Invited Commentary: De-escalation of axillary surgery in node-positive breast cancer patients after neoadjuvant therapy

The surgical management of patients presenting with node-positive breast cancer who receive neoadjuvant chemotherapy has been an area of focus and debate as neoadjuvant chemotherapy regimens increasingly eradicate the nodal disease. Axillary lymph node dissection has been the standard surgical approach, which carries morbidity risks of lymphedema, pain, and limited range of motion. Although there has been interest in de-escalating axillary surgery, hurdles must be addressed. The first is finding an accurate way to assess nodal response. Many trials have looked at this using the false negative rate as the defining endpoint, all finding that surgical techniques such as using a dual tracer technique, adding immunohistochemistry, and ensuring removal of the node that had biopsy-confirmed disease at diagnosis can impact the accuracy of minimally invasive approaches to evaluate the axilla. However, the second hurdle of defining the impact of minimizing axillary surgery on locoregional and overall outcomes has yet to be answered. Ongoing trials may give us insights over the next few years.