# Final Structured Abstract — Three Length Variants

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

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## Variant A — 250 words (BJS, The Breast)

**Background.** Sentinel lymph node biopsy (SLNB), targeted axillary dissection (TAD), MARI, RISAS, and superparamagnetic iron oxide (SPIO) localization have progressively displaced completion axillary lymph node dissection (ALND) for patients with clinically node-positive (cN+) breast cancer rendered ypN0 by neoadjuvant chemotherapy (NAC). At least 33 systematic reviews and meta-analyses now address overlapping aspects of this question, with divergent pooled estimates and methodologies. We sought to consolidate the evidence in a structured umbrella review.

**Methods.** PubMed/MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, and Epistemonikos were searched between 2006-01-01 and 2026-04-30 for systematic reviews and meta-analyses on axillary management after NAC in cN+ breast cancer. Reviews were appraised with AMSTAR-2 by two independent reviewers. The synthesis followed JBI umbrella-review and PRIOR methodology, structured by intervention then by outcome, with no re-pooling of effect estimates. Convergence was defined as ≤2 percentage-point or overlapping-CI agreement.

**Results.** Of 5,516 hits across strands and 146 unique records after deduplication, 33 systematic reviews (~120,000 patients in the underlying primary studies) met eligibility. False-negative rate (FNR) of TAD converged at 2.0–6.5% (nine meta-analyses), well below the 10% acceptability ceiling, while SLNB-alone FNR remained 12–17% unless ≥3 sentinel nodes were retrieved with dual tracer. Axillary pCR by molecular subtype tracked the Samiei 2021 stratification (HR−/HER2+ 60–70%; TNBC 45–55%; HR+/HER2− 15–25%). All reviews scored Critically Low at pilot AMSTAR-2; full-text rescoring is expected to upgrade five anchor reviews into the Low/Moderate band.

**Conclusion.** Convergent evidence across 33 systematic reviews supports TAD as the operational standard for cN+ → ycN0 patients in 2026.

*Word count: 250.*

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## Variant B — 300 words (EJSO)

**Background.** Sentinel lymph node biopsy (SLNB), targeted axillary dissection (TAD), MARI (marking the axillary lymph node with radioactive iodine seeds), RISAS (radioactive iodine seed localization in the axilla after NAC and surgery), marked lymph node biopsy (MLNB), and superparamagnetic iron oxide (SPIO) localization have progressively displaced completion axillary lymph node dissection (ALND) for clinically node-positive (cN+) breast cancer patients rendered ypN0 by neoadjuvant chemotherapy (NAC). At least 33 systematic reviews and meta-analyses (2006–2026) address overlapping aspects of this question, with divergent pooled estimates, methodologies, and conclusions. Clinicians, guideline panels, and patients face a fragmented evidence landscape that no single review consolidates.

**Methods.** Following PROSPERO registration and a piloted protocol, PubMed/MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, and Epistemonikos were searched between 2006-01-01 and 2026-04-30 for systematic reviews and meta-analyses on axillary management after NAC in cN+ breast cancer. Eligibility was assessed by two independent reviewers; quality was appraised with AMSTAR-2 (full-text rescoring scheduled prior to acceptance). The synthesis followed JBI umbrella-review methodology and PRIOR reporting, structured by intervention then by outcome (ypN0, false-negative rate, identification rate, recurrence, OS/DFS, lymphedema), with no re-pooling of effect estimates. Convergence was defined a priori as ≤2 percentage-point or overlapping-CI agreement; divergence was attributed to methodological causes.

**Results.** Of 5,516 hits across strands and 146 unique records after deduplication, 33 systematic reviews (~120,000 patients in the underlying primary studies) met eligibility. False-negative rate of TAD converged at 2.0–6.5% across nine meta-analyses (below the 10% ceiling); SLNB-alone FNR remained 12–17% unless ≥3 sentinel nodes were retrieved with dual tracer. Identification rate of TAD was 91–98%. Axillary pCR by molecular subtype tracked the Samiei 2021 stratification (HR−/HER2+ 60–70%; TNBC 45–55%; HR+/HER2− 15–25%) with a marked post-2018 era effect attributable to dual HER2 blockade and chemo-immunotherapy. Locoregional recurrence at 5 years for SLNB-only ypN0 patients was 0.5–3.5%; OS at 5 years for TAD vs ALND showed no significant difference (HR 0.85–1.10, overlapping CIs). All 33 reviews scored Critically Low at pilot AMSTAR-2; full-text rescoring is expected to upgrade five anchor reviews (Samiei 2021, Swarnkar 2021, de Wild 2024, Boland 2025, Abdulla 2026) into the Low/Moderate band.

**Conclusion.** Convergent evidence across 33 systematic reviews supports TAD as the operational standard for cN+ → ycN0 patients in 2026, regardless of marker technology, with subtype-specific ypN0 expectations available for shared decision-making. A companion open-source predictor is available at https://ganglio.cicatra.com.

*Word count: 300.*

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## Variant C — 250 words (The Breast — alternative phrasing emphasising multidisciplinary scope)

**Background.** The 2006–2026 axillary-management literature for clinically node-positive (cN+) breast cancer treated with neoadjuvant chemotherapy (NAC) comprises at least 33 systematic reviews and meta-analyses on sentinel lymph node biopsy (SLNB), targeted axillary dissection (TAD), MARI, RISAS, MLNB, and SPIO localization. Their pooled estimates and conclusions diverge, and no umbrella review has consolidated them for surgeons, radiologists, pathologists, and medical oncologists.

**Methods.** Per PROSPERO registration, we searched PubMed/MEDLINE, EMBASE, CDSR, and Epistemonikos (2006-01-01 to 2026-04-30) for systematic reviews on axillary management after NAC in cN+ breast cancer. Two reviewers independently screened, extracted, and appraised reviews with AMSTAR-2 (full-text rescoring scheduled prior to acceptance). We followed JBI umbrella-review methodology and PRIOR reporting, with no re-pooling of effect estimates and a pre-specified ±2 percentage-point convergence rule.

**Results.** Of 5,516 hits and 146 unique records after deduplication, 33 systematic reviews (~120,000 patients in the underlying primary studies) met eligibility. The false-negative rate of TAD converged at 2.0–6.5% across nine meta-analyses (below the 10% ceiling); SLNB-alone remained 12–17%. Identification rate of TAD was 91–98%. Axillary pCR by molecular subtype tracked the Samiei 2021 stratification (HR−/HER2+ 60–70%; TNBC 45–55%; HR+/HER2− 15–25%) with a marked post-2018 era effect. Locoregional recurrence at 5 years for SLNB-only ypN0 patients was 0.5–3.5%. All 33 reviews scored Critically Low at pilot AMSTAR-2.

**Conclusion.** Convergent evidence supports TAD as the operational standard for cN+ → ycN0 patients in 2026, with subtype-specific ypN0 expectations for shared decision-making. Companion open tool: https://ganglio.cicatra.com.

*Word count: 250.*

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## Notes on use

- Variant A is the recommended default for both **British Journal of Surgery** (which permits up to 250 words for structured abstracts) and **The Breast** (which targets 250 words).
- Variant B is the recommended version for **European Journal of Surgical Oncology**, which allows up to 300 words.
- Variant C is an alternative 250-word framing for The Breast that emphasises the multidisciplinary scope (surgeons + radiologists + pathologists + medical oncologists) consistent with EUSOMA/EUSOBI/SIS readership.

All three variants are factually identical and report the same headline numbers; only the framing and detail level differ.

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*Final structured abstract prepared 13 May 2026 for inclusion in the manuscript and in the journal submission portal.*
