BACKGROUND: Axillary lymph node dissection (ALND) can be avoided in selected patients with positive sentinel lymph nodes (SLNs). However, regional lymph node recurrence may occur after SLN biopsy (SLNB). This study aimed to identify the risk factors for axillary recurrence to ensure safe axillary surgery. METHODS: Between June 2004 and December 2017, a total of 1056 women underwent SLNB without ALND. Patient data were prospectively entered into the breast cancer database at Kawaguchi Municipal Medical Center. From October 2012, we did not perform ALND in patients with (a) 1 or 2 positive SLNs, (b) positive SLNs that were unmatted or did not show gross extra nodal extension, (c) a clinical tumor size ≤5 cm, and in (d) those who received adjuvant endocrine therapy or chemotherapy and radiotherapy. Subsequently, appropriate adjuvant systemic and/or radiation treatment was administered. RESULTS: Of the 1056 patients included, 996 had negative SLNs, 49 had positive SLNs, and 11 had undetectable SLNs. The identification rate for SLNs was 99.0%, and the median number of removed SLNs was 2. During the median 6.9-year follow-up period, 10 patients (1.0%) showed axillary recurrence without SLNs metastasis. Hormone receptor negativity (p < 0.01), triple-negative type (0.047), mastectomy (<0.01) and not receiving adjuvant radiotherapy (<0.01) were significantly related to axillary recurrence. CONCLUSION: ALND can be safely avoided in selected patients with early breast cancer. Patients with hormone receptor-negative tumors, especially triple-negative breast cancer, patients who underwent mastectomy without ALND or those who did not receive adjuvant radiotherapy should be followed up carefully.