During the Breast Global International Cancer Conference (BGICC) 2026, Prof. Sherif Naguib delivered a comprehensive and historically grounded lecture addressing the progressive de-escalation of axillary surgery in breast cancer. His presentation traced the evolution of axillary management from radical surgical approaches to contemporary strategies focused on minimizing morbidity while maintaining oncologic safety.
Early Evidence Challenging Axillary Dissection
Prof. Naguib began by revisiting a landmark study published in 1977 by Fisher and colleagues, which evaluated outcomes in approximately 1,600 patients with breast cancer and clinically negative axillae. Patients were randomized to axillary dissection, axillary radiotherapy, or observation. The study demonstrated no significant differences in local control or overall survival among the three approaches.
Despite these findings, axillary dissection remained the standard of care for several decades, highlighting the gap between evidence generation and clinical adoption. It was not until the early 1990s that de-escalation began to gain broader acceptance.
Emergence of Sentinel Lymph Node Biopsy
The introduction of sentinel lymph node biopsy (SLNB) marked a pivotal shift in axillary management. Multiple validation studies confirmed high identification rates and accuracy, establishing SLNB as a reliable staging tool in patients with clinically node-negative disease. Large trials demonstrated identification rates exceeding 90 percent and false-negative rates below accepted thresholds.
Comparative analyses showed that SLNB provided outcomes equivalent to axillary lymph node dissection in terms of disease control, while significantly reducing surgical morbidity. This led to the widespread replacement of routine axillary dissection with SLNB in selected patients.
De-escalation in Sentinel Node Positive Disease
Further de-escalation was introduced with trials evaluating omission of completion axillary dissection in patients with limited sentinel node involvement. The ACOSOG Z0011 trial, published in 2011, demonstrated that patients with one or two positive sentinel lymph nodes undergoing breast-conserving surgery and whole-breast radiotherapy did not benefit from additional axillary dissection in terms of locoregional control or survival.
Subsequent studies validated and expanded these findings. Later analyses included patients with larger tumors, mastectomy patients, and selected cases with extracapsular extension, consistently showing comparable overall and disease-free survival when axillary dissection was omitted.
Real-world data further supported this trend. Analyses from national databases revealed that a substantial proportion of patients with three or more positive sentinel nodes did not undergo completion axillary dissection, yet continued to demonstrate acceptable regional control rates, particularly in low-risk populations.
Axillary Radiotherapy as an Alternative to Surgery
The role of axillary radiotherapy as a substitute for surgical dissection was another major focus of the lecture. Early evidence from the EORTC and AMAROS trials showed that axillary radiotherapy provided disease control equivalent to axillary dissection, with significantly lower rates of lymphedema.
While regional recurrence rates were slightly higher in the radiotherapy arms, these differences were not statistically significant. Importantly, radiotherapy was associated with nearly half the incidence of lymphedema compared with surgical dissection, reinforcing its role as a less morbid alternative.
Complete Omission of Axillary Surgery
Prof. Naguib then discussed studies exploring the feasibility of omitting axillary surgery altogether in carefully selected patients. Early work in older patients with low-risk breast cancer demonstrated no significant differences in survival outcomes when axillary surgery was avoided.
More recent prospective trials, including SOUND and INSEMA, evaluated omission of SLNB in patients with clinically and radiologically negative axillae assessed by ultrasound. These trials showed that avoiding axillary surgery was non-inferior to SLNB in terms of overall and disease-free survival.
However, Prof. Naguib emphasized important limitations. Large tumors and high-risk subtypes were underrepresented, and concerns remain regarding potential undertreatment, particularly in patients who may benefit from nodal-based systemic therapy escalation. Additionally, omission of surgical staging may lead to broader use of regional nodal irradiation in the absence of pathological confirmation.
De-escalation in the Neoadjuvant Setting
The lecture also addressed evolving strategies in the neoadjuvant setting. Ongoing trials are evaluating whether axillary dissection can be replaced by radiotherapy in patients who convert to node-negative status following neoadjuvant chemotherapy. Other studies are assessing whether axillary surgery can be omitted entirely in patients achieving a pathological complete response, particularly in HER2-positive and triple-negative breast cancer.
Emerging concepts such as tailored axillary surgery were discussed as intermediate strategies, aiming to selectively remove only suspicious or involved nodes while preserving uninvolved lymphatic structures to reduce morbidity.
Future Directions
In closing, Prof. Naguib summarized the trajectory of axillary management over the past three decades, highlighting a clear and continuous movement toward de-escalation. From omission of axillary dissection in node-negative disease, to selective omission in sentinel node–positive patients, to replacement with radiotherapy, and now to complete omission in selected cases, axillary surgery is undergoing profound transformation.Imaging Assessment of Nodal Burden.
Prof. Jessica Leung
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