The other point of view supporting preoperative axillary US argues that the finding of an abnormal axillary node on axillary US followed by percutaneous biopsy confirmation would help to identify those patients with higher tumor burden [54,55], and these patients would benefit from proceeding directly to ALND. This approach avoids the need for a second surgery. One study, supporting the utilization of preoperative axillary US from a single center, reported that only 3% to 5% of patients had an abnormal axillary US and met the Z0011 criteria (ie, ALND was not necessary in these patients with preoperative abnormal axillary US). Other studies also supporting the addition of preoperative axillary US to the management of patients who met Z0011 criteria argue that axillary US can help identify patients with more extensive nodal disease who meet the Z0011 criteria [56-58]. Patients with negative preoperative axillary US and SLN had fewer positive nodes, smaller nodal metastases, and lower extranodal extension on final pathology [58]. Imaging of the Axilla US-guided biopsy of any suspicious axillary node either via FNA or core biopsy is commonly performed when preoperative axillary US is done. The sensitivity of US-guided biopsy is variable with a wide range of 52% to 90%, whereas the specificity is higher, ranging from 98% to 100% [59-63]. CT Chest, Abdomen, and Pelvis Contrast-enhanced CT is not routinely used to stage the axilla, even in patients with clinically positive axillary findings. While CT chest can visualize and assess the level I, II, and III regions of the axilla, the predictive accuracy of CT is not high enough to replace SLNB [50,51,95]. When adenopathy is seen on CT, the Hounsfield unit of the metastatic lymph node is likely higher than nonmetastatic nodes.
Imaging of the Axilla. The other point of view supporting preoperative axillary US argues that the finding of an abnormal axillary node on axillary US followed by percutaneous biopsy confirmation would help to identify those patients with higher tumor burden [54,55], and these patients would benefit from proceeding directly to ALND. This approach avoids the need for a second surgery. One study, supporting the utilization of preoperative axillary US from a single center, reported that only 3% to 5% of patients had an abnormal axillary US and met the Z0011 criteria (ie, ALND was not necessary in these patients with preoperative abnormal axillary US). Other studies also supporting the addition of preoperative axillary US to the management of patients who met Z0011 criteria argue that axillary US can help identify patients with more extensive nodal disease who meet the Z0011 criteria [56-58]. Patients with negative preoperative axillary US and SLN had fewer positive nodes, smaller nodal metastases, and lower extranodal extension on final pathology [58]. Imaging of the Axilla US-guided biopsy of any suspicious axillary node either via FNA or core biopsy is commonly performed when preoperative axillary US is done. The sensitivity of US-guided biopsy is variable with a wide range of 52% to 90%, whereas the specificity is higher, ranging from 98% to 100% [59-63]. CT Chest, Abdomen, and Pelvis Contrast-enhanced CT is not routinely used to stage the axilla, even in patients with clinically positive axillary findings. While CT chest can visualize and assess the level I, II, and III regions of the axilla, the predictive accuracy of CT is not high enough to replace SLNB [50,51,95]. When adenopathy is seen on CT, the Hounsfield unit of the metastatic lymph node is likely higher than nonmetastatic nodes.