Omitting axillary dissection in breast cancer patients with one to two positive sentinel nodes undergoing mastectomy: a retrospective and prospective cohort study with a target trial emulation
In brief
Omitting axillary dissection gives 5-year recurrence-free survival of 91% in mastectomy patients
In a combined retrospective-prospective cohort of 1,090 women with one to two positive sentinel nodes, those who skipped completion axillary dissection after mastectomy had a 5-year recurrence-free survival of 91.5%, essentially identical to the 91.8% seen with full dissection. The finding supports de-escalating axillary surgery in this group, though longer follow-up and broader populations remain to be studied.
- Journal
- International journal of surgery (London, England) (Q1)
- Published
- 15 April 2026
- Study design
- Retrospective cohort
- Evidence level
- Level 3, Low (CEBM 3b)
- Authors
- Haitong Xie, Xin Wang, Xianlin Gu, Chihua Wu, Wanying Guo, Rui Li, et al.
- PMID
- 42682276
- DOI
- 10.1097/JS9.0000000000004708
Why clinicians should know about it
- Picked for Breast and Endocrine Surgery (paper of the day, 5 September 2026): Axillary surgery omission trial in mastectomy patients with limited sentinel
Abstract
BACKGROUND: Previous trials have demonstrated the safety of omitting axillary lymph node dissection (ALND) in cT1-3, cN0 breast cancer patients with one to two sentinel lymph node (SLN) involvement undergoing breast-conserving surgery (BCS). However, their applicability to mastectomy patients - who do not routinely receive chest wall irradiation - remains unclear. This study aimed to evaluate whether omitting ALND is noninferior to completion of ALND among patients undergoing mastectomy. METHODS: We emulated a target multicenter, nonblinded, noninferiority trial to compare sentinel lymph node biopsy only (SLNB only) and SLNB plus ALND using combined prospective and retrospective cohorts. Eligible patients had cT1-3, cN0 breast cancer with one to two SLN metastases. The primary endpoint was 5-year recurrence-free survival (RFS). Noninferiority was defined as a hazard ratio (HR) of less than 1.54 comparing the SLNB-only group to the ALND group. This study was prospectively registered with Chictr.org.cn. RESULTS: Among 1090 included patients, 438 (40.2%) received SLNB only and 652 (59.8%) received ALND. After a median follow-up of 4.74 years, 88 patients experienced recurrence or died. The estimated 5-year RFS was 91.5% (95% CI, 89.1-93.9) in the SLNB only group and 91.8% (95% CI, 88.7-95.1) in the ALND group (HR = 0.83; 95% CI, 0.51-1.33; Pnoninferiority = 0.005). Primary findings were consistent across subgroups and sensitivity analyses. CONCLUSION: Results of this targeted trial revealed that ALND can be omitted in patients undergoing mastectomy with clinically node-negative, cT1-3 invasive breast cancer who had one to two SLN metastases. These findings further inform the de-escalation of axillary surgery in breast cancer management.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.