Nomogram-guided sentinel node strategy in early breast cancer: Evaluation and comparison with current de-escalation approaches

Clinical Surgical Oncology Pub Date : 2026-03-01 Epub Date: 2026-02-13 DOI:10.1016/j.cson.2026.100122

Justin James , Sumudu Welikumbura , Emily Schembri , Kirti Mehta , Michael Law , Shomik Sengupta , Christobel Saunders

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Abstract

Background and purpose

We externally validated the Memorial Sloan Kettering Cancer Center (MSKCC) sentinel node nomogram and compared its performance as an SLNB omission strategy with that of the SOUND and INSEMA trial strategies and the ASCO 2021 guideline.

Methods

We retrospectively analysed 1080 women with clinically and sonographically node-negative EBC treated at a tertiary Australian center between 2012 and 2020. Predicted nodal risk was generated using the MSKCC calculator. Discrimination and calibration were assessed, and clinical utility was evaluated using false-negative rate (FNR) and negative predictive value (NPV). A nomogram-guided strategy was simulated by applying an MSKCC probability cut-off to identify patients eligible for SLNB omission. Trial and guideline criteria were applied for direct comparison.

Results

Macrometastatic nodal disease was present in 187 patients (17.3%). The MSKCC nomogram showed good discrimination (AUC 0.77, 95% CI 0.73–0.80) and reasonable calibration. At a 23% risk threshold, 308 patients (29%) were eligible for SLNB omission, with an FNR of 9.6% and the highest NPV (94.2%) among all strategies evaluated. The SOUND strategy spared 493 patients (46%), with an FNR of 29.4% and an NPV of 88.8%, while the INSEMA strategy spared 723 patients (67%), with an FNR of 53.5% and an NPV of 86.2%. The ASCO 2021 guideline was the most conservative, sparing 162 patients (15%), with an FNR of 6.9% and an NPV of 92.0%.

Conclusions

A nomogram-guided approach may offer a flexible, risk-adapted alternative for SLNB omission, though prospective validation and long-term follow-up are required.

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早期乳腺癌的nomogram引导前哨淋巴结策略：与当前降压方法的评价和比较

背景和目的我们外部验证了纪念斯隆-凯特琳癌症中心（MSKCC）前哨淋巴结nomogram，并将其作为SLNB省略策略与SOUND和INSEMA试验策略以及ASCO 2021指南的性能进行了比较。方法回顾性分析2012年至2020年在澳大利亚一家三级中心接受临床和超声检查淋巴结阴性EBC治疗的1080名妇女。预测节点风险使用MSKCC计算器生成。通过假阴性率（FNR）和阴性预测值（NPV）评估鉴别和校准，并评估临床效用。通过应用MSKCC概率截止值来模拟nomogram guided strategy，以确定有资格省略SLNB的患者。采用试验标准和指南标准进行直接比较。结果大转移性淋巴结病187例（17.3%）。MSKCC图具有良好的鉴别能力（AUC 0.77, 95% CI 0.73-0.80）和合理的校正。在23%的风险阈值下，308例患者（29%）符合遗漏SLNB的条件，FNR为9.6%，NPV最高（94.2%）。SOUND策略挽救了493例患者（46%），FNR为29.4%，NPV为88.8%，而INSEMA策略挽救了723例患者（67%），FNR为53.5%，NPV为86.2%。ASCO 2021指南是最保守的，保留了162例患者（15%），FNR为6.9%，NPV为92.0%。结论：尽管需要前瞻性验证和长期随访，但nomogram guided approach可能为SLNB遗漏提供了一种灵活的、适应风险的替代方法。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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Clinical Surgical Oncology

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