Implementation of Targeted Axillary Dissection in Clinically Node-Positive Breast Cancer: Adoption Trends and...

Historically, axillary lymph node dissection (ALND) was the standard of care for patients with node-positive breast cancer following neoadjuvant systemic therapy (NST). Current evidence supports de-escalated axillary procedures, including targeted axillary dissection (TAD) after NST, which demonstrate low false-negative rates and reduced morbidity compared with ALND. This study analyzed the temporal trends in the adoption of TAD among clinically node-positive breast cancer patients at a single institution.

Our retrospective cohort study included patients diagnosed with clinical N1 (cN1) breast cancer who underwent axillary lymph node excision at the Breast Care Center at Montefiore Einstein between 2017 and 2024. Annual evaluations assessed temporal trends in the planning and completion of TAD compared to ALND. Multivariate analyses were performed to identify clinically relevant factors associated with the utilization of TAD.

The study cohort included 224 patients, of whom 116 (51%) received TAD, 14 (6%) received SNLB, and 94 (43%) received ALND. Compared to TAD, patients who received ALND had a greater average number of nodes removed (4.5 vs. 15.3, P < .001). Pathologic outcomes favored TAD, with significantly higher rates of pathologic complete response (pCR) (47.7% vs. 8.5%, P < .001) and axillary complete response (66.2% vs. 13.8%, P < .001). Temporal trend analysis indicated a significant increase in TAD planning from 2017 to 2024 (P < .001), with 37.2% higher odds of planned TAD each year. In contrast, the actual completion of TAD rose more modestly, with a 13.7% increase (P = .032).

TAD is increasingly selected as the planned surgical approach, particularly for patients who have a higher response to NST. High conversion rates to ALND reflect ongoing preoperative challenges, with limited frozen analysis causing overtreatment in ALND patients with pCR and undertreatment in TAD patients needing delayed ALND. These findings highlight the evolving practice patterns toward axillary conservation and the crucial role of intraoperative evaluation of residual nodal disease in optimizing surgical management.