From Regional Lymph Node Innovation to Advanced Axillary Management Decisions | 17th Shanghai Breast Cancer Symposium
Editor’s Note: Breast cancer has recently surpassed lung cancer as the most commonly diagnosed cancer among women worldwide. The status of regional lymph node involvement remains a key prognostic factor, directly influencing disease staging, treatment planning, and survival outcomes. While axillary lymph node dissection (ALND) has long been the standard for staging, it carries substantial morbidity. As modern breast surgery moves toward precision and minimally invasive approaches, sentinel lymph node biopsy (SLNB) has replaced ALND as the preferred axillary staging strategy, significantly reducing surgical trauma and complications.To further promote standardized care, the Chinese Anti-Cancer Association Breast Cancer Committee (CACA-CBCS) has updated the Chinese Breast Cancer Diagnosis and Treatment Guidelines (2026 Pocket Edition)—commonly known as the “New Little Red Book.” In this context, Oncology Frontier interviewed Professor Yongsheng Wang of Shandong Cancer Hospital, who provided an in-depth interpretation of key surgical updates, particularly in regional lymph node and sentinel node management.
Key Updates in Breast Cancer Surgery: Regional and Sentinel Lymph Node Management
Oncology Frontier: The 2026 Pocket Guidelines have recently been released. What are the major updates regarding regional lymph node and SLN management?
Professor Yongsheng Wang: The updated guidelines introduce refinements across four major dimensions:
- Regional lymph node surgical management
- Indications and contraindications for SLNB
- Management strategies based on SLNB results in cN0 patients
- SLNB decision-making after neoadjuvant therapy
1. Regional Lymph Node Surgery: Toward Selective Omission
Recent high-quality trials such as INSEMA and SOUND suggest that omitting axillary surgical staging may be feasible in selected early-stage breast cancer patients.
However, Chinese experts remain cautious about broad implementation. Reasons include:
- Even among T1N0 patients, approximately 15% still harbor SLN metastases, risking under-staging if SLNB is omitted
- Heterogeneity in ultrasound quality across institutions limits reliable preoperative axillary assessment
Nonetheless, experts agree that carefully selected patients may safely avoid axillary surgery, and this strategy holds future clinical value.
2. Updated SLNB Indications in Ipsilateral Breast Recurrence
The 2026 guidelines revise recommendations for repeat SLNB in ipsilateral breast tumor recurrence.
New evidence shows that after prior axillary surgery:
- Up to 40% of sentinel nodes are located outside the ipsilateral axilla, including internal mammary, supraclavicular, or contralateral nodes
Therefore, the new recommendation is:
All patients with ipsilateral breast recurrence—regardless of prior axillary surgery—should undergo repeat SLNB, rather than defaulting to ALND.
This improves anatomic accuracy and avoids under-mapping lymphatic drainage pathways.
3. Updated Management of SLNB Results in cN0 Patients
Previously, studies on SLN-positive patients lacked standardized radiation field protocols, leading to debate.
New high-level evidence—particularly the SENOMAC trial (NEJM)—clarifies that:
- Patients with 1–2 positive SLNs can safely omit ALND
- Regional nodal irradiation (RNI) is crucial to maintaining oncologic safety
- Approximately 90% of trial patients received nodal radiation
Guideline Update
For breast-conserving surgery patients:
- Radiotherapy now takes priority over observation when SLNs are positive
- This provides clearer, more consistent treatment pathways
4. SLNB After Neoadjuvant Therapy: Risk-Adapted Strategy
Neoadjuvant therapy—especially in HER2-positive and triple-negative breast cancer—achieves axillary pCR in >60% of patients, enabling de-escalation.
Initial cN0 Patients
- Post-NAT SLN-negative: Omit ALND and RNI
- Isolated tumor cells (ITC): Prefer radiotherapy instead of ALND
- Micrometastasis or macrometastasis: HER2+/TNBC: Recommend ALND + radiotherapy Luminal subtype: Consider radiotherapy instead of ALND if nodal burden is low
Initial cN1 Patients
Findings from NSABP B-51 (NEJM) show:
- Patients achieving SLN negativity after NAT may safely omit ALND
- Omission of regional nodal radiotherapy is under exploration
However:
- For cN2–cN3 patients, SLNB accuracy remains uncertain
- Macrometastatic SLNs post-NAT still warrant ALND
- ITC or micrometastasis still requires axillary treatment until stronger evidence emerges
Conclusion: Precision-Driven Surgical De-Escalation
The 2026 Pocket Guidelines highlight the convergence of:
- Precision medicine
- Evidence-based de-escalation
- Individualized surgical decision-making
The guiding philosophy remains:
“Less is more—but only when evidence is sufficient.”
Safe surgical de-escalation must be grounded in robust clinical data, ensuring patients benefit from both oncologic safety and improved quality of life.
Expert Profile
Professor Yongsheng Wang
Shandong Cancer Hospital Leading authority in breast cancer surgery, specializing in axillary management, sentinel lymph node strategies, and evidence-based surgical optimization.
