Can We Identify or Exclude Extensive Axillary Nodal Involvement in Breast Cancer Patients Preoperatively?

Omission of axillary surgery in cN0, postmenopausal ER-positive/HER2-negative breast cancer patients undergoing breast-conserving treatment

Background

Previous clinical trials have diminished the significance of lymph node (LN) metastasis and axillary surgery in breast cancer, particularly in cN0, postmenopausal estrogen receptor (ER)-positive/human epidermal growth factor receptor 2 (HER2)-negative patients undergoing breast-conserving treatment (BCT). We assessed the replacement of axillary surgery with preoperative imaging modalities by analyzing the proportion of high nodal burden (HNB) patients with ≥3 LN metastases in these patients.

Methods

We retrospectively identified 333 cN0, postmenopausal ER-positive/HER2-negative breast cancer patients who underwent BCT in two hospitals between January 2003 and December 2017. The proportion of LN metastasis patients and the number of metastatic LN were investigated. Risk factors of LN metastasis were analyzed and recurrence-free survival (RFS) was compared.

Results

Axillary surgery confirmed LN metastasis in 81 (24.3%) of the cN0 patients. The clinical tumor size (cT) and age were factors associated with LN metastasis [cT: odds ratio (OR), 2.92, 95% confidence interval (CI): 1.69-5.05, P<0.001; age: OR, 0.33, 95% CI: 0.11-0.99, P=0.048]. However, HNB patients with ≥3 LN metastases were 15 (4.5%) of all the patients. There was statistically significant difference in the incidence of HNB between patients with cT1 tumors (3.6%) and those with cT2 tumors (7.4%) (P<0.001).

Conclusions

In cN0, postmenopausal ER-positive/HER2-negative patients who underwent BCT, patients with cT1 tumors had lower rate of LN metastasis, and there were fewer instances of HNB. Therefore, in these patients, omission of axillary surgery including SLNB can be carefully considered.

[Can we avoid axillary lymph node dissection in patients with node positive invasive breast carcinoma?]

OBJECTIVES

The indications and modalities of breast and axillary surgery are undergoing profound change, with the aim of personalizing surgical management while avoiding over-treatment. To update best practices for axillary surgery, four questions were selected by the Senology Commission of the Collège National des Gynécologues et Obstétriciens Français (CNGOF), focusing on, firstly, the definition and evaluation of targeted axillary dissection (TAD) techniques; secondly, the possibility of surgical de-escalation in case of initial lymph node involvement while performing initial surgery; thirdly, in case of surgery following neo-adjuvant systemic therapy (NAST), and fourthly, contra-indications to de-escalation of axillary surgery to allow access to particular adjuvant systemic therapies.

METHODS

The Senology Commission based its responses primarily on an analysis of the international literature, clinical practice recommendations and national and international guidelines.

RESULTS

Firstly, TAD is a technique that combines excision of clipped metastatic axillary node(s) and the axillary sentinel lymph nodes (ASLNs). The detection rate and sensitivity are increased but it still needs to be standardized and practices better evaluated. Secondly, TAD represents an alternative to axillary clearance in cases of metastatic involvement of a single node that can be resected. Thirdly, neither TAD nor ASLN alone is recommended in France after NAST outside of clinical trials, although it is used in several countries in cases of complete pathological response in the lymph nodes, and when at least three lymph nodes have been removed. Fourthly, as some adjuvant targeted therapies are indicated in cases of lymph node invasion of more than three lymph nodes, the place of TAD in this context remains to be defined.

CONCLUSION

Axillary surgical de-escalation can limit the morbidity of axillary clearance. Having proved that TAD does not reduce patient survival, it will most probably replace axillary clearance in well-defined indications. This will require prior standardization of the method and its indications and contra-indications, particularly to enable the use of new targeted therapies.

Selective use of radiological staging in node-positive stage II breast cancer patients may have a role in treatment

BACKGROUND

Advanced-staging radiography is used inconsistently for patients with early-stage (stage I + II) breast cancer. However, accurate and appropriate staging of newly diagnosed breast cancer may significantly impact treatment decisions.

METHODS

Four hundred and ninety-nine patients with stages II and III breast cancer were seen in the breast service at Waitemata DHB, New Zealand from 2013 to 2018 were enrolled in the study and audited for radiological staging.

RESULTS

One hundred and two stage II patients had computed tomography (CT) at baseline; 88 of 102 (86%) of stage II patients were node-positive (≥N1) with six patients (6.8%) having distant metastatic disease, and were upstaged to stage IV. Fifty-two stage III patients out of 72 (72%) had baseline staging CTs. Nine out of 52 patients (17%) of stage III patients were upstaged to stage IV. Despite guideline recommendations, baseline staging for T4 disease (stage IIIB) was poor, with only 7 out of 13 patients with stage IIIB disease radiologically staged.

CONCLUSION

Consideration for baseline radiological staging should be given to stages II and III, cN1 breast cancer patients, in which diagnosis of distant metastatic disease would change the treatment plan. Regional guidelines for baseline radiological staging for breast cancer patients may have an impact on patient management in breast cancer patients.

Correlation Analysis of Pathological Features and Axillary Lymph Node Metastasis in Patients with Invasive Breast Cancer

Objective

To investigate the risk factors of axillary lymph node metastasis in patients with invasive breast cancer.

Methods

This study retrospectively included 122 cases of invasive breast cancer patients admitted to the First Medical Center of PLA General Hospital from January 2019 to September 2020. According to postoperative pathological results, axillary lymph node metastasis was divided into axillary lymph node metastasis (ALNM) group (n =40) and non-axillary lymph node metastasis (NALNM) group (n =82). General demographic information was collected and compared between the two groups. Collected pathological results included lymphovascular invasion (LVI) and the expression of estrogen receptor (ER), progestogen receptor (PR), human epidermal growth factor receptor 2 (HER-2), and Ki-67 detected by immunohistochemistry. Imaging parameters of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) including apparent diffusion coefficient (ADC), early enhanced rate, and time-intensity curve (TIC) were also included into univariate analysis. The variables with differences between the two groups were compared by univariate analysis, and the related factors of axillary lymph node metastasis were analyzed by logistic regression model.

Results

There was no significant difference in general demographic information between the two groups. No significant differences were found in the positive rates of HER-2, ER, PR, Ki-67, pathological types, and clavicular lymph node metastasis and skin chest wall invasion between the two groups (P > 0.05). The proportion of LVI in ALNM group was significantly higher than that in NALNM group (37.50% vs. 6.10%, P < 0.001). The proportion of breast cancer on the left side in the ALNM group was higher than that in the NALNM group, and the difference was statistically significant (70.00% vs. 47.56%, P = 0.019). There were no significant differences in the imaging parameters obtained by DCE-MRI between the two groups. Binary logistics regression analysis showed that LVI (OR =12.258, 95% CI =3.681-40.812, P < 0.001) and left breast cancer (OR =3.598, 95% CI =1.404-9.219, P = 0.008) were risk factors for axillary lymph node metastasis in patients with invasive breast cancer.

Conclusion

The formation of vascular tumor thrombi in breast cancer tissue and left breast cancer are risk factors for axillary lymph node metastasis in invasive breast cancer and might be helpful for preoperative detailed assessment of the patient's condition.

Beyond N Staging in Breast Cancer: Importance of MRI and Ultrasound-based Imaging

The correct N-staging in breast cancer is crucial to tailor treatment and stratify the prognosis. N-staging is based on the number and the localization of suspicious regional nodes on physical examination and/or imaging. Since clinical examination of the axillary cavity is associated with a high false negative rate, imaging modalities play a central role. In the presence of a T1 or T2 tumor and 0–2 suspicious nodes, on imaging at the axillary level I or II, a patient should undergo sentinel lymph node biopsy (SLNB), whereas in the presence of three or more suspicious nodes at the axillary level I or II confirmed by biopsy, they should undergo axillary lymph node dissection (ALND) or neoadjuvant chemotherapy according to a multidisciplinary approach, as well as in the case of internal mammary, supraclavicular, or level III axillary involved lymph nodes. In this scenario, radiological assessment of lymph nodes at the time of diagnosis must be accurate. False positives may preclude a sentinel lymph node in an otherwise eligible woman; in contrast, false negatives may lead to an unnecessary SLNB and the need for a second surgical procedure. In this review, we aim to describe the anatomy of the axilla and breast regional lymph node, and their diagnostic features to discriminate between normal and pathological nodes at Ultrasound (US) and Magnetic Resonance Imaging (MRI). Moreover, the technical aspects, the advantage and limitations of MRI versus US, and the possible future perspectives are also analyzed, through the analysis of the recent literature.

Does ultrasound evaluation of the axilla increase the rate of axillary lymph node dissection in early stage clinically node negative breast cancer patients?

Background

Management and axillary staging of breast cancer has become less invasive and more conservative, over the decades. Considering Z011, axillary lymph node dissection (ALND) can be avoided in T1-2 N0-1 breast cancers with one or two positive sentinel lymph nodes (SLNs), if they are candidates for breast conserving surgery and radiotherapy. The aim of this study was to recognize if pre-operative axillary US evaluation in early-stage breast cancer could lead to more ALND in post Z011 era.

Method

463 breast cancer patients were evaluated. 368 early-stage breast cancer patients (T1-2 N0) were included. We did not perform axillary US in early stage clinically node negative patients; however, 97 patients had axillary US prior to our visit. If axillary US could detect more than two suspicious LNs, US guided biopsy was performed. The remaining clinically node negative patients underwent upfront SLNB. ALND was performed if more than two SLNs were metastatic, or US-guided ALN biopsy proved metastatic involvement.

Results

97 patients had axillary US evaluation before the surgery. 67 patients (69.2%) did not have any suspicious US detected axillary LNs, 17 patients (17.5%) had one, 7 patients (7.2%) had two, and 6 patients (6.2%) had more than two suspicious LNs according to their axillary US evaluation. Those with more than two suspicious LNs underwent ALN US-guided biopsy. Metastatic involvement of the LNs was proved in all of them and they underwent upfront ALND. ALND revealed more than 2 metastatic LNs in 2/6 patients (33.3%). 91 patients who were evaluated by axillary US, had less than two US detected suspicious LNs and underwent SLNB. Amongst 24 patients with one or two US detected suspicious LNs, 1/24 patient had more than two positive SLNs and underwent ALND. In this group 15.6% underwent ALND and 5.2% of them were unnecessary according to the recent guidelines. Axillary US had a false positive rate of 36.6%. The sensitivity of axillary US in distinguishing patients with more than two suspicious LNs in clinically node negative patients was 25%. In the second group (without pre-operative axillary US evaluation), SLNB was performed. 204/272 patients (75%) did not have LN metastasis. 54/272 patients (19.9%) had one or two metastatic SLNs and according to Z011, ALND was omitted. 5.1% had more than two metastatic SLNs and underwent ALND.

Conclusion

US evaluation of the axilla in early stage, clinically node negative breast cancer patients, is not sensitive enough to recognize more than two metastatic ALNs. It leads to more unnecessary ALND. Despite the small number of patients in this study, these results question the rationale of axillary US guided biopsy in low burden (less than two) suspicious LNs. looking for an imaging modality with a higher sensitivity in detecting the Burdon of axillary metastatic involvement is mandatory.

The impact of body mass index (BMI) on MRI diagnostic performance and surgical management for axillary lymph node in breast cancer

Background

We hypothesized that different BMI might have different impact on pre-operative MRI axillary lymph node (ALN) prediction accuracy and thereby subsequent surgical lymph node management. The aim of this study is to evaluate the effect of BMI on presentation, surgical treatment, and MRI performance characteristics of breast cancer with the main focus on ALN metastasis evaluation.

Methods

The medical records of patients with primary invasive breast cancer who had pre-operative breast MRI and underwent surgical resection were retrospectively reviewed. They were categorized into 3 groups in this study: underweight (BMI < 18.5), normal (BMI of 18.5 to 24), and overweight (BMI > 24). Patients’ characteristics, surgical management, and MRI performance for axillary evaluation between the 3 groups were compared.

Results

A total of 2084 invasive breast cancer patients with a mean age of 53.4 ± 11.2 years were included. Overweight women had a higher rate of breast conserving surgery (56.7% vs. 54.5% and 52.1%) and initial axillary lymph node dissection (15.9% vs. 12.2% and 8.5%) if compared to normal and underweight women. Although the post-operative ALN positive rates were similar between the 3 groups, overweight women were significantly found to have more axillary metastasis on MRI compared with normal and underweight women (50.2% vs 37.7% and 18.3%). There was lower accuracy in terms of MRI prediction in overweight women (65.1%) than in normal and underweight women (67.8% and 76.1%).

Conclusion

Our findings suggest that BMI may influence the diagnostic performance on MRI on ALN involvement and the surgical management of the axilla in overweight to obese women with breast cancer.

18F-Alfatide II for the evaluation of axillary lymph nodes in breast cancer patients: comparison with 18F-FDG

PURPOSE

¹⁸F-Alfatide II has been translated into clinical use and been proven to have good performance in identifying breast cancer. In this study, we investigated ¹⁸F-Alfatide II for evaluation of axillary lymph nodes (ALN) in breast cancer patients and compared the performance with ¹⁸F-FDG.

METHODS

A total of 44 female patients with clinically suspected breast cancer were enrolled and underwent ¹⁸F-Alfatide II and ¹⁸F-FDG PET/CT within a week. Tracer uptakes in ALN were evaluated by visual analysis, semi-quantitative analysis with maximum standardized uptake value (SUV_max), mean standardized uptake value (SUV_mean), and SUV_max ratio of target/non-target (T/NT).

RESULTS

Among 44 patients, 37 patients were pathologically diagnosed with breast cancer with metastatic (17 cases) or non-metastatic (20 cases) ALN. The sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of visual analysis were 70.6%, 90%, 81.1%, 85.7%, and 78.3% for ¹⁸F-Alfatide II, 64.7%, 90%, 78.4%, 84.6%, and 75% for ¹⁸F-FDG, respectively. By combining ¹⁸F-Alfatide II and ¹⁸F-FDG, the sensitivity significantly increased to 82.4%, the specificity was 85%, the accuracy increased to 83.8%, the PPV was 82.4%, and the NPV significantly increased to 85.0%. Three cases of luminal B subtype were false negative for both ¹⁸F-Alfatide II and ¹⁸F-FDG. The other 2 false negative cases of ¹⁸F-Alfatide II were triple-negative subtype and 3 false negative cases of ¹⁸F-FDG were luminal B subtype too. The AUCs of three semi-quantitative parameters (SUV_max, SUV_mean, T/NT) for ¹⁸F-Alfatide II were between 0.8 and 0.9, whereas those for ¹⁸F-FDG were more than 0.9. ¹⁸F-Alfatide II T/NT had the highest Youden index (76.5%), specificity (100%), accuracy (89.2%), and PPV (100%) among these semi-quantitative parameters. ¹⁸F-Alfatide II uptake as well as ¹⁸F-FDG uptake in metastatic axillary lymph nodes (MALN) was significantly higher than that in benign axillary lymph nodes (BALN). Both ¹⁸F-Alfatide II and ¹⁸F-FDG did not show difference in primary tumor uptake irrespective of ALN status.

CONCLUSION

¹⁸F-Alfatide II can be used in breast cancer patients to detect metastatic ALN, however, like ¹⁸F-FDG, with high specificity but relatively low sensitivity. The combination of ¹⁸F-Alfatide II and ¹⁸F-FDG can significantly improve sensitivity and NPV. ¹⁸F-Alfatide II T/NT may serve as the most important semi-quantitative parameter to evaluate ALN.

The new perspective of PET/CT for axillary nodal staging in early breast cancer patients according to ACOSOG Z0011 trial PET/CT axillary staging according to Z0011

OBJECTIVE

Post Z0011 trial, axillary lymph node dissections (ALNDs) can be performed in patients with ≥3 positive axillary lymph nodes (ALNs). We investigated the diagnostic performance of 18F-fluorodeoxyglucose PET/computed tomography (FDG PET/CT) to predict ≥3 metastasis [high nodal burden (HNB)].

METHODS

We retrospectively analyzed preoperative FDG PET/CT from January 2010 to June 2012. Patients had clinical T1-2N0 primary invasive breast cancer and underwent breast-conserving surgery with sentinel lymph node biopsy ± ALND. All suspicious ALNs were counted considering FDG-avidity with morphologic changes. Images were considered positive if the axillary basin took up more FDG than the surrounding tissue. On CT, abnormal ALNs were round/ovoid or had cortical thickening with contrast enhancement. PET/CT results were compared with the histology and follow-up findings.

RESULTS

In total, 221 females with 224 axillae were enrolled; 161 had negative, 53 had 1-2 metastasis [low nodal burden (LNB)] and 10 had HNB. The sensitivity, specificity, negative predictive value and positive predictive value of PET/CT for HNB were 70, 100, 98.6 and 100%, respectively. There was a correlation between the number of suspicious ALNs on PET/CT and the metastatic nodes on final histology. There were no significant differences in age, tumor size and FDG-avidity between patients with negative or LNB and HNB. During follow-up, 25 patients had a recurrence. The three false-negative patients did not show recurrence.

CONCLUSION

Preoperative PET/CT predicts HNB with high accuracy and is useful for evaluating clinical T1-2N0 invasive breast cancer.

How to Perform Repeat Sentinel Node Biopsy Safely After a Previous Mastectomy: Technical Features and Oncologic Outcomes

BACKGROUND

The latest National Comprehensive Cancer Network Breast Cancer Guidelines still discourage repeat sentinel node biopsy (SNB) after mastectomy, and the largest multicentric study available reports only 35 cases in the absence of previous axillary dissection (AD).

METHODS

From January 2003 to November 2018, 89 patients of the European Institute of Oncology with local recurrence of breast cancer after mastectomy, free of distant metastases, with a clinically negative axilla and a negative axillary ultrasound, in absence of AD, underwent lymphatic mapping before wide local excision.

RESULTS

During surgery, SNB was successful for 99% of the patients, with 14% being metastatic. Additional metastatic nodes removed by AD after a positive sentinel node occurred in 82% of cases. After a medium follow-up period of 3.7 years, the overall survival rate was 96.7%, and the disease-free survival rate was 84.4%. No axillary relapse after AD was recorded. One patient who refused human epidermal growth factor receptor 2 (HER2)-targeted treatment experienced ipsilateral axillary recurrence after a negative repeat SNB. The first axillary level was never directly irradiated because all the patients with positive repeat SNB underwent AD. For invasive luminal-like HER2-negative recurrences, the metastatic sentinel node was significantly associated with the choice to prescribe adjuvant chemotherapy (p = 0.003).

CONCLUSIONS

In specialized centers, repeat axillary SNB for patients with local recurrence after mastectomy in the absence of previous AD can represent a safe option for detection and removal of occult axillary disease that would otherwise not be excised/irradiated to achieve better local control and could possibly influence the choice of adjuvant treatments.

Is pre-operative axillary ultrasound alone sufficient to determine need for axillary dissection in early breast cancer patients?

Pre-operative status of axillary lymph node (ALN) in early breast cancer is usually initially assessed by pre-operative ultrasound, followed by ultrasound-guided needle biopsy (UNB) confirmation. Patients with positive nodal status will undergo axillary lymph node dissection (ALND), while those with negative nodal status will have sentinel lymph node biopsy. ALND is associated with higher morbidity than Sentinel lymph node biopsy. The objective of this study is to determine if axillary ultrasound alone without UNB is predictive enough to assign patients to ALND and to identify ultrasound features that are significantly associated with pathologically positive ALN.383 newly diagnosed primary breast cancer patients between 2012 and 2014, and who had undergone pre-operative axillary ultrasound in University Malaya Medical Centre with a complete histopathology report of the axillary surgery were retrospectively reviewed. ALN was considered positive if it had any of these features: cortical thickening > 3 mm, loss of fatty hilum, hypoechoic solid node, mass-like appearance, round shape and lymph node size > 5 mm. Post-operative histopathological reports were then analyzed for nodal involvement.The overall sensitivity, specificity, and accuracy of pre-operative axillary ultrasound in detecting diseased nodes were 45.5%, 80.7%, and 60.3% respectively. The positive (PPV) and negative predictive values were 76.5% and 51.8%. Round shape, loss of fatty hilum and mass-like appearance had the highest PPVs of 87%, 83% and 81.6% respectively and significant odds ratios (ORs) of 5.22 (95% confidence interval [CI]: 1.52 - 17.86), ORs of 4.77 (95% CI: 2.62 - 8.70) and ORs of 4.26 (95% CI: 2.37 - 7.67) respectively (P-value < .05). Cortical thickness of > 3 mm was identified to have low PPV at 69.1%, ORs of 1.71 (95% CI: 0.86 - 3.41, P = .126).There are features on axillary ultrasound that confer high PPV for axillary involvement i.e. round shape, loss of fatty hilum, and mass-like appearance. In a low resource setting, these features may benefit from ALND without further pre-operative biopsies. However, pre-operative UNB for features with low PPV that is, cortical thickness > 3 mm should be considered to obviate the unnecessary morbidity associated with ALND.

Added Value of MRI for Invasive Breast Cancer including the Entire Axilla for Evaluation of High-Level or Advanced Axillary Lymph Node Metastasis in the Post-ACOSOG Z0011 Trial Era

Background In the post-American College of Surgeons Oncology Group Z0011 trial era, radiologists have increasingly focused on excluding high-level or advanced axillary lymph node metastasis (ALNM) by using an additional MRI scan positioned higher than lower axillae; however, the value of these additional scans remains undetermined. Purpose To evaluate whether a standard MRI protocol is sufficient to exclude high-level or advanced ALNM in breast cancer or additional MRI of entire axilla is needed. Materials and Methods This retrospective study evaluated women with invasive breast cancer who underwent breast MRI from April 2015 to December 2016. Some underwent neoadjuvant chemotherapy (NAC) and others underwent upfront surgery. Standard (routine axial scans including the lower axillae) and combined (routine axial scans plus additional scans including the entire axilla) MRI protocols were compared for high-level or advanced ALNM detection. Clinical-pathologic characteristics were analyzed. Uni- and multivariable logistic regression was performed to identify predictors of high-level or advanced ALNM. Results A total of 435 women (mean age ± standard deviation, 52 years ± 11) were evaluated (65 in the NAC group, 370 in the non-NAC group). With the standard MRI protocol, predictors of high-level ALNM were peritumoral edema (odds ratio [OR], 12.3; 95% CI: 3.9, 39.4; P < .001) and positive axilla (OR, 5.9; 95% CI: 2.0, 15.2; P < .001). Only three of 289 women with negative axillae without peritumoral edema had high-level ALNM. Predictors of advanced ALNM were positive axillae (OR, 8.9; 95% CI: 3.7, 21.5; P < .001) and peritumoral edema (OR, 2.8; 95% CI: 1.1, 6.9; P = .03). Only six of 310 women who had negative axillae without peritumoral edema had advanced ALNM. Conclusion The performance of standard MRI was satisfactory in excluding high-level and advanced axillary lymph node metastasis in most patients with breast cancer. However, the presence of peritumoral edema or positive axillae in the MRI findings emphasizes the benefits of a combined MRI protocol. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Abe in this issue.

Breast cancer patients with a negative axillary ultrasound may have clinically significant nodal metastasis

INTRODUCTION

The non-invasive nature of the preoperative axillary ultrasound (AUS) fits the current trend of increasingly conservative axillary management. Recent publications suggest that early disease patients with clinically and radiologically negative axillae do not require sentinel lymph node biopsy (SLNB). This study aims to determine the true extent of axillary node disease in negative preoperative AUS patients.

METHODS

A 10-year breast cancer registry was reviewed to identify women with pathologically confirmed T1-2 invasive breast cancer and a negative preoperative AUS. Patients who received neoadjuvant chemotherapy were excluded. Combined positive lymph node count of SLNB ± ALND was used to determine total nodal burden (TNB). Axillae were classified into low nodal burden (LNB) defined as 1-2 positive nodes and high nodal burden (HNB) defined as ≥ 3 positive nodes.

RESULTS

762 patients with negative AUS were included. There were 46.9% and 53.0% T1 and T2 tumours, respectively. 76.9% were node negative (0 LN +), 18.9% had LNB (1-2 LN +) and 4.2% had HNB (≥ 3LN +). Specifically, HNB disease was seen in 2% of T1 tumours and 6.2 % of T2 tumours with a negative AUS. In multivariate analysis, T2 strongly associated with ≥ 3 positive ALNs (OR 2.66 CI 1.09-6.51 p = 0.03) as did lymphovascular invasion (OR 3.56 CI 1.52-8.30 p =  < 0.01).

CONCLUSION

This study shows that AUS in its current form cannot exclude HNB axillary metastasis to the extent of eliminating the need for surgical staging of the axilla. This may impact axillary local-regional recurrence and disease-free survival. We caution that a negative AUS has a rate of 4.2% of HNB. Therefore, in cases of negative AUS with a T2 tumour, we advocate continued use of SLNB.