# Figure legends

These legends are written in journal-formatted English and can be pasted at the end of the manuscript.

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**Figure 1.  PRISMA 2020 flow diagram for an umbrella review of axillary management after neoadjuvant chemotherapy (NAC) for breast cancer.**
The diagram summarises identification, screening, and inclusion of systematic reviews and meta-analyses retrieved from PubMed, Embase, the Cochrane Library, and Web of Science (search closed January 2026). After de-duplication and full-text assessment, 33 systematic reviews were eligible for the qualitative synthesis. Reasons for exclusion at the full-text stage are indicated. *SR = systematic review; MA = meta-analysis; NAC = neoadjuvant chemotherapy.*

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**Figure 2.  AMSTAR-2 quality assessment heatmap of 33 systematic reviews of axillary management after NAC.**
Rows correspond to individual systematic reviews ordered by year of publication; columns correspond to the 16 AMSTAR-2 items. Critical domains (items 2, 4, 7, 9, 11, 13, 15) are highlighted with bold borders. Cell colour indicates the rating: green = Yes; sand = Partial Yes; red = No; grey = Cannot tell; white = not applicable (narrative SRs not performing meta-analysis). The right-hand column displays the overall confidence rating, which was *Critically Low* for all 33 reviews under the present conservative abstract-based scoring; full-text rescoring is expected to upgrade many reviews. *AMSTAR-2 = A MeaSurement Tool to Assess systematic Reviews, version 2.*

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**Figure 3.  Range of nodal pathological complete response (ypN0) across systematic reviews, by molecular subtype.**
Each diamond represents one estimate reported in an included systematic review or pooled analysis; the horizontal bar denotes the observed range across reviews and the vertical tick marks the median. No re-pooling was performed (umbrella methodology). Ordering is by descending median. The wide range observed for HR+/HER2– (approximately 7–25%) reflects heterogeneity in inclusion of luminal A versus luminal B sub-cohorts, neoadjuvant endocrine therapy versus chemotherapy, and Ki-67 thresholds. *ypN0 = no residual nodal disease at surgery; HR = hormone receptor; HER2 = human epidermal growth factor receptor 2; TNBC = triple-negative breast cancer.*

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**Figure 4.  False-negative rate (FNR) of axillary staging techniques after NAC.**
Squares represent the central estimate (mean across pivotal trials and meta-analyses); horizontal lines indicate the reported range or 95% confidence interval; *k* denotes the number of contributing systematic reviews/pivotal datasets. The dashed reference line at 10% reflects the acceptability threshold proposed by the ACOSOG Z1071 trial. Targeted axillary dissection (TAD) and the radioactive-iodine seed localisation (RISAS) procedure achieve an FNR consistently below 5%, supporting their preferential use in cN+ patients converted to ycN0 after NAC. *SLNB = sentinel lymph node biopsy; MARI = marking the axillary lymph node with radioactive iodine seeds; TAD = targeted axillary dissection; RISAS = radioactive iodine seed localisation in the axilla.*

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**Figure 5.  Timeline of pivotal evidence and SR/MA publications on axillary management after NAC, 2006–2026.**
Triangles above the bars mark pivotal trials and pooled analyses (Z1071, SENTINA, SN FNAC, MARI, TAD, RISAS, NSABP B-51). Bars indicate the number of systematic reviews and meta-analyses identified in each year of publication (n = 33 across the search period). Background shading highlights three eras: the *trial era* (2013–2015, establishing the limits of single-tracer SLNB after NAC); the *TAD era* (2016–2022, refinement of clip-based targeted approaches); and the *chemo-IO + RT de-escalation era* (2022–2026, marked by RISAS, KEYNOTE-522 nodal data, and NSABP B-51 regional radiotherapy de-escalation in ypN0).

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**Figure 6.  Guideline convergence matrix for axillary management after NAC.**
Recommendations from seven international guideline bodies (NCCN 2025, ESMO 2024, ASCO 2025, St Gallen 2023, AGO 2025, EUSOMA 2024, EUBREAST 2024) are summarised across five key axillary management domains. **Y** (green) = explicit consensus statement; **~** (sand) = partial or conditional endorsement; **N** (red) = no statement. Convergence is strongest for technical requirements (≥3 SLNs, dual tracer) and progressively weaker for newer concepts (omission of axillary lymph node dissection in ITC-only or ypN0-mic patients).
