Neoadjuvant systemic therapy and the evolution of axillary management in breast cancer: a mini review and future directions
- 1Department of Surgical Oncology, Sri Shankara Cancer Hospital and Research Centre
Abstract
Neoadjuvant Systemic Therapy (NST) has undergone a remarkable evolution over five decades, evolving from a strategy employed to render inoperable tumors resectable to a therapeutic platform whose post-treatment pathological assessment now serves as a powerful in vivo readout of tumor biology, enabling real-time personalization of both surgical and systemic tumor management. Alongside advances in systemic therapy, our approach to the axilla has been fundamentally transformed. Management of the axilla has evolved from routine axillary lymph node dissection (ALND), regardless of treatment response, to a nuanced, response-adapted surgical approach. This review traces the historical trajectory of NST in breast cancer, with a particular focus on its impact on axillary surgical planning. We examine landmark clinical trials establishing sentinel lymph node biopsy (SLNB) feasibility after NST, the development of targeted axillary dissection (TAD) as a precision staging technique, and the critical role of pathologic complete response (pCR) as both a prognostic endpoint and a surgical decision-making tool. The evidence base for ALND omission across the spectrum of nodal response — from complete sterilization to low-volume residual disease — is examined in depth, alongside the challenges of residual disease management, staging information loss, surgical morbidity, and global disparities in access. Emerging directions including circulating tumor DNA, artificial intelligence-based imaging tools, and novel systemic agents are discussed in the context of an evolving paradigm in which surgical extent is increasingly determined by tumor biology and treatment response rather than anatomical convention.
Related
- Correlation of Axillary Nodal with Breast Response Following Neoadjuvant Chemotherapy in Early Breast Cancer
- Relative change rate of neutrophil-to-albumin ratio (ΔNAR) during neoadjuvant chemotherapy predicts axillary pathological complete response in locally advanced breast cancer
- [18F]FDG PET/CT-Derived Metabolic Characteristics and Tumour-Infiltrating Lymphocytes for Predicting Axillary Response to Neoadjuvant Chemo-(Immuno)Therapy in Clinically Node-Positive Breast Cancer
- Diagnostic accuracy of ultrasound-based imaging modalities for assessing residual axillary lymph node disease after neoadjuvant chemotherapy in patients with breast cancer: a systematic review and meta-analysis.
- Quantitative Molecular Breast Imaging for Early Prediction of Neoadjuvant Systemic Therapy Response in Locally Advanced Breast Cancer Patients
BibTeX
@article{krishna2026neoadjuvant,
title = {{Neoadjuvant systemic therapy and the evolution of axillary management in breast cancer: a mini review and future directions}},
author = {Kanyadhara Lohita Krishna and Srinath B. S.},
journal = {Frontiers in Oncology},
year = {2026},
month = nov,
doi = {10.3389/fonc.2026.1893067},
url = {https://www.frontiersin.org/articles/10.3389/fonc.2026.1893067/full},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Neoadjuvant systemic therapy and the evolution of axillary management in breast cancer: a mini review and future directions
AU - Kanyadhara Lohita Krishna
AU - Srinath B. S.
PY - 2026
DA - 2026/11/02
JO - Frontiers in Oncology
DO - 10.3389/fonc.2026.1893067
UR - https://www.frontiersin.org/articles/10.3389/fonc.2026.1893067/full
AB - Neoadjuvant Systemic Therapy (NST) has undergone a remarkable evolution over five decades, evolving from a strategy employed to render inoperable tumors resectable to a therapeutic platform whose post-treatment pathological assessment now serves as a powerful in vivo readout of tumor biology, enabling real-time personalization of both surgical and systemic tumor management. Alongside advances in systemic therapy, our approach to the axilla has been fundamentally transformed. Management of the axilla has evolved from routine axillary lymph node dissection (ALND), regardless of treatment response, to a nuanced, response-adapted surgical approach. This review traces the historical trajectory of NST in breast cancer, with a particular focus on its impact on axillary surgical planning. We examine landmark clinical trials establishing sentinel lymph node biopsy (SLNB) feasibility after NST, the development of targeted axillary dissection (TAD) as a precision staging technique, and the critical role of pathologic complete response (pCR) as both a prognostic endpoint and a surgical decision-making tool. The evidence base for ALND omission across the spectrum of nodal response — from complete sterilization to low-volume residual disease — is examined in depth, alongside the challenges of residual disease management, staging information loss, surgical morbidity, and global disparities in access. Emerging directions including circulating tumor DNA, artificial intelligence-based imaging tools, and novel systemic agents are discussed in the context of an evolving paradigm in which surgical extent is increasingly determined by tumor biology and treatment response rather than anatomical convention.
SN - 2234-943X
ER -