palavras-chave:
triple-negative breast cancer, upfront surgery, tumor-infiltrating lymphocytes, sentinel lymph node biopsy, neoadjuvant chemotherapy, post-mastectomy radiotherapyResumo
Objective: To disseminate the clinical guidelines established at the 2025 São Paulo Breast Diseases Symposium regarding the management of early triple-negative breast cancer (TNBC). Methods: The symposium convened 110 panelists, predominantly mastologists from São Paulo (101 mastologists, of which 94 from São Paulo and 7 from other regions: 1 from Bahia [Northeast], 2 from Rio Grande do Sul [South], 1 from Minas Gerais, 2 from Goiânia [central region], and 1 from Fortaleza [Northeast]), plus 6 oncologists, 2 pathologists, and 1 radiotherapist (all from São Paulo). Four priority topics were presented in evidence-based lectures, followed by technical discussions and anonymous electronic voting by all panelists. Consensus was defined as ≥75% agreement. Results: Voting showed 40% support for T1cN0 as the cutoff for upfront surgery, 16% for T2N0, but no consensus was reached. Consensus was achieved for using tumor-infiltrating lymphocytes (TILs) as an adjunct biomarker to guide initial systemic treatment (83%) and for sentinel lymph node biopsy (SLNB) as standard following neoadjuvant chemotherapy (NACT) (78%). Post-mastectomy radiotherapy was recommended even after pathological complete response (pCR) by 72%, though without consensus. Conclusions: The 2025 São Paulo Breast Diseases Symposium established guidelines for early TNBC management. Consensus was achieved for using TILs as an adjunct biomarker (83%) and SLNB as standard post-NACT (78%), while upfront surgery cutoff (40% for T1cN0) and radiotherapy omission post-pCR (72%) did not reach consensus, reflecting heterogeneous practices and the need for individualized approaches and further research.
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1. Fisher B, Brown A, Mamounas E, Verstraelen H, Monstrey S, Van den Broecke R, et al. Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer: findings from NSABP B-18. J Clin Oncol. 1997;15(7):2483-93. https://doi.org/10.1200/JCO.1997.15.7.2483
2. Perou CM, Sørlie T, Eisen MB, van de Rijn M, Jeffrey SS, Rees CA, et al. Molecular portraits of human breast tumours. Nature. 2000;406(6797):747-52. https://doi.org/10.1038/35021093
3. Spring LM, Fell G, Arfe A, Sharma C, Greenup R, Reynolds KL, et al. Pathological complete response after neoadjuvant chemotherapy and impact on breast cancer recurrence and survival: a comprehensive meta-analysis. Clin Cancer Res. 2020;26(12):2838-48. https://doi.org/10.1158/1078-0432.CCR-19-3492
4. Tutt ANJ, Garber JE, Kaufman B, Viale G, Fumagalli D, Rastogi P, et al. Adjuvant olaparib for patients with BRCA1- or BRCA2-mutated breast cancer. N Engl J Med. 2021;384(25):2394-405. https://doi.org/10.1056/NEJMoa2105215
5. Fasano GA, Bayard S, Chen Y, Varella L, Cigler T, Bensenhaver J, et al. Benefit of adjuvant chemotherapy in node-negative T1a versus T1b and T1c triple-negative breast cancer. Breast Cancer Res Treat. 2022;192(1):163-73. https://doi.org/10.1007/s10549-021-06476-7
6. Schmid P, Cortes J, Dent R, McArthur H, Pusztai L, Kümmel S, et al. Overall survival with pembrolizumab in early-stage triple-negative breast cancer. N Engl J Med. 2024;391(21):1976-87. https://doi.org/10.1056/NEJMoa2409932
7. Masuda N, Lee SJ, Ohtani S, Im YH, Lee ES, Yokota I, et al. Adjuvant capecitabine for breast cancer after preoperative chemotherapy. N Engl J Med. 2017;376(22):2147-59. https://doi.org/10.1056/NEJMoa1612645
8. Rastogi P, Anderson SJ, Bear HD, Geyer CE Jr, Kahlenberg MS, Robidoux A, et al. Preoperative chemotherapy: updates of NSABP protocols B-18 and B-27. J Clin Oncol. 2008;26(5):778-85. https://doi.org/10.1200/JCO.2007.15.0235
9. National Comprehensive Cancer Network. Breast cancer (version 4.2022) [Internet]. NCCN; 2022 [cited on 2026 Mar 6]. Available from: https://www.nccn.org
10. Cardoso F, Paluch-Shimon S, Senkus E, Curigliano G, Aapro MS, André F, et al. 5th ESO-ESMO international consensus guidelines for advanced breast cancer (ABC 5). Ann Oncol. 2020;31(12):1623-49. https://doi.org/10.1016/j.annonc.2020.09.010
11. Rodin D, Glicksman RM, Hepel JT, Huber K, Kirova Y, Loap P, et al. Early-stage breast cancer: a critical review of current and emerging practice. Int J Radiat Oncol Biol Phys. 2024;120(5):1260-72. https://doi.org/10.1016/j.ijrobp.2024.08.037
12. De Lena M, Zucali R, Viganotti G, Valagussa P, Bonadonna G. Combined chemotherapy-radiotherapy approach in locally advanced (T3b-T4) breast cancer. Cancer Clin Trials. 1981;4(2):117-24. https://doi.org/10.1007/BF00253147
13. Rastogi P, Anderson SJ, Bear HD, Geyer CE Jr, Kahlenberg MS, Robidoux A, et al. Preoperative chemotherapy: updates of National Surgical Adjuvant Breast and Bowel Project protocols B-18 and B-27. J Clin Oncol. 2008;26(5):778-85. https://doi.org/10.1200/JCO.2007.15.0235
14. Loi S, Drubay D, Adams S, Pruneri G, Francis PA, Lacroix-Triki M, et al. Tumor-infiltrating lymphocytes and prognosis in early-stage triple-negative breast cancer: a pooled analysis of 2,148 patients. J Clin Oncol. 2019;37(7):559-69. https://doi.org/10.1200/JCO.18.01010
15. Helal C, Djerroudi L, Ramtohul T, Laas E, Vincent-Salomon A, Jin M, et al. Clinico-pathological factors predicting pathological response in early triple-negative breast cancer. NPJ Breast Cancer. 2025;11(1):15. https://doi.org/10.1038/s41523-025-00729-8
16. Leon-Ferre RA, Jonas SF, Salgado R, Loi S, de Jong V, Carter JM, et al. Tumor-infiltrating lymphocytes in triple-negative breast cancer. JAMA. 2024;331(13):1135-44. https://doi.org/10.1001/jama.2024.3056
17. De Boo LW, Jóźwiak K, Joensuu H, van Diest PJ, Opdam M, Wang Y, et al. Prognostic value of tumor-infiltrating lymphocytes and lymphovascular invasion in early-stage triple-negative breast cancer. ESMO Open. 2024;9(3):102923. https://doi.org/10.1016/j.esmoop.2024.102923
18. Carvalho FM. Targeting low-risk triple-negative breast cancer: de-escalation strategies for a new era. Transl Breast Cancer Res. 2024;6:4. https://doi.org/10.21037/tbcr-24-28
19. Krag DN, Anderson SJ, Julian TB, Brown AM, Harlow SP, Costantino JP, et al. Sentinel lymph node resection compared with conventional axillary lymph node dissection in clinically node-negative breast cancer: overall survival from NSABP B-32. Lancet Oncol. 2010;11(10):927-33. https://doi.org/10.1016/S1470-2045(10)70207-2
20. Lee SC, Jain PA, Jethwa SC, Tripathy D, Yamashita MW. Radiologist’s role in breast cancer staging: providing key information for clinicians. Radiographics. 2014;34(2):330-42. https://doi.org/10.1148/rg.342135071
21. Mamounas EP, Brown A, Anderson S, Smith R, Julian T, Miller B, et al. Sentinel node biopsy after neoadjuvant chemotherapy in breast cancer: results from NSABP B-27. J Clin Oncol. 2005;23(12):2694-702. https://doi.org/10.1200/JCO.2005.05.188
22. Classe JM, Bordes V, Campion L, Mignotte H, Dravet F, Leveque J, et al. Sentinel lymph node biopsy after neoadjuvant chemotherapy for advanced breast cancer. J Clin Oncol. 2009;27(5):726-32. https://doi.org/10.1200/JCO.2008.18.3228
23. Hunt KK, Yi M, Mittendorf EA, Guerrero C, Babiera GV, Bedrosian I, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy reduces the need for axillary dissection. Ann Surg. 2009;250(4):558-66. https://doi.org/10.1097/SLA.0b013e3181b8fd5e
24. Boughey JC, Suman VJ, Mittendorf EA, Ahrendt GM, Wilke LG, Taback B, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy in node-positive breast cancer: ACOSOG Z1071 trial. JAMA. 2013;310(14):1455-61. https://doi.org/10.1001/jama.2013.278932
25. Kuehn T, Bauerfeind I, Fehm T, Fleige B, Hausschild M, Helms G, et al. Sentinel lymph node biopsy before and after neoadjuvant chemotherapy (SENTINA). Lancet Oncol. 2013;14(7):609-18. https://doi.org/10.1016/S1470-2045(13)70166-9
26. Boileau JF, Poirier B, Basik M, Holloway CM, Gaboury L, Sideris L, et al. Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer. J Clin Oncol. 2015;33(3):258-64. https://doi.org/10.1200/JCO.2014.55.7827
27. Fayanju OM, Ren Y, Thomas SM, Greenup RA, Plichta JK, Rosenberger LH, et al. Clinical significance of breast-only and node-only pathological complete response after neoadjuvant chemotherapy. Ann Surg. 2018;268(4):591-601. https://doi.org/10.1097/SLA.0000000000002953
28. Nagar H, Mittendorf EA, Strom EA, Perkins GH, Oh JL, Tereffe W, et al. Local-regional recurrence after neoadjuvant chemotherapy and mastectomy for T3N0 breast cancer. Int J Radiat Oncol Biol Phys. 2011;81(3):782-7. https://doi.org/10.1016/j.ijrobp.2010.06.027
29. Mamounas EP, Bandos H, White JR, Julian TB, Khan AJ, Shaitelman SF, et al. Omitting regional nodal irradiation after response to neoadjuvant chemotherapy. N Engl J Med. 2025;392(21):2113-24. https://doi.org/10.1056/NEJMoa2414859
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Copyright (c) 2026 Eduardo Carvalho Pessoa, Fabio Bagnoli, Marcelo Madeira, Joaquim Teodoro Araujo Neto, Giuliano Mendes Tosello, Fabricio Brenelli, Beatriz Baaklini Geronymo, Daniel de Araujo Buttros, Felipe Zerwes, Marcelo Antonini, Daniel Luiz Gimenes, Silvio Eduardo Bromberg, Augusto Tufi Hassan
Este trabalho está licenciado sob uma licença Creative Commons Attribution 4.0 International License.
