Axillary Management After Neoadjuvant Endocrine Therapy in HR-Positive/HER2-Negative Breast Cancer

To provide a clinically focused review of axillary management after neoadjuvant endocrine therapy (NET) in hormone receptor-positive/HER2-negative breast cancer and to define where selective de-escalation appears reasonable in current practice. This narrative review used targeted searches of PubMed/MEDLINE, Embase, Google Scholar, Cochrane Library, and ClinicalTrials.gov through April 2026. Direct post-NET axillary evidence was prioritized. Surgery-first, post-neoadjuvant chemotherapy, radiotherapy, and guidance papers were included when they clarified decision-making but were categorized as contextual or extrapolated evidence. The post-NET axilla does not behave like the post-neoadjuvant chemotherapy axilla. Nodal pathologic complete response is uncommon, especially in initially node-positive disease, but limited residual nodal burden after NET may not carry the same clinical meaning as residual disease after chemotherapy. The available evidence supports 3 cautious recommendations: post-NET sentinel lymph node biopsy is generally reasonable for cN0 patients; selective de-escalation may be considered for carefully chosen low-burden cN1 patients; and bulky residual nodal disease or situations in which exact nodal counts would alter adjuvant management still favor more complete axillary treatment. Current evidence supports selective rather than routine axillary de-escalation after NET. Decisions should integrate baseline nodal status, residual burden, tumor biology, radiotherapy, and ongoing endocrine therapy. Short follow-up and the long natural history of HR-positive disease remain important limitations.