Background Axillary assessment is a key component of breast cancer care because nodal involvement affects prognosis, staging, and treatment selection. Ultrasound-guided fine-needle aspiration cytology (US-FNAC) can provide preoperative cytological evidence of axillary metastasis. This study assessed whether positive US-FNAC findings in clinically node-negative (cN0) early breast cancer were associated with a higher axillary nodal burden than sentinel lymph node biopsy (SLNB) positivity. Methods This prospective observational study was performed at Bangladesh Medical University (BMU), Dhaka, Bangladesh, from August 2021 to July 2022. The study included 32 women with histologically confirmed early breast cancer and a cN0 axilla. All patients underwent preoperative axillary ultrasonography (AUS). Patients with detectable axillary lymph nodes (ALNs) underwent US-FNAC; those with positive US-FNAC results proceeded directly to axillary lymph node dissection (ALND), whereas those with negative US-FNAC results or no detectable lymph nodes underwent SLNB, followed by ALND if SLNB was positive. Final axillary histopathology served as the reference standard for evaluating the diagnostic performance of US-FNAC and comparing axillary nodal burden. Results AUS showed no lymph nodes in 16 (50.0%) patients, suspicious nodes in six (18.8%) patients, and non-suspicious nodes in 10 (31.2%) patients. The median metastatic ALN count was higher among US-FNAC-positive patients than among SLNB-positive patients (4.0 vs. 2.5; p = 0.094). More than three metastatic nodes were found in six (85.7%) US-FNAC-positive patients and three (37.5%) SLNB-positive patients. US-FNAC had a sensitivity of 87.5%, specificity of 100.0%, positive predictive value (PPV) of 100.0%, negative predictive value (NPV) of 88.9%, and an overall accuracy of 93.7%. Conclusion In patients with early breast cancer and a cN0 axilla, positive preoperative US-FNAC was associated with heavier axillary metastatic involvement. These findings support the role of US-FNAC in preoperative axillary staging and surgical decision-making.

Targeted axillary dissection (TAD) has been introduced to improve axillary staging accuracy after neoadjuvant chemotherapy (NAC) in patients with node-positive breast cancer; however, reliable localization of the clipped lymph node (clipLN) remains technically challenging, particularly in cases with discordance between sentinel lymph node (SLN) and clipLN. We retrospectively reviewed a single-institution case series of patients with node-positive breast cancer who underwent TAD after NAC. CT-lymphography (CT-LG) was used for preoperative assessment of lymphatic anatomy, and the tattooing technique was applied for intraoperative localization of the clipLN. A total of 12 patients were included. SLN-clipLN discordance was frequently observed on CT-LG, including among ypN0 cases. ClipLN retrieval was successful in all patients who underwent the tattooing-assisted procedure. The combination of CT-LG and the tattooing technique facilitated intraoperative identification of clipLN, even in anatomically discordant cases. In this single-institution experience, TAD using CT-LG and the tattooing technique was technically feasible for clipLN localization after NAC. CT-LG aided preoperative recognition of anatomical discordance, while tattooing contributed to reproducible intraoperative localization. This experience reflects an initial implementation phase of TAD, and further studies are warranted to define optimal localization strategies for axillary management after NAC.

With the continuous optimization of systemic treatment regimens and the advancement of imaging assessment technologies, the overall survival rate of early-stage breast cancer has been steadily improving, providing an evidence-based basis for exploring de-escalation of local surgical treatment. This article systematically reviews five pathways for de-escalation of local surgical treatment in breast cancer and their key clinical evidence: selective exemption from breast surgery after neoadjuvant therapy by verifying pathologic complete response through imaging combined with vacuum-assisted biopsy (NRG-BR005, MICRA, MD Anderson Exceptional Responders trials, etc.); active surveillance replacing immediate surgery for low-risk ductal carcinoma in situ (COMET, LORIS, LORD, etc.); percutaneous ablation replacing partial breast-conserving surgery (ICE3, PO-RAFAELO, etc.); exemption from sentinel lymph node biopsy for patients with clinically negative lymph nodes and negative axillary ultrasound (INSEMA, SOUND, etc.); and reducing the false-negative rate (FNR) by using sentinel combined with targeted axillary dissection to avoid axillary lymph node dissection in initially node-positive patients who convert to clinically node-negative after neoadjuvant therapy (ACOSOG Z1071, SENTINA, SN FNAC, etc.). The clinical translation of the above strategies requires precise risk stratification, standardized pathological assessment, closed-loop long-term follow-up, and fully informed decision-making. Its core lies in establishing a comprehensive management plan based on rigorous screening and evidence-driven approaches, grounded in verifiable complete remission or low risk.

Neoadjuvant therapy (NAT) has strengthened systemic control in breast cancer and promoted precision de-escalation of axillary management. For clinically node-negative patients, evidence supports sentinel lymph node biopsy (SLNB) after NAT; among human epidermal growth factor receptor 2(HER2)-positive and triple-negative breast cancer patients achieving breast pathological complete response, the risk of residual axillary metastasis is extremely low, suggesting the potential omission of axillary surgery. For clinically node-positive patients converting to node-negative (cN1➝ycN0) after NAT, targeted axillary dissection can reduce the false-negative rate of SLNB to 2%-4% with good local control, supporting SLNB as a substitute for axillary lymph node dissection. In patients with low-volume residual nodal disease, axillary radiotherapy is increasingly considered as an alternative to surgery, though long-term evidence is still required. With studies such as NSABP B-51 demonstrating reduced regional irradiation in selected patients, dual de-escalation of surgery and radiotherapy has become a research focus. Future advances in imaging, artificial intelligence, and circulating tumor DNA (ctDNA) may enable individualized axillary decision-making.

In recent years, with the publication of multiple prospective randomized controlled trials, abundant evidence-based data have accumulated for axillary management in early breast cancer, and the concept of axillary de-escalation therapy has been widely recognized. Clinical strategies have evolved from the traditional invasive axillary lymph node dissection to minimally invasive sentinel lymph node biopsy, and further to precise individualized treatment with axillary surgery omission (non-invasive management). Such approaches maintain therapeutic efficacy, reduce postoperative complications and improve patients' quality of life. This paper systematically reviews landmark clinical trials in this field and thoroughly interprets their core findings. Integrating the latest evidence-based data and clinical practical experience, it discusses the core controversies, key clinical implementation considerations and future prospects of axillary de-escalation therapy, so as to provide references for clinical decision-making.

Endoscopic thyroid surgery is increasingly used for papillary thyroid carcinoma (PTC), but whether robotic bilateral axillo-breast approach (BABA) offers meaningful perioperative advantages over endoscopic contralateral axillo-bilateral-breast approach (CABBA) for unilateral lobectomy with ipsilateral central lymph node dissection (CLND) is unclear. This retrospective cohort study at Shanghai Sixth People's Hospital (2021-2025) aimed to compare outcomes between robotic BABA and endoscopic CABBA after lobectomy plus ipsilateral CLND for PTC, stratified by body mass index (BMI: <24 vs. ≥ 24 kg/m[2]). Propensity score matching was applied within each BMI stratum. Among 116 non-overweight patients (BMI < 24; median age 33.0 years; 87.1% female), operative time (150.0 vs. 137.5 min; median diff 12.0 min; 95% CI 0 to 24; P = 0.087) and central lymph node yield (7.0 vs. 6.0; median diff - 1.0; 95% CI - 3 to 1; P = 0.435) were comparable between robotic BABA and endoscopic CABBA. Robotic BABA was associated with significantly higher cost (median ¥51,394 vs. ¥22,043; median diff ¥29,351; 95% CI ¥26,100-¥32,600; P < 0.001) and longer incision length (median 4.00 vs. 2.80 cm; median diff - 1.20 cm; 95% CI - 1.20 to - 1.20; P < 0.001). Among 32 overweight/obese patients (BMI ≥ 24; median age 32.0 vs. 31.0 years; 56.3% female), robotic BABA achieved higher central lymph node yield (6.5 vs. 2.5; median diff - 4.0; 95% CI - 8 to - 1; P = 0.003), with comparable operative time (142.5 vs. 140.0 min; median diff - 5.0; 95% CI - 20 to 10; P = 0.595) and hospital stay (3.0 vs. 3.0 days; median diff 0; 95% CI 0 to 1; P = 0.147). Endoscopic CABBA retained cost and cosmetic advantages in both strata (both P < 0.001). In non‑overweight patients undergoing lobectomy with ipsilateral CLND for PTC, robotic BABA provides no perioperative advantage over endoscopic CABBA and is less cost‑effective. In overweight/obese patients, robotic BABA improves central lymph node clearance. These findings support BMI‑based patient selection for robotic thyroidectomy.

Adenoid cystic carcinoma (ACC) of the breast is an exceptionally rare malignancy, representing less than 0.1% of all breast cancers. Although it often demonstrates a triple-negative immunophenotype, its clinical course is typically more indolent than conventional triple-negative breast carcinomas. We report the case of a 64-year-old woman who presented with spontaneous nipple discharge from the left breast. Imaging revealed a suspicious lesion (Breast Imaging-Reporting and Data System (BI-RADS 5), leading to a core needle biopsy and tumorectomy, which identified a 2 cm invasive carcinoma of no special type. Completion mastectomy with axillary lymph node dissection revealed an 18 mm residual grade 1 tumor with clear margins and no nodal involvement. Immunohistochemistry confirmed a triple-negative profile, and staging CT scans showed no evidence of distant metastasis. The patient subsequently underwent adjuvant radiotherapy to the left chest wall. Given these findings, including complete surgical resection, absence of nodal involvement, and lack of distant metastasis, the clinical course is consistent with the favorable prognosis typically observed in breast ACC. This case highlights the diagnostic challenges, distinctive pathological features, and favorable outcomes associated with this rare entity, emphasizing the importance of accurate histopathologic evaluation and appropriate surgical management in guiding long-term prognosis.