Management of the Axilla for Early-Stage Breast Cancer: A State-Of-The-Art Review

Axillary management in early-stage breast cancer has shifted from routine clearance to selective, biology-driven intervention. Advances in systemic therapy, imaging, and radiotherapy have reduced the need for axillary lymph node dissection (ALND), limiting morbidity without compromising oncologic outcomes.

This narrative review summarizes evidence supporting surgical de-escalation, targeted axillary dissection (TAD), and regional nodal irradiation (RNI), drawing on randomized trials, prospective cohorts, and international guidelines.

Randomized trials show that completion ALND can be safely omitted in patients with limited sentinel lymph node (SLN) involvement, with equivalent survival and lower lymphedema rates. Noninferiority studies indicate that SLN biopsy itself may be omitted in selected low-risk patients with negative axillary imaging. In biopsy-proven node-positive disease treated with neoadjuvant therapy, TAD-retrieving the clipped node together with SLNs-reduces false-negative rates to ≤ 5%, allowing omission of ALND in responders.

Axillary treatment has evolved toward individualized, minimally invasive strategies guided by tumor biology, treatment response, and patient priorities, requiring multidisciplinary decision-making to optimize outcomes.