Neoadjuvant therapy has created new opportunities for breast-conserving surgery and axillary preservation in patients with breast cancer. However, accurately defining the extent of surgery after neoadjuvant treatment and determining the optimal management of axillary lymph nodes remain among the most important and challenging issues in contemporary breast cancer care.At the 2026 Lingnan Breast Cancer Forum in Guangzhou, Oncology Frontier interviewed Ciqiu Yang from Guangdong Provincial People’s Hospital to discuss the principles of establishing a standardized breast- and axillary-conserving treatment strategy, the impact of different tumor regression patterns on surgical planning, and the safety criteria for omitting axillary lymph node dissection after nodal downstaging.
Oncology Frontier: Neoadjuvant therapy has expanded opportunities for both breast conservation and axillary preservation. In clinical practice, these decisions must balance oncologic safety with patients’ quality of life. What principles are most important when establishing a standardized and widely applicable treatment strategy?
Ciqiu Yang:
The original goal of neoadjuvant therapy was to allow patients with tumors that were initially too large for breast-conserving surgery or axillary preservation to undergo preoperative systemic therapy, thereby shrinking the tumor and making less extensive surgery feasible.
As clinical experience has grown, the indications for neoadjuvant therapy have continued to expand. Today, it is generally preferred for patients with triple-negative breast cancer or HER2-positive breast cancer with tumors larger than 2 cm, as well as for patients with clinically positive lymph nodes. Its principal advantage is tumor downstaging before surgery.
The major challenge after neoadjuvant therapy is determining the optimal extent of surgery. This requires not only high-quality imaging but also a comprehensive assessment system before and after treatment.
When removing the tumor, we must ensure complete oncologic resection without unnecessarily enlarging the surgical field, which could compromise upper limb function. This is a challenge we face routinely in clinical practice.
Therefore, patients with different clinical stages, molecular subtypes, and responses to neoadjuvant therapy require individualized evaluation. Our objective is to design the most appropriate surgical strategy while maximizing the chance of cure and minimizing surgical morbidity.
Oncology Frontier: Different molecular subtypes exhibit distinct patterns of tumor regression after neoadjuvant therapy. How do these patterns influence surgical margins for breast-conserving surgery and axillary management? How should imaging and pathological response guide individualized surgical planning?
Ciqiu Yang:
This is one of the most important issues following neoadjuvant therapy.
Tumor regression generally follows two patterns: concentric regression and scattered (or patchy) regression.
Concentric regression, in which the tumor shrinks progressively toward its center, represents the ideal pattern. In these patients, the extent of breast-conserving surgery can be planned according to the residual tumor seen after neoadjuvant therapy, with appropriate margin assessment.
In contrast, scattered regression is characterized by multiple dispersed residual tumor foci. In these cases, the original tumor extent before neoadjuvant treatment must often be used to determine the surgical boundaries, resulting in a larger volume of tissue resection.
Accurately distinguishing between these two regression patterns is therefore critical.
In addition to conventional imaging, our center, under the leadership of Kun Wang, has developed radiomics-based prediction models that analyze magnetic resonance imaging (MRI) features before and after neoadjuvant therapy. These techniques enable more precise prediction of tumor regression patterns, and the results have already been published in international peer-reviewed journals.
Oncology Frontier: Management of the axilla after neoadjuvant therapy remains controversial. Based on your experience, is it safe to omit axillary lymph node dissection in patients who were node-positive before treatment but convert to clinically node-negative afterward? What conditions must be met?
Ciqiu Yang:
Reducing the extent of surgery while preserving axillary function is extremely important for both long-term outcomes and upper limb function.
For patients who initially present with axillary lymph node metastases but achieve an excellent response to neoadjuvant therapy, with conversion to clinically node-negative disease, sentinel lymph node biopsy (SLNB) can be considered to minimize surgical morbidity.
However, strict quality control is essential. This includes:
- Dual-tracer mapping using both a radioactive tracer and blue dye.
- Retrieval of at least three sentinel lymph nodes.
- Targeted axillary dissection (TAD), which includes removal of the lymph node that was biopsy-proven positive and marked before neoadjuvant therapy.
Together, these measures reduce the false-negative rate to an acceptable level.
In many centers where dual-tracer mapping is unavailable, our group has demonstrated that ultrasound-guided localization combined with carbon nanoparticle tracing can achieve detection and false-negative rates comparable to those of the dual-tracer technique.
Ultimately, retrieving at least three sentinel lymph nodes is the key factor in minimizing false-negative results.
For patients whose axillary lymph nodes become clinically negative after neoadjuvant therapy, we should make every effort to perform sentinel lymph node biopsy instead of routine axillary lymph node dissection whenever appropriate. This approach maintains oncologic safety while maximizing preservation of upper limb function.
Professor
Ciqiu Yang
Guangdong Provincial People’s Hospital
