Accurate axillary nodal staging can be achieved after neoadjuvant therapy for locally advanced breast cancer

Lymph node status remains the most important prognostic indicator for breast cancer. Recent reports have established that the accuracy of assessing lymph node status is proportional to the number of nodes dissected. The accuracy of axillary staging following neoadjuvant chemotherapy has been cited as a technical concern due to limited node retrieval. The current study attempts to evaluate the ability to perform sentinel node biopsy (SNB) and formal axillary node dissection (AND) following neoadjuvant chemotherapy and to compare these results with non-neoadjuvant patients. One hundred sixteen consecutive patients undergoing SNB with simultaneous AND were retrospectively reviewed. Forty-two of these patients were treated with neoadjuvant chemotherapy prior to AND. Overall success rate in performing SNB in the neoadjuvant group was 95 per cent, and no false negatives have been noted to date. The overall SNB success rate in the non-neoadjuvant group was also 95 per cent with a false negative rate of 3 per cent. After AND in each group, a mean of 21 nodes were retrieved in the neoadjuvant group and 17.9 nodes in the non-neoadjuvant group (P = 0.018). In the neoadjuvant group, there were 19 node positive patients (42%) and 21 patients (28%) in the non-neoadjuvant group (P = 0.16). The mean number of positive nodes per patient was also similar between the two groups (2.9 in the neoadjuvant group vs 1.67 in the non-neoadjuvant group, P = 0.10). Following neoadjuvant therapy, accurate evaluation of the axilla is feasible. In this study, the mean number of nodes is significantly different in favor of the neoadjuvant group, but there is no significant difference in the number of node positive patients identified or in the mean number of positive nodes identified per patient. SNB is technically feasible with accuracy similar to that seen in patients with no history of neoadjuvant therapy. Neoadjuvant chemotherapy extends the use of breast-conserving therapy without sacrificing the ability to accurately stage the axilla either by use of standard axillary dissection or SNB.     

Sentinel node biopsy for breast cancer larger than 3 cm in diameter

BACKGROUND: Sentinel node biopsy (SNB) is a standard staging procedure in early breast cancer. Its suitability for larger tumours has been questioned. This study evaluated the reliability of SNB in women with invasive breast cancer larger than 3 cm in diameter who were clinically axillary node negative. METHODS: Some 109 women with a tumour larger than 3 cm on pathological analysis were identified from the Swedish prospective SNB database. They were included if a completion axillary clearance was planned, regardless of SNB results. RESULTS: The sentinel node detection rate was 103 (94.5 per cent) of 109. The overall false-negative rate was eight (13 per cent) of 64. Although a preoperative diagnosis of multifocal tumour was an exclusion criterion, 16 such cases were revealed on postoperative pathological examination. The false-negative rate in this subgroup was higher than that in women with a unifocal tumour (four (31 per cent) of 13 versus four (8 per cent) of 51; P = 0.012). No other significant predictors of a false-negative sentinel node biopsy were identified. CONCLUSION: SNB is feasible in patients with unifocal breast tumours larger than 3 cm. When large tumour size coincides with multifocality, however, the false-negative rate seems to be increased and a completion axillary clearance should be considered even if the SNB is negative.     

Removal of two sentinel nodes accurately stages the axilla in breast cancer

BACKGROUND: Assessment of lymph node status in breast cancer is still necessary for staging. Sentinel lymph node biopsy (SNB) may provide accurate staging with less morbidity than axillary clearance. The aim of this study was to assess the effect of the number of sentinel nodes removed on the false-negative rate. METHODS: Data were collected prospectively from 395 women undergoing SNB for breast cancer, between June 1995 and December 2001. All nodes that were hot and/or blue were removed and analysed. RESULTS: During this interval 136 patients who had SNB were lymph node positive. The median number of sentinel nodes removed was two (range one to five). The overall false-negative rate of SNB in these women was 7.1 per cent. If only one sentinel node had been removed, the false-negative rate would have been 16.5 per cent. The removal of more than two nodes had no effect on axillary staging in all but two women. CONCLUSION: In early breast cancer, when there were multiple sentinel nodes, removal of two sentinel nodes significantly reduced the false-negative rate compared with removal of one node. Removing more than two sentinel nodes did not significantly reduce the false-negative rate further.     

A comparison of sentinel node biopsy before and after neoadjuvant chemotherapy: timing is important

BACKGROUND: Because neoadjuvant chemotherapy is being used more frequently, the optimal timing of sentinel node biopsy (SNB) remains controversial. We previously evaluated the predictive value of SNB before neoadjuvant chemotherapy in clinically node-negative breast cancer. Our identification rate of the sentinel node among 52 patients before chemotherapy with a mean tumor size of 4 cm was 100%. In this study, we compared the identification rates of SNB before and after neoadjuvant chemotherapy and evaluated the false-negative rate of SNB after chemotherapy. METHODS: A retrospective institutional database review identified 36 women who underwent SNB after neoadjuvant chemotherapy for breast cancer from 1999 to 2004. The initial clinical tumor size and lymph node status, SNB pathology, axillary lymph node dissection pathology, and residual pathologic tumor size were reviewed. RESULTS: Sixteen of 36 patients had a clinically negative axilla before neoadjuvant therapy. SNB after neoadjuvant therapy was successful in 29 patients (80.6%), although 7 patients did not map (19.4%). Six of the 7 patients who failed to map had a clinically positive axilla initially. Axillary disease was found in 6 of 7 of these patients at dissection (85.7%). Of the 29 patients who mapped successfully, 13 (45%) were SNB negative, and 16 (55%) were SNB positive. Of the 13 SNB-negative patients, 2 had a positive axillary lymph node dissection, yielding a false-negative rate of 11%. Thirteen patients who mapped had a clinically positive axilla before therapy (45%). Of the 11 patients with true-negative SNBs, 7 (64%) were clinically node negative at presentation. The initial tumor sizes on examination ranged from 2 to 9 cm (mean, 5.0 cm), and residual pathologic tumor sizes ranged from 0 to 6 cm (mean, 1.8 cm). Failure to map correlated with a clinically positive axilla at presentation (100% vs 45%) but did not correlate with initial tumor size. CONCLUSIONS: Sentinel node identification rates are significantly better when mapping is performed before neoadjuvant chemotherapy (100% vs 80.6%), with failure to map correlated with clinically positive nodal disease at presentation and residual disease at axillary lymph node dissection. Among patients who map successfully after chemotherapy, the false-negative rate is high (11%). Given these findings, we currently recommend SNB before neoadjuvant chemotherapy for clinically node-negative patients, and raise concerns about the use of SNB after neoadjuvant therapy in patients with an initially clinically positive axilla.     

Clinical relevance of multiple sentinel nodes in patients with breast cancer

BACKGROUND: Indiscriminate removal of axillary nodes may not be justified as it may potentially worsen the morbidity of the sentinel lymph node biopsy (SNB) procedure. This study examined the factors associated with removal of multiple sentinel lymph nodes and determined whether there was an upper threshold for the number of sentinel nodes that should be removed. METHODS: A total of 803 patients with breast cancer underwent successful SNB using peritumoral injection of (99m)Tc-labelled albumin colloid and Patent Blue V dye. SNB was followed by standard axillary treatment at the same operation in all patients. RESULTS: The mean number of sentinel nodes removed per procedure was 2.2 (range 1-9). Multiple sentinel nodes (mean 2.9, range 2-9) were found in 501 patients (62.4 per cent). The false-negative rate in patients who had one sentinel node harvested was 10 per cent, compared with 1 per cent in patients who had three or more nodes removed (P = 0.010). Factors associated with finding multiple sentinel nodes were age less than 50 years (P = 0.004), low body mass index (P < 0.001), tumour in the outer half of the breast (P = 0.013), sentinel node visualization on lymphoscintigraphy (P < 0.001) and an interval of 12 h or less between radioisotope injection and SNB (P = 0.014). For 99.6 per cent of node-positive tumours, metastasis was detected within the first four sentinel nodes removed. CONCLUSION: The identification of multiple sentinel nodes, when present, reduced the false-negative rate. These data suggested that removal of more than four nodes was unnecessary.     

Sentinel lymph node biopsy examination for breast cancer patients with clinically negative axillary lymph nodes after neoadjuvant chemotherapy

BACKGROUND: The feasibility and accuracy of sentinel lymph node (SLN) biopsy examination for breast cancer patients with clinically node-negative breast cancer after neoadjuvant chemotherapy (NAC) have been investigated under the administration of a radiocolloid imaging agent injected intradermally over a tumor. In addition, conditions that may affect SLN biopsy detection and false-negative rates with respect to clinical tumor response and clinical nodal status before NAC were analyzed. METHODS: Seventy-seven patients with stages II and III breast cancer previously treated with NAC were enrolled in the study. All patients were clinically node negative after NAC. The patients then underwent SLN biopsy examination, which involved a combination of intradermal injection over the tumor of radiocolloid and a subareolar injection of blue dye. This was followed by standard level I/II axillary lymph node dissection. RESULTS: The SLN could be identified in 72 of 77 patients (identification rate, 93.5%). In 69 of 72 patients (95.8%) the SLN accurately predicted the axillary status. Three patients had a false-negative SLN biopsy examination result, resulting in a false-negative rate of 11.1% (3 of 27). The SLN identification rate tended to be higher, although not statistically significantly, among patients who had clinically negative axillary lymph nodes before NAC (97.6%; 41 of 42). This is in comparison with patients who had a positive axillary lymph node before NAC (88.6%; 31 of 35). CONCLUSIONS: The SLN identification rate and false-negative rate were similar to those in nonneoadjuvant studies. The SLN biopsy examination accurately predicted metastatic disease in the axilla of patients with tumor response after NAC and clinical nodal status before NAC. This diagnostic technique, using an intradermal injection of radiocolloid, may provide treatment guidance for patients after NAC.     

Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy Is Accurate in Breast Cancer Patients with a Clinically Negative Axillary Nodal Status at Presentation

Background In breast cancer, neoadjuvant chemotherapy (NAC) is widely used in order to enable a conservative surgery. In patients treated with NAC, the use of sentinel lymph node (SLN) biopsy, which is a good predictor of the axillary nodal status in previously untreated patients, is still discussed. The aim of our study was to determine clinicopathological factors that may influence the accuracy of SLN biopsy after NAC. Methods Between March 2001 and December 2006, 129 patients with infiltrating breast carcinoma were studied prospectively. Preoperatively, all of them underwent NAC. At surgery, SLN biopsy followed by axillary lymph node (ALN) dissection was performed. Lymphatic mapping was done using the isotope method. Results The SLN identification rate was 93.8% (121/129). Fifty-six out of the 121 successfully mapped patients had positive ALN. Eight out of these 56 patients had tumor-free SLN (false-negative rate of 14.3%). The false-negative rate was correlated with larger tumor size (T1-T2 versus T3; P = 0.045) and positive clinical nodal status (N0 versus N1-N2; P = 0.003) before NAC. In particular, the false-negative rate was 0% (0/29) in N0 patients and 29.6% (8/27) in N1-N2 patients. Clinical and pathological responses to NAC did not influence the accuracy of SLN biopsy. Conclusion Our results show that clinical nodal status is the main clinicopathological factor influencing the false-negative rate of SLN biopsy after NAC for breast cancer. SLN biopsy after NAC can predict the ALN status with a high accuracy in patients who are clinically lymph node negative at presentation.     

Clinical impact of false-negative sentinel node biopsy in primary breast cancer

BACKGROUND: The aim was to assess the false-negative sentinel node biopsy rate in women with early breast cancer and its implications in patient treatment. METHODS: Between January 1995 and March 2001, 328 consecutive patients with clinically lymph node-negative primary operable breast cancer underwent lymphatic mapping and sentinel node biopsy using a combination of preoperative lymphoscintigraphy and/or blue dye. All underwent immediate axillary dissection. The intraoperative success rate in sentinel node identification, false-negative rate, predictive value of negative sentinel node status and overall accuracy were assessed. The clinical features and primary tumour characteristics for each false-negative case were reviewed. RESULTS: The sentinel node was identified in 285 (86.9 per cent) of 328 women. The false-negative rate was 7.9 per cent (eight of 101). Most members of the breast multidisciplinary team would have instituted adjuvant systemic therapy for six false-negative cases based on clinical features and primary tumour histology. In all, only two (0.7 per cent) of 285 women who had sentinel node biopsy may have had their management and survival prospects potentially jeopardized owing to a false-negative sentinel node. CONCLUSION: The results of this study suggest that the clinical impact of a false-negative sentinel node is low.     

Sentinel Node Biopsy Before Neoadjuvant Chemotherapy Spares Breast Cancer Patients Axillary Lymph Node Dissection

Background Neoadjuvant chemotherapy in breast cancer patients is a valuable method to determine the efficacy of chemotherapy and potentially downsize the primary tumor, which facilitates breast-conserving therapy. In 18 studies published about sentinel node biopsy after neoadjuvant chemotherapy, the sentinel node was identified in on average 89%, and the false-negative rate was on average 10%. Because of these mediocre results, no author dares to omit axillary clearance just yet. In our institute, sentinel lymph node biopsy is performed before neoadjuvant chemotherapy. The aim of this study was to evaluate our experience with this approach. Methods Sentinel node biopsy was performed before neoadjuvant chemotherapy in 25 T2N0 patients by using lymphoscintigraphy, a gamma ray detection probe, and patent blue dye. Axillary lymph node dissection was performed after chemotherapy if the sentinel node contained metastases. Results Ten patients had a tumor-positive axillary sentinel node, and one patient had an involved lateral intramammary node. Four patients had additional involved nodes in the completion lymph node dissection specimen. The other 14 patients (56%) had a tumor-negative sentinel node and did not undergo axillary lymph node dissection. No recurrences have been observed after a median follow-up of 18 months. Conclusions Fourteen (56%) of the 25 patients were spared axillary lymph node dissection when the sentinel node was found to be disease free. Performing sentinel node biopsy before neoadjuvant chemotherapy seems successful and reliable in patients with T2N0 breast cancer.     

Sentinel lymph node biopsy after neoadjuvant systemic therapy

As sentinel node biopsy has emerged as a possible alternative to axillary node dissection in patients with operable breast cancer, this procedure is also emerging as a possible alternative in patients who have received prior neoadjuvant chemotherapy. Initial smaller, single-institution series with the latter approach have shown significant variability in the identification rates and false negative rates resulting in inconsistent--and at times disparate--conclusions regarding the appropriateness of this technique in this group of patients. Subsequent larger, multicenter series have shown, that the identification rates and false negative rates with sentinel node biopsy after neoadjuvant chemotherapy are similar to those when sentinel node biopsy is performed after breast cancer diagnosis. Thus, it appears that the sentinel node concept is also applicable in patients who have undergone neoadjuvant chemotherapy. This observation has the potential to expand the utility of neoadjuvant chemotherapy in patients with operable breast cancer.     

Sentinel Lymph Node Biopsy Performed After Neoadjuvant Chemotherapy is Accurate in Patients with Documented Node-Positive Breast Cancer at Presentation

Background The optimal strategy for incorporating lymphatic mapping and sentinel lymph node biopsy into the management of breast cancer patients receiving neoadjuvant chemotherapy remains controversial. Previous studies of sentinel node biopsy performed following neoadjuvant chemotherapy have largely reported on patients whose prechemotherapy, pathologic axillary nodal status was unknown. We report findings using a novel comprehensive approach to axillary management of node-positive-patients receiving neoadjuvant chemotherapy. Methods We evaluated 54 consecutive breast cancer patients with biopsy-proven axillary nodal metastases at the time of diagnosis that underwent lymphatic mapping with nodal biopsy as well as concomitant axillary lymph node dissection after receiving neoadjuvant chemotherapy. All cases were treated at a single comprehensive cancer center between 2001 and 2005. Results The sentinel node identification rate after delivery of neoadjuvant chemotherapy was 98%. Thirty-six patients (66%) had residual axillary metastases (including eight patients that had undergone resection of metastatic sentinel nodes at the time of diagnosis), and in 12 cases (31%) the residual metastatic disease was limited to the sentinel lymph node. The final, post-neoadjuvant chemotherapy sentinel node was falsely negative in three cases (8.6%). The negative final sentinel node accurately identified patients with no residual axillary disease in 17 cases (32%). Conclusions Sentinel lymph node biopsy performed after the delivery of neoadjuvant chemotherapy in patients with documented nodal disease at presentation accurately identified cases that may have been downstaged to node-negative status and can spare this subset of patients (32%) from experiencing the morbidity of an axillary dissection.     

Sentinel lymph node biopsy before versus after neoadjuvant chemotherapy for breast cancer

Axillary lymph node status is the most important prognostic factor in the treatment of breast cancer. In recent years, sentinel lymph node biopsy (SLNB) has replaced conventional axillary lymph node dissection for predicting axillary lymph node status with higher accuracy. Moreover, neoadjuvant chemotherapy (NAC) is being used increasingly to treat not only patients with locally advanced inoperative breast cancer, but also those with initially operable breast cancer. The application of SLNB has now expanded to include this patient population, who were not previously considered good candidates for SLNB. A number of recent studies have evaluated the feasibility and accuracy of SLNB after NAC in breast cancer patients. Moreover, SLNB has been shown to be accurate in patients scheduled to receive NAC, and repeat SLNB has been performed after NAC for patients with positive nodes detected by the initial SLNB before NAC. Thus, the optimal timing of SLNB for patients with breast cancer in the neoadjuvant setting remains controversial. This article reviews the issues surrounding SLNB before vs. after NAC, according to the published literature and our experience.     

Sentinel node biopsy after primary chemotherapy in breast cancer: a note of caution from results of ABCSG-14

Over the past years, experience has been increasing with lymphatic mapping and sentinel node biopsy (SNB) after preoperative chemotherapy for breast cancer, with a wide range of results reported in the literature and final conclusions on the diagnostic value and clinical consequences of this sequential approach still missing. Between 1999 and 2002, the Austrian Breast and Colorectal Cancer Study Group (ABCSG) conducted a prospective randomized multicenter trial comparing three versus six preoperative cycles of epirubicin/docetaxel + granulocyte colony-stimulating factor for operable breast cancer. Of the 292 patients recruited to the trial overall, 111 were enrolled in a prospective subprotocol for performing LM and SNB in addition to obligatory axillary lymph node dissection (ALND) after PC. SNB after PC identified at least one sentinel node in 100 of 111 patients (identification rate 90%). In six cases, a false-negative SN was identified, resulting in a false-negative rate of 13% (6 of 47). We only found little correlation between patients and tumor characteristics and the identification rate or false-negative rate. Lymphatic mapping and SNB after primary chemotherapy failed to predict histologic infiltration of the sentinel node with sufficient sensitivity. The routine use of SNB after primary chemotherapy should therefore be discouraged.     

乳腺癌新辅助化疗后蓝染法行前哨淋巴结活检术的临床分析

【摘要】 目的 研究乳腺癌患者新辅助化疗后蓝染法行前哨淋巴结活检术(SLNB)的可行性。方法〓回顾性分析2012年1月至2015年6月初诊于广西柳州市工人医院普外四病区的IIA-IIIB期乳腺癌患者69例。所有患者均接受新辅助化疗,疗程4~8个周期,分析新辅助化疗后蓝染法行SLNB的检出率、假阴性率。结果〓入组患者SLNB检出率为85.5%,假阴性率为18.2%;SLNB的检出率因腋窝淋巴结状态不同而存在统计学差异,在不同肿瘤的大小、肿瘤位置、患者年龄和SLNB时注射染料位置无统计学差异,假阴性率在上述不同分组中均无统计学差异。结论〓NAC后蓝染法SLNB可应用于治疗前腋窝淋巴结阴性的乳腺癌患者;对于治疗前腋窝淋巴结阳性的患者则存在风险。增加SLN检出数目可增加NAC后行SLNB的可靠性。     

Multicentre validation study of sentinel node biopsy for staging in breast cancer

BACKGROUND: The aim of this study was to validate sentinel node biopsy for axillary staging after the initial learning phase, and to analyse factors associated with false-negative biopsies. METHODS: Some 675 patients, who had standard sentinel node biopsy followed by level I and II axillary clearance in one of 20 hospitals in Sweden and were operated on by 36 different surgeons, were recruited prospectively. RESULTS: The overall detection rate was 94.5 per cent. It varied between surgeons but was not influenced by the number of operations per surgeon. Moreover, it was lower among older patients. The overall false-negative rate was 7.7 per cent. This rate was not affected by patient age, tumour histological type or Elston grade, but was increased in patients with multifocal tumours. Some 21 per cent of patients with a multifocal tumour diagnosed on postoperative histopathological analysis had a false-negative biopsy compared with 5.6 per cent of those with unifocal tumours (P = 0.004). CONCLUSION: Sentinel node biopsy was shown to be a reliable method for axillary staging of unifocal breast tumours.     

Sentinel lymphadenectomy after neoadjuvant chemotherapy for breast cancer may reliably represent the axilla except for inflammatory breast cancer

Background After neoadjuvant chemotherapy, women with locally advanced breast cancer (LABC) undergo a modified radical mastectomy or lumpectomy with axillary lymph node dissection (ALND) and radiotherapy. Sentinel lymphadenectomy (SL) is accepted for axillary evaluation in early breast cancer. We assessed the feasibility and predictive value of SL after neoadjuvant chemotherapy. Methods Eligible women received neoadjuvant therapy for LABC and were scheduled to undergo a definitive surgical procedure. Vital blue dye SL was attempted followed by level I and II axillary dissection. Results SL was successful in 29 of 34 patients (detection rate, 85%). Thirteen patients (45%) had positive nodes, and eight (28%) had negative nodes on both SL and ALND. In five patients (17%), the sentinel node was the only positive node identified. Overall, there was a 90% concordance between SL and ALND. The false-negative rate and negative predictive value were 14% and 73%, respectively. Among the subgroup without inflammatory cancer, the detection and concordance rates were 89% and 96%, respectively. The false-negative rate was 6%, and the negative predictive value was 88%. Conclusions SL after neoadjuvant chemotherapy may reliably predict axillary staging except in inflammatory breast cancer. Further studies are required to assess the utility of SL as the only mode of axillary evaluation in these women.     

One-year morbidity after sentinel node biopsy and breast surgery

Posttreatment morbidity within 1 year after sentinel node biopsy was evaluated objectively by physical examination and also by evaluating patients self-reports of symptoms in a questionnaire. These patients were compared with patients who underwent axillary clearance. At 2 weeks after surgery patients who had undergone sole sentinel node biopsy had made significantly better recoveries than those who had undergone axillary clearance. Although every fourth patient complained of at least mild arm symptoms 1 year after sole SNB, the risk of severe long-term morbidity is minimal. In particular, the risk of disabling lymphoedema seems to be negligible after SNB only.     

Axillary Staging in the Neoadjuvant Setting

Neoadjuvant chemotherapy (NAC) is increasingly being used in the treatment of locally advanced breast cancer as well as for early breast cancer. Axillary lymph node dissection has been the standard method of staging the axilla in the neoadjuvant setting. Since the sentinel lymph node biopsy was introduced in the early 1990s, less invasive approaches to axillary staging in patients undergoing neoadjuvant therapy have been proposed. In this review, we discuss the effects of NAC, the imaging modalities that have been used to evaluate the axillary lymph nodes, and the role and timing of sentinel lymph node biopsy in the neoadjuvant setting. Finally, we propose a treatment algorithm for patients undergoing NAC on the basis of the current data.     

Technical limitations of sentinel node biopsy in breast cancer: a single surgeon's experience

Few studies have attempted to critically identify patient- and tumor-related factors that limit sentinel node biopsy (SNB). These studies have been limited by sample size and surgeon variability. The present study attempts to enumerate these limitations in a unique group of patients. One hundred twenty-five SNBs performed by a single surgeon between May 1997 and June 2001 were reviewed. Overall SNB was successful in 96 per cent of patients with a 97 per cent correlation with the axillary node dissection. Sentinel node identification was not affected by age, tumor size, tumor location, prior segmental resection, or neoadjuvant therapy. No false negatives were noted in the neoadjuvant group. The use of blue dye alone significantly understaged patients when compared with isotope alone (P = 0.02). SNB is a highly accurate method to identify axillary metastases and its limitations are not affected by patient or tumor related factors. In the present study SNB detection by both isotope and blue dye has been shown to be superior to blue dye alone. This finding demonstrates that these limitations may be overcome with the standardization of the technique used.     

Cost/Accuracy Ratio Analysis in Breast Cancer Patients Undergoing Ultrasound-Guided Fine-Needle Aspiration Cytology,Sentinel Node Biopsy,and Frozen Section of Node

We evaluated the effectiveness and the cost of axillary staging in breast cancer patients by ultrasound-guided fine-needle aspiration cytology (US-FNAC), sentinel node biopsy (SNB), and frozen sections of the sentinel node to achieve the target of the highest number of immediate axillary dissections. From January 2003 through October 2005, a total of 404 consecutive eligible breast cancer patients underwent US-FNAC of suspicious axillary lymph nodes. If tumor cells were found, immediate axillary dissection was proposed (33% of node-positive cases). If US or cytology was negative, SNB was performed. Frozen sections of the sentinel node allowed immediate axillary dissection in 31% of node-positive cases. The remaining 36% underwent delayed axillary dissection. We compared our policy with clinical evaluation of the axilla, showing better specificity of US-FNAC, the cost balanced by a 12% reduction of SNBs, and a marked reduction of unnecessary axillary dissections resulting from false-positive clinical staging. Moreover, the comparison between our policy and permanent histology of the sentinel node showed an 8% cost saving, mainly associated with the immediate axillary dissections. US-FNAC of axillary lymph nodes in breast cancer patients reliably predicts the presence of metastases and therefore refers a significant number of patients to the appropriate surgical treatment, avoiding an SNB. As cost saving to the health care system in our study is mainly related to one-step axillary surgery, US-FNAC of axillary lymph nodes and frozen section of the sentinel node generate significant cost saving for patients who have metastatic nodes.