[Optimized regional lymph node management after neoadjuvant therapy in breast cancer]

Neoadjuvant therapy (NAT) has strengthened systemic control in breast cancer and promoted precision de-escalation of axillary management. For clinically node-negative patients, evidence supports sentinel lymph node biopsy (SLNB) after NAT; among human epidermal growth factor receptor 2(HER2)-positive and triple-negative breast cancer patients achieving breast pathological complete response, the risk of residual axillary metastasis is extremely low, suggesting the potential omission of axillary surgery. For clinically node-positive patients converting to node-negative (cN1➝ycN0) after NAT, targeted axillary dissection can reduce the false-negative rate of SLNB to 2%-4% with good local control, supporting SLNB as a substitute for axillary lymph node dissection. In patients with low-volume residual nodal disease, axillary radiotherapy is increasingly considered as an alternative to surgery, though long-term evidence is still required. With studies such as NSABP B-51 demonstrating reduced regional irradiation in selected patients, dual de-escalation of surgery and radiotherapy has become a research focus. Future advances in imaging, artificial intelligence, and circulating tumor DNA (ctDNA) may enable individualized axillary decision-making.