De-escalating axillary surgery in node-positive early breast cancer patients undergoing primary surgery: current evidence and recommendations

Landmark trials have shown that axillary lymph node dissection (ALND) can be safely omitted in early breast cancer patients with 1-2 positive nodes. Despite lack of prospective data, the National Comprehensive Cancer Network (NCCN) guidelines recommend that patients with 1-2 suspicious or biopsy-proven positive lymph nodes having primary surgery can undergo sentinel lymph node biopsy (SLNB). In the era of de-escalation of axillary surgery, breast cancer management in patients with clinically node-positive (cN +) axilla is driven by tumour biology and response to neoadjuvant chemotherapy (NACT). In this review, we discuss the management of the axilla in early breast cancer patients with low-volume biopsy-proven nodal disease and summarise the evidence supporting omission of ALND in these patients undergoing primary surgery.