Abstract
Background:
The optimal management of axillary lymph nodes after neoadjuvant systemic therapy (NST) in breast cancer remains controversial. The oncological outcomes of sentinel lymph node biopsy (SLNB) alone compared with axillary lymph node dissection (ALND) after NST are not well established.
Objective:
This study comprehensively evaluated the long-term outcomes of SLNB alone versus ALND following NST in breast cancer patients achieving ycN0 status.
Design:
A retrospective, multicenter, real-world study.
Methods:
Patients initially presenting with clinically node-negative (cN0) or clinically node-positive (cN+) breast cancer who remained or converted to ycN0 after NST (2011–2022) were included. Patients were divided into SLNB-alone and ALND groups. Primary endpoints were disease-free survival (DFS) and overall survival (OS). Secondary endpoints included recurrence rates, local recurrence-free survival (LRFS), regional recurrence-free survival (RRFS), and distant metastasis-free survival (DMFS). Inverse probability of treatment weighting (IPTW) was applied to balance baseline characteristics.
Results:
A total of 1381 patients were included: 461 received SLNB alone, and 920 underwent ALND. Median follow-up was 34.2 months (range: 1.2–142.6 months). Local (2.8% vs 3.3%, p = 0.656) and regional (2.0% vs 1.3%, p = 0.353) recurrence rates were comparable between SLNB and ALND groups; distant metastases occurred in 5.6% versus 8.5% (p = 0.059). No significant differences in DFS, OS, LRFS, RRFS, or DMFS were observed between the SLNB-alone and ALND groups after IPTW adjustment. Subgroup analyses confirmed similar DFS or OS between the two surgical approaches across initial cN0 and cN+ subgroups; however, patients with initial cN2-3 disease exhibited inferior LRFS with SLNB alone.
Conclusion:
SLNB alone achieves oncologic outcomes comparable to ALND in ycN0 breast cancer patients after NST, regardless of initial nodal status, with caution warranted in initial cN2-3 disease. This suggests that SLNB alone can safely substitute ALND without compromising oncologic outcomes in appropriately selected patients.
Keywords
Introduction
In recent years, neoadjuvant systemic therapy (NST) has been increasingly utilized for patients with operable early-stage breast cancer.1,2 Pathologic complete response (pCR) rates following NST can reach as high as 50%–70% in patients with human epidermal growth factor receptor 2 (HER2)-positive tumors 3 or triple-negative breast cancer. 4 NST has the potential to eradicate axillary lymph nodes, with pCR rates in the axilla exceeding 40%–50% in patients initially presenting with clinically node-positive (cN+) disease.5,6
For patients who undergo primary surgery, sentinel lymph node biopsy (SLNB) has emerged as the standard of care for axillary node staging. In recent years, there has been a growing shift toward using SLNB alone after NST to avoid the adverse effects of axillary lymph node dissection (ALND). Nonetheless, the accuracy and timing of SLNB in the neoadjuvant setting remain subjects of controversy, particularly for patients presenting with cN+ disease prior to NST. Previous studies demonstrated that identification rates of sentinel lymph nodes (SLNs) and false-negative rates (FNRs) were comparable between clinically node-negative (cN0) patients undergoing SLNB prior to neoadjuvant chemotherapy (NAC) and those treated with SLNB after NAC, thereby supporting the feasibility of SLNB following NAC in cN0 patients.7,8
By contrast, the surgical management of the axilla for patients with initial cN+ disease remains a topic of ongoing debate. Three prospective studies (ACOSOG Z1071 (Alliance), 5 SN FNAC, 9 and SENTINA 10 trials) showed that, among patients who initially presented with cN+ disease and converted to cN0 after NST, SLNB following NST resulted in FNR exceeding 10%, failing to achieve their primary study endpoints. Nevertheless, technical modifications, including the use of dual tracer and removal of ⩾3 SLNs, could lead to achieving clinically acceptable FNRs of <10%.5,9,10 Two subsequent meta-analyses further confirmed the accuracy and reliability of SLNB after NST in patients with cN+ breast cancer.11,12 While these studies established the technical reliability of SLNB, most required completion of ALND for all patients to determine FNRs. Data on long-term clinical outcomes following SLNB alone versus ALND, particularly in patients with higher initial nodal burden (e.g., cN2-3) and in real-world, multicenter settings, remain limited and contentious.
This study aimed to comprehensively evaluate oncologic outcomes of SLNB alone versus complete ALND in multicenter cohorts of patients who initially presented with cN0 or cN+ breast cancer and remained or converted to ycN0 after NST. By including patients with higher initial nodal stage and applying inverse probability of treatment weighting (IPTW) to reduce confounding, this study provides novel evidence supporting axillary de-escalation and complements existing literature with long-term outcome data in a broader patient population.
Materials and methods
Study design and patients
In this retrospective, real-world, multicenter study, patients with pathologically diagnosed invasive breast cancer who underwent NAC followed by surgery from January 2011 to September 2022 at Sun Yat-sen Memorial Hospital, Sun Yat-sen University, and Henan Provincial People’s Hospital were reviewed. Eligible criteria comprised the following: (1) female patients aged 18 years or older; (2) patients with biopsy-confirmed early-stage (clinically T1-4, N0-3, and M0) breast cancer who were treated with NST; and (3) patients who converted to ycN0 status after NST through physical or radiological examination. Exclusion criteria included the following: (1) bilateral cancers; (2) unknown data regarding cT/cN stage, pathological T or N stage (ypT/ypN), or molecular subtype; (3) prior axillary surgery (including SNLB before NST) or neoadjuvant radiotherapy to the breast or axilla; (4) persistent ycN+ disease post-NST; (5) use of NST regimens rather than chemotherapy (such as endocrine therapy alone) or unknown regimens, or disease progression during NST; (6) missing axillary management data and follow-up data; and (7) concomitant malignancies. Ultimately, 1381 eligible patients were included. Based on axillary surgery after NST, 461 and 920 patients were divided into the SLNB-alone group and the ALND group (including ALND alone, and SLNB followed by staged ALND), respectively. Figure 1 depicts the study selection process.
Flow diagram depicting the study design and selection process.
The study was conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines and received approval by the ethics committee of Sun Yat-sen Memorial Hospital, Sun Yat-sen University, with a waiver for informed consent (No. SYSKY-2024-655-01). The last follow-up was conducted on March 13th, 2024. The reporting of this study conforms to the STROBE statement (see Supplemental Material 1).
Treatment
Axillary clinical staging was assessed before NST using radiological examination and a fine needle aspiration of suspicious nodes. All patients received NAC, with treatment regimens selected according to standard protocols at the discretion of treating physicians. Neoadjuvant anti-HER2-targeted therapies with single or dual HER2 blockade were administered to a subset of HER2-positive patients. After NST and within 4 weeks before surgery, patients received a physical examination and a radiological examination. Axillary and breast surgical approach was determined based on clinical and pathological considerations, the treating physician’s discretion, and discussion with the patient. SLNB was performed with blue dye and/or 99Tc-labeled colloid injection technique. Lymph nodes that are radioactive, blue, or palpably abnormal were considered SLNs and were resected for pathological analysis. At least two SLNs were resected. The breast surgery approach consisted of either mastectomy or breast-conserving surgery (BCS). Subsequently, patients underwent adjuvant therapy in line with the established clinical guidelines.
Study endpoints
The primary endpoints were disease-free survival (DFS) and overall survival (OS). DFS was defined as the time from surgery to the first evidence of relapse at any site (local, regional, and distant), appearance of a second contralateral primary breast cancer (excluding in situ carcinoma), other secondary malignancies, or death from any cause, whichever occurs first. OS was defined as the time from surgery to death from any cause.
Secondary endpoints included recurrence (including local recurrence, regional recurrence, and distant metastases) rates, local recurrence-free survival (LRFS), regional recurrence-free survival (RRFS), and distant metastasis-free survival (DMFS). Local recurrence was defined as a recurrence in the ipsilateral breast. Regional recurrence was defined as a recurrence in the ipsilateral axillary, supraclavicular, or internal mammary lymph nodes. Recurrence other than local or regional was defined as distant metastases. LRFS was defined as the time interval from surgery to local recurrence. RRFS was defined as the time interval from surgery to regional recurrence. DMFS was defined as the time interval from surgery to distant metastases.
Statistical analysis
The differences in characteristics between groups were evaluated using the Mann–Whitney U test for continuous variables and the Pearson χ2 test for categorical variables. The Kaplan–Meier method and log-rank test were employed to analyze LRFS, RRFS, DMFS, DFS, and OS. Cox proportional-hazards regression was utilized to calculate hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs). Univariate and multivariable Cox regression analyses were used to assess the predictive value of each variable on survival outcomes.
In addition, to account for potential cofounding variables between groups in comparisons of outcomes, IPTW calculated from the propensity score was applied to control for imbalances in baseline characteristics between the SLNB-alone group and the ALND group. 13 In this approach, patients were weighted using a propensity score derived from a multivariable logistic-regression model that encompassed all available covariates. Details of the IPTW analyses are found in Supplemental Material 2. Covariate balance between the SLNB-alone and ALND groups before and after IPTW was assessed using standardized mean differences, with values <0.1 indicating good balance. The propensity score model included age, menopausal status, clinical T and N stage, clinical stage, histologic type, estrogen receptor (ER) and progesterone receptor (PR) status, HER2 status, Ki-67 index, molecular subtype, pathologic T stage, pCR status, type of breast surgery, adjuvant radiotherapy, and adjuvant systemic therapy. IPTW-adjusted Kaplan–Meier curves and log-rank test were employed to compare survival outcomes between patients who received SLNB alone and those who underwent ALND. 14 In addition, weighted Cox proportional-hazards models were utilized to compute the IPTW-adjusted HR. 15
All statistical tests were two-sided, and a p value less than 0.05 was considered statistically significant. Statistical analyses were conducted using R software, version 4.1.3 (https://www.R-project.org).
Results
Clinical and treatment characteristics
Among 1381 patients included, 461 (33.4%) patients received SLNB alone, while 920 (66.6%) underwent ALND. Over the period from 2011 to 2021, there was a notable increase in the utilization of SLNB alone, rising from 18.2% in 2011 to 44.5% in 2021 (Figure S1). Before IPTW matching, significant differences in baseline patient and treatment characteristics were observed between the two groups. Patients treated with SLNB alone tended to be younger and presented with lower cT stage and cN stage. In addition, the SLNB alone group exhibited a higher likelihood of having ER-positive tumors and PR-positive tumors, and a lower prevalence of HER2-positive diseases. In terms of treatment, compared to patients treated with ALND, a greater proportion of patients in the SLNB-alone group underwent BCS, while fewer patients received adjuvant radiotherapy. After IPTW matching, the two treatment groups were well balanced for all baseline clinical and treatment characteristics (Table S1). Detailed characteristics for the unmatched cohort and the IPTW-matching cohort are described in Table 1.
Clinical and treatment characteristics of patients by the type of axillary surgery before and after IPTW.*
Counts in the IPTW-weighted cohort may not precisely add up to the expected totals due to rounding. Percentages may not sum up to 100 owing to rounding, and discrepancies between counts and percentages in the IPTW-weighted cohort arise from rounding of non-integer values.
The p values were calculated by the chi-square test.
The p values were calculated by IPTW logistic-regression models.
ALND, axillary lymph node dissection; ER, estrogen receptor; HER2, human epidermal growth factor receptor 2; IPTW, inverse probability of treatment weight; pCR, pathological complete response; PR, progesterone receptor; SLNB, sentinel lymph node biopsy; TNBC, triple-negative breast cancer.
Recurrences and deaths
The median follow-up duration was 34.2 months (range: 1.2–142.6 months) for all patients, 33.2 months (range: 1.3–142.6 months) for the SLNB-alone group, and 34.7 months (range: 1.2–132.2 months) for the ALND group. During the follow-up period, the proportions of patients with local recurrences (2.8% vs 3.3%, p = 0.656) and regional recurrences (2.0% vs 1.3%, p = 0.353) were comparable between the SLNB-alone group and the ALND group (Table 2). By contrast, distant metastases tended to be less frequent in the SLNB-alone group (5.6% vs 8.5%), although this difference did not reach statistical significance (p = 0.059). In addition, there were fewer deaths in the SLNB-alone group (1.7% vs 4.3%, p = 0.012). Consistent results were observed for the DFS events and number of deaths between the two treatment groups when stratified by initial cN stage (cN0 vs cN+; Table 2). Similar findings were also noted when outcomes were compared between patients with cN1 and cN2-3 diseases (Table S2).
Recurrence pattern and death by type of axillary surgery and initial clinical N stage.
ALND, axillary lymph node dissection; cN+, clinically node-positive; cN0, clinically node-negative; SLNB, sentinel lymph node biopsy.
Survival outcomes
Before IPTW adjustment, both univariate and multivariable analyses revealed no significant differences in terms of DFS, LRFS, RRFS, and DMFS between the SLNB-alone group and the ALND group (Table 3). On univariate analysis, SLNB alone was associated with improved OS compared with ALND (HR 0.41, 95% CI: 0.19–0.87, p = 0.021). However, after adjustment for other confounding variables on multivariable analysis, no significant differences in OS were observed between the two groups (HR 0.50, 95% CI: 0.21–1.18, p = 0.11). Kaplan–Meier survival analysis showed that the DFS at 5 years was 87.0% (95% CI: 82.4–91.9) in the SLNB-alone group, compared to 84.5% (81.4–87.7) in the ALND group (log-rank p = 0.155; Figure 2(a); Table S3). Likewise, there were no significant differences in LRFS, RRFS, and DMFS between the two groups (Figure S2; Table S3). By contrast, improved OS was observed in the SLNB-alone group compared to the ALND group, with an estimated 5-year OS of 97.1% (95% CI: 94.8–99.4) versus 92.8% (95% CI: 90.5–95.3; log-rank p = 0.017; Figure 2(b); Table S3).
Univariate and multivariable analyses of DFS, OS, RRFS, LRFS, and DMFS before and after IPTW.
Adjusted for variables listed in Table 1.
HRs after IPTW were estimated with the use of IPTW Cox proportional-hazards models.
ALND, axillary lymph node dissection; CI, confidence interval; DFS, disease-free survival; DMFS, distant metastasis-free survival; HR, hazard ratio; IPTW, inverse probability of treatment weight; LRFS, local recurrence-free survival; OS, overall survival; RRFS, regional recurrence-free survival; SLNB, sentinel lymph node biopsy.
Kaplan–Meier estimates of DFS and OS according to the type of axillary surgery before and after IPTW. (a) DFS before IPTW matching; (b) OS before IPTW matching; (c) DFS after IPTW matching; and (d) OS after IPTW matching.
For the ITPW-matched cohort, both univariate and multivariable analyses revealed that DFS, OS, LRFS, RRFS, and DMFS did not differ between the two treatment groups (Table 3). The IPTW-adjusted Kaplan–Meier curves exhibited no significant differences between the SLNB-alone group and the ALND group in terms of DFS, OS, LRFS, RRFS, and DMFS (Figure 2(c) and (d); Figure S2).
Subgroup analyses
Subgroup analyses for DFS were further performed across clinically relevant subgroups (Figure 3). There were no significant differences in risk of recurrence or death between the SLNB-alone group and the ALND group in all the subgroups, except for the ER-negative subgroup, the HER2-negative subgroup, and the subgroup of patients with Luminal A or B disease, where SLNB alone was associated with improved DFS.
Subgroup analysis of disease-free survival. Subgroup analysis was performed in the IPTW-unmatched cohort. Arrows indicate that the 95% CI exceeds the graphed area.
Survival outcomes were also analyzed based on initial lymph nodal status. Among patients with initially cN0 disease, no statistically significant differences were observed in DFS (HR 0.75, 95% CI: 0.39–1.43, p = 0.386) and OS (HR 0.44, 95% CI: 0.15–1.32, p = 0.139) between the SLNB-alone group and the ALND group (Figure 4(a) and (b); Table S4). Similarly, in patients who were initially cN+ and converted to ycN0 after NST, there were no significant differences in DFS (HR 0.90, 95% CI: 0.56–1.45, p = 0.669) and OS (HR 0.34, 95% CI: 0.10–1.11, p = 0.07) between the two groups (Figure 4(c) and (d); Table S4). Comparable results were also observed for LRFS, RRFS, and DMFS (Table S3 and Figure S3).
Kaplan–Meier estimates of DFS and OS according to the type of axillary surgery in patients with initially cN0 breast cancer and those with cN+ disease. (a) DFS for the cN0 subgroup; (b) OS for the cN0 subgroup; (c) DFS for the cN+ subgroup; and (d) OS for the cN+ subgroup.
Further stratification of cN+ diseases into cN1 and cN2-3 subgroups similarly revealed no significant differences in DFS, OS, RRFS, or DMFS between the SLNB-alone and ALND groups, either in the cN1 or cN2-3 subgroups (Table S5; Figures S4 and S5). Notably, in patients with cN2-3 disease, SLNB alone was associated with inferior LRFS compared with ALND, with a 5-year LRFS rate of 87.5% (95% CI: 67.3–100) versus 97.2% (95% CI: 94.9–99.5; log-rank p = 0.018).
Discussion
This multicenter study included a large, real-world cohort of cT1-4/cN0-3 breast cancer patients who achieved ycN0 status, and comprehensively compared the oncologic outcomes of SLNB alone versus ALND following NST. Our findings demonstrated no significant differences in DFS, OS, LRFS, RRFS, and DMFS between the two groups, and the incidence of local recurrences, regional recurrences, and distant metastases was comparable, even in patients with initial cN+ disease. These results support the oncologic safety of SLNB alone in appropriately selected patients and provide meaningful real-world evidence supporting the ongoing paradigm shift toward surgical de-escalation of the axilla.
With the increasing adoption of NST in breast cancer, optimal management of the axilla in patients converting to ycN0 has been under active investigation. A Dutch population-based study, involving 12,461 patients, revealed a substantial decrease in ALND and an increase in SLNB alone after NST in cN0 patients, alongside an increasing trend of ALND omission after NST in cN+ patients. 16 Our study also observed a considerable shift in axillary surgical management among patients undergoing NST in the past decades, characterized by a growing preference for SLNB alone and a decline in ALND utilization. This observation was in line with earlier studies,17–20 which reflects an evolving clinical paradigm that prioritizes de-escalation of axillary surgery. Importantly, these trends align with current NCCN guideline recommendations, which advocate the following: (1) SLNB alone for cN0 patients; (2) selective SLNB for cN1 patients achieving ycN0, with dual tracer mapping and retrieval of ⩾3 SLNs, alongside multidisciplinary assessment of tumor biology; and (3) ALND for cN2-3 patients, irrespective of post-NST nodal status.
Existing evidence underscores that SLNB is an accurate and feasible method of determining nodal status post-NST, which provides a compelling rationale for the omission of ALND after NST. 21 Nevertheless, the oncologic safety of SLNB after NST remains an area of controversy, especially in initially nodal-positive patients. In the GANEA 2 study, among 419 patients with initial cN0 disease who underwent SLNB alone, only one axillary relapse was reported during the follow-up period. 22 Similarly, in another retrospective study, no axillary relapse occurred after a median follow-up of 51.1 months among 181 patients with an initially negative axilla, treated with SLNB alone after NAC. 23 As for cN1 disease, a study by Barrio et al. found that among 234 patients with cN1 disease undergoing NAC followed by SLNB using dual tracer mapping and retrieval of three or more negative SLNs, only one (0.4%) patient who declined adjuvant radiotherapy experienced nodal recurrence. 24 Our results corroborate these findings, showing a low rate of local or regional recurrence in the SLNB-alone group, and further confirming comparable recurrence rates to those observed in the ALND group. Importantly, our results extend this evidence by demonstrating no significant difference in DFS, OS, LRFS, RRFS, or DMFS, even among patients with initially cN+ disease who converted to ycN0 after NST. Our findings contribute to the ongoing discussion on the optimal surgical management of the axilla in cN+ breast cancer patients who convert to ycN0 following NST.
Previous efforts have primarily focused on the technical precision of SLNB, rather than its implications for patient prognosis. Notably, high FNRs (>10%) have been reported for SLNB in patients initially diagnosed with cN1 disease who subsequently converted to cN0 status after NST.5,9–12 The high rate of FNRs has posed a primary concern regarding the use of SLNB alone post-NAT. However, it is important to recognize that the high FNRs do not necessarily translate into impaired clinical outcomes. Galimberti et al. demonstrated that the oncological impact of high FNRs in the neoadjuvant setting had no discernible influence on OS and DFS in patients initially diagnosed with cN1/2 disease who achieved ycN0 status after NST.25,26 Consistent with this, our study extended the analysis to long-term oncological outcomes, showing no significant differences in DFS, OS, LRFS, RRFS, or DMFS between the SLNB-alone and ALND groups, in both the unmatched and IPTW-adjusted cohorts. These findings align with previous studies.18–20,27 In light of these results, our study provides important information on the oncologic safety of SLNB alone in appropriately selected patients treated with NST. Importantly, these findings help clarify that technical concerns regarding FNR should not necessarily preclude the use of SLNB in clinical practice, particularly as modern imaging, clip placement, and targeted axillary dissection techniques continue to improve the accuracy of nodal staging.
A distinctive strength of our study is the inclusion of patients with initial cN2-3 disease, a subgroup largely underrepresented in prior studies. Across most clinically relevant subgroups, including stratification by initial nodal status (cN0 vs cN+ or cN1 vs cN2-3), no significant differences in DFS or OS were observed between the SLNB-alone group and the ALND group. These results may indicate that SLNB alone serves as a surrogate for a higher nodal disease burden (cN+ disease). Consistent with our results, two recent studies reported no statistically significant differences in axillary recurrence-free survival, RRFS, DFS, or OS between the SLNB-alone and ALND groups among cN2-3, ypN0 patients after NST.28,29 Notably, however, we found that patients with initial cN2-3 disease exhibited inferior LRFS in the SLNB-alone group. This finding may be attributable to residual microscopic disease not captured by limited nodal sampling. Accurate axillary staging after NST in this high-risk subgroup remains technically challenging due to nodal fibrosis and treatment-induced changes. Moreover, variations in regional nodal irradiation fields and doses could further contribute to differences in locoregional control. Finally, the relatively small number of locoregional events may also have limited the statistical power of subgroup analyses. Collectively, these results suggest that caution should be exercised when considering axillary de-escalation in high-risk patients with extensive initial nodal involvement and reinforce current NCCN recommendations that ALND remains standard for cN2-3 patients. Careful patient selection, multidisciplinary coordination, and an individualized approach to axillary management after NST are warranted to ensure oncologic safety.
From a clinical perspective, these results have important implications for surgeons and multidisciplinary teams. For cN0 patients and cN1 patients who achieve ycN0, SLNB alone, which is performed according to technical standards and within a multidisciplinary framework, appears oncologically safe and reduces morbidity such as lymphedema, shoulder dysfunction, and sensory loss. For cN2-3 patients, however, our findings may support guideline-directed ALND due to the observed risk of inferior locoregional control with SLNB alone. In patients with extensive nodal involvement, incomplete systemic response, or uncertain pathologic clearance, a more cautious and individualized approach remains appropriate.
This study has several limitations. A major limitation is the retrospective nature of this study, which inevitably introduces potential selection biases. Consequently, clear criteria for the use of SLNB alone and ALND were not delineated. Second, the median follow-up of 34.2 months remains relatively short for assessing definitive long-term outcomes, and late axillary recurrences may emerge with longer surveillance. Ongoing follow-up of this cohort will be essential to confirm the durability of these findings. In addition, the specific regimens used for NST were not subjected to analysis, potentially influencing results. Furthermore, variations in adjuvant radiotherapy and systemic therapy may have introduced residual confounding, despite adjustment for these factors in the IPTW model. Such treatment heterogeneity reflects real-world practice and should be considered when interpreting our findings. Finally, the number of events in certain subgroups, such as patients with initially cN2-3 disease, was limited, which may restrict the statistical power. Therefore, the findings in these high-risk subgroups should be interpreted with caution.
Despite these limitations, our study possesses several notable strengths. This study included a large patient cohort from multiple centers. In addition, the IPTW was used for balancing patient, tumor, and treatment-related factors between the SLNB-alone group and the ALND group. This, coupled with robust multivariable and subgroup analyses, served to mitigate the influence of potential confounders. Moreover, by including patients with higher initial nodal burden, particularly cN2-3, this study provides novel evidence supporting selective axillary de-escalation strategies while reinforcing guideline-based caution in high-risk patients. The integration of our findings into clinical decision-making may help refine multidisciplinary algorithms, guiding surgeons to adopt a more nuanced, evidence-based approach to axillary surgery after NST.
Conclusion
In conclusion, this study demonstrated that SLNB alone was comparable to ALND in achieving oncologic outcomes for patients who initially presented with cN0 or cN1 breast cancer and remained or converted to ycN0 after NST. For patients with initial cN2-3 disease, ALND may remain warranted due to a higher risk of locoregional recurrence. Although the relatively short follow-up duration limits definitive assessment of long-term outcomes, the findings of this study provide robust real-world evidence that carefully selected patients can be safely spared complete ALND. Further larger, prospective studies with extended follow-up are warranted to confirm the long-term durability of these results and to refine patient selection, particularly for those with high-risk features such as cN2-3 disease, ensuring oncologic safety remains uncompromised.
Supplemental Material
sj-docx-1-tam-10.1177_17588359251405095 – Supplemental material for De-escalation of axillary surgery after neoadjuvant therapy in breast cancer: long-term outcomes of sentinel lymph node biopsy alone versus complete axillary lymph node dissection
Supplemental material, sj-docx-1-tam-10.1177_17588359251405095 for De-escalation of axillary surgery after neoadjuvant therapy in breast cancer: long-term outcomes of sentinel lymph node biopsy alone versus complete axillary lymph node dissection by Haizhu Chen, Xiaoyan Qian, Luhui Mao, Yunxia Tao, Yaping Yang, Xiujuan Gui, Qiang Liu and Herui Yao in Therapeutic Advances in Medical Oncology
Supplemental Material
sj-docx-2-tam-10.1177_17588359251405095 – Supplemental material for De-escalation of axillary surgery after neoadjuvant therapy in breast cancer: long-term outcomes of sentinel lymph node biopsy alone versus complete axillary lymph node dissection
Supplemental material, sj-docx-2-tam-10.1177_17588359251405095 for De-escalation of axillary surgery after neoadjuvant therapy in breast cancer: long-term outcomes of sentinel lymph node biopsy alone versus complete axillary lymph node dissection by Haizhu Chen, Xiaoyan Qian, Luhui Mao, Yunxia Tao, Yaping Yang, Xiujuan Gui, Qiang Liu and Herui Yao in Therapeutic Advances in Medical Oncology
Footnotes
References
Supplementary Material
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