Radiology. 2013 Oct;269(1):54-60. doi: 10.1148/radiol.13122637.

Axillary lymph node biopsy in newly diagnosed invasive breast cancer: comparative accuracy of fine-needle aspiration biopsy versus core-needle biopsy.

Rautiainen S, Masarwah A, Sudah M, Sutela A, Pelkonen O, Joukainen S, Sironen R, Kärjä V, Vanninen R.

From the Departments of Clinical Radiology, Surgery and Clinical Pathology Kuopio University Hospital, PO Box 1777, Puijonlaaksontie 2, 70210 Kuopio, Finland.




To compare the diagnostic accuracy of ultrasonographically (US)-guided fine-needle aspiration biopsy (FNAB) and core-needle biopsy (CNB) of the axillary lymph nodes (LNs) of patients with newly diagnosed invasive breast cancer.


This prospective single-center study had institutional review board approval, and written informed consent was obtained. Between April 2011 and March 2012, 178 consecutive patients (182 axillae) were evaluated by using axillary US. Sixty-six axillae fulfilled the inclusion criteria (cortical thickness greater than 2 mm or abnormal morphologic characteristics), and patients with these axillae underwent US-guided axillary LN biopsy. Both FNAB and CNB were obtained from the same suspicious LN. Patients with biopsy-proved metastasis underwent axillary clearance, and those with a negative biopsy underwent sentinel LN biopsy with completion axillary clearance if needed. Diagnostic performance was calculated separately for US, FNAB, and CNB. Statistical differences in sensitivities were evaluated by using the McNemar test.


From the total study population, 45.6% (83 of 182 axillae) had metastases. A total of 66 axillae underwent both FNAB and CNB. The sensitivity for US was 61.4% (51 of 83 axillae), and specificity was 84.8% (84 of 88 axillae). The sensitivities for FNAB and CNB were 72.5% (37 of 51 axillae) and 88.2% (45 of 51 axillae), respectively (P = .008). Specificity for both was 100% (15 of 15 axillae). The negative predictive value for FNAB was 81.7%, and that for CNB was 91.2%. The positive predictive value was 100% for both methods.


When accurate preoperative staging of the axilla is needed in patients with newly diagnosed invasive breast cancer, CNB is more sensitive than FNAB.

PMID: 23771915



  • The current standard of care for staging the axilla is sentinel Lymph node biopsy (SLNB), and typically, only patients with lymph nodes (LN) positive for metastasis require further care, eliminating the need for routine ALND (1,2). Less aggressive axillary surgery is beneficial, resulting in reduced arm stiffness, pain, paraesthesia, and risk of lymphedema (3).
  • Preoperative axillary ultrasonography (US) increases the sensitivity for detection of axillary metastasis versus clinical palpation in patients with early-stage breast cancer (4). However, neither is sufficiently accurate to properly stage the axilla, with unacceptably low sensitivities and specificities. The sensitivity of axillary US has been further increased with the introduction of US-guided axillary LN sampling with either fine-needle aspiration biopsy (FNAB) or core-needle biopsy (CNB) (5,6). SLNB is still needed for patients with negative percutaneous biopsy results to rule out false-negative outcomes. Thus, preoperative US-guided LN sampling, when positive for metastasis, is beneficial for decreasing the number of patients directed to SLNB and, thereby, reducing costs and surgical times (7,8).
  • We hypothesized that CNB has a higher sensitivity than does FNAB for the detection of axillary metastasis. In the published literature, higher sensitivities for the detection of axillary LN metastasis have been achieved, but according to a recent meta-analysis (6), this difference was not significant. It was therefore concluded that both methods provide good accuracy, and each breast center can decide which method to use according to the expertise of its physicians.
  • Nevertheless, to the best of our knowledge, our study was the first one to compare these techniques within the same patient population. Our purpose was to compare the diagnostic performance of US-guided FNAB with that of CNB of the axillary LNs in patients with newly diagnosed invasive breast cancer.
  • The following figures and tables summarize our study plan and results: Amro Masarwah-fig1


Amro Masarwah-fig2

Amro Masarwah-fig3

  • Axillary CB decreased the total number of patients that would have underwent SLNB in our study population by 24.7%, while FNA decreased it by 20.3%.
  • There were no serious biopsy related complications for either FNA or CB, only two patients (3%) complained of minor bruising after undergoing CB.
  • The information needed from needle sampling is to confirm the presence of neoplastic involvement in a patient with previously diagnosed invasive breast cancer with known histology from previous CB. To the best of our knowledge, this is the first study comparing CB and FNA techniques within the same patient population and within the same axillary LN.
  • FNA holds a few advantages such as being cheap, rapid and safe. But on the other hand, with FNA there is a need for both experienced cytopathologists and radiologists familiar with the FNA biopsy technique. And more importantly, the presence of inadequate samples.
  • Our study concluded that when accurate preoperative staging of the axilla is needed in patients with newly diagnosed invasive breast cancer, core-needle biopsy is a safe and feasible biopsy method with no serious complications. CNB is significantly more sensitive than fine-needle aspiration biopsy (FNAB) (P = .008). Hence, CNB  should be considered as the first line biopsy method in the evaluation of axillary LNs.



1. Goldhirsch A, Wood WC, Coates AS, et al. Strategies for subtypes: dealing with the diversity of breast cancer—highlights of the St. Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2011. Ann Oncol 2011;22(8):1736–1747. .

2. Fisher B, Jeong JH, Anderson S, Bryant J, Fisher ER, Wolmark N. Twenty-five-year follow- up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med 2002;347(8):567–575.

3. Carlson GW, Wood WC. Management of axillary lymph node metastasis in breast cancer: making progress. JAMA 2011;305(6):606–607.

4. Bruneton JN, Caramella E, Héry M, Aubanel D, Manzino JJ, Picard JL. Axillary lymph node metastases in breast cancer: preoperative detection with US. Radiology 1986;158(2):325–326.

5. Alvarez S, Añorbe E, Alcorta P, López F, Alonso I, Cortés J. Role of sonography in the diagnosis of axillary lymph node metastases in breast cancer: a systematic review. AJR Am J Roentgenol 2006;186(5):1342–1348.

6. Houssami N, Ciatto S, Turner RM, Cody HS 3rd, Macaskill P. Preoperative ultrasoundguided needle biopsy of axillary nodes in invasive breast cancer: meta-analysis of its accuracy and utility in staging the axilla. Ann Surg 2011;254(2):243–251.

7. van Rijk MC, Deurloo EE, Nieweg OE, et al. Ultrasonography and fine-needle aspiration cytology can spare breast cancer patients unnecessary sentinel lymph node biopsy. Ann Surg Oncol 2006;13(1):31–35.

8. Genta F, Zanon E, Camanni M, et al. Cost/ accuracy ratio analysis in breast cancer patients undergoing ultrasound-guided fineneedle aspiration cytology, sentinel node biopsy, and frozen section of node. World J Surg 2007;31(6):1155–1163.

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