Axillary lymph node dissection (ALND) has been a cornerstone of breast cancer (BC) treatment, traditionally ensuring loco-regional control but associated with significant morbidity. Recent advancements suggest sentinel lymph node biopsy (SLNB) as a less invasive alternative. This review examines the outcomes of omitting ALND in BC patients with positive sentinel lymph nodes (SLNs) undergoing mastectomy. We conducted a comprehensive review of historical comparative studies and pivotal randomized clinical trials. Key sources included the ACOSOG Z0011 and SINODAR-ONE trials, alongside retrospective studies and ongoing trials like SENOMAC and POSNOC. Historical studies predominantly focused on patients undergoing breast-conserving surgery, revealing low recurrence rates and comparable survival outcomes between SLNB alone and ALND. Retrospective analyses of mastectomy patients indicated that omitting ALND did not significantly impact recurrence-free survival (RFS) or overall survival (OS). The SINODAR-ONE trial sub-analysis, involving 218 mastectomy patients, found no significant differences in 5-year OS and RFS between ALND and SLNB groups. The SENOMAC trial similarly showed non-inferior outcomes for mastectomy patients treated without ALND. The ongoing POSNOC trial aims to provide further insights, particularly focusing on the subgroup of mastectomy patients. Emerging evidence supports the feasibility of omitting ALND in BC patients with positive SLNs undergoing mastectomy, potentially reducing surgical morbidity without compromising oncological outcomes. However, further randomized clinical trials are essential to confirm these findings and refine treatment guidelines, ensuring optimal patient care.
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