The Clinical Impact of Not Performing Axillary Lymph Node Dissection in pN+sn Breast Cancer Patients Undergoing Total...

The sentinel lymph node (SLN) concept has changed the paradigm of surgical staging of breast cancer (BC) patients, allowing fewer patients to undergo axillary lymph node dissection (ALND) when the SLN is metastasized. This study aimed to evaluate regional and distant recurrences, axillary node metastasis-free survival and overall survival in patients with metastasized SLN submitted to total mastectomy (TM), following the application of the Clinical Decision Rule of Unidade Local de Saúde São João (ULSSJ). Additionally, we assessed the impact on adjuvant radiotherapy (RT) proposals and upper limb morbidity in these patients.

We performed a retrospective analysis with 121 patients treated for BC at ULSSJ, between July 1st, 2012 and September 30th, 2022 and followed up until September 30th, 2025, submitted to SLN biopsy (SLNB) and TM. Patients receiving neoadjuvant chemotherapy or who had bilateral disease were excluded.

No statistically significant differences were observed in overall survival (OS) and disease-free survival (DFS) between the patients who underwent ALND and those treated with SLNB alone (P = .131 and P = .223, respectively). Adjuvant axillary RT was administered to most patients, regardless of whether ALND was performed, with no statistically significant differences between the stages (P = .378; P = .129). Upper limb morbidity was higher in the ALND group (P < .001).

These findings support the surgical de-escalation of axillary management, showing no differences in OS and DFS, while reducing upper limb morbidity. Therefore, omission of ALND should be considered an option for a selected group of patients, according to selecting tools.