Axillary management in the surgical treatment of breast cancer has become one of the most important and rapidly evolving issues in recent years. For decades, biopsy- proven clinically positive axillary lymph nodes — cN(+) status — almost automatically implied the need for axillary lymph node dissection (ALND). Contemporary evidence, advances in neoadjuvant systemic therapy, and the principles of personalized treatment have significantly changed this approach. However, the key message is not a simplistic statement that “ALND is no longer needed.”
The more accurate question is: which patients still require ALND, in whom can it be safely omitted, and under what circumstances should surgical de-escalation not be attempted? The presentation discusses a modern approach based on risk stratification and treatment response. Management of cN(+) patients should no longer be guided solely by the initial nodal status. Instead, decisive importance is given to the actual residual risk after neoadjuvant treatment.
If a patient with initially biopsy-proven cN1 disease converts to ycN0/ypN0 status after neoadjuvant therapy, axillary surgical de-escalation may be considered. Conversely, if clinically or pathologically confirmed residual nodal disease persists — ypN(+) — or if the patient presents with high-volume, bulky cN2–3 disease, ALND remains the standard and safest treatment option. ALND is an effective procedure for staging, regional disease control, and planning subsequent treatment; however, it is not a harmless intervention. Lymphedema, pain, restricted shoulder mobility, sensory disturbances, and impaired quality of life have become increasingly relevant in an era when breast cancer survival has substantially improved. Therefore, the goal of de-escalation is not “less oncology,” but rather fewer treatment-related complications while maintaining oncological safety.
It is essential to distinguish between evidence derived from clinically node- negative patients and biopsy-proven cN(+) disease. Trials such as Z0011, AMAROS, SENOMAC, SOUND, and INSEMA have demonstrated that less extensive axillary surgery may be safe in selected patients. However, these data cannot be directly extrapolated to all patients who initially present with cN(+) disease. In this setting, stricter patient selection, technically reliable staging, and multidisciplinary decision- making are required.
One of the central topics of the presentation is Targeted Axillary Dissection — TAD — which combines sentinel lymph node biopsy with removal of the initially metastatic lymph node that was marked before neoadjuvant therapy. This technique increases the reliability of post-treatment axillary staging and reduces the risk of false- negative results. The use of dual tracers, retrieval of an adequate number of sentinel lymph nodes, and successful identification of the marked node are particularly important.
The practical message is clear: de-escalation is reasonable only in carefully selected patients — those with initially non-bulky cN1 disease, a good response to neoadjuvant treatment resulting in ycN0 status, technically successful SLNB/TAD, and confirmed ypN0 disease. In contrast, in cases of persistent ycN(+), ypN(+), cN2–3 disease, failed mapping, failure to retrieve the clipped node, or inflammatory breast cancer, omission of ALND should not be considered a safe approach. For Georgia and the wider region, this issue has particular practical relevance.
Safe de-escalation requires high-quality imaging, reliable nodal marking, availability of tracers, surgical expertise, accurate pathology, appropriate planning of regional radiotherapy, and a functional multidisciplinary team. If these components are incomplete, “less surgery” may ultimately become undertreatment. The aim of modern axillary surgery is no longer to remove as many lymph nodes as possible. Its purpose is to ensure that no patient is undertreated, while also preventing harm caused by overtreatment.
Professor Irakli Kokhreidze, MD, PhD Associate Professor, Department of Oncology, Tbilisi State Medical University, Head of Oncology, Caraps Medline Member of the VIAN Oncology and Hematology Board Founder and Full Member of MOB, International Healthcare Conference GIMPHA Session Chair and Speaker
