Abstract:Axillary management for early-stage breast cancer is shifting from maximal tolerated treatment to minimal effective intervention. The introduction of sentinel lymph node biopsy (SLNB) markedly reduced surgical morbidity, and growing evidence now supports omitting axillary surgery in selected patients. The SOUND and INSEMA trials demonstrated that, among strictly defined cN0 patients assessed by high-quality imaging, omission of SLNB is non-inferior to SLNB in terms of invasive disease-free survival while significantly reducing complications such as lymphedema. In ductal carcinoma in situ, low-burden tumors, and elderly patients aged ≥70 years with HR+/HER2- disease, omission of axillary staging has minimal impact on regional control and survival outcomes. Advances in imaging technologies, dedicated lymph node PET, and artificial intelligence have improved the accuracy of identifying true node-negative patients. Furthermore, highly selected HER2+/triple-negative patients who achieve breast pathologic complete response after neoadjuvant therapy may also be candidates for axillary surgery omission. Accurate patient selection remains central to safe de-escalation, although the loss of pathological staging information may influence subsequent systemic and radiation therapy decisions. With accumulating evidence and more refined assessment tools, axillary surgery is expected to evolve toward increasingly individualized and precise management.