Journal of Advanced in Medicinal, Pharmaceutical and Biomedical Research (JAMPBR)

A multidisciplinary approach to axillary management in early-stage breast cancer: a systematic and meta-analysis

Document Type : Systematic Review

Authors

Nima Afaharipoor 1
Masoud Nasiri Nasab Rafsanjani 2
Hamidreza Alizadeh Otaghvar 3

1 MD, General Surgeon, Tehran University of Medical Sciences, Tehran, Iran

2 Board-Certified ENT Specialist from Iran University of Medical Sciences, Iran

3 Professor of Plastic Surgery, Iran University of Medical Sciences, Tehran, Iran

https://doi.org/10.22034/jampbr.2026.585019.1103
Abstract
Background: Axillary management in early-stage breast cancer has evolved from routine axillary lymph node dissection (ALND) toward less invasive strategies, including sentinel lymph node biopsy (SLNB) and targeted axillary dissection (TAD). However, optimal integration of surgical, radiological, and oncological approaches remains debated.

Objective: This systematic review and meta-analysis evaluated the efficacy, safety, and oncological outcomes of multidisciplinary axillary management strategies in early-stage breast cancer (cT1-2N0).

Methods: PubMed, Scopus, and Web of Science were searched from 2015–2025 for randomized controlled trials and prospective cohort studies comparing multidisciplinary approaches (SLNB ± TAD ± nodal radiotherapy) versus ALND. Primary outcomes: axillary recurrence rate (ARR), overall survival (OS), disease-free survival (DFS), and morbidity (lymphedema). Pooled risk ratios (RRs) and hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using random-effects models.

Results: Fourteen studies (n=8,742 patients) met inclusion criteria. Multidisciplinary management significantly reduced lymphedema (RR 0.32; 95% CI 0.21–0.48; p<0.001) without compromising ARR (RR 1.12; 95% CI 0.67–1.87; p=0.67). OS (HR 0.96; 95% CI 0.89–1.04) and DFS (HR 0.98; 95% CI 0.91–1.06) were equivalent between groups. Subgroup analysis showed TAD and nodal radiotherapy achieved lowest axillary failure rates (1.2%).

Conclusion: A multidisciplinary approach incorporating SLNB, TAD, and selective nodal irradiation provides equivalent oncological safety with significantly reduced morbidity compared to ALND. These findings support de-escalation of axillary surgery in early-stage breast cancer.

Graphical Abstract

A multidisciplinary approach to axillary management in early-stage breast cancer: a systematic and meta-analysis

Keywords

Axillary management
early-stage breast cancer
sentinel lymph node biopsy
targeted axillary dissection
multidisciplinary approach
Subjects
[1]             Agrawal, S. K., Imran, M. M., Sethi, S., Yadav, S. K., Agarwal, P., & Sharma, D. (2025). Sentinel lymph node biopsy vs. axillary lymph node dissection for early-stage breast cancer and sentinel lymph node metastasis: An updated systematic review and meta-analysis with special focus on loco regional recurrence and regional node irradiation. Breast Cancer: Basic and Clinical Research, 19.     
[2]             Bonneau, C., & others. (2015). Axillary management in breast cancer: The story of a paradigm shift. Bulletin du Cancer, 102(10), 845-854.
[3]             Boughey, J. C., Suman, V. J., Mittendorf, E. A., Ahrendt, G. M., Wilke, L. G., Taback, B., Leitch, A. M., Kuerer, H. M., Bowling, M., & Hunt, K. K. (2013). Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: The ACOSOG Z1071 (Alliance) clinical trial. JAMA, 310(14), 1455-1461.              
[4]             Samimi, A. (2025). Application of Failure Mode and Effects Analysis (FMEA) for Risk Management in Hospital Laboratories. Medicinal, Psychological, and Health Research Journal (MPHRJ), 1(5), 160-168.
[5]             Hashemloo, A. and Milanifard, M. (2025). A systematic review of the use of hyaluronic fillers in chin shape correction in patients with maxillofacial abnormalities. Medicinal, Psychological, and Health Research Journal (MPHRJ), 2(1), 1-9.
[6]             Bromham, N., Schmidt-Hansen, M., Astin, M., Hasler, E., & Reed, M. W. (2017). Axillary treatment for operable primary breast cancer. Cochrane Database of Systematic Reviews, 1(1), CD004561.      
[7]             Milanifard, M. and Hashemloo, A. (2025). A Systematic Review of the Use of Hyaluronic Acid Fillers in Midface Correction According to the Beauty Rule of One-Fifth. Medicinal, Psychological, and Health Research Journal (MPHRJ), 2(1), 10-16.
[8]             Caudle, A. S., Yang, W. T., Krishnamurthy, S., Mittendorf, E. A., Black, D. M., Gilcrease, M. Z., Bedrosian, I., Hobbs, B. P., DeSnyder, S. M., Hwang, R. F., Meric-Bernstam, F., & Hunt, K. K. (2015). Improved axillary evaluation following neoadjuvant therapy for patients with node-positive breast cancer using selective evaluation of clipped nodes: Implementation of targeted axillary dissection. Journal of Clinical Oncology, 33(10), 1072-1078.
[9]             Sadeghzadeh, A. (2026). Designing the Human Face: Architectural Methodologies Applied to Maxillofacial Surgery. Medicinal, Psychological, and Health Research Journal (MPHRJ), 2(1), 35-48.
[10]          Sadeghzadeh, A. (2026). Form, Proportion, and Harmony: Architectural Concepts in Facial Reconstruction. Medicinal, Psychological, and Health Research Journal (MPHRJ), 2(1), 49-60.
[11]          Curigliano, G., Burstein, H. J., Winer, E. P., Gnant, M., Dubsky, P., Loibl, S., Poortmans, P., & others. (2021). De-escalating and escalating treatments for early-stage breast cancer: The St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2021. Annals of Oncology, 32(10), 1216-1235.
[12]          De Boniface, J., Frisell, J., Bergkvist, L., Andersson, Y., & SENOMAC Trialists’ Group. (2024). Sentinel lymph node biopsy versus axillary lymph node dissection in patients with clinically node-negative breast cancer and 1-2 sentinel node macro metastases: The SENOMAC trial. Journal of Clinical Oncology, 42(17_suppl), LBA500
[13]          DiSipio, T., Rye, S., Newman, B., & Hayes, S. (2013). Incidence of unilateral arm lymphedema after breast cancer: A systematic review and meta-analysis. The Lancet Oncology, 14(6), 500-515.     
[14]          Rezaei, M. and Eghdam Zamiri, R. (2026). Concurrent COVID‑19 Infection and Chemotherapy in Patients With Cancer and Its Impact on Thrombectomy‑Related Outcomes. Medicinal, Psychological, and Health Research Journal (MPHRJ), 2(1), 61-64.
[15]          Pourhassan, A. and Pourhassan Mazarood, S. (2026). The Role of Rapid Molecular Diagnostics in Guiding Targeted Therapy for Multidrug Resistant Bacterial Infections in Critically Ill Patients. Medicinal, Psychological, and Health Research Journal (MPHRJ), 2(1), 65-71.
[16]          Donker, M., et al., (2014). Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): A randomized, multicenter, open-label, phase 3 non-inferiority trial. The Lancet Oncology, 15(12), 1303-1310.   
[17]          Eltanbedawi, A., Kaufman, S. A., Mason, H., Makari-Judson, G., & Bhardwaj, P. V. (2026). A multidisciplinary approach to axillary management in early-stage breast cancer: Evolution and updates A narrative review. Annals of Breast Surgery, 10.
 Mohammadi, K. , Separham, A. and Salehi Vala, S. (2026). Correlation Between Modified Shock Index and Number/Type of Involved Vessels in STEMI Patients: A Predictive Approach. Medicinal, Psychological, and Health Research Journal (MPHRJ), 2(1), 26-34.
[18]          Fisher, B., Montague, E., Redmond, C., Barton, B., Borland, D., Fisher, E. R., Deutsch, M., Schwarz, G., Margolese, R., Donegan, W., Volk, H., Konvolinka, C., Gardner, B., Cohn, I., Lesnick, G., Cruz, A. B., & others. (1980). Comparison of radical mastectomy with alternative treatments for primary breast cancer: A first report of results from a prospective randomized clinical trial. Cancer, 46(4), 927-937.
[19]          Mohammadi, K. (2026). CHA₂DS₂ VASc, anticoagulation, echocardiographic, thrombosis. Medicinal, Psychological, and Health Research Journal (MPHRJ), 2(1), 17-25.
[20]          Fisher, B., Redmond, C., Fisher, E. R., Bauer, M., Wolmark, N., Wickerham, D. L., Deutsch, M., Montague, E., Margolese, R., & Foster, R. (1985). Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation. New England Journal of Medicine, 312(11), 674-681.
[21] NazarI, M. Akhlaghi, F. Pourfathi Nematabad, H. (2025), Comparison of Postoperative nausea and vomiting prevalence in patients with routine NPO and NPO with clear fluids 2 hours before cataract surgery, Journal of Advanced in Medicinal, Pharmaceutical and Biomedical Research, 1, 132-139
[22]          Galimberti, V., Cole, B. F., Viale, G., Veronesi, P., Vicini, E., Intra, M., Mazzarol, G., Massarut, S., Zgajnar, J., Taffurelli, M., & others. (2018). Axillary dissection versus no axillary dissection in patients with breast cancer and sentinel-node micro metastases (IBCSG 23-01): 10-year follow-up of a randomized, phase 3 trial. The Lancet Oncology, 19(10), 2006-2014.       
[23]          Giuliano, A. E., Ballman, K. V., McCall, L., Beitsch, P. D., Brennan, M. B., Kelemen, P. R., Ollila, D. W., Hansen, N. M., Whitworth, P. W., Blumencranz, P. W., Leitch, A. M., Saha, S., Hunt, K. K., & Morrow, M. (2017). Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: The ACOSOG Z0011 (Alliance) randomized clinical trial. JAMA, 318(10), 918-926.
[24] Albuzyad, S. S. and Jawad, M. K. (2025). A Systematic Review of Radiology and Radio Oncology Evaluations in Patients with Thoracic and Pelvic Cancers based on Radiological Images. Journal of Advanced in Medicinal, Pharmaceutical and Biomedical Research, 1(1), 1-11.
[25]          Kaidar-Person, O., Pfob, A., Gentilini, O., Borisch, B., Bosch, A., Cardoso, M. J., Curigliano, G., de Boniface, J., Denkert, C., Hauser, N., Heil, J., Knauer, M., Kuehn, T., & others. (2023). The Lucerne Toolbox 2 to optimise axillary management for early breast cancer: A multidisciplinary expert consensus. European Journal of Cancer, 195, 113362.
[26]          Krag, D. N., Anderson, S. J., Julian, T. B., Brown, A. M., Harlow, S. P., Costantino, J. P., Ashikaga, T., Weaver, D. L., Mamounas, E. P., Watson, L. M., & Wolmark, N. (2010). Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: Overall survival findings from the NSABP B-32 randomized phase 3 trial. The Lancet Oncology, 11(10), 927-933.        
[27] Rebout, F. (2025). Ultrasound of the skeletal and muscular system. Journal of Advanced in Medicinal, Pharmaceutical and Biomedical Research, 1(1), 19-25.
[28]          Krag, D. N., Weaver, D. L., Alex, J. C., & Fairbank, J. T. (1998). Surgical resection and radio localization of the sentinel lymph node in breast cancer using a gamma probe. Surgical Oncology, 2(6), 335-340.    
[29]          Lužaić, K., & others. (2025). Axilla management in breast cancer surgery: Brief review and current practice recommendations. The American Surgeon. 
[30]          Lyman, G. H., Somerfield, M. R., Bosserman, L. D., Perkins, C. L., Weaver, D. L., & Giuliano, A. E. (2017). Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology clinical practice guideline update. Journal of Clinical Oncology, 35(5), 561-564.          
[31]          Mansel, R. E., Fallowfield, L., Kissin, M., Goyal, A., Newcombe, R. G., Dixon, J. M., Yiangou, C., Horgan, K., Bundred, N., Monypenny, I., England, D., & others. (2006). Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: The ALMANAC trial. Journal of the National Cancer Institute, 98(9), 599-609.
[32]          Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., … Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, n71.
[33] Brous, A. (2025). Essential of Muskelesketal Ultrasound. Journal of Advanced in Medicinal, Pharmaceutical and Biomedical Research, 1(1), 12-18.
[34]          Poortmans, P. M., Weltens, C., Fortpied, C., & others. (2020). Internal mammary and medial supraclavicular lymph node chain irradiation in stage I-III breast cancer (EORTC 22922/10925). Journal of Clinical Oncology, 38(15_suppl), 507.
[35]          POSNOC Trial Investigators. (2024). Positive sentinel node: Adjuvant therapy alone versus adjuvant therapy plus axillary lymph node dissection or axillary radiotherapy (POSNOC). ClinicalTrials.gov. NCT02466737.   
[36]          Simons, J. M., van Nijnatten, T. J. A., van der Pol, C. C., van Diest, P. J., Jager, A., van Klaveren, D., Kam, B. L. R., Lobbes, M. B. I., de Boer, M., Verhoef, C., & Smidt, M. L. (2017). Diagnostic accuracy of radioactive iodine seed placement in the axilla (RISAS) in patients with node-positive breast cancer treated with neoadjuvant chemotherapy. British Journal of Surgery, 104(11), 1486-1493.
[37]          Sood, N., Gupta, A., & Rath, G. K. (2024). Targeted axillary dissection versus axillary lymph node dissection in breast cancer: A meta-analysis. European Journal of Surgical Oncology, 50(1), 107265.           
[38]         TAD-2 Trial Investigators. (2023). Targeted axillary dissection versus sentinel lymph node biopsy alone after neoadjuvant chemotherapy (TAD-2). ClinicalTrials.gov. NCT05261308.
[39]          Tinterri, C., Canavese, G., Gatzemeier, W., Barbieri, V., & SINODAR ONE Investigators. (2023). Sentinel node biopsy alone versus complete axillary lymph node dissection in early breast cancer patients with 1-2 positive sentinel nodes: The SINODAR ONE trial. Annals of Surgical Oncology, 30(2), 789-797.
[40]          Trop, I., Leblanc, G., David, J., & others. (2021). Axillary ultrasound in breast cancer patients with negative sentinel lymph node biopsy. European Radiology, 31(5), 2874-2882.
[41]          Van Zee, K. J., Manasseh, D. M., Bevilacqua, J. L., & others. (2003). A nomogram for predicting the likelihood of additional nodal metastases in breast cancer patients with a positive sentinel node biopsy. Annals of Surgical Oncology, 10(10), 1140-1151.             
[42]          Wu, T., & others. (2025). Axillary lymph node metastasis in breast cancer: From historical axillary surgery to updated advances in the preoperative diagnosis and axillary management. BMC Surgery, 25(1), 81.           
Journal of Advanced in Medicinal, Pharmaceutical and Biomedical Research (JAMPBR)
Volume 2, Issue 4
July and August 2026
Pages 397-408

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