Annals of SBV
Volume 12 | Issue 2 | Year 2023

Ultrasound Morphology of Axillary Lymph Nodes as a Non-invasive Alternative to Detect Metastasis in Early Breast Cancer

Sandeep Reuben Manohar1, Tirou Aroult2

1Department of General Surgery, Mahatma Gandhi Medical College and Research Institute, Chennai, Tamil Nadu, India

2Department of General Surgery, Mahatma Gandhi Medical College and Research Institute, Puducherry, India

Corresponding Author: Sandeep Reuben Manohar, Department of General Surgery, Mahatma Gandhi Medical College and Research Institute, Chennai, Tamil Nadu, India, Phone: +91 8754464488, e-mail:

How to cite this article: Manohar SR, Aroult T. Ultrasound Morphology of Axillary Lymph Nodes as a Non-invasive Alternative to Detect Metastasis in Early Breast Cancer. Ann SBV 2023;12(2):33–37.

Source of support: Nil

Conflict of interest: None

Received on: 25 November 2022; Accepted on: 25 December 2023; Published on: 02 February 2024


The axillary lymph node status is the most important prognostic factor in early stage breast cancer. A sentinel lymph node biopsy determines whether axillary node dissection is necessary. The use of the operating room and the administration of radioisotopes are also costs associated with this operation. As a result, patients with nodal metastases that could lead to axillary dissection should be identified before surgery. Axillary ultrasound is widely being used to determine nodal status prior to surgery. It has been shown to be a receptive and accurate modality for detecting nodal metastases. When combined with fine-needle aspiration, this modality’s precision is greatly improved. This article discusses preoperative axillary ultrasound (PAUS) in early and locally advanced breast cancer patients with and without fine-needle aspiration biopsy. Based on this analysis, we estimate the proportion of patients who would be able to escape a sentinel lymph node biopsy, as well as the cost benefit of axillary ultrasound.

Keywords: Axillary lymph node, Axillary ultrasound, Sentinel lymph node biopsy.


Growth size and axillary nodal status are the main prognostic factors for bosom disease in anticipating generally and illness free endurance.1 The organic elements of the cancer assume a significant part in deciding the gamble of metastasis.2 Estimation of axillary lymph node status is becoming less relevant, and biological tumor characteristics are having less of an effect on adjuvant treatment strategy.2 Because of current bosom malignant growth screening programs, bosom disease is presently more frequently analyzed at a beginning phase, with axillary nodal negative infection representing 70–85% of cases.3

All patients going through bosom malignant growth medical procedure today get a sentinel lymph hub biopsy (SLNB) to decide their axillary nodal status; in any case, most of patients needn’t bother with this surgery.47 Since SLNB and lymphadenectomy (axillary lymph hub analyzation, ALND) are simply arranging methodology, there has recently been a lot of research on seeking non-invasive axillary staging procedures.8 The gold standard for assessing axillary nodal status is preoperative axillary ultrasound (PAUS).911 Two continuous clinical examinations (SOUND and INSEMA) are at present surveying imbalances in generally endurance, illness free endurance, and personal satisfaction in ladies with bosom disease by isolating them into two gatherings: the people who had SLNB and the individuals who had clinically and sonographically growth free axillary lymph hubs (c/sN0) yet didn’t have SLNB.12,13 Patients with clinically important axillary hub sores (metastases in at least three lymph hubs) are thought to be recognized by preoperative ultrasound testing, and SLNB can be kept away from assuming the axillary lymph hubs seem normal on ultrasound (PAUS-negative).

The utilization of ultrasonographic (US) appraisal of the bosom and axilla in the preoperative assessment of bosom disease patients is turning out to be more normal. Therefore, a few habitats have acquired extensive involvement in this methodology, yet it is administrator subordinate. We directed a survey to all the more likely figure out the clinical viability of axillary ultrasound in both early and privately progressed bosom disease.

Axillary Ultrasound’s Accuracy in Detecting Nodal Metastases

Axillary ultrasound has turned into a typical adjunctive strategy for diagnosing axillary lymph hubs in bosom malignant growth patients, and its exactness in recognizing nodal metastases has been broadly examined. Perception of the nodal cortex and subcortical designs is conceivable with the headway of high-goal transducers of something like 7.5 MHz, and existing gadgets working in the 12–15 MHz range. Higher frequencies have better resolution but less penetration into deeper tissues, making axillary node evaluation more difficult. This technique has been shown to be useful in detecting potentially metastatic nodal foci prior to surgery (Table 1).14,15

Table 1: Utility of axillary ultrasound in invasive breast cancer patients with clinically negative axilla using size as criterion for malignancy
Study No. of patients Sensitivity (%) Specificity (%) Accuracy (%) PPV (%) NPV (%)
Bruneton et al.16 60 58.3 (27.6–84.8) 97.3 (86.1–99.9) 88.0 94.1 86.0
Vaidya et al.17 200 58.3 (43.2–72.4) 95.5 (87.5–99.0) 78.0 90.0 69.0
Bonnema et al.18 150 87.1 (76.1–94.3) 55.6 (44.7–66.3) 67.0 86.0 63.0
Deurloo et al.19 268 48.8 (39.6–58) 76.9 (71.0–83.3) NA NA NA

Bruneton et al.16 contrasted clinical review and axillary ultrasound for detecting axillary metastases in primary breast carcinoma in 1986. Clinical exam sensitivity was 45.4%, while US sensitivity was 72.7%, according to the authors. Bonnema et al.18 evaluated 148 patients with primary breast carcinoma using axillary ultrasound in 1997. Contingent upon the reverberation design, axillae were named harmless or dubious of danger. Hubs that were reverberation rich and homogeneous were named harmless, though hubs that were reverberation poor and homogeneous were delegated danger dubious.

Numbers in parenthesis represent 95% confidence intervals. Data adapted from Alvarez et al.24 PPV Positive predictive value, NA Not available, NPV Negative predicted value, data not provided in original article (Table 2).

Table 2: Utility of axillary ultrasound in invasive breast cancer patients with clinically negative axilla using morphology as criteria for malignancy
Study No. of patients Sensitivity (%) Specificity (%) Accuracy (%) PPV (%) NPV (%)
Yang et al.20 114 75.9 (56.4–89.7) 98.1 (90.1–99.9) 92.1 94.9 90.7
Bonnema et al.18 150 35.0 (23.7–48.7) 95.5 (88.7–98.7) 68.0 58.0 86.0
Deurloo et al.19 268 40.5 (31.7–49.8) 88.4 (82.1–93.1) NA NA NA
Bedrosian et al.21 144 26.4 (15.3–40.3) 91.0 (85.3–95.0) 74.5 50 78.3
van Rijk et al.22 732 35.0 (29.0–41.0) 82.0 (78.0–86.0) 64.6 53.4 68.2
Cowher et al.23 152 18.52 96.36 70.7 71.4 70.6

Numbers in parenthesis represent 95% confidence intervals. Data adapted from Alvarez et al.24 Morphologic criteria of malignancy include loss of fatty hilum, round hypoechoic node, and eccentric cortical thickening. PPV Positive predictive value, NA Not available; NPV negative predicted value, data not provided in original article.

Bonnema et al.18 reported findings that are similar to those of other researchers. According to Vaidya et al.,17 Yang et al.,20 Verbanck et al.,25 and Motomura et al.,26 high-goal US can distinguish axillary metastases with responsiveness, accuracy, and generally precision of 50–92%, 90–100%, and 76–92%, individually. These examinations give verification of idea to axillary US as a reasonably delicate and exceptionally specific methodology for distinguishing nodal metastases. Alvarez et al.24 distributed an orderly survey of the exactness of axillary ultrasound in identifying axillary metastases in essential bosom carcinoma. They found that when size was utilized as the sole standard for dangerous contribution, US had a responsiveness of 68% in patients with discernible axillary hubs (5 mm or noticeable hubs on US). Similarly, the typical exactness rate was 75.2%. The typical responsiveness of US was 71% when morphologic boundaries (e.g., oval, hypoechoic hub, destruction of hilum, and cortical hypertrophy) were utilized to recognize hubs as harmless or dangerous. Explicitness, then again, expanded decisively, arriving at a normal of 96.1%. Size boundaries used to characterize metastases in patients with nonpalpable axillary hubs had a responsiveness and explicitness of 60.9 and 75.2%, separately. The awareness and particularity of US were 43.9 and 92.4%, separately, while involving the morphologic models for threat referenced above.24

The nonuniform morphologic models involved across studies might make sense of a portion of the variety in the responsiveness and particularity related with sonographic morphologic boundaries of metastatic nodal contribution. Deurloo et al.19 found that cortical thickness (2.3 mm) was a precise model for recognizing a lymph hub associated with harm, with a responsiveness and particularity of 40.5 and 88.4%, separately.27

As per the discoveries of these examinations, axillary ultrasound is touchier than a clinical test in identifying metastatic nodal illness. Moreover, morphologic nodal contribution boundaries, for example, loss of hilum, a round hypoechoic knob, and capricious cortical thickening work on the test’s responsiveness and particularity.24 These and different discoveries, in any case, demonstrate that US alone probably won’t be delicate or exact to the point of dispensing with the requirement for SLN biopsy.28,29 Because of this disclosure, auxiliary methods have been utilized to expand the viability of axillary US.29

Ultrasound Sensitivity with or without Biopsy and Tumor Burden

The sensitivity of US is linked to the size of the primary tumor and the number of axillary nodes involved.30,31 This may be due to the fact that nodal metastases occur more often in larger tumors than in smaller tumors. Despite the fact that the latter theory is self-evident, it has sparked much discussion. No statistically significant link was found between nodal tumor burden [tumor size (or 5 mm)], primary tumor size, number of involved LN, and US sensitivity by Bedrosian et al.21 Patients with positive nodes detected on US were reportedly removed from the sample, which the researchers believe was due to bias.

On the surface, larger LNs and the number of LNs involved should be correlated with greater sensitivity. Both de Kanter et al.32 and Alvarez et al.24 found a connection. The way that lymph hub size on ultrasound is an autonomous mark of threatening inclusion upholds this speculation.27 As indicated by Krishnamurthy et al.,33 US-directed FNAB had the option to distinguish 93% of lymph hubs with a metastatic store more noteworthy than 5 mm in 93% of cases. As indicated by the scientists, hubs with metastatic stores less than 0.5 cm had a 44% chance of being found.

Swinson et al.34 found that axillary US and FNAB are more responsive and exact in macrometastatic nodal association than in micrometastatic nodal contribution. In their series of patients, there was no quiet with micrometastatic nodal association. In patients with micrometastatic sickness, Britton et al.27 found that US-directed CB had a lower responsiveness. CB was utilized to distinguish 4/15 hubs that were positive for micrometastatic mediation on conclusive histology in their examination, with a responsiveness of 26.7%. This is altogether higher than Swinson et al.’s findings, which might be because of the greater tissue yield got with CB vs FNAB.

The quantity of involved hubs has a great connection with the axillary US and FNAB responsiveness. At the point when at least two lymph hubs were involved, awareness expanded from 47.1 to 80%, as indicated by Tahir et al.35 In general, the discoveries show that in patients with macrometastatic sickness, axillary US, and designated biopsy by FNAB or CB are bound to create positive outcomes than in patients with micrometastatic illness. Patients with a higher gamble of axillary sickness are bound to be determined preoperatively than those to have a lower trouble. Subsequently, patients with cumbersome nodal sickness and enlarged hubs might be bound to keep away from SLN biopsy than patients with micrometastatic contribution in less hubs.

The Role of Axillary Ultrasound in Patients with Locally Advanced Breast Cancer

Approximately, 10–20% of patients with essential bosom malignant growth might have privately progressed illness and need neoadjuvant chemotherapy (NACT) prior to acquiring authoritative careful attention.36 The circumstances for finishing ALND post-NACT have as of late been tested because of the related bleakness and mortality. As per research, nodal metastases are restricted to the SLN in roughly 30-half of patients. Moreover, in 25–33% of cases, NACT has been displayed to clean axillary hubs. Subsequently, around 30% of patients with hub positive sickness before NACT can encounter an unnecessary ALND after NACT.3638 Albeit a few writers have recorded SN acknowledgment paces of 95% and bogus negative paces of 10% after NACT, others have neglected to show such encouraging outcomes, forestalling its far reaching use.36 Accordingly, researchers are as yet searching for painless ways of deciding ALN status. Axillary ultrasound regardless of FNAB has been demonstrated to be very responsive and explicit in recognizing patients with hub positive illness in patients without privately progressed bosom malignant growth (LABC). Before starting NACT, the creators of Oruwari et al.38 utilized US alone and in mix with FNAB to break down 27 axillae in ladies with LABC. The creators found that U/S had responsiveness, particularity, and generally exactness of 91, 100, and 92%, individually, while U/S? FNAB had responsiveness, particularity, and generally speaking exactness of 100, 100, and 100%, separately. The responsiveness and particularity announced in this review for the US alone are higher than those recently revealed in early bosom malignant growth patients.18,24 In any case, bigger growths and substantial axillary hubs were viewed as in 70% of the patients in the review.

At present, there is no proof to help the utilization of axillary ultrasound as an organizing methodology in patients with LABC after NACT. The worth of clinical evaluation, mammography, and ultrasound in surveying essential cancer and nodal metastatic reaction to NACT was explored by Herrada et al.,39 who found that ultrasound is a viable indicator of nodal contribution. In this review, clinical assessment, mammography, and sonography were utilized to decide the essential cancer and nodal metastases of 100 patients with LABC.

Estimations were taken when the fourth step of a doxorubicin-based NACT convention. Most of the patients in this gathering had progressed disease, with 83% of them being in stage III at the hour of the review. Also, practically each of the members had clinically tangible axillary lymph hubs. From that point forward, the patients in general, including ALND, got decisive careful attention. The clinical test and imaging discoveries were then contrasted with the pathologic experimental outcomes. The creators utilized a relative chances model to foresee pathologic cancer size in view of the clinical computation. At the point when surface region was utilized as a boundary to foresee lymph hub metastases, axillary ultrasound was the best indicator of nodal contribution (p = 0.0005). Axillary ultrasound, as per this article, can be a helpful instrument for evaluating nodal status after NACT.39

Klauber-DeMore et al.37 checked out at the adequacy of axillary ultrasound after NACT in 53 ladies with histologically affirmed stage II and III disease. Yang et al.20 laid out morphologic necessities for deciding if hubs were destructive. The creators found that axillary ultrasound without clinical assessment had a responsiveness, accuracy, positive prescient worth (PPW), and negative prescient worth (NPW) of 59, 79, 83, and 52%, individually. At the point when both the clinical test and the US were negative, the axillary US post-NACT had a responsiveness, particularity, and NPV of 64, 74, and 54%, separately. The responsiveness, accuracy, and positive prescient worth (PPV) were 33, 100, and 100%, individually, when the clinical assessment and ultrasound were positive. Nodal metastatic stores were barely more modest (middle = 0.4 cm) when axillary US was negative than when it was positive (middle = 2 cm). Thus, the creators reached the resolution that axillary US was not adequately exact to recognize hub negative patients who could forestall ALND during NACT. Others40,41 have supported these outcomes, which contrast from those expressed by Oruwari et al.38 Kuerer et al.40 concentrated on 147 ladies with LABC who were going through acceptance chemotherapy and had their axillae checked clinically and sonographically when treatment. The clinical estimations were then contrasted with the last pathologic examination of the axillary items.

The axillary US had a responsiveness of 62% and an explicitness of 70%, separately. Clinical and sonographic investigation uncovered that 55 of the 147 patients were hub negative after chemotherapy. On last pathologic investigation, 29 of them were viewed as hub positive, with the larger part (97%) having 2–5 mm metastases including one to three hubs. As per Klauber-DeMore et al.,37 the creators reasoned that axillary US post chemotherapy is inadequately delicate to precisely recognize hub negative patients who could forego ALND.37, 40 In a concentrate by Vlastos et al.,41 48% of patients with negative axillae on clinical and US investigation were found to have metastatic nodal foci on last pathologic assessment. In any case, the metastatic foci that remained were little, as in the past two examinations. The outcomes are summed up in Table 3.

Table 3: Utility of clinical axillary exam and axillary ultrasound in the evaluation of nodal metastases in patients with locally advance breast cancer
Study Modality Sensitivity (%) Specificity (%) PPV (%) NPV (%)
Oruwari et al.38 PE 76.0 100 NA NA
  U/S 91.0 100 NA NA
Klauber-Demore et al.37 PE 47.0 96.0 93.0 58.0
  U/S 59.0 79.0 83.0 52.0
Kuerer et al.40 PE 45.0 84.0 87.0 39.0
  U/S 62.0 70.0 83.0 44.0
Vlastos et al.41 PE 34.2 87.0 78.8 48.4
  U/S 51.3 64.8 67.2 48.6
NA, not available; NPV, negative predicted value, data not provided in original article; PPV, positive predictive value

According to the studies above, post-NACT axillary US has strong specificity in identifying node-positive disease, and when combined with FNAB, the sensitivity, and specificity may be as high as 100% in a single sample. The majority of available evidence suggests, however, that axillary US alone cannot be used to differentiate patients with node-negative disease after NACT down staging.


Ultrasound is a useful tool for identifying nodal metastases in certain patients with breast cancer. Rather than nodal size alone, morphologic nodal parameters are more sensitive and specific predictors of malignancy. When paired with FNAB or CB, the sensitivity and specificity of axillary US surpass 94.9 and 100%, respectively, in certain sequences. The size of the primary tumor and the involved nodes, as well as the number of nodes involved, are all factors that influence sensitivity. It’s perhaps unsurprising that axillary ultrasound is more effective at detecting macrometastatic disease than micrometastatic disease whether used alone or in conjunction with FNAB or CB.


Sandeep Reuben Manohar


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