Context: Fine-needle aspiration biopsy (FNAB) is frequently used to stage the axilla preoperatively in patients with primary breast carcinoma. In the light of the ACOSOG-Z0011 and AMAROS trials that specified sentinel lymph node biopsy as an inclusion criterion, the role of FNAB in axillary staging is changing. Objective: This article will review the diagnostic accuracy of FNAB in staging of the axilla in patients with primary breast carcinoma. The efficacy of axillary FNAB compared with core-needle biopsy will be evaluated. The evolving approach to staging of the axilla, in the light of ACOSOG-Z0011 and AMAROS trials, will be discussed. Data Sources: Data were sourced from published peer-reviewed articles in PubMed (US National Library of Medicine) and published guidelines including the European Guidelines for Quality Assurance in Breast Cancer and those from the European Society of Medical Oncology (ESMO), Union for International Cancer (UICC), American Society of Clinical Oncology (ASCO), and the American Society of Breast Surgeons. Conclusions: FNAB of the axilla is almost 100% specific with a sensitivity between 40 and 90%. A positive FNAB reduces the need for a second axillary procedure by up to 20% with reduced morbidity and cost. The recent ACOSOG-Z0011 and AMAROS trials have reduced the use of FNAB axilla in American protocols, but it remains the standard of care in Europe.

1.
Maguire
A
,
Brogi
E
.
Sentinel Lymph Nodes for Breast Carcinoma: A Paradigm Shift
.
Arch Pathol Lab Med
.
2016
Aug
;
140
(
8
):
791
8
.
[PubMed]
0003-9985
2.
Organization
WH
:
Guidelines for Management of Breast Cancer.
3.
Boland
MR
,
Prichard
RS
,
Daskalova
I
,
Lowery
AJ
,
Evoy
D
,
Geraghty
J
, et al
Axillary nodal burden in primary breast cancer patients with positive pre-operative ultrasound guided fine needle aspiration cytology: management in the era of ACOSOG Z011
.
Eur J Surg Oncol
.
2015
Apr
;
41
(
4
):
559
65
.
[PubMed]
0748-7983
4.
Ozmen
T
,
Huff Vinyard
A
,
Avisar
E
.
Management of the Positive Axilla in 2017
.
Cureus
.
2017
May
;
9
(
5
):
e1216
.
[PubMed]
2168-8184
5.
Donker
M
,
van Tienhoven
G
,
Straver
ME
,
Meijnen
P
,
van de Velde
CJ
,
Mansel
RE
, et al
Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial
.
Lancet Oncol
.
2014
Nov
;
15
(
12
):
1303
10
.
[PubMed]
1470-2045
6.
Senkus
E
,
Kyriakides
S
,
Ohno
S
,
Penault-Llorca
F
,
Poortmans
P
,
Rutgers
E
, et al;
ESMO Guidelines Committee
.
Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up
.
Ann Oncol
.
2015
Sep
;
26
Suppl 5
:
v8
30
.
[PubMed]
0923-7534
7.
Schijven
MP
,
Vingerhoets
AJ
,
Rutten
HJ
,
Nieuwenhuijzen
GA
,
Roumen
RM
,
van Bussel
ME
, et al
Comparison of morbidity between axillary lymph node dissection and sentinel node biopsy
.
Eur J Surg Oncol
.
2003
May
;
29
(
4
):
341
50
.
[PubMed]
0748-7983
8.
Warmuth
MA
,
Bowen
G
,
Prosnitz
LR
,
Chu
L
,
Broadwater
G
,
Peterson
B
, et al
Complications of axillary lymph node dissection for carcinoma of the breast: a report based on a patient survey
.
Cancer
.
1998
Oct
;
83
(
7
):
1362
8
.
[PubMed]
0008-543X
9.
Surgeons TASoB: Position Statement on Management of the Axilla in Patients with Invasive Breast Cancer.
2011
10.
Giuliano
AE
,
Hunt
KK
,
Ballman
KV
,
Beitsch
PD
,
Whitworth
PW
,
Blumencranz
PW
, et al
Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial
.
JAMA
.
2011
Feb
;
305
(
6
):
569
75
.
[PubMed]
0098-7484
11.
Morrow
M
.
Management of the Node-Positive Axilla in Breast Cancer in 2017: Selecting the Right Option
.
JAMA Oncol
.
2018
Feb
;
4
(
2
):
250
1
.
[PubMed]
2374-2437
12.
Perry
N
,
Broeders
M
,
de Wolf
C
,
Tornberg
S
,
Holland
R
,
von Karsa
L
.
European guidelines for quality assurance in breast cancer screening and diagnosis.
Fourth edition--summary document. Ann Oncol
2008
;19:614-622.
13.
Gilani
SM
,
Fathallah
L
,
Al-Khafaji
BM
.
Preoperative fine needle aspiration of axillary lymph nodes in breast cancer: clinical utility, diagnostic accuracy and potential pitfalls
.
Acta Cytol
.
2014
;
58
(
3
):
248
54
.
[PubMed]
0001-5547
14.
Hayes
BD
,
Feeley
L
,
Quinn
CM
,
Kennedy
MM
,
O’Doherty
A
,
Flanagan
F
, et al
Axillary fine needle aspiration cytology for pre-operative staging of patients with screen-detected invasive breast carcinoma
.
J Clin Pathol
.
2011
Apr
;
64
(
4
):
338
42
.
[PubMed]
0021-9746
15.
Fung
AD
,
Collins
JA
,
Campassi
C
,
Ioffe
OB
,
Staats
PN
.
Performance characteristics of ultrasound-guided fine-needle aspiration of axillary lymph nodes for metastatic breast cancer employing rapid on-site evaluation of adequacy: analysis of 136 cases and review of the literature
.
Cancer Cytopathol
.
2014
Apr
;
122
(
4
):
282
91
.
[PubMed]
1934-662X
16.
Ciatto
S
,
Brancato
B
,
Risso
G
,
Ambrogetti
D
,
Bulgaresi
P
,
Maddau
C
, et al
Accuracy of fine needle aspiration cytology (FNAC) of axillary lymph nodes as a triage test in breast cancer staging
.
Breast Cancer Res Treat
.
2007
May
;
103
(
1
):
85
91
.
[PubMed]
0167-6806
17.
Bonnema
J
,
van Geel
AN
,
van Ooijen
B
,
Mali
SP
,
Tjiam
SL
,
Henzen-Logmans
SC
, et al
Ultrasound-guided aspiration biopsy for detection of nonpalpable axillary node metastases in breast cancer patients: new diagnostic method
.
World J Surg
.
1997
Mar-Apr
;
21
(
3
):
270
4
.
[PubMed]
0364-2313
18.
Alkuwari
E
,
Auger
M
.
Accuracy of fine-needle aspiration cytology of axillary lymph nodes in breast cancer patients: a study of 115 cases with cytologic-histologic correlation
.
Cancer
.
2008
Apr
;
114
(
2
):
89
93
.
[PubMed]
0008-543X
19.
Houssami
N
,
Diepstraten
SC
,
Cody
HS
 3rd
,
Turner
RM
,
Sever
AR
.
Clinical utility of ultrasound-needle biopsy for preoperative staging of the axilla in invasive breast cancer
.
Anticancer Res
.
2014
Mar
;
34
(
3
):
1087
97
.
[PubMed]
1791-7530
20.
Jain
A
,
Haisfield-Wolfe
ME
,
Lange
J
,
Ahuja
N
,
Khouri
N
,
Tsangaris
T
, et al
The role of ultrasound-guided fine-needle aspiration of axillary nodes in the staging of breast cancer
.
Ann Surg Oncol
.
2008
Feb
;
15
(
2
):
462
71
.
[PubMed]
1068-9265
21.
Kuenen-Boumeester
V
,
Menke-Pluymers
M
,
de Kanter
AY
,
Obdeijn
IM
,
Urich
D
,
Van Der Kwast
TH
.
Ultrasound-guided fine needle aspiration cytology of axillary lymph nodes in breast cancer patients. A preoperative staging procedure
.
Eur J Cancer
.
2003
Jan
;
39
(
2
):
170
4
.
[PubMed]
0959-8049
22.
Rattay
T
,
Muttalib
M
,
Khalifa
E
,
Duncan
A
,
Parker
SJ
.
Clinical utility of routine pre-operative axillary ultrasound and fine needle aspiration cytology in patient selection for sentinel lymph node biopsy
.
Breast
.
2012
Apr
;
21
(
2
):
210
4
.
[PubMed]
0960-9776
23.
Schiettecatte
A
,
Bourgain
C
,
Breucq
C
,
Buls
N
,
De Wilde
V
,
de Mey
J
.
Initial axillary staging of breast cancer using ultrasound-guided fine needle aspiration: a liquid-based cytology study
.
Cytopathology
.
2011
Feb
;
22
(
1
):
30
5
.
[PubMed]
0956-5507
24.
Jung
J
,
Park
H
,
Park
J
,
Kim
H
.
Accuracy of preoperative ultrasound and ultrasound-guided fine needle aspiration cytology for axillary staging in breast cancer
.
ANZ J Surg
.
2010
Apr
;
80
(
4
):
271
5
.
[PubMed]
1445-1433
25.
Park
SH
,
Kim
MJ
,
Park
BW
,
Moon
HJ
,
Kwak
JY
,
Kim
EK
.
Impact of preoperative ultrasonography and fine-needle aspiration of axillary lymph nodes on surgical management of primary breast cancer
.
Ann Surg Oncol
.
2011
Mar
;
18
(
3
):
738
44
.
[PubMed]
1068-9265
26.
Yu
YH
,
Mo
QG
,
Zhu
X
,
Gao
LQ
,
Liang
C
,
Huang
Z
, et al
Axillary fine needle aspiration cytology is a sensitive and highly specific technique for the detection of axillary lymph node metastasis: a meta-analysis and systematic review
.
Cytopathology
.
2016
Feb
;
27
(
1
):
59
69
.
[PubMed]
0956-5507
27.
Lyman
GH
,
Giuliano
AE
,
Somerfield
MR
,
Benson
AB
 3rd
,
Bodurka
DC
,
Burstein
HJ
, et al;
American Society of Clinical Oncology
.
American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer
.
J Clin Oncol
.
2005
Oct
;
23
(
30
):
7703
20
.
[PubMed]
0732-183X
28.
Urizar Gorosarri
M
,
Llana Alvarez
L
,
Bueno Zamora
O
,
Daviu Cobian
C
,
Siegrist Ridruejo
J
,
Garcia Laborda
E
,
Olcoz Monreal
FJ
,
Cuesta Guardiola
T
: Accuracy of ultrasound and ultrasound-guided fine needle aspiration cytology for axillary staging in breast cancer - Abstract.
29.
Boughey
JC
,
Suman
VJ
,
Mittendorf
EA
,
Ahrendt
GM
,
Wilke
LG
,
Taback
B
, et al;
Alliance for Clinical Trials in Oncology
.
Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial
.
JAMA
.
2013
Oct
;
310
(
14
):
1455
61
.
[PubMed]
0098-7484
30.
Hinson
JL
,
McGrath
P
,
Moore
A
,
Davis
JT
,
Brill
YM
,
Samoilova
E
, et al
The critical role of axillary ultrasound and aspiration biopsy in the management of breast cancer patients with clinically negative axilla
.
Ann Surg Oncol
.
2008
Jan
;
15
(
1
):
250
5
.
[PubMed]
1068-9265
31.
Motomura
K
,
Komoike
Y
,
Nagumo
S
,
Kasugai
T
,
Hasegawa
Y
,
Inaji
H
, et al
Sentinel node biopsy to avoid axillary lymph node dissection in breast cancer
.
Breast Cancer
.
2002
;
9
(
4
):
337
43
.
[PubMed]
1340-6868
32.
Black
D
.
Axillary Ultrasound: For All, for None, to Diagnose Positive Nodes, or to Support Avoiding Sentinel Lymph Node Biopsy Altogether
.
Ann Surg Oncol
.
2017
Jan
;
24
(
1
):
64
9
.
[PubMed]
1068-9265
33.
Vidya
R
,
Iqbal
FM
,
Bickley
B
.
Pre-operative axillary staging: should core biopsy be preferred to fine needle aspiration cytology?
Ecancermedicalscience
.
2017
Mar
;
11
:
724
.
[PubMed]
1754-6605
34.
Rautiainen
S
,
Masarwah
A
,
Sudah
M
,
Sutela
A
,
Pelkonen
O
,
Joukainen
S
, et al
Axillary lymph node biopsy in newly diagnosed invasive breast cancer: comparative accuracy of fine-needle aspiration biopsy versus core-needle biopsy
.
Radiology
.
2013
Oct
;
269
(
1
):
54
60
.
[PubMed]
0033-8419
35.
Solon
JG
,
Power
C
,
Al-Azawi
D
,
Duke
D
,
Hill
AD
.
Ultrasound-guided core biopsy: an effective method of detecting axillary nodal metastases
.
J Am Coll Surg
.
2012
Jan
;
214
(
1
):
12
7
.
[PubMed]
1072-7515
36.
Ganott
MA
,
Zuley
ML
,
Abrams
GS
,
Lu
AH
,
Kelly
AE
,
Sumkin
JH
, et al
Ultrasound Guided Core Biopsy versus Fine Needle Aspiration for Evaluation of Axillary Lymphadenopathy in Patients with Breast Cancer
.
ISRN Oncol
.
2014
Feb
;
2014
:
703160
.
[PubMed]
2090-5661
37.
Mitra
S
,
Dey
P
.
Fine-needle aspiration and core biopsy in the diagnosis of breast lesions: A comparison and review of the literature
.
Cytojournal
.
2016
Aug
;
13
(
1
):
18
.
[PubMed]
1742-6413
38.
Rao
R
,
Lilley
L
,
Andrews
V
,
Radford
L
,
Ulissey
M
.
Axillary staging by percutaneous biopsy: sensitivity of fine-needle aspiration versus core needle biopsy
.
Ann Surg Oncol
.
2009
May
;
16
(
5
):
1170
5
.
[PubMed]
1068-9265
39.
Lakhani
S
,
Ellis
I
,
Schnitt
S
, et al
WHO Classification of Tumours of the Breast
. 4th ed.
Lyon
:
IARC Press
;
2012
. pp.
40
2
.
40.
Sinn
HP
,
Kreipe
H
.
A Brief Overview of the WHO Classification of Breast Tumors
, 4th Edition, Focusing on Issues and Updates from the 3rd Edition. Breast Care (Basel)
2013
;8:149-154.
41.
Fortunato
L
,
Mascaro
A
,
Poccia
I
,
Andrich
R
,
Amini
M
,
Costarelli
L
, et al
Lobular breast cancer: same survival and local control compared with ductal cancer, but should both be treated the same way? analysis of an institutional database over a 10-year period
.
Ann Surg Oncol
.
2012
Apr
;
19
(
4
):
1107
14
.
[PubMed]
1068-9265
42.
Yang
LP
,
Sun
HF
,
Zhao
Y
,
Chen
MT
,
Zhang
N
,
Jin
W
.
Clinicopathological characteristics and survival outcomes in pleomorphic lobular breast carcinoma of the breast: a SEER population-based study
.
Cancer Med
.
2017
Dec
;
6
(
12
):
2867
75
.
[PubMed]
2045-7634
43.
Mersin
H
,
Yildirim
E
,
Gülben
K
,
Berberoğlu
U
.
Is invasive lobular carcinoma different from invasive ductal carcinoma?
Eur J Surg Oncol
.
2003
May
;
29
(
4
):
390
5
.
[PubMed]
0748-7983
44.
Fernández
B
,
Paish
EC
,
Green
AR
,
Lee
AH
,
Macmillan
RD
,
Ellis
IO
, et al
Lymph-node metastases in invasive lobular carcinoma are different from those in ductal carcinoma of the breast
.
J Clin Pathol
.
2011
Nov
;
64
(
11
):
995
1000
.
[PubMed]
0021-9746
45.
Topps
A
,
Clay
V
,
Absar
M
,
Howe
M
,
Lim
Y
,
Johnson
R
, et al
The sensitivity of pre-operative axillary staging in breast cancer: comparison of invasive lobular and ductal carcinoma
.
Eur J Surg Oncol
.
2014
Jul
;
40
(
7
):
813
7
.
[PubMed]
0748-7983
46.
Kim
SY
,
Kim
EK
,
Moon
HJ
,
Yoon
JH
,
Kim
MJ
.
Is Pre-Operative Axillary Staging with Ultrasound and Ultrasound-Guided Fine-Needle Aspiration Reliable in Invasive Lobular Carcinoma of the Breast?
Ultrasound Med Biol
.
2016
Jun
;
42
(
6
):
1263
72
.
[PubMed]
0301-5629
47.
Boughey
JC
,
Middleton
LP
,
Harker
L
,
Garrett
B
,
Fornage
B
,
Hunt
KK
, et al
Utility of ultrasound and fine-needle aspiration biopsy of the axilla in the assessment of invasive lobular carcinoma of the breast
.
Am J Surg
.
2007
Oct
;
194
(
4
):
450
5
.
[PubMed]
0002-9610
48.
Baruah
BP
,
Goyal
A
,
Young
P
,
Douglas-Jones
AG
,
Mansel
RE
.
Axillary node staging by ultrasonography and fine-needle aspiration cytology in patients with breast cancer
.
Br J Surg
.
2010
May
;
97
(
5
):
680
3
.
[PubMed]
0007-1323
49.
Sahoo
S
,
Sanders
MA
,
Roland
L
,
Pile
N
,
Chagpar
AB
.
A strategic approach to the evaluation of axillary lymph nodes in breast cancer patients: analysis of 168 patients at a single institution
.
Am J Surg
.
2007
Oct
;
194
(
4
):
524
6
.
[PubMed]
0002-9610
50.
Gentilini
O
,
Veronesi
U
.
Abandoning sentinel lymph node biopsy in early breast cancer? A new trial in progress at the European Institute of Oncology of Milan (SOUND: sentinel node vs Observation after axillary UltraSouND)
.
Breast
.
2012
Oct
;
21
(
5
):
678
81
.
[PubMed]
0960-9776
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.