Key Points

• Clinicians should NOT recommend axillary lymph node dissection (ALND) for women with early-stage breast cancer:
  • Who do not have nodal metastases (Strong Recommendation: EB-B-H).
  • Who have one or two sentinel lymph node metastases and will receive breast-conserving surgery (BCS) with conventionally fractionated whole-breast radiotherapy^a (Strong Recommendation: EB-B-H).
• Clinicians may offer ALND for women with early-stage breast cancer with nodal metastases found on sentinel lymph node (SNB) who will receive mastectomy (Weak Recommendation: EB-B-L).
• Clinicians may offer SNB for women who have operable breast cancer who have the following circumstances:
  • Multicentric tumors (Moderate Recommendation: EB-B-I).
  • Ductal carcinoma in situ (DCIS) when mastectomy is performed. (Weak Recommendation: IC-B-Ins).
  • Prior breast and/or axillary surgery (Strong Recommendation: EB-B-I).
  • Preoperative/neoadjuvant systemic therapy^b (Moderate Recommendation: EB-B-I).
• There are insufficient data to change the 2005 recommendation that clinicians should NOT perform SNB for women who have early-stage breast cancer and are in the following circumstances:
  • Large or locally advanced invasive breast cancers (tumor size T3/T4) (Weak Recommendation: IC-Ins).
  • Inflammatory breast cancer (Weak Recommendation: IC-Ins).
  • DCIS when breast-conserving surgery is planned (Strong Recommendation: IC-Ins).
  • Pregnancy (Weak Recommendation: IC-Ins).

^a Clinicians should consider this recommendation with caution in patients with clinically enlarged axillary lymph nodes, those with large primary tumors (>5 cm), those with large or bulky metastatic axillary sentinel lymph nodes, and/or those with gross extranodal extension of the tumor.
^b SNB may be offered before or after neoadjuvant chemotherapy (NACT), but the false negative rate is higher afterward, and therefore, the procedure seems less accurate after NACT and may be unacceptably high with known metastatic nodes.

Illustration of Sentinel Nodes