De-escalation of Axillary Surgery in Early-Stage Breast Cancer: A Comprehensive Narrative Review

Axillary management in early-stage breast cancer has shifted from routine axillary lymph node dissection (ALND) toward morbidity-sparing strategies that preserve oncologic outcomes. This narrative review summarizes the key practice-changing trials and contemporary guidance across the axillary de-escalation continuum: omission of completion ALND for limited sentinel lymph node metastasis, use of axillary radiotherapy when additional regional treatment is indicated, and omission of sentinel lymph node biopsy (SLNB) in carefully selected low-risk clinically node-negative patients. In the neoadjuvant setting, optimized SLNB and targeted axillary dissection can allow many initially node-positive patients to avoid ALND. Across scenarios, optimal axillary management increasingly depends on multidisciplinary integration of nodal burden, tumor biology, systemic therapy, and planned radiotherapy fields.