Since the Halstedian era, high-quality evidence has resulted in a trend toward de-escalation of surgery without compromise to oncologic outcomes for patients with breast cancer. Management of the axilla has seen the historical standard of axillary lymph node dissection (ALND) give way to sentinel lymph node biopsy (SLNB) for most patients with breast cancer who proceed to upfront surgery. However, in patients with confirmed axillary metastasis (cN+) who receive neoadjuvant systemic therapy (NST), management of the axilla remains controversial.