Preoperative Axillary Ultrasound in the Era of Z0011: A Model for Predicting High Axillary Disease Burden

The ACOSOG Z0011 and IBCSG 23-01 trials demonstrated that axillary lymph node dissection (ALND) offers no prognostic benefit in breast cancer patients with clinically negative axillae and low disease burden (one to two positive nodes) on sentinel lymph node biopsy (SLNB). However, uncertainty remains regarding the management of patients with clinically negative axillae (cN0) who are found to have suspicious lymph nodes on imaging that are subsequently confirmed positive by biopsy. The current practice often directs these patients to upfront ALND, potentially exposing them to unnecessary surgical morbidity. This study aimed to assess the role of axillary ultrasound in predicting high axillary nodal burden and guiding surgical management. Using the Alberta Cancer Registry, we identified 107 cN0 breast cancer patients from 2010 to 2017 who underwent preoperative axillary ultrasound with positive biopsy followed by ALND. Our findings reveal that 42% of these patients had low axillary nodal burden on final pathology, meeting Z0011 criteria, and might potentially have avoided ALND. Furthermore, axillary ultrasound findings were not predictive of high axillary burden. These results highlight that many patients undergoing upfront ALND based on positive ultrasound-guided biopsy could benefit from SLNB alone. This supports the 2023 NCCN guidelines advocating for more selective use of ALND to minimize overtreatment and associated morbidity.