ASO Author Reflections: All Positive, Not All Necessary: Reconsidering Axillary Lymph Node Dissection When Every Sentinel Node is Positive

The management of axillary lymph nodes (LNs) in breast cancer treatment has undergone a significant evolution in the past 30 years.While axillary lymph node dissection (ALND) was historically the standard of care for any patient with breast cancer, there has been a trend towards less axillary surgery to decrease the morbidity that comes with ALND.The advent of sentinel lymphadenectomy (SLNB) in the 1990s reduced morbidity, particularly lymphedema, by sparing patients unnecessary dissection when nodes were negative. 1The landmark American College of Surgeons Oncology Group Z0011 (Z0011) and European After Mapping of the Axilla: Radiotherapy Or Surgery (AMAROS) trials extended this principle, showing that patients with one or two positive sentinel lymph nodes (SLNs) could safely avoid ALND without compromising survival or local control. 2,3onetheless, there is hesitation to omit ALND in patients with fewer than three SLNs retrieved and all are positive due to the concern that additional axillary disease may be left behind.