De-escalation of axillary surgery and targeted axillary dissection following neoadjuvant chemotherapy: multicentre prospective regional audit

Abstract Background Emerging evidence supports axillary de-escalation in patients with clinically node-positive breast cancer with low-volume residual disease following neoadjuvant chemotherapy, avoiding axillary node clearance in selected patients. Targeted axillary dissection, which retrieves a known metastatic, clipped node alongside standard sentinel node biopsy aims to reduce false-negative rates. This study evaluated axillary surgery after neoadjuvant chemotherapy across NHS Greater Glasgow and Clyde, and examined 10-year trends. Methods Patients with node-positive breast cancer receiving neoadjuvant chemotherapy between 2017 and 2024 were identified from multidisciplinary team records. Clinicopathological and surgical data were collected. Outcomes were compared using χ2 tests and logistic regression. Additional data from 2015–2016 were extracted from the Regional Cancer Registry. Results Of 498 patients, primary axillary surgery included Magseed®-localized targeted axillary dissection (27.5%), wire-localized targeted axillary dissection (0.4%), non-localized targeted axillary dissection (7.0%), sentinel node biopsy (14.3%), and axillary node clearance (50.8%). The clipped node retrieval rate was 100% with Magseed®-localized and 91.4% with non-localized targeted axillary dissection; sentinel node concordance rates were 85.8 and 66.7%, respectively. Completion axillary node clearance was undertaken in 27 patients (11.0%) and was associated with an increased risk of complications including seroma, restricted shoulder movement, and wound infection, compared with de-escalated surgery (odds ratio (OR) 2.88, 95% confidence interval (CI) 1.28 to 6.49; P = 0.011) and upfront axillary node clearance (OR 1.86, 95% CI 1.27 to 2.72; P = 0.001). Use of axillary de-escalation increased over 10 years, surpassing 50% recently (χ²(4) = 25.3, P 0.001). Conclusion Targeted axillary dissection enables safe de-escalation of axillary surgery in patients with low-volume residual disease. Localization enhances clipped node retrieval. Completion axillary node clearance carries higher morbidity, reinforcing the need for careful patient selection.