In the last two decades, surgical methods for axillary staging in breast cancer patients have become less extensive, and full axillary lymph node dissection (ALND) is confined to selected patients. In initially node-positive patients undergoing neoadjuvant chemotherapy, however, the optimal management remains unclear. Current guidelines vary widely, endorsing different strategies. We performed a literature review on axillary staging strategies and their place in international recommendations. This overview defines knowledge gaps associated with specific procedures, summarizes currently ongoing clinical trials that address these unsolved issues, and provides the rationale for further research. While some guidelines have already implemented surgical de-escalation, replacing ALND with, e.g., sentinel lymph node biopsy (SLNB) or targeted axillary dissection (TAD) in cN+ patients converting to clinical node negativity, others recommend ALND. Numerous techniques are in use for tagging lymph node metastasis, but many questions regarding the marking technique, i.e., the optimal time for marker placement and the number of marked nodes, remain unanswered. The optimal number of SLNs to be excised also remains a matter of debate. Data on oncological safety and quality of life following different staging procedures are lacking. These results provide the rationale for the multinational prospective cohort study AXSANA initiated by EUBREAST, which started enrollment in June 2020 and aims at recruiting 3000 patients in 20 countries (NCT04373655; Funded by AGO-B, Claudia von Schilling Foundation for Breast Cancer Research, AWOgyn, EndoMag, Mammotome, and MeritMedical).

11th Department of Oncological Surgery and Gynecological Oncology Iuliu Hațieganu University of Medicine and Pharmacy 400012 Cluj Napoca Romania

1st Department of Surgery Laiko Hospital National and Kapodistrian University of Athens 115 27 Athens Greece

Brandenburg Medical School Theodor Fontane 16816 Neuruppin Germany

Breast and Endocrine Unit General Surgery Department Zonguldak BEUN The School of Medicine Kozlu Zonguldak 67600 Turkey

Breast Center Department of Gynecology and Obstetrics University of Frankfurt 60590 Frankfurt am Main Germany

Breast Surgery Unit Comprehensive Cancer Center Helsinki University Hospital University of Helsinki 00280 Helsinki Finland

Breast Surgery Unit San Raffaele Hospital Milan 20132 Milano MI Italy

Breast Surgical Oncology and Oncoplastic Surgery Max Institute of Cancer Care Max Healthcare Delhi Delhi 110092 India

Breast Surgical Unit Clínica Universidad de Navarra 28027 Madrid Spain

Champalimaud Clinical Center Breast Unit Champalimaud Foundation 1400 038 Lisboa Portugal

Collegium Medicum University of Zielona Góra 65 046 Zielona Góra Poland

Department for Breast and Endocrine Surgery Oslo University Hospital 0188 Oslo Norway

Department of Breast and Sarcoma Surgery National Institute of Oncology 1122 Budapest Hungary

Department of Gynecology and Breast Cancer Center Charite Berlin 10117 Berlin Germany

Department of Gynecology and Gynecological Oncology AGAPLESION Markus Krankenhaus 60431 Frankfurt am Main Germany

Department of Gynecology and Obstetrics Ente Ospedaliero Cantonale Ospedale Regionale di Lugano 6900 Lugano Switzerland

Department of Gynecology and Obstetrics Klinikum Esslingen 73730 Esslingen Germany

Department of Gynecology and Obstetrics Regio Klinikum Pinneberg 25421 Pinneberg Germany

Department of Gynecology and Obstetrics University Hospital Aachen 52074 Aachen Germany

Department of Gynecology and Obstetrics University Hospital Rostock 18059 Rostock Germany

Department of Molecular Medicine and Surgery Karolinska Institutet 171 77 Stockholm Sweden

Department of Obstetrics and Gynecology Campus Lübeck University Hospital of Schleswig Holstein 23538 Lübeck Germany

Department of Surgery Capio St Göran's Hospital 112 19 Stockholm Sweden

Department of surgical oncology Institut de cancerologie de l'Ouest Nantes 44800 Saint Herblain France

Department of Surgical Oncology Prof Dr Ion Chiricuță Institute of Oncology 400015 Cluj Napoca Romania

Faculty of Biomedicine University of the Italian Switzerland 6900 Lugano Switzerland

Gynecologic Oncology Center Department of Obstetrics and Gynecology 1st Faculty of Medicine Charles University General University Hospital 128 00 Prague Czech Republic

Institut für Pathologie Medical University of Graz 8010 Graz Austria

Medical Faculty Heinrich Heine University Düsseldorf 40225 Düsseldorf Germany

Oncology Hospital University Hospital Center Nene Tereza 1000 Tirana Albania

Petrov Research Institute of Oncology 197758 Saint Petersburg Russia

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