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Breast Imaging

E2410. Current Controversies in Axillary Management of Patients With Breast Cancer

Hayward J,  Carpentier B,  Strachowski L. University of California, San Francisco, San Francisco, CA

Address correspondence to J. Hayward (

Background Information: Axillary metastatic disease is the most important prognostic factor in patients with breast cancer. As such, radiologists play a central role in preoperative imaging and sampling of axillary lymph nodes. As surgical and oncologic management evolve with new trials and surgical techniques, our role as radiologists has become controversial and sometimes confusing. The purpose of this exhibit is to review the current controversies in axillary management with a focus on the latest trials and new imaging techniques pertinent to the radiologist.

Educational Goals/Teaching Points: Three teaching points will be covered in this exhibit. First: to look or not to look? We begin with a review of the controversy surrounding imaging the axilla preoperatively. The basis of this discussion will be the evolving surgical management of the axilla with a focus on the Z0011 trial. Referring clinicians have had varied responses to this trial, but it raises important questions about our role as radiologists in preoperative imaging and the importance of evidence based medicine. Second: to clip or not to clip? Placing a clip in affected axillary lymph nodes at the time of sampling is controversial, but it can help the surgeon perform targeted axillary dissection. We will review how to perform this procedure and the potential impact on surgeons and patients. Third, to seed or not to seed? Preoperative localization of clipped nodes can help the surgeon perform a new technique called targeted axillary dissection. The radiologist can help the surgeon localize clipped nodes with radioactive 125I seed or wire localization. We will review how to perform these procedures and challenges for the radiologist.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques: We review a basic approach to axillary ultrasound using anatomic landmarks, as well as the pathophysiology of lymph node drainage in breast cancer. The latest imaging techniques in preoperative localization of metastatic lymph nodes will be reviewed, including axillary placement of biopsy clips, radioactive seeds, and wires.

Conclusion: Controversies on axillary management directly impact the radiologist, surgeon, and most importantly, the patient. Our role as radiologists will continue to evolve as new research is published and new techniques arise. This exhibit reviewed the latest controversies and techniques in management to help shed light on our current role.