De-escalation of axillary treatment in early breast cancer—a narrative review of current trials

Background and Objective: In the era of de-escalation and minimally invasive locoregional treatments across many fields of surgical oncology, the treatment of the axilla in breast cancer has garnered significant interest. While the knowledge of axillary lymph node involvement is crucial for multidisciplinary management, the surgical approach to the axillary basin can have potential disadvantages that may impact the quality of life. The objective of this narrative review is to examine studies about de-escalation of axillary treatment in various clinical scenarios, namely the settings of upfront surgery and neoadjuvant systemic treatments. Moreover, trials investigating omission of axillary surgery were examined. Methods: As of July 2024, a comprehensive literature search, compilation, and analysis were conducted across PubMed, Scopus, Web of Sciences, and ClinicalTrials.gov. Key Content and Findings: In patients with clinically node-negative lymph nodes and up to two positive sentinel nodes, avoiding axillary lymph node dissection is a safe option. As for patients receiving neoadjuvant systemic treatment, axillary lymph node dissection is unnecessary if no residual tumor burden remained in the lymph nodes after surgery. Additionally, studies have shown that axillary radiotherapy can be as effective as axillary dissection in certain cases. The avoidance of any axillary surgery might be proposed to highly select sub-groups patients with small tumors and negative on clinical and ultrasound evaluation lymph nodes. Conclusions: To date, determining the appropriate axillary treatment remains a complex decision that must be made by multidisciplinary teams with expertise in personalized breast cancer treatment.