Sentinel: a brief history of nodal surgery in breast cancer

Since the introduction of radical breast and axillary surgery by William Halsted, breast cancer treatment-including nodal surgery-has gradually evolved toward more conservative approaches. This narrative review outlines the key steps in the de-escalation of axillary management, including the adoption of sentinel lymph node biopsy for clinically node-negative early breast cancer and later for larger tumors; the omission of completion axillary dissection in cases with minimal or limited macrometastatic sentinel lymph node involvement; the substitution of surgery with radiotherapy and systemic therapy, or omission in selected patients; and subsequent application in the neoadjuvant setting. Future directions in the de-escalation process are also outlined.