Leveraging Neoadjuvant Chemotherapy to Minimize the Burden of Axillary Surgery: a Review of Current Strategies and Surgical Techniques

Abstract

Axillary nodal disease is significantly less likely in both clinically node-negative (cN0) and node-positive (cN+) breast cancer patients after neoadjuvant chemotherapy (NAC). There have thus been significant efforts to “de-escalate” axillary surgery in this setting. This review discusses modern axillary surgical paradigms and techniques after NAC. In cN0 patients, the accuracy and feasibility of sentinel lymph node biopsy (SLNB) after NAC is well-established, with prospective evidence supporting its oncologic safety. SLNB is also acceptable in select cN+ patients when certain criteria are met. There is mounting “real-world” evidence for the technical feasibility of this approach, including various methods of localizing and excising biopsy-proven nodes, with the ability to avoid axillary lymph node dissection in a substantial proportion of patients. However, outcome data is limited to small retrospective series. In appropriately selected patients, there is increasing opportunity to leverage the benefits of NAC to minimize the burden of axillary surgery.