The treatment of breast cancer has fully entered the era of precision therapy. Sentinel lymph node biopsy (SLNB) first replaced axillary lymph node dissection (ALND) in breast cancer patients with negative clinical lymph nodes. Subsequent clinical studies have confirmed the feasibility of using SLNB alone in selected patients with limited lymph node metastasis, which has changed clinical practice. For even lower-risk patients, there is growing evidence supporting the complete omission of axillary surgery. Furthermore, with the emerging evidence from studies on axillary preservation after neoadjuvant therapy in patients from cN+ to cN0 status, it has become possible for these patients to avoid ALND. Even for those with persistent node-positive disease after neoadjuvant therapy, the possibility of avoiding ALND is under clinical investigation. However, it is important to acknowledge the remaining uncertainties in clinical practice. These include the challenges to the conventional concept of radical resection, the balance between axillary surgery and radiotherapy, the implications of de-escalated axillary staging on systemic therapy decisions. Careful evaluation and a balanced integration of surgery, radiotherapy, and systemic therapy are crucial to achieving truly precise de-escalation in axillary management.
