August 13, 2025Open Access

The Role of Axillary Lymph Node Dissection in Breast Cancer Patients With Residual Nodal Disease After Receiving Neoadjuvant Chemotherapy

KSKristina ShafferUniversity of North Carolina at Chapel Hill LHLilian HarrisNovant Health LGLori F. GentileNovant Health

Key Points

Axillary lymph node dissection did not improve survival or recurrence outcomes compared to sentinel lymph node biopsy.
Overall survival rates were nearly identical: 68.6% for ALND and 70.6% for SLNB, with no significant difference at P = 1.
Analysis included 155 patients, predominantly receiving neoadjuvant chemotherapy and followed for a median of 56 months.
Lymphedema rates were significantly higher in the ALND group at 57.9%, compared to 35.3% for SLNB, indicating a treatment risk.

Abstract

Background: While sentinel lymph node biopsy (SLNB) in breast cancer patients with limited axillary disease undergoing upfront surgery is well-accepted, there are insufficient data supporting its safety with residual nodal disease (RND) following neoadjuvant chemotherapy (NAC). Objectives: To evaluate axillary management and oncologic outcomes of patients with RND. Design: A retrospective review comparing patients receiving SLNB to those receiving axillary lymph node dissection (ALND). Methods: Patients treated for breast cancer at our institution between 2015 and 2023, who received NAC and had RND, were identified. Patient and tumor characteristics, treatments, and outcomes information were collected. The relationship between axillary management and oncologic outcomes was examined. Results: Of 155 patients, median age was 55 years (interquartile range IQR 46–64) and follow-up 56 months (IQR 34–73). Most patients were pathologic tumor stage 1–2 (105, 67.7%) and nodal stage 1 (106, 68.4%), with ductal histology (127, 81.9%). The most common receptor pattern was estrogen receptor-positive, progesterone receptor-positive, and human epidermal growth factor receptor 2-negative. A total of 107 (69.0%) underwent mastectomy, 47 (30.3%) lumpectomy, and 138 (89.0%) received adjuvant radiation. Regarding axillary management, 121 (78.1%) underwent ALND and 34 (21.9%) SLNB. Univariate analysis found no differences in overall survival (68.6% vs 70.6%; P = 1), any recurrence (local, axillary, or distant; 36.4% vs 35.3%; P = 1), or specifically axillary recurrence (9.9% vs 8.8%; P = 1), between ALND and SLNB groups, respectively. This was also demonstrated on multivariate analysis. Conversely, there was a significantly increased rate of lymphedema in the ALND, 57.9%, vs the SLNB group, 35.3% ( P = 0.03). Conclusions: ALND was not associated with improved survival or recurrence risk compared with SLNB in patients with RND following NAC, but was found to have a higher rate of lymphedema. This study is limited due to its retrospective nature. Further data, such as from the ALLIANCE A011202 trial, will help to further clarify the optimal oncologic management for this group of patients.

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