对于体检淋巴结阴性但放射学发现淋巴结异常（cN0/rNa）的乳腺癌患者，NCCN 和 ASCO 指南推荐前哨淋巴结活检（SLNB）作为一线腋窝分期。然而，首先接受手术的患者可能会升级至病理II-III状态，而这些患者恰好是新辅助治疗（NAT）的适应性人群。对于 cN0/rNa 患者的最佳管理尚未达成共识。目的是探索这些患者的最佳治疗策略。我们对2014年6月至2022年10月的1414名cN0/rNa患者进行了回顾性现实世界研究。其中1003名患者先接受手术，411名患者在NAT后接受手术。我们分析了这些患者的真实情况，比较了两组之间的腋窝肿瘤负荷。此外，我们还比较了两种策略下腋窝手术和区域淋巴结照射（RNI）降阶梯的获益率。 1003例首次接受手术的患者中，细针抽吸（FNA）阳性率和阴性率分别为18.5%和81.5%。 66.1%有≤≤2个淋巴结。有40.8%的FNA患者可以免除ALND而先行手术。 411例NAT后接受手术的患者中，FNA阳性率和阴性率分别为60.8%和49.2%。有 54.4% 的 FNA 患者达到腋窝病理完全缓解 (apCR)，并且在 NAT 后可以省略 ALND。 HER2/TNBC 亚型的 apCR 为 67.3%。根据 NSABP-B51 试验，先行手术和 NAT 后手术中分别有 0 和 54.4% 的 FNA 患者可以省略 RNI。在 1-2 名前哨淋巴结 (SLN) 阳性患者中，首先接受手术，中位随访时间为 49 个月，仅 SLNB 和 SLNB-ALND 之间的生存获益没有差异。与1-2例无RNI的SLN患者相比，RNI可带来更好的侵袭性无病生存（97.38% vs. 89.36%，P = 0.046）和乳腺癌特殊生存（100% vs. 94.68%，P = 0.020）。当 cN0/rNa 患者检测到 1-2 个阳性 SLN 时，进行 SLNB 省略 ALND 是安全的。 HER2 /TNBC 亚型患者在 NAT 后接受手术有更多机会从双重降阶梯中受益，包括腋窝手术和 RNI 降阶梯。© 2024。作者。

For breast cancer patients with physical exam node negative but radiological finding node abnormal (cN0/rNa), the NCCN and ASCO guidelines recommend sentinel lymph node biopsy (SLNB) as the first-line axillary staging. However, patients who undergo surgery firstly may be upstaged to pathological II-III status, and these patients happen to be the adaptive population of neoadjuvant therapy (NAT). There is no consensus on the optimal management of cN0/rNa patients. The aim is to explore the optimal management strategy of these patients. We performed a retrospective real-world study of 1414 cN0/rNa patients from June 2014 to October 2022. There were 1003 patients underwent surgery first and 411 patients underwent surgery after NAT. We analyzed the real-world conditions of these patients, compared axilla tumor burden between these two groups. In addition, we compared benefit ratio of axillary surgery and regional nodal irradiation (RNI) de-escalation under the two strategies. Among 1003 patients underwent surgery first, the positive and negative rates of fine needle aspiration (FNA) were 18.5% and 81.5%, respectively. There were 66.1% had ≤ 2 lymph nodes+. There were 40.8% of FNA+ patients could be exempted from ALND underwent surgery first. In 411 patients underwent surgery after NAT, the FNA positive and negative rates were 60.8% and 49.2%, respectively. There were 54.4% of FNA+ patients achieved axilla pathologic complete response (apCR) and could omit ALND after NAT. The apCR was 67.3% in HER2+/TNBC subtypes. According to the NSABP-B51 trial, there were 0 and 54.4% of FNA+ patients could omit RNI among surgery first and after NAT, respectively. Among 1-2 sentinel lymph node (SLN)-positive patients underwent surgery first, with a median follow-up 49 months, there was no difference of survival benefit between SLNB-only and SLNB-ALND. Compared with 1-2 SLN+ patients without RNI, RNI could bring better invasive disease-free survival (97.38% vs. 89.36%, P = 0.046) and breast cancer special survival (100% vs. 94.68%, P = 0.020). It is safe to perform SLNB omitting ALND when detected 1-2 positive SLNs in cN0/rNa patients. Patients with HER2+/TNBC subtypes underwent surgery after NAT had more chance to benefit from dual de-escalation, including axillary surgery and RNI de-escalation.© 2024. The Author(s).