The standard imaging evaluation of a palpable axillary lump for females over the age of 30 years in most of the USA typically includes a mammogram with a “skin marker” overlying the palpable finding followed by a focussed ultrasound of the area of concern. This may vary in different countries and typically in the UK, for example, mammographic evaluation begins at age 40 years. In younger patients, imaging begins with ultrasound. For patients with a focal lump, scanning is typically targeted over the area of concern; however, if there is a suspicious finding, it is important to cover the entire axillary region to evaluate for any associated findings. When the study is being performed in a female newly diagnosed with breast cancer, imaging should be performed broadly to include the entire extent of the axillary contents. Examination of level I lymph nodes necessitates visualising the axillary vessels as well as scanning the entire fatty contents from the margin of the pectoralis muscles anteromedially to the latissimus dorsi and teres major margin posterolaterally. The lateral thoracic and thoracodorsal arteries and smaller branches will be seen variably along each margin, respectively
. Although node groups typically follow these vessels, lymph nodes are frequently found in isolation within the axillary fat. It is also very important to scan inferiorly, down through the axillary tail, because abnormal nodes are frequently found in this location as well. Levels II and III are not routinely scanned, although large level II nodes can sometimes be seen [
1].
Axillary ultrasound should be performed using a high-frequency (7.5–17-MHz) linear-array transducer. A lower frequency (5–7.5-MHz) setting may be needed for larger patients or for patients with a large axillary fat pad; however, the spatial resolution will be compromised. The patient should lie in a supine oblique position, with her hand above her head with the arm abducted and externally rotated (“bathing beauty” position). All findings should be documented in orthogonal planes with and without calipers and a lesion’s largest dimension should also be recorded. Some facilities employ grey-scale and colour Doppler US or power Doppler US during the study, especially when assessing lymph nodes. When colour Doppler US is used, it is important to use low wall filter settings and low velocity settings (higher pulse repetition frequency) to detect abnormal blood flow. The colour gain should be increased high enough to detect subtle flow without causing a colour noise artefact. When evaluating lymph nodes, ultrasound is 94 % sensitive and 72 % specific in characterising nodes as suspicious or benign based on size and morphologic features [
2].
If the initial imaging evaluation of the axilla reveals a suspicious finding, percutaneous procedures, such as ultrasound-guided fine-needle aspiration (FNA) or ultrasound-guided core biopsy, may be performed. At most institutions, FNA is currently the preferred approach as the procedure is usually diagnostic and potential complications are minimal (bleeding, infection, non-diagnostic sample). FNA is typically performed using 22–25-gauge needles with aspirates sent to cytology. In most cases, at least three passes are made, especially if the cytologist is not on site during the procedure. If lymphoma is of clinical concern, additional aspirates should be obtained for flow cytometry. However, limitations do exist for FNA as it can be operator dependent, requires access to reliable cytology and carries a relatively high false-negative rate of 12–23 % [
3] . Most commonly performed for suspicious lymphadenopathy, the confirmation of metastatic involvement in a lymph node precludes sentinel lymph node biopsy in females with newly diagnosed breast cancer leading to full axillary node dissection. In one study of 224 patients, the sensitivity of ultrasound-guided FNA for suspicious, indeterminate and normal-appearing axillary nodes was 93, 44 and 11 %, respectively, with an overall sensitivity of 59 % and overall specificity of 100 % [
2]. The likelihood of a positive FNA correlated directly with the size of the primary breast malignancy, being 29 % for tumours <1 cm, 50 % for tumours 1–2 cm, 69 % for tumours 2–5 cm and 100 % for tumours >5 cm [
2]. Alternatively, percutaneous core needle biopsy using 12–18 gauge spring-loaded or vacuum-assisted devices can safely be performed [
4‐
7]. The risks of axillary core biopsy are similar to other image-guided procedures, namely bleeding and infection. However, given the presence of axillary vessels and nerves coursing through the axilla, a “no-throw” technique is preferred as this minimises the risk of haematoma or unintended nerve damage. If a spring-loaded device is used, this most commonly is performed on masses that exceed the throw of the device so that the needle does not pass into unaffected axillary tissue, thereby minimising the risk of unintended complications. In one study of 39 patients with suspicious lymphadenopathy, axillary core biopsy revealed 90 % sensitivity, 100 % specificity and 92 % accuracy [
8] without any clinically significant complications. By recognising that the nerves course alongside the axillary vessels, the risk of bleeding and untoward nerve injury can easily be avoided in almost all cases. Although core biopsy may yield a benign aetiology, there is conflicting evidence concerning whether this approach is substantially better than FNA as the upgrade rate on surgical excision ranges from 0 to 36 % in several studies, possibly related to the small cohort size and inherent sampling error [
8].