Introduction
Increasing evidence suggests that de-escalation of axillary surgery is safe, without significantly impacting patient outcome.

Obtaining positive lymph nodes at sentinel lymph node biopsy (SNB) can guide decisions towards requirement of axillary nodal clearance (ANC). However, methods to predict how many further nodes will be positive are not available.

This study investigates the feasibility of predicting the likelihood of a negative ANC based on the ratio between positive nodes to the total number of lymph nodes excised at SNB.

Methods
Retrospective data from January 2017 to March 2022 was collected from electronic medical records at Broomfield Hospital. Patients with estrogen receptor (ER) positive and HER2 negative receptor disease were included in the study. ER negative and HER2 positive disease was excluded, alongside patients who had chemotherapy before ANC.

Results
Of 102 patients, 58.8% (n=60) had no macro-metastasis at ANC. On average, 2.76 lymph nodes were removed at SNB. A higher SNB ratio of positive to total nodes (OR 11.09 [CI 95% 2.33-52.72], P 0.002) had significant association with positive nodes during ANC. SNB ratio ≤0.33 (1/3) had a specificity of 79.2% in identifying cases that later had a negative completion ANC, with a 95.8% specificity of no further upgrade of nodal staging.

Conclusion
Low SNB ratio of less than 0.33 (1/3) has a high specificity in excluding upgradation of nodal staging on completion ANC, with false negative rate of less than 5%. This may be used to identify patients with low risk of axillary metastasis, who can avoid ANC.