{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T06:59:19Z","timestamp":1785135559891,"version":"3.55.0"},"reference-count":52,"publisher":"MDPI AG","issue":"15","license":[{"start":{"date-parts":[[2026,7,26]],"date-time":"2026-07-26T00:00:00Z","timestamp":1785024000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>Axillary lymph node management in early-stage breast cancer has undergone a fundamental transformation over the past three decades, shifting from routine radical clearance to precision-guided de-escalation. Ultrasound (US) has emerged as the central imaging modality in this paradigm shift, serving as the first-line tool for preoperative nodal assessment, guidance for biopsy and clip placement, monitoring of response to neoadjuvant chemotherapy (NAC), and localization of marked nodes for targeted axillary dissection (TAD). This review systematically examines the evolution of axillary management in early-stage breast cancer through a US-centric lens. We summarize the historical transition from Halstedian axillary lymph node dissection (ALND) to sentinel lymph node biopsy (SLNB), critically appraise the landmark trials\u2014Z0011, AMAROS, OTOASOR, and SOUND\u2014that have progressively de-escalated axillary surgery, and detail the role of US in preoperative staging (including conventional B-mode, superb microvascular imaging, contrast-enhanced US, elastography, and AI-assisted diagnostics), US-guided biopsy and node marking, and post-NAC TAD. We further explore the integration of US with liquid biopsy, multigene profiling, and molecular subtype-guided systemic therapy to enable individualized decision-making. Finally, we propose a stepwise US-centric clinical algorithm and discuss future directions, including AI-powered real-time interpretation, imaging-omics, and US-guided targeted therapy. This review provides a comprehensive framework for incorporating ultrasound as a key component of multidisciplinary decision-making\u2014alongside pathological, surgical, radiotherapeutic, and molecular inputs\u2014in contemporary axillary management.<\/jats:p>","DOI":"10.3390\/cancers18152405","type":"journal-article","created":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T05:49:27Z","timestamp":1785131367000},"page":"2405","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Ultrasound-Guided Axillary Management in Early-Stage Breast Cancer: From Diagnosis to De-Escalation"],"prefix":"10.3390","volume":"18","author":[{"given":"Xiangmin","family":"Shen","sequence":"first","affiliation":[{"name":"Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha 410011, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zi","family":"Yi","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Surgery Intensive Care Unit, The Second Xiangya Hospital of Central South University, Changsha 410011, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0769-5397","authenticated-orcid":false,"given":"Kui","family":"Tang","sequence":"additional","affiliation":[{"name":"Department of Ultrasound Diagnosis, The Second Xiangya Hospital of Central South University, Changsha 410011, China"},{"name":"Research Center of Ultrasonography, The Second Xiangya Hospital of Central South University, Changsha 410011, China"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,26]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"200","DOI":"10.21614\/chirurgia.3289","article-title":"From axillary dissection to sentinel node biopsy: Three decades redefining axillary surgery in early breast cancer\u2014A narrative review","volume":"121","author":"Mandi","year":"2026","journal-title":"Chirurgia"},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Izzo, P., Molle, M., Di Cello, P., Meloni, P., Lai, S., Izzo, L., Sibio, S., Messineo, D., and Izzo, S. (2026). Breast cancer surgery: Past, present and future\u2014A narrative review. J. Clin. Med., 15.","DOI":"10.3390\/jcm15103778"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Stanczyk, M., Cheung, T.C., and Lang, J.E. (2026). The past, present, and future of sentinel lymph node biopsy in breast cancer. Ann. Surg. Oncol., ahead of print.","DOI":"10.1245\/s10434-026-19672-4"},{"key":"ref_4","first-page":"e105464","article-title":"De-escalation of axillary surgery in early-stage breast cancer: A comprehensive narrative review","volume":"18","author":"Munagapati","year":"2026","journal-title":"Cureus"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"277","DOI":"10.14740\/wjon2710","article-title":"De-escalation of axillary surgery: A review of choosing wisely guideline evidence","volume":"17","author":"Grapes","year":"2026","journal-title":"World J. Oncol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1342","DOI":"10.2214\/AJR.05.0936","article-title":"Role of sonography in the diagnosis of axillary lymph node metastases in breast cancer: A systematic review","volume":"186","author":"Alvarez","year":"2006","journal-title":"AJR Am. J. Roentgenol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1007\/s10549-022-06699-w","article-title":"The role of pre-operative axillary ultrasound in assessment of axillary tumor burden in breast cancer patients: A systematic review and meta-analysis","volume":"196","author":"Man","year":"2022","journal-title":"Breast Cancer Res. Treat."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Lucocq, J., Karakatsanis, A., Kirwan, C., Boughey, J., Tseng, J., Sun, S.X., Gentilini, O.D., Barber, M., Chagla, L., and Buccimazza, I. (2026). International consensus on axillary staging after neoadjuvant chemotherapy in node-positive breast cancer. Eur. J. Surg. Oncol., ahead of print.","DOI":"10.1016\/j.ejso.2026.111522"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Lattimore, C.M., Johnson, H.M., Kuerer, H.M., Caudle, A.S., Giordano, S.H., Singh, P., Hunt, K.K., Huo, L., and Wanis, K.N. (2026). Clipped node pathology as a guide for limited axillary surgery in occult breast cancer. Ann. Surg., ahead of print.","DOI":"10.1097\/SLA.0000000000007093"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"297","DOI":"10.1186\/s12957-026-04430-3","article-title":"Carbon tattooing localization of biopsy-proven metastatic axillary lymph nodes for targeted axillary dissection after neoadjuvant therapy in breast cancer: A systematic review and single-arm meta-analysis","volume":"24","author":"Mirza","year":"2026","journal-title":"World J. Surg. Oncol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1007\/s10549-026-07968-8","article-title":"Correlation between the drainage time in dynamic indocyanine green lymphography (ICG) and axillary lymph nodes metastatic involvement in breast cancer patients-a prospective study","volume":"217","author":"Anuszkiewicz","year":"2026","journal-title":"Breast Cancer Res. Treat."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Li, S.Y., Li, Y.M., Fang, Y.Q., Jin, Z.Y., Li, J.K., Zou, X.M., Huang, S.S., Niu, R.L., Fu, N.Q., and Shao, Y.H. (2025). Contrast-enhanced ultrasound radiomics model for predicting axillary lymph node metastasis and prognosis in breast cancer: A multicenter study. BMC Cancer, 25.","DOI":"10.1186\/s12885-025-14632-9"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"206","DOI":"10.4048\/jbc.2024.0303","article-title":"Efficacy of a real-time artificial intelligence ultrasound system with computer-aided detection and diagnosis for breast cancer: A feasibility study","volume":"28","author":"Lee","year":"2025","journal-title":"J. Breast Cancer"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Asadoorian, N., Yaraghi, S., Tahmasian, A., Fatehifard, R., Rezazadegan, M., and Mottaghi, N. (2026). DeiT-MLP-mixer for the preoperative prediction of axillary lymph node involvement in breast cancer via ultrasound imaging. BMC Med. Imaging, 26.","DOI":"10.1186\/s12880-026-02256-9"},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Allfelt, A., Bendahl, P.-O., Dihge, L., Ohlsson, M., Ryd\u00e9n, L., and Skarping, I. (2026). Human factors validation study of an artificial neural network-based preoperative decision-support tool for noninvasive lymph node staging (NILS) in women with primary breast cancer. BMC Cancer, 26.","DOI":"10.1186\/s12885-026-16161-5"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1237","DOI":"10.1016\/j.ultrasmedbio.2013.12.012","article-title":"The combination of intralymphatic chemotherapy with ultrasound and nano-\/microbubbles is efficient in the treatment of experimental tumors in mouse lymph nodes","volume":"40","author":"Sato","year":"2014","journal-title":"Ultrasound Med. Biol."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Pati, A., Parhi, M., Pattanayak, B.K., Singh, D., Singh, V., Kadry, S., Nam, Y., and Kang, B.-G. (2023). Breast Cancer Diagnosis Based on IoT and Deep Transfer Learning Enabled by Fog Computing. Diagnostics, 13.","DOI":"10.3390\/diagnostics13132191"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Pati, A., Panigrahi, A., Parhi, M., Giri, J., Qin, H., Mallik, S., Pattanayak, S.R., and Agrawal, U.K. (2024). Performance assessment of hybrid machine learning approaches for breast cancer and recurrence prediction. PLoS ONE, 19.","DOI":"10.1371\/journal.pone.0304768"},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Yu, T., Li, R., and Cai, C. (2026). Synchronous bilateral phyllodes tumors with discordant grades and false-positive axillary 18F-FDG PET-CT uptake: A case report and literature review. Front. Oncol., 16.","DOI":"10.3389\/fonc.2026.1825190"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"111790","DOI":"10.1016\/j.ejso.2026.111790","article-title":"Management of non-detection of the sentinel node in breast cancer: A scoping review","volume":"52","author":"Andersen","year":"2026","journal-title":"Eur. J. Surg. Oncol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"e520754","DOI":"10.1200\/EDBK-26-520754","article-title":"Right-Sizing Locoregional Management in the Era of Neoadjuvant Therapy for Breast Cancer","volume":"46","author":"Wong","year":"2026","journal-title":"Am. Soc. Clin. Oncol. Educ. Book"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1922","DOI":"10.62347\/WHZX9613","article-title":"Impact of axillary management approaches on postoperative complication rates in breast cancer and exploration of targeted prevention strategies","volume":"16","author":"Chen","year":"2026","journal-title":"Am. J. Cancer Res."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Knopf, E., Childers, L.T., Woodward, M., Gray, I.M., Childers, J.T., and Ahmad, S. (2026). Comprehensive overview of management and risk assessment of breast cancer-related lymphedema: A multidisciplinary approach. Front. Oncol., 16.","DOI":"10.3389\/fonc.2026.1796657"},{"key":"ref_24","first-page":"573154","article-title":"From axillary lymph node dissection to sentinel node biopsy in breast cancer: A 23-year population-based large-sample study with long-term survival outcomes","volume":"18","author":"Mangone","year":"2026","journal-title":"Breast Cancer"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"rjag359","DOI":"10.1093\/jscr\/rjag359","article-title":"Indocyanine green focused near-infrared fluorescence lymphography localization in treatment of chyle leak after mastectomy with targeted left axillary sentinel node biopsy for breast cancer","volume":"2026","author":"Kruithoff","year":"2026","journal-title":"J. Surg. Case Rep."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"111867","DOI":"10.1016\/j.ejso.2026.111867","article-title":"AGO Breast Committee recommendations for the surgical therapy of breast cancer: Working Group on Gynecologic Cancers (AGO) update 2026","volume":"52","author":"Solbach","year":"2026","journal-title":"Eur. J. Surg. Oncol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"918","DOI":"10.1001\/jama.2017.11470","article-title":"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","volume":"318","author":"Giuliano","year":"2017","journal-title":"JAMA"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"569","DOI":"10.1001\/jama.2011.90","article-title":"Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: A randomized clinical trial","volume":"305","author":"Giuliano","year":"2011","journal-title":"JAMA"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1303","DOI":"10.1016\/S1470-2045(14)70460-7","article-title":"Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): A randomised, multicentre, open-label, phase 3 non-inferiority trial","volume":"15","author":"Donker","year":"2014","journal-title":"Lancet Oncol."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Hong, C., Chen, J., Chen, Y., Li, L., Du, X., Chen, D., and Lian, W. (2026). Omission of axillary lymph node dissection in breast cancer patients with 1\u20132 positive sentinel lymph nodes: A multicenter real-world cohort study in a Chinese population. Curr. Oncol., 33.","DOI":"10.3390\/curroncol33050247"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1007\/s10549-026-07993-7","article-title":"Retrospective study on regional nodal irradiation after omission of axillary lymph node dissection in sentinel lymph node-positive breast cancer: A propensity score matching analysis","volume":"217","author":"Xia","year":"2026","journal-title":"Breast Cancer Res. Treat."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1557","DOI":"10.1001\/jamaoncol.2023.3759","article-title":"Sentinel lymph node biopsy vs no axillary surgery in patients with small breast cancer and negative results on ultrasonography of axillary lymph nodes: The SOUND randomized clinical trial","volume":"9","author":"Gentilini","year":"2023","journal-title":"JAMA Oncol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"587","DOI":"10.1016\/j.breast.2012.06.013","article-title":"Abandoning sentinel lymph node biopsy in early breast cancer? A new trial in progress at the European Institute of Oncology","volume":"21","author":"Gentilini","year":"2012","journal-title":"Breast"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1051","DOI":"10.1056\/NEJMoa2412063","article-title":"Axillary surgery in breast cancer\u2014Primary results of the INSEMA trial","volume":"392","author":"Reimer","year":"2024","journal-title":"N. Engl. J. Med."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Lowe, R., Das Gupta, S., Leiss, A., Frank, A., Banfield, D., Llewellyn-Bennett, R., Egbeare, D., Hunter-Smith, A., Crocker, L., and Mills, H. (2026). Omitting the sentinel lymph node biopsy: A region\u2019s perspective following recommendations from the SOUND trial. Ann. R. Coll. Surg. Engl., ahead of print.","DOI":"10.1308\/rcsann.2026.0014"},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Park, K.U., Delisle, M., Hassett, M.J., Minami, C.A., Punglia, R.S., Woodbury, S.R., Brindle, M., Mittendorf, E.A., and King, T.A. (2026). From clinical trial awareness to practice: Factors associated with intent to omit axillary surgery based on the SOUND clinical trial. Ann. Surg. Oncol., ahead of print.","DOI":"10.1245\/s10434-026-19792-x"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1007","DOI":"10.1002\/jso.70256","article-title":"Omission of sentinel lymph node biopsy in breast cancer: A real-world validation of the patient populations of the SOUND and INSEMA trials","volume":"133","author":"Puiras","year":"2026","journal-title":"J. Surg. Oncol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"545","DOI":"10.23736\/S2724-5691.24.10485-6","article-title":"Sentinel lymph node biopsy versus axillary lymph node dissection in breast cancer patients undergoing mastectomy","volume":"79","author":"Gentile","year":"2024","journal-title":"Minerva Surg."},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Imoto, S., Matsumoto, A., Nakamura, R., Masuda, N., Yasojima, H., Onishi, T., Minami, S., Kuba, S., Wada, N., and Jinno, H. (2026). Optimizing axillary surgery for patients with clinically node-negative and node-positive breast cancer. Surg. Today, ahead of print.","DOI":"10.1007\/s00595-026-03342-9"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"e6196988","DOI":"10.1155\/tbj\/6196988","article-title":"Selected pathological criteria that predict low rates of axillary lymph node metastases regardless of patient age: A single institution study","volume":"2026","author":"Nathanson","year":"2026","journal-title":"Breast J."},{"key":"ref_41","first-page":"e250001","article-title":"Dermatofibrosarcoma Protuberans, Version 1.2025, NCCN Clinical Practice Guidelines In Oncology","volume":"23","author":"Bordeaux","year":"2025","journal-title":"J. Natl. Compr. Cancer Netw."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1455","DOI":"10.1001\/jama.2013.278932","article-title":"Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: The ACOSOG Z1071 (Alliance) clinical trial","volume":"310","author":"Boughey","year":"2013","journal-title":"JAMA"},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"De Rose, F., Lucidi, S., Bonzano, E., De Santis, M.C., Meduri, B., Colciago, R.R., Prisco, A., Dicuonzo, S., La Rocca, E., and Pasinetti, N. (2026). Axillary management in patients with cN+ breast cancer undergoing neoadjuvant chemotherapy: Pattern of practice in Italy. Clin. Transl. Oncol., ahead of print.","DOI":"10.1007\/s12094-026-04360-2"},{"key":"ref_44","first-page":"e107344","article-title":"Cross-sectional study to compare sentinel lymph node biopsy vs. complete axillary lymph node dissection for the evaluation of lymph node metastasis in females with locally advanced breast carcinoma post neoadjuvant chemotherapy","volume":"18","author":"Patel","year":"2026","journal-title":"Cureus"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"604","DOI":"10.1016\/S1470-2045(26)00064-1","article-title":"Lymph node surgery and CDK4\/6 inhibitors in early breast cancer: A pooled analysis from five randomised trials","volume":"27","author":"Pfob","year":"2026","journal-title":"Lancet Oncol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"15330338261450066","DOI":"10.1177\/15330338261450066","article-title":"RNI precision trial protocol: Optimization of regional node irradiation for sentinel lymph node-positive breast cancer omitting axillary dissection based on clinical and genomic risk assessment: A prospective clinical trial","volume":"25","author":"Qi","year":"2026","journal-title":"Technol. Cancer Res. Treat."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1720","DOI":"10.1200\/JCO-25-00099","article-title":"Sentinel lymph node biopsy in early-stage breast cancer: ASCO guideline update","volume":"43","author":"Park","year":"2025","journal-title":"J. Clin. Oncol."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"103161","DOI":"10.1016\/j.ctrv.2026.103161","article-title":"The role of the 21-gene assay in the neoadjuvant setting for hormone receptor-positive HER2-negative breast cancer: Impact on systemic and surgical treatment decisions","volume":"147","author":"Zotano","year":"2026","journal-title":"Cancer Treat. Rev."},{"key":"ref_49","doi-asserted-by":"crossref","unstructured":"Aksel, B., Sagdic, M.F., and Dogan, L. (2026). Is sentinel lymph node frozen section analysis necessary in hormone receptor-positive, HER2-negative, clinically node-negative breast cancer patients undergoing upfront mastectomy?. Front. Oncol., 16.","DOI":"10.3389\/fonc.2026.1792989"},{"key":"ref_50","first-page":"45","article-title":"Axillary nodal disease burden is not associated with an elevated 21-gene recurrence score in post-menopausal women presenting with a clinically negative axilla","volume":"233","author":"Bruele","year":"2024","journal-title":"Am. J. Surg."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1016\/S1470-2045(22)00694-5","article-title":"Abemaciclib plus endocrine therapy for hormone receptor-positive, HER2-negative, node-positive, high-risk early breast cancer (monarchE): Results from a preplanned interim analysis of a randomised, open-label, phase 3 trial","volume":"24","author":"Johnston","year":"2023","journal-title":"Lancet Oncol."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"7237","DOI":"10.1245\/s10434-026-19783-y","article-title":"Sentinel lymph node positivity and utility of frozen section diagnosis following neoadjuvant therapy in patients with clinically node-negative, hormone receptor-positive, HER2-negative breast cancer","volume":"33","author":"Wanis","year":"2026","journal-title":"Ann. Surg. Oncol."}],"container-title":["Cancers"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6694\/18\/15\/2405\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T06:03:58Z","timestamp":1785132238000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6694\/18\/15\/2405"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,26]]},"references-count":52,"journal-issue":{"issue":"15","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["cancers18152405"],"URL":"https:\/\/doi.org\/10.3390\/cancers18152405","relation":{},"ISSN":["2072-6694"],"issn-type":[{"value":"2072-6694","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,26]]}}}