Prediction model of axillary lymph node status using an automated breast volume ultrasound radiomics nomogram in early breast cancer with negative axillary ultrasound
Axillary lymph node (ALN) status is the most strongly associated factor affecting the survival and prognosis of breast cancer patients ( , ). Although sentinel lymph node (SLN) biopsy is widely used to detect ALN status. However, the false-negative rate of SLNB is 5.5%-16.7% ( , ), and SLNB may be associated with sensory nerve damage, lymphedema, and limited shoulder motion ( ). In addition, according to the ACOSOG Z0011 trial, patients with SLN metastases of less than 2 early-stage breast cancers who do not undergo axillary surgery do not have affected overall survival and disease-free survival rates ( , ). Therefore, ALN status is adequately assessed by radiographic methods prior to surgery to minimize unnecessary invasive exploration. The most valuable radiological method for assessing ALNs is axillary ultrasound (AUS) ( – ). Owing to the noninvasive and inexpensive nature of ultrasound, it is very suitable for long-term observation of ALNs. Approximately 15.5-35.0% of AUS negatives show positivity on pathology, which makes it particularly important to reduce false negatives ( – ). Studies have shown that adding tumor characteristics to the diagnosis of ALNs can significantly reduce this deficiency of AUS ( ). Certain ultrasound features of primary breast cancer are associated with ALN metastasis, such as the diameter of the lesion, microcalcification, architectural distortion, and tumor distance from the skin ( – ). Furthermore, with the advancement of pattern recognition tools, radiomics has attracted increasing interest. Combining the imaging features of a lesion with radiomics features has greatly improved diagnostic performance ( , , ). Radiomics is the process of converting medical images into mineable data by extracting high-throughput quantitative features that effectively reduce inter-examiner variability. In the past, free-form imaging methods and the reliance on adjustable parameters during the examination made the development of radiomics in ultrasound difficult ( ), and the emergence of an automatic breast volume scanner (ABVS) has solved this problem. ABVS allows comprehensive and standardized scanning of the entire breast and coronal and sagittal display in specific workstations. The coronal plane of the lesion provides additional information for diagnosis ( ), and standardized images also open up new opportunities for ultrasound radiomics ( ). Therefore, we aimed to develop and validate two nomograms (one based on sonogram features and the other based on radiomics and sonogram features) for assessing ALN status in AUS-negative early-stage breast cancers and to explore the value of the nomogram for the preoperative assessment of patients with ALN ≥3. 

Patient The study was approved by the Institutional Review Board and requirement for informed consent was waived (PJ2023-07-11). A retrospective collection of 499 patients who were diagnosed with breast cancer by histopathology between November 2017 and August 2021 and underwent ABVS at our institution was performed. The inclusion criteria were as follows: (1) patients who underwent SLNB or ALND; (2) unifocal masses ≤ 5 cm in diameter (T1 and T2 stages); (3) ABVS within 2 weeks prior to SLNB or ALND; and (4) no suspicious lymph nodes on AUS (asymmetric or diffuse thickening of the lymph node cortex, an LN with a cortex thickness ≥ 3 mm loss of hilum, and nonhilar blood flow) ( ). The exclusion criteria were as follows: (1) patients who received chemotherapy, radiotherapy or endocrine therapy, (2) patients with multifocal or bilateral breast cancer, and (3) patients with nonoccupying lesions without demarcated borders ( ). 174 patients were finally included in this study and randomized into training and test sets at a ratio of 7:3. Baseline clinical data were acquired from the patient medical record system, including age, pathologic type, immunohistochemical (IHC) results and postoperative ALN status (ALN+ or ALN-). ALN+ patients were further classified into low burden (1-2 ALNs) and high burden (≥3 ALNs) groups. IHC was performed to assess HER-2, Progesterone Receptor (PR), Estrogen Receptor (ER) and Ki-67 status and recorded as positive (+) or negative (-). Image acquisition and assessment Details of image acquisition are provided in . Reader 1 and Reader 2 (11 and 20 years of experience, respectively) analyzed these images. Cases of disagreement were independently resolved by a third Reader (Reader 3, 25 years of experience). None of the sonographers had knowledge of the pathological results. Orientation (parallel or not parallel), margin (circumscribed, noncircumscribed), shape (regular or irregular), echogenicity (hypoechoic, hybrid echo or extremely low echo), microcalcification, tumor location (left, right), quadrant (upper inner, lower inner, upper outer, lower outer, central), convergence sign, distance from nipple, and distance from skin and maximum diameter of the lesion were recorded. Segmentation and extraction of radiomics features The flowchart of the study was showed in . Tumor regions of interest (ROIs) were manually depicted slice-by-slice by Reader 1 using ITK-SNAP 3.6. Next, using Python 3.7, areas 1, 3, 5, 7, and 9 mm around the ROI will be generated. shows an example of the ROI segmentation and expansion process for ABVS. Fifty images were randomly selected and re-segmented by Reader 1 and Reader 2 after 2 weeks to calculate intra- and inter-class correlation coefficients (ICC). Radiomics features were extracted using the “PyRadiomics (3.7.0)” Python package (Detailed in ). Feature screening, machine learning classifier, and Model 1 building The obtained intratumoral region (ITR) features are preprocessed and the model is constructed using classifiers employing logistic regression (LR), random forest (RF) and support vector machine (SVM). An optimal ML classifier was used to construct a joint ITR and peritumoral region (PTR) radiomics model, named Model 1. The radiomics-score (RS) was calculated for each patient. Methods of preprocessing and ML classifiers are shown in the . Radiomics habitat analysis The k-means method performed cluster analysis on subregions using all data without splitting into training and testing sets. The optimal number of clusters was determined by the elbow method after plotting the within-cluster sum of squares (WCSS) with k values ( ). The number of clusters from 1 to 10 was tested in this study. The ITR and PTRs were divided into subregions (habitats) based on optimal k values. Extraction of valuable radiomics features in each habitat and analysis of these features in relation to ER, PR, HER-2, and Ki-67 were conducted. Construction of Model 2 and Model 3 For sonographic feature variables, univariate logistic regression was used to evaluate their correlation with lymph node metastasis, and factors with P <0.1 were introduced into multivariate logistic regression. Factors with P <0.05 were identified as independent predictors, whereby an ultrasound feature model was created and named Model 2. RS was combined with ultrasound features to create a sonography radiomics model named Model 3. The Nomo-score was determined for each patient according to Model 2 and Model 3. Assessment of the models and construction of the nomogram The predictive performance of Model 1, Model 2, and Model 3 was evaluated by area under curve (AUC) of receiver operating characteristic (ROC), accuracy, sensitivity, and specificity. Plotting Decision Curve Analysis (DCA) assesses the net benefits of the model. Finally, nomogram-model 2 and nomogram-model 3 were constructed based on Model 2 and Model 3. Associations between Nomo-scores and ALN burden were assessed using correlation analysis. Furthermore, the value of the model for ALN ≥ 3 was assessed based on the Nomo-score cutoff value. (Statistical analyses, .) 

The study was approved by the Institutional Review Board and requirement for informed consent was waived (PJ2023-07-11). A retrospective collection of 499 patients who were diagnosed with breast cancer by histopathology between November 2017 and August 2021 and underwent ABVS at our institution was performed. The inclusion criteria were as follows: (1) patients who underwent SLNB or ALND; (2) unifocal masses ≤ 5 cm in diameter (T1 and T2 stages); (3) ABVS within 2 weeks prior to SLNB or ALND; and (4) no suspicious lymph nodes on AUS (asymmetric or diffuse thickening of the lymph node cortex, an LN with a cortex thickness ≥ 3 mm loss of hilum, and nonhilar blood flow) ( ). The exclusion criteria were as follows: (1) patients who received chemotherapy, radiotherapy or endocrine therapy, (2) patients with multifocal or bilateral breast cancer, and (3) patients with nonoccupying lesions without demarcated borders ( ). 174 patients were finally included in this study and randomized into training and test sets at a ratio of 7:3. Baseline clinical data were acquired from the patient medical record system, including age, pathologic type, immunohistochemical (IHC) results and postoperative ALN status (ALN+ or ALN-). ALN+ patients were further classified into low burden (1-2 ALNs) and high burden (≥3 ALNs) groups. IHC was performed to assess HER-2, Progesterone Receptor (PR), Estrogen Receptor (ER) and Ki-67 status and recorded as positive (+) or negative (-). 

Details of image acquisition are provided in . Reader 1 and Reader 2 (11 and 20 years of experience, respectively) analyzed these images. Cases of disagreement were independently resolved by a third Reader (Reader 3, 25 years of experience). None of the sonographers had knowledge of the pathological results. Orientation (parallel or not parallel), margin (circumscribed, noncircumscribed), shape (regular or irregular), echogenicity (hypoechoic, hybrid echo or extremely low echo), microcalcification, tumor location (left, right), quadrant (upper inner, lower inner, upper outer, lower outer, central), convergence sign, distance from nipple, and distance from skin and maximum diameter of the lesion were recorded. 

The flowchart of the study was showed in . Tumor regions of interest (ROIs) were manually depicted slice-by-slice by Reader 1 using ITK-SNAP 3.6. Next, using Python 3.7, areas 1, 3, 5, 7, and 9 mm around the ROI will be generated. shows an example of the ROI segmentation and expansion process for ABVS. Fifty images were randomly selected and re-segmented by Reader 1 and Reader 2 after 2 weeks to calculate intra- and inter-class correlation coefficients (ICC). Radiomics features were extracted using the “PyRadiomics (3.7.0)” Python package (Detailed in ). 

The obtained intratumoral region (ITR) features are preprocessed and the model is constructed using classifiers employing logistic regression (LR), random forest (RF) and support vector machine (SVM). An optimal ML classifier was used to construct a joint ITR and peritumoral region (PTR) radiomics model, named Model 1. The radiomics-score (RS) was calculated for each patient. Methods of preprocessing and ML classifiers are shown in the . 

The k-means method performed cluster analysis on subregions using all data without splitting into training and testing sets. The optimal number of clusters was determined by the elbow method after plotting the within-cluster sum of squares (WCSS) with k values ( ). The number of clusters from 1 to 10 was tested in this study. The ITR and PTRs were divided into subregions (habitats) based on optimal k values. Extraction of valuable radiomics features in each habitat and analysis of these features in relation to ER, PR, HER-2, and Ki-67 were conducted. 

For sonographic feature variables, univariate logistic regression was used to evaluate their correlation with lymph node metastasis, and factors with P <0.1 were introduced into multivariate logistic regression. Factors with P <0.05 were identified as independent predictors, whereby an ultrasound feature model was created and named Model 2. RS was combined with ultrasound features to create a sonography radiomics model named Model 3. The Nomo-score was determined for each patient according to Model 2 and Model 3. 

The predictive performance of Model 1, Model 2, and Model 3 was evaluated by area under curve (AUC) of receiver operating characteristic (ROC), accuracy, sensitivity, and specificity. Plotting Decision Curve Analysis (DCA) assesses the net benefits of the model. Finally, nomogram-model 2 and nomogram-model 3 were constructed based on Model 2 and Model 3. Associations between Nomo-scores and ALN burden were assessed using correlation analysis. Furthermore, the value of the model for ALN ≥ 3 was assessed based on the Nomo-score cutoff value. (Statistical analyses, .) 

Patient characteristics The 174 patients enrolled in this study were randomized into a training set (n=121) and a test set (n=53) at a ratio of 7:3. displays the distribution of the patients, and no significant difference in training and test sets. Feature selection, classifiers performance comparison and Model 1 construction A total of 1688 features were extracted from the ITR and models were constructed using LR, SVM and RF classifiers. The AUC of the LR classifier is highest in the training (0.718) and test (0.725) sets. and provide the data preprocessing procedure, three classifier structures and performance. Extracted features of PTR 1mm , PTR 3mm , PTR 5mm , PTR 7mm and PTR 9mm PTR. The ITR is modeled in conjunction with the PTR using the LR classifier. ITR+PTR5mm model had AUCs of 0.761 and 0.753 in the training and test sets, respectively, and showed balanced sensitivity, specificity, and accuracy. It was used as the final radiomics model, named Model 1. Based on this model, RS was calculated for each patient. The feature screening and building methods are described in and . The performance of the radiomics models for the ITR and PTR combinations are shown in . Radiomics habitat analysis Following the k-means clustering method, ITR and PTR 5mm were classified into three habitats ( , ). Detailed steps for the habitat analysis are given in . The results show that the exponential_ngtdm_Busyness of PTR 5mm Habitat-2 differed in PR expression ( P =0.034) and Exponential_ngtdm_Busyness of PTR 5mm Habitat-3 differed differs in HER-2 expression ( P =0.004). Habitat radiomics features with the distribution of ER, PR, HER-2, and Ki-67 expression are shown in the . Model 2 and Model 3 establishment Multivariate regression in the training set showed that diameter and microcalcification were independent predictors of ALN+ ( ). These factors were used to construct Model 2. After adding RS features to the model, RS and microcalcification were independent predictors of ALN+, and these factors were used to construct Model 3. The Nomo-score of the patients was calculated as follows: Nomo-score (Model 2) =-2.904 + 1.445* Microcalcification  + 0.077*Diameter Nomo-score (Model 3) =-0.521 + 1.063*RS  +1.518*Microcalcification The performance of Model 1, Model 2, and Model 3 are shown in . In the training set, model 3 outperforms model 1 and model 2 (Delong test, P =0.033 and 0.027, respectively). AUC of Model 3 was also higher than that of the other 2 models in the test set. The ROC curves of the three models are shown in . The DCA curve also reveals that Model 3 had the highest net benefit in most of the threshold probabilities ( ). Assessment of the models and construction of the nomogram Nomogram-model 2 and nomogram-model 3 were constructed based on the factors of Model 2 and Model 3, respectively ( ). The calibration curves and nonsignificant Hosmer-Lemeshow test statistics (0.894 and 0.568 for the nomogram-model 2 training and test sets, respectively, and 0.538 and 0.148 for the nomogram-model 3 training and test sets, respectively) show that the training and test sets are well calibrated, suggesting that the nomogram can show good agreement between predictions and observations ( ). As shown in , the Nomo-score (Model 2) was positively correlated with the ALN burden (training set r =0.375, P <0.001; test set r =0.410, P =0.002). The optimal threshold when using the Nomo-score to predict ALN state was 47.778 (Youden=0.357). When the Nomo-score was ≥47.778, 54.6% (6/11, training set) and 100% (3/3, test set) of patients had at least 3 ALNs. As shown in , the Nomo-score (Model 3) was also positively correlated with the ALN burden (training set r =0.552, P <0.001; test set r =0.473, P <0.000). The optimal threshold when using the Nomo-score to predict ALN state was 60.237 (Youden=0.616). When the Nomo-score was ≥60.237, 81.8% (9/11, training set) and 100% (3/3, test set) of patients had at least 3 ALNs. 

The 174 patients enrolled in this study were randomized into a training set (n=121) and a test set (n=53) at a ratio of 7:3. displays the distribution of the patients, and no significant difference in training and test sets. 

A total of 1688 features were extracted from the ITR and models were constructed using LR, SVM and RF classifiers. The AUC of the LR classifier is highest in the training (0.718) and test (0.725) sets. and provide the data preprocessing procedure, three classifier structures and performance. Extracted features of PTR 1mm , PTR 3mm , PTR 5mm , PTR 7mm and PTR 9mm PTR. The ITR is modeled in conjunction with the PTR using the LR classifier. ITR+PTR5mm model had AUCs of 0.761 and 0.753 in the training and test sets, respectively, and showed balanced sensitivity, specificity, and accuracy. It was used as the final radiomics model, named Model 1. Based on this model, RS was calculated for each patient. The feature screening and building methods are described in and . The performance of the radiomics models for the ITR and PTR combinations are shown in . 

Following the k-means clustering method, ITR and PTR 5mm were classified into three habitats ( , ). Detailed steps for the habitat analysis are given in . The results show that the exponential_ngtdm_Busyness of PTR 5mm Habitat-2 differed in PR expression ( P =0.034) and Exponential_ngtdm_Busyness of PTR 5mm Habitat-3 differed differs in HER-2 expression ( P =0.004). Habitat radiomics features with the distribution of ER, PR, HER-2, and Ki-67 expression are shown in the . 

Multivariate regression in the training set showed that diameter and microcalcification were independent predictors of ALN+ ( ). These factors were used to construct Model 2. After adding RS features to the model, RS and microcalcification were independent predictors of ALN+, and these factors were used to construct Model 3. The Nomo-score of the patients was calculated as follows: Nomo-score (Model 2) =-2.904 + 1.445* Microcalcification  + 0.077*Diameter Nomo-score (Model 3) =-0.521 + 1.063*RS  +1.518*Microcalcification The performance of Model 1, Model 2, and Model 3 are shown in . In the training set, model 3 outperforms model 1 and model 2 (Delong test, P =0.033 and 0.027, respectively). AUC of Model 3 was also higher than that of the other 2 models in the test set. The ROC curves of the three models are shown in . The DCA curve also reveals that Model 3 had the highest net benefit in most of the threshold probabilities ( ). 

Nomogram-model 2 and nomogram-model 3 were constructed based on the factors of Model 2 and Model 3, respectively ( ). The calibration curves and nonsignificant Hosmer-Lemeshow test statistics (0.894 and 0.568 for the nomogram-model 2 training and test sets, respectively, and 0.538 and 0.148 for the nomogram-model 3 training and test sets, respectively) show that the training and test sets are well calibrated, suggesting that the nomogram can show good agreement between predictions and observations ( ). As shown in , the Nomo-score (Model 2) was positively correlated with the ALN burden (training set r =0.375, P <0.001; test set r =0.410, P =0.002). The optimal threshold when using the Nomo-score to predict ALN state was 47.778 (Youden=0.357). When the Nomo-score was ≥47.778, 54.6% (6/11, training set) and 100% (3/3, test set) of patients had at least 3 ALNs. As shown in , the Nomo-score (Model 3) was also positively correlated with the ALN burden (training set r =0.552, P <0.001; test set r =0.473, P <0.000). The optimal threshold when using the Nomo-score to predict ALN state was 60.237 (Youden=0.616). When the Nomo-score was ≥60.237, 81.8% (9/11, training set) and 100% (3/3, test set) of patients had at least 3 ALNs. 

In this study, we developed nomogram-model 2 and nomogram-model 3 capable of effectively assessing ALN metastasis in AUS-negative early breast cancer with AUC, accuracy, sensitivity, and specificity of 0.708, 0.717,0.733, 0.711; 0.768, 0.755, 0.733, 0.763, respectively. This method was effective in reducing unnecessary SLNB. Both nomograms are also effective in assessing axillary lymph node burden, and it helps clinics make effective treatment decisions, thereby reducing over- or under-treatment. In addition, habitat analysis showed that the radiomics features of the PTR 5mm subregion differed in the expression of PR and HER-2, which provided a basis for the validity of the model. Axillary staging, in addition to biological and anatomical staging of the tumor, is very important in the treatment and prognosis of breast cancer. AUS is the most effective radiologic method for evaluating ALNs ( – ). Ultrasound reporting of suspicious LNs has been shown in several studies to have a significant influence in predicting ALN+ ( , , ), but ultrasound has a high false-negative rate of predicting ALNs (15.5%-35.0%) ( – ). To maximize the performance of ultrasound in predicting ALNs, we focused on ultrasound-negative ALNs. In the construction of Model 1, we differ from other models that only analyze the radiomics features within the tumor ( ); we combined ITR and PTR features and obtained the best imaging histology model in the ITR+PTR 5mm model. Three radiomics features were screened, one from the ITR (wavelet.LLL_glcm_Imc2) and two from the PTR (exponential_ngtdm_Busyness, wavelet.LHL_glszm_SizeZoneNonUniformityNo- rmalized). This suggests that the PTR improves predictive performance in radiographic analysis ( ). This is because the peritumoral environment secretes many growth factors and cytokines that can induce hypoxia and angiogenesis, which play an important role in tumorigenesis, progression, or metastasis. Integrating tumor and peritumor data allows for a more comprehensive characterization of tumor invasion and metastasis ( ). The complex vascular system within a tumor result in intratumoral heterogeneity. Heterogeneity is uniformly scattered across the tumor, and regional phenotypic variation inside the tumor is then overlooked ( ). Based on speculation by some scholars, the subregions containing voxels with similar imaging characteristics will share common tumor biology properties ( , ). Habitat analysis methods were developed to divide tumors into subregions containing clusters of voxels with similar characteristics, which allows for better quantification of heterogeneity within the tumor ( , ). Recently the method has made significant breakthroughs in the assessment of lung, colorectal, and ovarian cancers ( , ). In this study, an unsupervised clustering method was used to classify the ITR and the PTR 5mm area of breast tumors into three categories. The results showed that the distribution of the exponential_ngtdm_Busyness feature of Habitat-2 and the exponential_ngtdm_Busyness feature of Habitat-3 in the PTR 5mm was correlated with the expression of PR and HER-2, and it has been demonstrated that patients with different expression of PR and HER-2 tended to have differences in ALN status ( , , ). This provides strong evidential support for our model and further demonstrates the reliability of the model in predicting ALN status in breast tumors. Ultrasound characteristics of the tumor are also valuable in the diagnosis of ALN metastases. In a recent report, Xiong et al. ( ) combined sonographic features and clinicopathologic features for the prediction of AUS-negative ALNs, with AUCs of 0.705 and 0.745 for the training and test sets, respectively, and showed results similar to those of model 2 in this study. However, pathology indicators were not included in our nomogram, and some histopathology can only be assessed after surgical resection or after aspiration, which may limit the use of the model. Furthermore, in our study, microcalcification was an important factor in the diagnosis of ALN+ ( ). Calcification of the tumor is often indicative of a poor prognosis ( ), and calcium deposits in the necrotic areas of the tumor appear as gravel or pinpoints, occurring mainly in clusters. Xiong et al. ( ) did not analyze calcification, probably because ultrasound does not preserve all images of the lesion, making it difficult to perform an accurate analysis in a retrospective study of the presence or absence of calcification in the lesion. With ABVS, in addition to preserving the complete breast image for subsequent analysis, it also shows microcalcifications more clearly than conventional ultrasound ( ). Irregularly shaped ultrasound features in breast cancer significantly correlate with ALN metastasis ( ). In invasive breast cancer, cancer cells may infiltrate the surrounding tissue at varying growth rates, creating inconsistent tumor margins. The margins may produce irregular shapes, whereas margins presenting as fuzzy, microfollicular, or acinar may not directly form irregular shapes ( ). In our study, however, there was no significant difference in AUS-negative lesions, but the availability of peripheral regions in radiomics explains this phenomenon. Differences in the margins of AUS-negative tumors have altered textural features, although they cannot be recognized by the naked eye. The diameter of the lesion is a major predictor of ALN as well ( , – ). Larger breast cancers have more extensive glandular invasion by cancer cells and a higher likelihood of metastatic ALNs via lymphatic drainage ( ). The results of Model 2 also showed that tumor diameter was an important predictor of ALN metastasis, which is consistent with previous reports. In patients with invasive breast cancer, there is a nonlinear association between tumor size and ALN metastasis ( , ), which further emphasizes the important role of tumor diameter in predicting ALN metastasis. Sonogram features are usually combined with radiomics features to further improve diagnostic performance ( , , ). In this study, Model 3 combines the features of Model 1 and Model 2, and it obtained the highest AUC (training set: 0.827, test set: 0.768), and the DCA curve also showed that model 3 had a high net benefit. Based on the results of the Z0011 trial, the clinical practice guidelines were updated to state that women with T1 or T2 primary invasive breast cancer with 1-2 metastatic SLNs who are scheduled to undergo breast-conserving surgery with whole-breast radiotherapy no longer need ALND ( , ). Assessing ALN burden is also critical. The nomogram in this study was able to differentiate between ALN- and ALN+ patients. It also has better results for identifying ALN statuses with a high burden. A positive correlation between the Nomo-score and ALN burden is shown in . The higher the Nomo-score is, the greater the likelihood of a high ALN burden. Combined with the optimal thresholds, nomogram-model 2 screens 54.6-100% of those with an ALN high burden. Nomogram-model 3 screens 81.8-100% of those with a high ALN burden. This will increase surgeon confidence in performing ALND based on a positive SLN. There are some limitations in this study. First, this was a single-center retrospective study. The nongeneralizability of the ABVS examination resulted in a small sample size for this study, and prospective and multicenter studies may be conducted in the future for further validation. Second, influenced by different regional breast cancer management guidelines and subjective patient factors, some HER-2 positive patients in this study did not receive neoadjuvant therapy prior to surgery. In future studies, we will further expand the sample size and include patients receiving neoadjuvant therapy, so as to provide treatment recommendations for more breast cancer patients. Third, the ROI for each lesion was manually defined, and although we removed features with ICCs < 0.75, interobserver variability was unavoidable. In the future, we will solve this by automatic or semiautomatic segmentation. Lastly, owing to the difficulty of accurately drawing ROIs for nonoccupying lesions without borders and the difficulty of identifying which lesion is the cause of metastatic ALN for multiple lesions, these two types of lesions were excluded. This may cause selection bias and nomogram restriction. In conclusion, two nomograms were developed and validated in this study: one based on sonogram features named nomograms-Model 2; and one based on sonogram and radiomics features named nomograms-Model 3. They can predict ALN status more accurately in AUS-negative breast cancer patients and also show good performance in assessing ALN burden. These two nomograms can effectively help clinicians in the preoperative assessment of ALN status and contribute to the optimization of clinical decision-making in breast cancer patients. 

