Axillary Surgery in Breast Cancer: Evidence-Based De-escalation Across Upfront and Post-Neoadjuvant Settings Running title: Modern Trends in Axillary Surgery.

  • Post category:Breast Cancer
  • Reading time:2 mins read

Journal: Journal of breast cancer

This publication is a narrative review of the progressive de-escalation of axillary surgery in breast cancer and synthesizes data from major randomized trials across different levels of nodal disease burden and treatment settings.

Key points:

  • Historical shift in axillary management
  • Axillary lymph node dissection (ALND) has been largely replaced by sentinel lymph node biopsy (SLNB), significantly reducing lymphedema and shoulder dysfunction without compromising oncologic safety.
  • The field is now moving further, questioning the need for SLNB itself in carefully selected patients.
  • Evidence by nodal disease burden
  • Micrometastases (≤ 2 mm)
  • Trials such as IBCSG 23-01 and AATRM showed that omitting ALND in patients with one or more micrometastatic sentinel nodes does not worsen survival or locoregional control.
  • Mixed micrometastatic/macrometastatic disease (1–2 positive SLNs)
  • ACOSOG Z0011 and AMAROS included patients with 1–2 positive sentinel nodes, irrespective of metastasis size.
  • With appropriate systemic therapy and radiotherapy, avoidance of ALND was safe in terms of recurrence and survival.
  • Macrometastases (≥ 2 mm; 1–2 positive SLNs)
  • Trials such as SENOMAC, SINODAR-ONE, and POSNOC extended de-escalation to patients with 1–2 macrometastatic nodes, again showing that ALND omission is safe when contemporary systemic and radiation therapies are used.
  • Omission of SLNB in cN0 disease
  • SOUND and INSEMA demonstrated non-inferiority of axillary observation compared with SLNB in clinically node-negative, imaging-negative patients.
  • NAUTILUS and similar studies are validating this strategy in Asian populations.
  • Neoadjuvant setting
  • SLNB is standard for clinically node-negative patients and is feasible in those initially node-positive who convert to clinically node-negative after neoadjuvant chemotherapy.
  • Ongoing trials (ASICS, EUBREAST-01, ASLAN) are testing complete omission of axillary surgery in excellent responders, particularly in HER2-positive and triple-negative subtypes, where pathologic complete response rates are high.
  • Clinical implications
  • The overarching trend is from maximal clearance to biologically and response-adapted optimization of axillary treatment.
  • Decisions on axillary surgery should integrate tumor biology, systemic therapy responsiveness, imaging/clinical nodal status, and long-term quality-of-life considerations, rather than defaulting to extensive surgical staging.

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