Impact of axillary management approaches on postoperative complication rates in breast cancer and exploration of targeted prevention strategies

This study aimed to systematically identify axillary complication phenotypes after breast cancer surgery, characterize their evolutionary trajectories, and clarify how surgical approaches affect long-term complications. A total of 470 breast cancer patients (2020-2024) were retrospectively divided into SLNB (n = 192) and ALND (n = 278) groups. K-means clustering, multivariate logistic regression, mediation analysis, and multi-state models were used. Low-risk (SLNB-dominant, 42.13%), pain-dominant (ALND-related type, 26.17%), severe lymphedema (ALND-related type, 13.62%), and moderate-severe comorbidity (ALND-related type, 18.09%). ALND was the strongest predictor of the high-risk comorbidity phenotype (adjusted OR = 8.32, P < 0.001). Prolonged drainage mediated 35% of ALND's effect on lymphedema (P < 0.001). ALND increased chronic complication transition 5.2-fold and reduced recovery probability (P < 0.001). In conclusion, ALND is closely associated with high-risk axillary complication phenotypes, directly and indirectly (via prolonged drainage) elevating complication risk, altering their evolution and reducing recovery. Findings support phenotype-based individualized management and rational axillary lymph node management selection.