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For clinically node positive patients with breast cancer, traditionally the gold standard for management of the axilla has been axillary lymph node dissection. This however has been associated with a high rate of morbidity including lymphoedema and shoulder stiffness. With the introduction of neo-adjuvant systemic therapy many patients undergo pathological complete response within the breast and axilla, particularly in certain molecular subtypes of breast cancer propelling interest in de-escalation surgery to reduce this morbidity.

Targeted axillary dissection is a procedure combining targeted lymph node biopsy, removing a previously marked node with confirmed cancer prior to neo-adjuvant systemic therapy and sentinel lymph node biopsy. The aim of the procedure is to accurately re-stage the axilla in patients with known nodal metastases after systemic therapy and reduce the morbidity associated with axillary dissection. Current meta-analyses have demonstrated that performing targeted axillary clearance has a consistently lower false negative rate when re-staging the axilla compared to sentinel or targeted node biopsy alone. This has led to a huge increase in popularity for the procedure. However, long-term data for oncological outcomes and morbidity are still lacking.

This review article aims to provides an overview of targeted axillary dissection. Focusing on technical aspects, including clip selection, number of clipped nodes and localization techniques for identifying the clipped node prior to surgery. The improved false negative rates of targeted lymph node dissection compared to sentinel node biopsy in clinically node positive patients converting to clinically node negative patients after neo-adjuvant systemic therapy. Pathological and radiological factors that may help in predicting nodal response to neo-adjuvant systemic therapy. Current guidelines/ recommendations for patient selection and management of residual disease within the axilla based on limited data and future studies aiming to clarify treatment decisions for this group of patients.