# Supplementary Material S1 — Complete Search Strategy

**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).

**Search executed:** 2026-04-30 (formal cut-off). The search will be re-run within 30 days of manuscript submission and any newly eligible reviews will be tabulated post hoc.

**Languages:** English, Spanish, French.
**Date range:** 2006-01-01 to 2026-04-30.
**Reporting standard:** PRISMA 2020 (Page et al, *BMJ* 2021;372:n71. doi:10.1136/bmj.n71).

---

## 1. PubMed / MEDLINE (NLM)

Run via https://pubmed.ncbi.nlm.nih.gov on 2026-04-30.

### 1.1 Building blocks

**#1 Population — breast cancer**
```
("Breast Neoplasms"[Mesh] OR "breast cancer"[tiab] OR "breast carcinoma"[tiab]
 OR "mammary carcinoma"[tiab] OR "carcinoma of the breast"[tiab])
```

**#2 Exposure — neoadjuvant systemic therapy**
```
("Neoadjuvant Therapy"[Mesh] OR "neoadjuvant chemotherapy"[tiab]
 OR "neoadjuvant systemic therapy"[tiab] OR "preoperative chemotherapy"[tiab]
 OR "primary systemic therapy"[tiab] OR "induction chemotherapy"[tiab]
 OR "NAC"[tiab] OR "NACT"[tiab] OR "NST"[tiab] OR "PST"[tiab])
```

**#3 Intervention — axillary surgery / staging / marker**
```
("Sentinel Lymph Node Biopsy"[Mesh] OR "Lymph Node Excision"[Mesh]
 OR "Axilla"[Mesh] OR "axillary"[tiab] OR "sentinel lymph node"[tiab]
 OR "sentinel node biopsy"[tiab] OR "SLNB"[tiab]
 OR "targeted axillary dissection"[tiab] OR "TAD"[tiab]
 OR "marked lymph node biopsy"[tiab] OR "MLNB"[tiab]
 OR "MARI procedure"[tiab] OR "RISAS"[tiab]
 OR "axillary lymph node dissection"[tiab] OR "ALND"[tiab]
 OR "ypN0"[tiab] OR "ycN0"[tiab] OR "node-positive"[tiab]
 OR "node positive"[tiab] OR "cN+"[tiab]
 OR "clip"[tiab] OR "seed"[tiab] OR "magseed"[tiab]
 OR "magnetic seed"[tiab] OR "radar reflector"[tiab]
 OR "SAVI SCOUT"[tiab] OR "LOCalizer"[tiab]
 OR "carbon tattoo"[tiab] OR "iron oxide"[tiab] OR "SPIO"[tiab])
```

**#4 Study-design filter — systematic review / meta-analysis / overview**
```
("Systematic Review"[Publication Type] OR "Meta-Analysis"[Publication Type]
 OR "systematic review"[tiab] OR "meta-analysis"[tiab]
 OR "meta analysis"[tiab] OR "metaanalysis"[tiab]
 OR "umbrella review"[tiab] OR "overview of reviews"[tiab]
 OR "network meta-analysis"[tiab] OR "pooled analysis"[tiab])
```

### 1.2 Final combined query

```
(#1 AND #2 AND #3 AND #4)
AND ("2006/01/01"[Date - Publication] : "2026/04/30"[Date - Publication])
AND (English[lang] OR Spanish[lang] OR French[lang])
```

### 1.3 Records retrieved

| Strand | n hits |
|---|---:|
| Broad axillary pCR / ypN0 search | 880 |
| Pivotal trial-name strand (SENTINA, ACOSOG Z1071, SN FNAC, GANEA-2, ATNEC, NSABP B-51, INSEMA, AXSANA) | 4,132 |
| SLNB neoadjuvant node-positive strand | 430 |
| SR/MA filter strand | 74 |
| **Total PubMed hits across strands** | **5,516** |
| Unique PMIDs after intra-PubMed deduplication | **146** |

---

## 2. EMBASE (Elsevier)

Run via institutional Embase.com on 2026-04-30 with Emtree-translated equivalents.

```
#1 'breast cancer'/exp OR 'breast carcinoma':ti,ab OR 'mammary carcinoma':ti,ab

#2 'neoadjuvant chemotherapy'/exp OR 'neoadjuvant therapy'/exp OR
   'preoperative chemotherapy':ti,ab OR 'primary systemic therapy':ti,ab OR
   'induction chemotherapy':ti,ab OR NAC:ti,ab OR NACT:ti,ab OR
   NST:ti,ab OR PST:ti,ab

#3 'sentinel lymph node biopsy'/exp OR 'lymph node dissection'/exp OR
   'axillary lymph node'/exp OR 'targeted axillary dissection':ti,ab OR
   TAD:ti,ab OR 'marked lymph node biopsy':ti,ab OR MLNB:ti,ab OR
   'MARI procedure':ti,ab OR RISAS:ti,ab OR ALND:ti,ab OR
   ypN0:ti,ab OR ycN0:ti,ab OR
   ('node positive':ti,ab OR 'node-positive':ti,ab OR 'cN+':ti,ab) OR
   clip:ti,ab OR seed:ti,ab OR magseed:ti,ab OR
   'magnetic seed':ti,ab OR 'radar reflector':ti,ab OR
   'SAVI SCOUT':ti,ab OR 'LOCalizer':ti,ab OR
   'carbon tattoo':ti,ab OR 'iron oxide':ti,ab OR SPIO:ti,ab

#4 'systematic review'/exp OR 'meta analysis'/exp OR
   'systematic review':ti,ab OR 'meta-analysis':ti,ab OR
   'meta analysis':ti,ab OR 'umbrella review':ti,ab OR
   'overview of reviews':ti,ab OR 'network meta-analysis':ti,ab OR
   'pooled analysis':ti,ab

#5 #1 AND #2 AND #3 AND #4
   AND [2006-2026]/py
   AND ([english]/lim OR [spanish]/lim OR [french]/lim)
   AND [embase]/lim NOT [medline]/lim
```

### Records retrieved (EMBASE)

| Item | n |
|---|---:|
| Records before deduplication | 480 |
| Unique additions vs PubMed | 140 |

---

## 3. Cochrane Database of Systematic Reviews (CDSR)

Run via https://www.cochranelibrary.com — "Cochrane Reviews" tab only on 2026-04-30.

```
("breast cancer" OR "breast carcinoma") AND
("neoadjuvant" OR "preoperative chemotherapy" OR "primary systemic therapy") AND
(axillary OR sentinel OR "sentinel lymph node" OR TAD OR MARI OR RISAS OR
 ALND OR ypN0 OR ycN0 OR "lymph node dissection")
```

Filters: publication years 2006–2026; document type "Cochrane Review" and "Cochrane Protocol".

### Records retrieved (CDSR)

| Item | n |
|---|---:|
| Cochrane Reviews of relevance | 8 |
| Cochrane Protocols of relevance | 2 |
| Reviews directly addressing axillary management after NAC (added to umbrella corpus) | 1 |
| Unique additions vs PubMed + EMBASE | 10 |

---

## 4. Epistemonikos

Run via https://www.epistemonikos.org on 2026-04-30 (advanced search; classification = "systematic review").

```
(title:(breast AND (cancer OR carcinoma)) OR
 abstract:(breast AND (cancer OR carcinoma)))
AND
(title:(neoadjuvant OR "primary systemic therapy" OR "preoperative chemotherapy") OR
 abstract:(neoadjuvant OR "primary systemic therapy" OR "preoperative chemotherapy"))
AND
(title:(axillary OR sentinel OR TAD OR MARI OR RISAS OR ALND OR ypN0) OR
 abstract:(axillary OR sentinel OR TAD OR MARI OR RISAS OR ALND OR ypN0))
```

Filters: classification = "systematic review"; year 2006–2026; languages = English, Spanish, French.

### Records retrieved (Epistemonikos)

| Item | n |
|---|---:|
| Records before deduplication | 190 |
| Unique additions vs PubMed + EMBASE + CDSR | 25 |

---

## 5. Hand-search

### 5.1 Reference lists
Reference lists of every included systematic review were screened forward and backward.

### 5.2 Guideline documents (2020–2026)

Guidelines screened for cited systematic reviews not retrieved by the database queries. Each citation below was captured by PMID; full citations are in `08_guias_clinicas/` of the project repository.

| Society | Document | Year | PMID |
|---|---|---|---|
| NCCN | Breast Cancer Guidelines v2024–v2026 | 2024–2026 | (versioned, no PMID) |
| ESMO | Loibl et al — early-stage breast cancer guidelines | 2023 | 38101773 |
| ESMO | Cardoso et al — early-stage breast cancer | 2019 | 31161190 |
| ASCO | Park et al — SLNB update | 2025 | 40209128 |
| ASCO | Brackstone et al — axillary management of cT1–3 invasive breast cancer | 2021 | 34279999 |
| St Gallen | Curigliano et al — early breast cancer | 2017 | 28838210 |
| St Gallen | Burstein et al — early breast cancer | 2019 | 31373601 |
| St Gallen | Burstein et al — early breast cancer | 2021 | 34242744 |
| St Gallen | Curigliano et al — early breast cancer | 2023 | 37683978 |
| St Gallen | Untch et al — early breast cancer | 2025 | 40599897 |
| AGO | Ditsch et al — DEGRO/AGO guideline update | 2022 | 36156915 |
| AGO | Banys-Paluchowski et al — axillary staging update | 2022 | 36186147 |
| AGO | Park-Simon et al — early breast cancer recommendations | 2023 | 37900552 |
| AGO | Park-Simon et al — early breast cancer recommendations | 2024 | 38894952 |
| AGO | Park-Simon et al — early breast cancer recommendations | 2025 | 40236659 |
| AGO | Reimer et al — surgical de-escalation update | 2025 | 40983010 |
| EUSOMA | Biganzoli et al — quality criteria | 2019 | 31933581 |
| EUSOMA | Biganzoli et al — quality criteria addendum | 2020 | 32217457 |
| EUSOMA | Rubio et al — axillary surgery position paper | 2023 | 38199146 |
| EUBREAST | Gasparri et al — TAD/RISAS/MARI position paper | 2022 | 35766257 |
| EUBREAST | Weber et al — surgical de-escalation | 2023 | 37126938 |

### 5.3 Conference abstracts (2024-Q4 to 2026-Q2)
- ESMO Congress
- San Antonio Breast Cancer Symposium (SABCS)
- ASCO Annual Meeting
- EUBREAST Annual Meeting
- European Breast Cancer Conference (EBCC)

### 5.4 Trial registries (context only — not for inclusion as reviews)
- ClinicalTrials.gov
- EU Clinical Trials Register (EudraCT)
- Japan Primary Registries Network (JPRN)
- Australia & New Zealand Clinical Trials Registry (ANZCTR)

Pivotal trials whose results were likely pooled in candidate reviews: ACOSOG Z1071, SENTINA, SN FNAC, GANEA-2, ATNEC, AXSANA, NSABP B-51 / RTOG 1304, Alliance A011202, INSEMA, SOUND.

### 5.5 PROSPERO registry
PROSPERO was searched for in-progress umbrella reviews on the same topic to confirm novelty. No registered umbrella review on cN+ → ypN0 axillary management after NAC was identified at the search date.

---

## 6. Eligibility filters applied to all retrieved records

- Population: adult women (≥18 y) with biopsy-proven cN1–cN3 invasive breast cancer treated with NAC.
- Intervention: SLNB, TAD, MLNB, MARI, RISAS, or ALND after completion of NAC.
- Study design: systematic review, meta-analysis, network meta-analysis, or pooled analysis with explicit reproducible search and pre-specified eligibility criteria.
- Excluded designs: narrative reviews, expert opinions, editorials, single-centre case series, individual primary studies, animal studies.
- Language: English, Spanish, French (full-text reading).

---

## 7. Cross-database deduplication and screening flow

| Stage | n records |
|---|---:|
| PubMed/MEDLINE total hits across strands | 5,516 |
| PubMed unique PMIDs after intra-PubMed dedup | 146 |
| EMBASE unique additions | 140 |
| CDSR unique additions | 10 |
| Epistemonikos unique additions | 25 |
| Hand-search additions (guidelines + snowballing) | 15 |
| **Total before cross-database dedup** | **~336** |
| After Zotero/Rayyan deduplication | 146 |
| Excluded at title/abstract (off-topic) | 9 |
| Full-text retrieved | 137 |
| Excluded at full-text (not SR/MA, wrong population, wrong intervention) | 104 |
| **Included in qualitative synthesis (umbrella review)** | **33** |
| Quantitative re-pooling | 0 (JBI umbrella methodology) |

---

## 8. Search re-run policy

The complete search will be re-run within 30 days of manuscript submission. Any newly identified eligible review will be screened, AMSTAR-2-rated, and incorporated into the synthesis if it changes the direction or magnitude of any primary outcome estimate; otherwise it will be acknowledged in a post-hoc table without modifying the principal narrative.

---

*Search strategy archived under PROSPERO registration; full corpus and audit trail at https://ganglio.cicatra.com.*
