# Title Page

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## Title (full, English)

**Axillary management after neoadjuvant chemotherapy in node-positive breast cancer (cN+ to ypN0): an umbrella review of systematic reviews and meta-analyses (2006–2026).**

## Short title (running head; ≤55 characters)

**Axillary management post-NAC: an umbrella review.**

## Manuscript type

Original Article — Umbrella review of systematic reviews and meta-analyses, conducted per the JBI Manual for Evidence Synthesis (Aromataris 2024) and reported per PRISMA 2020 (Page 2021, doi:10.1136/bmj.n71) and PRIOR (Pollock 2023, doi:10.1136/bmj-2022-074091).

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## Authors

| # | Name | Degree(s) | ORCID |
|---:|---|---|---|
| 1 | Sergio Cervera | MD | (to be added) |
| 2 | David Duque | MD | (to be added) |
| 3 | [Biostatistician — to be confirmed] | PhD or MSc Biostatistics | — |
| 4 | [Senior Breast Surgeon co-author — to be confirmed] | MD, PhD | — |

## Affiliations

1. Sergio Cervera, MD — Breast Surgical Oncology Unit, [hospital affiliation to be confirmed], Spain.
2. David Duque, MD — Independent academic investigator; founder, https://ganglio.cicatra.com (open-source clinical decision-support project), Madrid, Spain.
3. [Biostatistician — to be confirmed] — [Department of Biostatistics, university to be confirmed], European Union.
4. [Senior Breast Surgeon co-author — to be confirmed] — [Breast Cancer Centre, hospital to be confirmed], European Union.

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## Corresponding author

**David Duque, MD**
Address: [postal address to be added]
Madrid, Spain
Telephone: [to be added]
Email: **david@davidduque.com**
ORCID: (to be added)

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## Funding sources

None. This umbrella review is investigator-initiated and receives no financial or in-kind support from industry, governmental agencies, or non-profit organizations.

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## Conflicts of interest

None declared. No author has equity, consultancy, speaker, or advisory-board ties to manufacturers of axillary localization devices (clip, radioactive seed, magnetic seed, radar reflector, or superparamagnetic iron oxide) or to providers of related diagnostic imaging.

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## Acknowledgments

The authors thank the developers and maintainers of PubMed (NLM), EMBASE (Elsevier), the Cochrane Library, Epistemonikos, and Rayyan for the freely available infrastructure that enabled the comprehensive search and deduplication for this umbrella review. We thank the international breast surgical oncology community whose primary studies and prior systematic reviews form the substrate of this synthesis. The companion patient- and clinician-facing predictor at https://ganglio.cicatra.com was developed without industry support and remains open-source.

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## Author contributions (CRediT)

A full CRediT statement is provided as a separate attachment (`07_submission/CRediT_statement.md`). In summary:
- **Conceptualization, Methodology, Investigation, Writing — Original Draft (Discussion), Project Administration, Supervision:** S. Cervera.
- **Conceptualization, Methodology, Software, Data Curation, Formal Analysis, Visualization, Writing — Original Draft (Methods/Results/Supplementary), Writing — Review & Editing:** D. Duque (corresponding author).
- **Methodology, Formal Analysis, Validation, Writing — Review & Editing:** Biostatistician.
- **Investigation, Writing — Review & Editing, Supervision:** Senior Breast Surgeon.

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## Word counts

| Component | Word count |
|---|---:|
| Abstract (BJS / The Breast — 250-word variant) | 250 |
| Abstract (EJSO — 300-word variant) | 300 |
| Body of manuscript (Introduction → Discussion, excl. abstract, references, tables, figures) | 4,800 |
| References | 96 references (33 included SRs + 28 guidelines/trials/methodological standards + 35 contextual citations) |
| Figures | 3 (PRISMA flow; convergence forest plot per outcome; AMSTAR-2 heatmap) |
| Tables | 4 (Table 1 — included SR characteristics; Table 2 — AMSTAR-2 summary; Table 3 — per-outcome convergence; Table 4 — GRADE summary at umbrella level) |
| Supplementary files | 6 (S1 search strategy; S2 PRISMA-2020 checklist; S3 AMSTAR-2 full; S4 excluded studies; S5 extended extraction; S6 glossary) |

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## Registration

PROSPERO registration ID: TBD (to be added upon registration acceptance). The full protocol is available at `01_protocolo/PROSPERO_protocol.md` of the project repository (https://ganglio.cicatra.com).

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## Data availability

Full extracted data, AMSTAR-2 scores, scripts, and the companion predictor source code are openly available at https://ganglio.cicatra.com (data CC-BY 4.0; predictor code MIT). A complete data availability statement is provided as `07_submission/data_availability.md`.

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## Ethics

Not applicable — synthesis of published systematic reviews; no individual patient data.

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## Reporting standards

PRISMA 2020 (Page 2021, doi:10.1136/bmj.n71) and PRIOR (Pollock 2023, doi:10.1136/bmj-2022-074091). The PRISMA 2020 checklist with manuscript locations is provided as Supplementary File S2.

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*Title page prepared 13 May 2026.*
