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In this institutional retrospective review, 14.4% of clinically node-negative patients meeting SOUND trial criteria had nodal metastases on SLNB, underscoring the need for careful multidisciplinary decision-making before integrating axillary staging de-escalation into practice.

In 167 patients with HR+/HER2− breast cancer after neoadjuvant chemotherapy, lymphovascular invasion, number of positive sentinel nodes, and >50% positive sentinel nodes were the strongest predictors of high axillary burden; a nomogram was developed to guide axillary management decisions.

A decision tree cost-utility analysis found ICG more cost-effective than methylene blue for SLNB in breast cancer (ICER $4,044/QALY), with Monte Carlo simulation showing an 80% probability of ICG superiority.

This literature review and institutional case report describes primary NECB with synchronous pancreatic and liver metastases as an extraordinarily rare, aggressive phenotype requiring multidisciplinary management driven by tumor biology rather than surgery.