Optimizing axillary surgery for patients with clinically node-negative and node-positive breast cancer

It is important that axillary surgery is optimized for de-escalation in the era of sentinel lymph node biopsy for early breast cancer. Several randomized trials of clinically node-negative breast cancer have demonstrated the non-inferiority of regional lymph node recurrence and distant metastasis in women aged ≥ 50 years with small tumors of the luminal subtype who did not undergo axillary surgery compared with those who underwent sentinel lymph node biopsy. Tailored axillary surgery has been attempted to personalize axillary management in patients with clinically node-positive breast cancer treated with neoadjuvant chemotherapy. Image-guided localization, such as clipping, has been shown to accurately diagnose lymph node involvement and reduce the rate of false negatives for sentinel lymph node biopsy. This technique also reduces regional lymph node recurrence, although regional nodal irradiation and adjuvant therapy are usually required for this purpose. In this review, we aimed to facilitate the optimization of axillary surgery for patients with clinically node-negative and node-positive breast cancer by discussing the findings of randomized trials and our own experiences at the Japanese Society for Sentinel Node Navigation Surgery.