Breast and axillary surgery after neoadjuvant therapy: targeted axillary dissection and the limits of de-escalation
Authors: Dr. Md. Zaker Ullah
Institution: Barts Health NHS Trust, London, UK
Introduction
To review breast and axillary surgery following neoadjuvant systemic therapy (NST), focusing on targeted axillary dissection (TAD) and de-escalation limits.
Methods
Key trials and cohort studies assessing sentinel lymph node biopsy (SLNB), targeted removal of positive nodes and axillary lymph node dissection (ALND) after NST were reviewed, including ACOSOG Z1071, SENTINA and RISAS.
Results
NST can downstage disease in the breast and axilla, allowing less extensive surgery in patients. In patients who are node-positive before treatment and node-negative afterwards, SLNB alone has a recognised false-negative rate. Accuracy improves with dual tracer, retrieval of several sentinel nodes and confirmation that the marked positive node has been removed. TAD combines SLNB with removal of the marked node and provides more accurate assessment of the axilla after treatment. In patients with no residual nodal disease, this may allow ALND to be avoided. However, de-escalation is less straightforward when residual disease remains, the marked node cannot be retrieved, nodal findings are discordant, or there was a high nodal burden before treatment. Regional nodal radiotherapy remains important.
Conclusion
TAD is an important part of axillary management after NST and can reduce the need for ALND in selected patients. It improves staging accuracy while limiting morbidity from extensive surgery. However, it should not replace ALND in all patients. Pretreatment disease burden, response to NST, node localisation, residual disease and planned radiotherapy must be considered. Long-term outcome data are needed to define how far breast and axillary surgery can safely be de-escalated without compromising oncological outcomes.