Re: selective application of routine preoperative axillary ultrasonography reduces costs for invasive breast cancers

The approach of selective use of axillary ultrasound concentrating on breast cancer patients most likely to benefit from knowing preoperatively that an ultrasound-guided fine-needle aspiration is cytologically positive is examined.How do we deal with axillary ultrasound assessment of women newly diagnosed with T1 or T2 breast cancer following the publication of the American College of Surgeons Oncology Group Z-0011 (hereafter, Z-11) trial? The Z-11 trial now questions the need for completion axillary dissections in women with early disease and one or two positive sentinel nodes in the setting of breast conservation and postoperative radiotherapy. Traditional practice in many centers has been to commit patients with positive axillary node cytology on ultrasound-guided fine-needle aspiration (FNA) to an axillary dissection—avoiding the intervening step of a sentinel node biopsy. An advantage of ultrasound-guided FNA is the positive identification of candidates for neoadjuvant preoperative chemotherapy (stage IIb and III).Turaga et al. [1] have provided us with a rational and thoughtful approach—that of selective use of axillary ultrasound concentrating on the individuals who are most likely to benefit from knowing preoperatively that an ultrasound-guided FNA is cytologically positive. By focusing on T2 patients, axillary ultrasound and FNA assessment of suspicious nodes will help select individuals who can be offered neoadjuvant strategies. Likewise, by eliminating T1 patients from the preoperative assessment, these individuals can proceed with a sentinel node biopsy. In the few who are positive and meet the Z-11 trial entry criteria, radiotherapy without a completion dissection can be applied to control the axilla with less morbidity and effective local control.Turaga et al. [1] have shown a better yield and even demonstrated a cost advantage by selectively applying axillary ultrasound to the T2 patient population. In the post-Z-11 world of axillary staging and assessment, these authors have demonstrated a reasoned approach that will maximize the benefit and limit any potential harm of axillary ultrasound and lymph node FNAs. By focusing on the T2 population, we can effectively stratify our patients, identify candidates for neoadjuvant regimens and trials, have a cost-effective approach, and avoid overassessment of the T1 group. Let''s get on with it!