Management of the Axilla in Patients With Invasive/In-Situ Breast Cancer

Publication Date: September 1, 2019
Last Updated: March 14, 2022


Indications for SLN surgery in patients with clinically negative axilla

All patients with a clinically negative axilla for whom axillary staging would provide actionable or relevant information should be offered SLN biopsy. An example of a patient population for whom the results of SLNB may not impact systemic management are those with a high burden of comorbidities; in such patients, the decision to omit SLNB may be considered.

Indications for omission of ALND in patients with positive sentinel nodes

Based on randomized clinical studies, axillary dissection can be omitted for patients with 1-2 positive sentinel nodes undergoing breast conserving surgery who meet the following inclusion criteria:
a. T1-2 tumors
b. One to two positive SLNs without gross extracapsular extension (microscopic extracapsular extension is allowed)
c. Patient acceptance and completion of standard whole-breast radiation therapy
d. Patient acceptance and completion of recommended adjuvant systemic therapy (endocrine, cytotoxic, or both)

Indications for axillary radiation in patients with positive sentinel nodes

Based on ACOSOG Z0011 and the AMAROS study, there are no clear indications for directed axillary radiation in patients with 1-2 positive sentinel nodes who undergo breast conserving surgery. Based on the subset of patients enrolled in IBCSG 23-01 and AMAROS who underwent mastectomy with 1-2 positive sentinel nodes (either micrometastatic or macrometastatic disease), axillary radiation alone without completion ALND may be considered.

Indications for the use of IHC cytokeratin staining of sentinel nodes

IHC should be used at the discretion of the pathologist based on an inability to resolve an area of concern for metastatic disease in the node. Routine use is not recommended in patients with surgical resection as first line of treatment. It should be considered in patients treated with neoadjuvant chemotherapy with node positive disease at presentation.

Indications for SLN surgery in patients undergoing neoadjuvant systemic therapy

a. SLNB prior to neoadjuvant systemic therapy is discouraged, as this prevents assessment of nodal response to systemic therapy.
b. In patients who present with a clinically negative axilla, SLNB is recommended following neoadjuvant therapy.
c. In patients with biopsy proven axillary nodal metastases prior to systemic therapy, the option of SLN surgery is left to the discretion of the surgeon after a shared decision-making discussion with the patient, taking into account the false-negative rates from ACOSOG 1071 and the SENTINA trial.
i. If SLN biopsy after neoadjuvant therapy is attempted, dual tracer should be used. At least 2 and ideally 3 sentinel nodes are advised to be identified and removed as the false-negative rate is lower with a greater number of SLNs removed.
ii. The false-negative rate is also lower if a clip was placed in the lymph node at the time of initial biopsy, and this clipped node is confirmed to be removed at the time of SLN biopsy.
iii. If a SLN and/or the clipped node (if clipped) is not identified, an ALND is recommended.

Role of SLN biopsy for clinical scenarios where there is no supporting randomized controlled trial data

There are a number of clinical scenarios for which randomized controlled trial data remain limited. Observational data suggests that SLN may be considered for women with multifocal or multicentric cancer, those with prior breast or axillary surgery, and during pregnancy. At present, SLN biopsy is not considered to be an acceptable method of staging the axilla for patients with inflammatory breast cancer. For patients undergoing surgery for DCIS only, those having an initial mastectomy or those for whom the breast conservation surgery may prevent future sentinel node mapping should have a simultaneous SLN biopsy.

Recommendation Grading



Management of the Axilla in Patients With Invasive/In-Situ Breast Cancer

Authoring Organization

Publication Month/Year

September 1, 2019

Last Updated Month/Year

January 31, 2024

Document Type


External Publication Status


Country of Publication


Document Objectives

To outline the management of the axilla for patients with invasive and in-situ breast cancer.

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Hospital, Operating and recovery room, Outpatient, Radiology services

Intended Users

Psychologist, clinical researcher, nurse, nurse practitioner, physician, physician assistant


Assessment and screening, Management

Diseases/Conditions (MeSH)

D001943 - Breast Neoplasms


breast cancer, Breast Cancer, axilla management, lymph node surgery