Imaging of the Axilla

Variant: 1 Female. New palpable, unilateral, axillary lump. Initial imaging of the axilla.

Procedure	Appropriateness Category	Relative Radiation Level
US axilla	Usually Appropriate	O
Digital breast tomosynthesis diagnostic	May Be Appropriate	☢☢
Mammography diagnostic	May Be Appropriate	☢☢
MRI breast without and with IV contrast	Usually Not Appropriate	O
MRI breast without IV contrast	Usually Not Appropriate	O
Sestamibi MBI	Usually Not Appropriate	☢☢☢
CT chest abdomen pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 2 Female. New palpable, bilateral, axillary lump. Initial imaging of the axilla.

Procedure	Appropriateness Category	Relative Radiation Level
US axilla	Usually Appropriate	O
Digital breast tomosynthesis diagnostic	Usually Not Appropriate	☢☢
Mammography diagnostic	Usually Not Appropriate	☢☢
MRI breast without and with IV contrast	Usually Not Appropriate	O
MRI breast without IV contrast	Usually Not Appropriate	O
Sestamibi MBI	Usually Not Appropriate	☢☢☢
CT chest abdomen pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 3 Female. Newly diagnosed breast cancer, 2 cm or less, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT.

Procedure	Appropriateness Category	Relative Radiation Level
US axilla	May Be Appropriate	O
MRI breast without and with IV contrast	Usually Not Appropriate	O
MRI breast without IV contrast	Usually Not Appropriate	O
Sestamibi MBI	Usually Not Appropriate	☢☢☢
CT chest abdomen pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 4 Female. Newly diagnosed breast cancer, 2 cm or less, with clinical node-positive. Initial imaging of the axilla following diagnostic mammography or DBT.

Procedure	Appropriateness Category	Relative Radiation Level
US axilla	Usually Appropriate	O
MRI breast without and with IV contrast	May Be Appropriate (Disagreement)	O
MRI breast without IV contrast	Usually Not Appropriate	O
Sestamibi MBI	Usually Not Appropriate	☢☢☢
CT chest abdomen pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 5 Female. Newly diagnosed breast cancer, greater than 2 cm, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT.

Procedure	Appropriateness Category	Relative Radiation Level
US axilla	May Be Appropriate	O
MRI breast without and with IV contrast	May Be Appropriate	O
MRI breast without IV contrast	Usually Not Appropriate	O
Sestamibi MBI	Usually Not Appropriate	☢☢☢
CT chest abdomen pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 6 Female. Newly diagnosed breast cancer, greater than 2 cm, with clinical node-positive. Initial imaging of the axilla following diagnostic mammography or DBT (prior to treatment).

Procedure	Appropriateness Category	Relative Radiation Level
US axilla	Usually Appropriate	O
MRI breast without and with IV contrast	May Be Appropriate	O
CT chest abdomen pelvis with IV contrast	May Be Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	May Be Appropriate	☢☢☢☢
MRI breast without IV contrast	Usually Not Appropriate	O
Sestamibi MBI	Usually Not Appropriate	☢☢☢
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 7 Female. Breast cancer, greater than 2 cm in size, at mid-treatment of neoadjuvant chemotherapy, with initial clinical node-negative disease but now presenting with new palpable axillary lump. Imaging of the axilla at mid-treatment.

Procedure	Appropriateness Category	Relative Radiation Level
US axilla	Usually Appropriate	O
Digital breast tomosynthesis diagnostic	Usually Not Appropriate	☢☢
Mammography diagnostic	Usually Not Appropriate	☢☢
MRI breast without and with IV contrast	Usually Not Appropriate	O
MRI breast without IV contrast	Usually Not Appropriate	O
Sestamibi MBI	Usually Not Appropriate	☢☢☢
CT chest abdomen pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 8 Female. Breast cancer, greater than 2 cm in size, clinical node-negative. Imaging of the axilla after completion of neoadjuvant chemotherapy.

Procedure	Appropriateness Category	Relative Radiation Level
US axilla	May Be Appropriate (Disagreement)	O
MRI breast without and with IV contrast	May Be Appropriate	O
Digital breast tomosynthesis diagnostic	Usually Not Appropriate	☢☢
Mammography diagnostic	Usually Not Appropriate	☢☢
MRI breast without IV contrast	Usually Not Appropriate	O
Sestamibi MBI	Usually Not Appropriate	☢☢☢
CT chest abdomen pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 9 Female. Breast cancer, greater than 2 cm in size, clinical node-positive. Imaging of the axilla after completion of neoadjuvant chemotherapy and prior to surgery.

Procedure	Appropriateness Category	Relative Radiation Level
US axilla	Usually Appropriate	O
MRI breast without and with IV contrast	May Be Appropriate	O
Digital breast tomosynthesis diagnostic	Usually Not Appropriate	☢☢
Mammography diagnostic	Usually Not Appropriate	☢☢
MRI breast without IV contrast	Usually Not Appropriate	O
Sestamibi MBI	Usually Not Appropriate	☢☢☢
CT chest abdomen pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 10 Female. Newly diagnosed locally recurrent breast cancer. Initial imaging of the axilla following diagnostic mammography or DBT.

Procedure	Appropriateness Category	Relative Radiation Level
US axilla	May Be Appropriate	O
MRI breast without and with IV contrast	May Be Appropriate	O
FDG-PET/CT skull base to mid-thigh	May Be Appropriate	☢☢☢☢
MRI breast without IV contrast	Usually Not Appropriate	O
Sestamibi MBI	Usually Not Appropriate	☢☢☢
CT chest abdomen pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 11 Female. Suspicious axillary node on mammography or ultrasound. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
US-guided core biopsy axillary node	Usually Appropriate	O
US-guided fine needle aspiration biopsy axillary node	Usually Appropriate	O
MRI breast without and with IV contrast	May Be Appropriate (Disagreement)	O
MRI breast without IV contrast	Usually Not Appropriate	O
Sestamibi MBI	Usually Not Appropriate	☢☢☢
CT chest abdomen pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 12 Female. Suspicious axillary node on any other imaging modality (excluding mammography and ultrasound). Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
US axilla	Usually Appropriate	O
Digital breast tomosynthesis diagnostic	Usually Appropriate	☢☢
Mammography diagnostic	Usually Appropriate	☢☢
US-guided core biopsy axillary node	May Be Appropriate (Disagreement)	O
US-guided fine needle aspiration biopsy axillary node	May Be Appropriate	O

Panel Members

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Discussion of Procedures by Variant

Variant 1: Female. New palpable, unilateral, axillary lump. Initial imaging of the axilla.

Variant 1: Female. New palpable, unilateral, axillary lump. Initial imaging of the axilla.
A. CT Chest, Abdomen, and Pelvis

Variant 1: Female. New palpable, unilateral, axillary lump. Initial imaging of the axilla.
B. Digital Breast Tomosynthesis Diagnostic

Variant 1: Female. New palpable, unilateral, axillary lump. Initial imaging of the axilla.
C. FDG-PET/CT Skull Base to Mid-Thigh

Variant 1: Female. New palpable, unilateral, axillary lump. Initial imaging of the axilla.
D. Mammography Diagnostic

Variant 1: Female. New palpable, unilateral, axillary lump. Initial imaging of the axilla.
E. MRI Breast

Variant 1: Female. New palpable, unilateral, axillary lump. Initial imaging of the axilla.
F. Sestamibi MBI

Variant 1: Female. New palpable, unilateral, axillary lump. Initial imaging of the axilla.
G. US Axilla

Variant 2: Female. New palpable, bilateral, axillary lump. Initial imaging of the axilla.

Variant 2: Female. New palpable, bilateral, axillary lump. Initial imaging of the axilla.
A. CT Chest, Abdomen, and Pelvis

Variant 2: Female. New palpable, bilateral, axillary lump. Initial imaging of the axilla.
B. Digital Breast Tomosynthesis Diagnostic

Variant 2: Female. New palpable, bilateral, axillary lump. Initial imaging of the axilla.
C. FDG-PET/CT Skull Base to Mid-Thigh

Variant 2: Female. New palpable, bilateral, axillary lump. Initial imaging of the axilla.
D. Mammography Diagnostic

Variant 2: Female. New palpable, bilateral, axillary lump. Initial imaging of the axilla.
E. MRI Breast

Variant 2: Female. New palpable, bilateral, axillary lump. Initial imaging of the axilla.
F. Sestamibi MBI

Variant 2: Female. New palpable, bilateral, axillary lump. Initial imaging of the axilla.
G. US Axilla

Variant 3: Female. Newly diagnosed breast cancer, 2 cm or less, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT.

Variant 3: Female. Newly diagnosed breast cancer, 2 cm or less, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT.
A. CT Chest, Abdomen, and Pelvis

Variant 3: Female. Newly diagnosed breast cancer, 2 cm or less, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT.
B. FDG-PET/CT Skull Base to Mid-Thigh

Variant 3: Female. Newly diagnosed breast cancer, 2 cm or less, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT.
C. MRI Breast

Variant 3: Female. Newly diagnosed breast cancer, 2 cm or less, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT.
D. Sestamibi MBI

Variant 3: Female. Newly diagnosed breast cancer, 2 cm or less, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT.
E. US Axilla

Variant 4: Female. Newly diagnosed breast cancer, 2 cm or less, with clinical node-positive. Initial imaging of the axilla following diagnostic mammography or DBT.

Variant 4: Female. Newly diagnosed breast cancer, 2 cm or less, with clinical node-positive. Initial imaging of the axilla following diagnostic mammography or DBT.
A. CT Chest, Abdomen, and Pelvis

Variant 4: Female. Newly diagnosed breast cancer, 2 cm or less, with clinical node-positive. Initial imaging of the axilla following diagnostic mammography or DBT.
B. FDG-PET/CT Skull Base to Mid-Thigh

Variant 4: Female. Newly diagnosed breast cancer, 2 cm or less, with clinical node-positive. Initial imaging of the axilla following diagnostic mammography or DBT.
C. MRI Breast

Variant 4: Female. Newly diagnosed breast cancer, 2 cm or less, with clinical node-positive. Initial imaging of the axilla following diagnostic mammography or DBT.
D. Sestamibi MBI

Variant 4: Female. Newly diagnosed breast cancer, 2 cm or less, with clinical node-positive. Initial imaging of the axilla following diagnostic mammography or DBT.
E. US Axilla

Variant 5: Female. Newly diagnosed breast cancer, greater than 2 cm, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT.

Variant 5: Female. Newly diagnosed breast cancer, greater than 2 cm, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT.
A. CT Chest, Abdomen, and Pelvis

Variant 5: Female. Newly diagnosed breast cancer, greater than 2 cm, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT.
C. MRI Breast

Variant 5: Female. Newly diagnosed breast cancer, greater than 2 cm, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT.
D. Sestamibi MBI

Variant 5: Female. Newly diagnosed breast cancer, greater than 2 cm, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT.
E. US Axilla

Variant 6: Female. Newly diagnosed breast cancer, greater than 2 cm, with clinical node-positive. Initial imaging of the axilla following diagnostic mammography or DBT (prior to treatment).

Variant 6: Female. Newly diagnosed breast cancer, greater than 2 cm, with clinical node-positive. Initial imaging of the axilla following diagnostic mammography or DBT (prior to treatment).
A. CT Chest, Abdomen, and Pelvis

Variant 7: Female. Breast cancer, greater than 2 cm in size, at mid-treatment of neoadjuvant chemotherapy, with initial clinical node-negative disease but now presenting with new palpable axillary lump. Imaging of the axilla at mid-treatment.

Variant 8: Female. Breast cancer, greater than 2 cm in size, clinical node-negative. Imaging of the axilla after completion of neoadjuvant chemotherapy.

Variant 8: Female. Breast cancer, greater than 2 cm in size, clinical node-negative. Imaging of the axilla after completion of neoadjuvant chemotherapy.
A. CT Chest, Abdomen, and Pelvis

Variant 8: Female. Breast cancer, greater than 2 cm in size, clinical node-negative. Imaging of the axilla after completion of neoadjuvant chemotherapy.
B. Digital Breast Tomosynthesis Diagnostic

Variant 8: Female. Breast cancer, greater than 2 cm in size, clinical node-negative. Imaging of the axilla after completion of neoadjuvant chemotherapy.
C. FDG-PET/CT Skull Base to Mid-Thigh

Variant 8: Female. Breast cancer, greater than 2 cm in size, clinical node-negative. Imaging of the axilla after completion of neoadjuvant chemotherapy.
D. Mammography Diagnostic

Variant 8: Female. Breast cancer, greater than 2 cm in size, clinical node-negative. Imaging of the axilla after completion of neoadjuvant chemotherapy.
E. MRI Breast

Variant 8: Female. Breast cancer, greater than 2 cm in size, clinical node-negative. Imaging of the axilla after completion of neoadjuvant chemotherapy.
F. Sestamibi MBI

Variant 8: Female. Breast cancer, greater than 2 cm in size, clinical node-negative. Imaging of the axilla after completion of neoadjuvant chemotherapy.
G. US Axilla

Variant 9: Female. Breast cancer, greater than 2 cm in size, clinical node-positive. Imaging of the axilla after completion of neoadjuvant chemotherapy and prior to surgery.

Variant 9: Female. Breast cancer, greater than 2 cm in size, clinical node-positive. Imaging of the axilla after completion of neoadjuvant chemotherapy and prior to surgery.
A. CT Chest, Abdomen, and Pelvis

Variant 9: Female. Breast cancer, greater than 2 cm in size, clinical node-positive. Imaging of the axilla after completion of neoadjuvant chemotherapy and prior to surgery.
E. MRI Breast

Variant 9: Female. Breast cancer, greater than 2 cm in size, clinical node-positive. Imaging of the axilla after completion of neoadjuvant chemotherapy and prior to surgery.
F. Sestamibi MBI

Variant 9: Female. Breast cancer, greater than 2 cm in size, clinical node-positive. Imaging of the axilla after completion of neoadjuvant chemotherapy and prior to surgery.
G. US Axilla

Variant 10: Female. Newly diagnosed locally recurrent breast cancer. Initial imaging of the axilla following diagnostic mammography or DBT.

Variant 10: Female. Newly diagnosed locally recurrent breast cancer. Initial imaging of the axilla following diagnostic mammography or DBT.
A. CT Chest, Abdomen, and Pelvis

Variant 10: Female. Newly diagnosed locally recurrent breast cancer. Initial imaging of the axilla following diagnostic mammography or DBT.
B. FDG-PET/CT Skull Base to Mid-Thigh

Variant 10: Female. Newly diagnosed locally recurrent breast cancer. Initial imaging of the axilla following diagnostic mammography or DBT.
C. MRI Breast

Variant 10: Female. Newly diagnosed locally recurrent breast cancer. Initial imaging of the axilla following diagnostic mammography or DBT.
D. Sestamibi MBI

Variant 10: Female. Newly diagnosed locally recurrent breast cancer. Initial imaging of the axilla following diagnostic mammography or DBT.
E. US Axilla

Variant 11: Female. Suspicious axillary node on mammography or ultrasound. Next imaging study.

Variant 11: Female. Suspicious axillary node on mammography or ultrasound. Next imaging study.
A. CT Chest, Abdomen, and Pelvis

Variant 11: Female. Suspicious axillary node on mammography or ultrasound. Next imaging study.
B. FDG-PET/CT Skull Base to Mid-Thigh

Variant 11: Female. Suspicious axillary node on mammography or ultrasound. Next imaging study.
C. MRI Breast

Variant 11: Female. Suspicious axillary node on mammography or ultrasound. Next imaging study.
D. Sestamibi MBI

Variant 11: Female. Suspicious axillary node on mammography or ultrasound. Next imaging study.
E. US-Guided Core Biopsy Axillary Node

Variant 11: Female. Suspicious axillary node on mammography or ultrasound. Next imaging study.
F. US-Guided Fine Needle Aspiration Biopsy Axillary Node

Variant 12: Female. Suspicious axillary node on any other imaging modality (excluding mammography and ultrasound). Next imaging study.

Variant 12: Female. Suspicious axillary node on any other imaging modality (excluding mammography and ultrasound). Next imaging study.
A. Digital Breast Tomosynthesis Diagnostic

Variant 12: Female. Suspicious axillary node on any other imaging modality (excluding mammography and ultrasound). Next imaging study.
B. Mammography Diagnostic

Variant 12: Female. Suspicious axillary node on any other imaging modality (excluding mammography and ultrasound). Next imaging study.
C. US Axilla

Variant 12: Female. Suspicious axillary node on any other imaging modality (excluding mammography and ultrasound). Next imaging study.
D. US-Guided Core Biopsy Axillary Node

Variant 12: Female. Suspicious axillary node on any other imaging modality (excluding mammography and ultrasound). Next imaging study.
E. US-Guided Fine Needle Aspiration Biopsy Axillary Node

Summary of Recommendations

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

References

1.	Park SH, Jeong YM, Cho SH, Jung HK, Kim SJ, Ryu HS. Imaging findings of variable axillary mass and axillary lymphadenopathy. [Review]. Ultrasound Med Biol. 40(9):1934-48, 2014 Sep.
2.	Ashikaga T, Krag DN, Land SR, et al. Morbidity results from the NSABP B-32 trial comparing sentinel lymph node dissection versus axillary dissection. J Surg Oncol 2010;102:111-8.
3.	Krag DN, Anderson SJ, Julian TB, et al. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol 2010;11:927-33.
4.	Galimberti V, Cole BF, Zurrida S, et al. Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): a phase 3 randomised controlled trial. Lancet Oncol 2013;14:297-305.
5.	Giuliano AE, Ballman KV, McCall L, et al. Effect of Axillary Dissection vs No Axillary Dissection on 10-Year Overall Survival Among Women With Invasive Breast Cancer and Sentinel Node Metastasis: The ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA 2017;318:918-26.
6.	The American Society of Breast Surgeons. Performance and Practice Guidelines for Sentinel Lymph Node Biopsy in Breast Cancer Patients. Available at: https://www.breastsurgeons.org/docs/statements/Performance-and-Practice-Guidelines-for-Sentinel-Lymph-Node-Biopsy-in-Breast-Cancer-Patients.pdf.
7.	NCCN Clinical Practice Guidelines in Oncology. Breast Cancer. Version 1.2021. Available at: https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf.
8.	Caudle AS, Yang WT, Krishnamurthy S, et al. Improved Axillary Evaluation Following Neoadjuvant Therapy for Patients With Node-Positive Breast Cancer Using Selective Evaluation of Clipped Nodes: Implementation of Targeted Axillary Dissection. J Clin Oncol. 34(10):1072-8, 2016 Apr 01.
9.	Boileau JF, Poirier B, Basik M, et al. Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study. J Clin Oncol 2015;33:258-64.
10.	Boughey JC, Ballman KV, Le-Petross HT, et al. Identification and Resection of Clipped Node Decreases the False-negative Rate of Sentinel Lymph Node Surgery in Patients Presenting With Node-positive Breast Cancer (T0-T4, N1-N2) Who Receive Neoadjuvant Chemotherapy: Results From ACOSOG Z1071 (Alliance). Ann Surg. 263(4):802-7, 2016 Apr.
11.	Boughey JC, Suman VJ, Mittendorf EA, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 2013;310(14):1455-1461.
12.	Kuehn T, Bauerfeind I, Fehm T, et al. Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study. Lancet Oncol 2013;14:609-18.
13.	Mamounas EP, Brown A, Anderson S, et al. Sentinel node biopsy after neoadjuvant chemotherapy in breast cancer: results from National Surgical Adjuvant Breast and Bowel Project Protocol B-27. J Clin Oncol 2005;23:2694-702.
14.	Ahn SK, Kim MK, Kim J, et al. Can We Skip Intraoperative Evaluation of Sentinel Lymph Nodes? Nomogram Predicting Involvement of Three or More Axillary Lymph Nodes before Breast Cancer Surgery. Cancer Res. Treat.. 49(4):1088-1096, 2017 Oct.
15.	An YS, Lee DH, Yoon JK, et al. Diagnostic performance of 18F-FDG PET/CT, ultrasonography and MRI. Detection of axillary lymph node metastasis in breast cancer patients. Nucl Med (Stuttg). 53(3):89-94, 2014.
16.	Agliata G, Valeri G, Argalia G, Tarabelli E, Giuseppetti GM. Role of Contrast-Enhanced Sonography in the Evaluation of Axillary Lymph Nodes in Breast Carcinoma: A Monocentric Study. J Ultrasound Med. 36(3):505-511, 2017 Mar.
17.	Ahmed M, Douek M. What is the future of magnetic nanoparticles in the axillary management of breast cancer?. Breast Cancer Res Treat. 143(2):213-8, 2014 Jan.
18.	Chmielewski A, Dufort P, Scaranelo AM. A Computerized System to Assess Axillary Lymph Node Malignancy from Sonographic Images. Ultrasound Med Biol. 41(10):2690-9, 2015 Oct.
19.	Spiliopoulos D, Mitsopoulos G, Kaptanis S, Halkias C. Axillary lymph node metastases in adenoid cystic carcinoma of the breast. A rare finding. G Chir. 36(5):209-13, 2015 Sep-Oct.
20.	Amitai Y, Menes T, Aviram G, Golan O. Do All Women With Abnormal Sonographic Axillary Lymph Nodes Need a Biopsy?. Can Assoc Radiol J. 67(2):173-8, 2016 May.
21.	NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/breast-screening.pdf.
22.	Moy L, Heller SL, Bailey L, et al. ACR Appropriateness Criteria® Palpable Breast Masses. J Am Coll Radiol 2017;14:S203-S24.
23.	Oliff MC, Birdwell RL, Raza S, Giess CS. The Breast Imager's Approach to Nonmammary Masses at Breast and Axillary US: Imaging Technique, Clues to Origin, and Management. [Review]. Radiographics. 36(1):7-18, 2016 Jan-Feb.
24.	Brandt KR, Craig DA, Hoskins TL, et al. Can digital breast tomosynthesis replace conventional diagnostic mammography views for screening recalls without calcifications? A comparison study in a simulated clinical setting. AJR Am J Roentgenol 2013;200:291-8.
25.	Gennaro G, Hendrick RE, Toledano A, et al. Combination of one-view digital breast tomosynthesis with one-view digital mammography versus standard two-view digital mammography: per lesion analysis. Eur Radiol. 2013;23(8):2087-2094.
26.	Waldherr C, Cerny P, Altermatt HJ, et al. Value of one-view breast tomosynthesis versus two-view mammography in diagnostic workup of women with clinical signs and symptoms and in women recalled from screening. AJR Am J Roentgenol 2013;200:226-31.
27.	Yang TL, Liang HL, Chou CP, Huang JS, Pan HB. The adjunctive digital breast tomosynthesis in diagnosis of breast cancer. Biomed Res Int. 2013;2013:597253.
28.	Friedewald SM, Rafferty EA, Rose SL, et al. Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA. 311(24):2499-507, 2014 Jun 25.
29.	Rafferty EA, Rose SL, Miller DP, et al. Effect of age on breast cancer screening using tomosynthesis in combination with digital mammography. Breast Cancer Research & Treatment. 164(3):659-666, 2017 Aug.
30.	Bertozzi S, Londero AP, Petri R, Bernardi S. Isolated axillary nodal swelling and cancer of unknown primary. Eur J Gynaecol Oncol. 36(2):131-7, 2015.
31.	Pentheroudakis G, Lazaridis G, Pavlidis N. Axillary nodal metastases from carcinoma of unknown primary (CUPAx): a systematic review of published evidence. Breast Cancer Res Treat 2010;119:1-11.
32.	Fayanju OM, Jeffe DB, Margenthaler JA. Occult primary breast cancer at a comprehensive cancer center. J Surg Res 2013;185:684-9.
33.	Soundararajan R, Naswa N, Karunanithi S, Walia R, Kumar R, Bal C. Occult breast primary malignancy presenting as isolated axillary lymph node metastasis - early detection of primary site by 18F-FDG PET/CT. Nucl Med Rev Cent East Eur. 19(B):5-7, 2016.
34.	Buchanan CL, Morris EA, Dorn PL, Borgen PI, Van Zee KJ. Utility of breast magnetic resonance imaging in patients with occult primary breast cancer. Ann Surg Oncol 2005;12:1045-53.
35.	Olson JA, Jr., Morris EA, Van Zee KJ, Linehan DC, Borgen PI. Magnetic resonance imaging facilitates breast conservation for occult breast cancer. Ann Surg Oncol 2000;7:411-5.
36.	Fernandez Canedo MI, Blazquez Sanchez N, Valdes Solis P, de Troya Martin M. Axillary Silicone Granulomas in Patients With Melanoma. Actas Dermosifiliogr. 107(4):e23-6, 2016 May.
37.	Lee SH, Yi A, Jang MJ, Chang JM, Cho N, Moon WK. Supplemental Screening Breast US in Women with Negative Mammographic Findings: Effect of Routine Axillary Scanning. Radiology. 286(3):830-837, 2018 03.
38.	Riegger C, Koeninger A, Hartung V, et al. Comparison of the diagnostic value of FDG-PET/CT and axillary ultrasound for the detection of lymph node metastases in breast cancer patients. Acta Radiol. 53(10):1092-8, 2012 Dec 01.
39.	de Bresser J, de Vos B, van der Ent F, Hulsewe K. Breast MRI in clinically and mammographically occult breast cancer presenting with an axillary metastasis: a systematic review. Eur J Surg Oncol 2010;36:114-9.
40.	Muttarak M, Chaiwun B, Peh WC. Role of mammography in diagnosis of axillary abnormalities in women with normal breast examination. Australas Radiol 2004;48:306-10.
41.	Leibman AJ, Kossoff MB. Mammography in women with axillary lymphadenopathy and normal breasts on physical examination: value in detecting occult breast carcinoma. AJR Am J Roentgenol 1992;159:493-5.
42.	Amin MB, Edge S, Greene F, et al. AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 2017.
43.	Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 70(1):7-30, 2020 01.
44.	James J, Teo M, Ramachandran V, Law M, Stoney D, Cheng M. Performance of CT scan of abdomen and pelvis in detecting asymptomatic synchronous metastasis in breast cancer. Int J Surg. 46:164-169, 2017 Oct.
45.	James J, Teo M, Ramachandran V, Law M, Stoney D, Cheng M. A critical review of the chest CT scans performed to detect asymptomatic synchronous metastasis in new and recurrent breast cancers. World J Surg Oncol. 17(1):40, 2019 Feb 23.
46.	Lewin AA, Moy L, Baron P, et al. ACR Appropriateness Criteria R Stage I Breast Cancer: Initial Workup and Surveillance for Local Recurrence and Distant Metastases in Asymptomatic Women. [Review]. Journal of the American College of Radiology. 16(11S):S428-S439, 2019 Nov.
47.	Cox J, Hancock H, Maier R, et al. Multidetector CT improving surgical outcomes in breast cancer (MISO-BC): A randomised controlled trial. BREAST. 32:217-224, 2017 Apr.
48.	Paydary K, Seraj SM, Zadeh MZ, et al. The Evolving Role of FDG-PET/CT in the Diagnosis, Staging, and Treatment of Breast Cancer. [Review]. Mol Imaging Biol. 21(1):1-10, 2019 02.
49.	Peare R, Staff RT, Heys SD. The use of FDG-PET in assessing axillary lymph node status in breast cancer: a systematic review and meta-analysis of the literature. Breast Cancer Res Treat 2010;123:281-90.
50.	Dialani V, Chadashvili T, Slanetz PJ. Role of imaging in neoadjuvant therapy for breast cancer. [Review]. Ann Surg Oncol. 22(5):1416-24, 2015 May.
51.	Lobbes MB, Prevos R, Smidt M, et al. The role of magnetic resonance imaging in assessing residual disease and pathologic complete response in breast cancer patients receiving neoadjuvant chemotherapy: a systematic review. Insights Imaging. 2013;4(2):163-175.
52.	Leenders M, Kramer G, Belghazi K, Duvivier K, van den Tol P, Schreurs H. Can We Identify or Exclude Extensive Axillary Nodal Involvement in Breast Cancer Patients Preoperatively? J Oncol 2019;2019:8404035.
53.	Evans DG, Kesavan N, Lim Y, et al. MRI breast screening in high-risk women: cancer detection and survival analysis. Breast Cancer Research & Treatment. 145(3):663-72, 2014 Jun.
54.	Del Riego J, Diaz-Ruiz MJ, Teixido M, et al. The impact of axillary ultrasound with biopsy in overtreatment of early breast cancer. Eur J Radiol. 98:158-164, 2018 Jan.
55.	Hieken TJ, Trull BC, Boughey JC, et al. Preoperative axillary imaging with percutaneous lymph node biopsy is valuable in the contemporary management of patients with breast cancer. Surgery 2013;154:831-8; discussion 38-40.
56.	Ibrahim-Zada I, Grant CS, Glazebrook KN, Boughey JC. Preoperative axillary ultrasound in breast cancer: safely avoiding frozen section of sentinel lymph nodes in breast-conserving surgery. J Am Coll Surg 2013;217:7-15; discussion 15-6.
57.	Verheuvel NC, van den Hoven I, Ooms HW, Voogd AC, Roumen RM. The role of ultrasound-guided lymph node biopsy in axillary staging of invasive breast cancer in the post-ACOSOG Z0011 trial era. Ann Surg Oncol 2015;22:409-15.
58.	Caudle AS, Kuerer HM, Le-Petross HT, et al. Predicting the extent of nodal disease in early-stage breast cancer. Ann Surg Oncol. 21(11):3440-7, 2014 Oct.
59.	Henry-Tillman R, Glover-Collins K, Preston M, et al. The SAVE review: sonographic analysis versus excision for axillary staging in breast cancer. J Am Coll Surg. 220(4):560-7, 2015 Apr.
60.	Barco I, Chabrera C, Garcia-Fernandez A, et al. Role of axillary ultrasound, magnetic resonance imaging, and ultrasound-guided fine-needle aspiration biopsy in the preoperative triage of breast cancer patients. Clin Transl Oncol. 19(6):704-710, 2017 Jun.
61.	Britton P, Willsher P, Taylor K, et al. Microbubble detection and ultrasound-guided vacuum-assisted biopsy of axillary lymph nodes in patients with breast cancer. Clin Radiol. 72(9):772-779, 2017 Sep.
62.	Houssami N, Ciatto S, Turner RM, Cody HS 3rd, Macaskill P. Preoperative ultrasound-guided needle biopsy of axillary nodes in invasive breast cancer: meta-analysis of its accuracy and utility in staging the axilla. Ann Surg. 254(2):243-51, 2011 Aug.
63.	Feng Y, Huang R, He Y, et al. Efficacy of physical examination, ultrasound, and ultrasound combined with fine-needle aspiration for axilla staging of primary breast cancer. Breast Cancer Res Treat. 149(3):761-5, 2015 Feb.
64.	Galimberti V, Cole BF, Viale G, et al. Axillary dissection versus no axillary dissection in patients with breast cancer and sentinel-node micrometastases (IBCSG 23-01): 10-year follow-up of a randomised, controlled phase 3 trial. Lancet Oncol 2018;19:1385-93.
65.	Donker M, van Tienhoven G, Straver ME, et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol 2014;15:1303-10.
66.	Rutgers EJ, Donker M, Poncet C, et al. Abstract GS4-01: Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer patients: 10 year follow up results of the EORTC AMAROS trial (EORTC 10981/22023). Cancer Research 2019;79:GS4-01-GS4-01.
67.	Park HL, Yoo IR, O JH, Kim H, Kim SH, Kang BJ. Clinical utility of 18F-FDG PET/CT in low 18F-FDG-avidity breast cancer subtypes: comparison with breast US and MRI. Nucl Med Commun. 39(1):35-43, 2018 Jan.
68.	Fujii T, Yajima R, Tatsuki H, Oosone K, Kuwano H. Implication of 18F-Fluorodeoxyglucose Uptake of Affected Axillary Lymph Nodes in Cases with Breast Cancer. Anticancer Res. 36(1):393-7, 2016 Jan.
69.	Liang X, Yu J, Wen B, Xie J, Cai Q, Yang Q. MRI and FDG-PET/CT based assessment of axillary lymph node metastasis in early breast cancer: a meta-analysis. Clin Radiol. 72(4):295-301, 2017 Apr.
70.	Orsaria P, Chiaravalloti A, Caredda E, et al. Evaluation of the Usefulness of FDG-PET/CT for Nodal Staging of Breast Cancer. Anticancer Res. 38(12):6639-6652, 2018 Dec.
71.	Koolen BB, van der Leij F, Vogel WV, et al. Accuracy of 18F-FDG PET/CT for primary tumor visualization and staging in T1 breast cancer. Acta Oncol. 53(1):50-7, 2014 Jan.
72.	Nakano Y, Noguchi M, Yokoi-Noguchi M, et al. The roles of 18F-FDG-PET/CT and US-guided FNAC in assessment of axillary nodal metastases in breast cancer patients. Breast Cancer. 24(1):121-127, 2017 Jan.
73.	Kim JY, Lee SH, Kim S, Kang T, Bae YT. Tumour 18 F-FDG Uptake on preoperative PET/CT may predict axillary lymph node metastasis in ER-positive/HER2-negative and HER2-positive breast cancer subtypes. Eur Radiol. 25(4):1172-81, 2015 Apr.
74.	Jung NY, Kim SH, Kang BJ, Park SY, Chung MH. The value of primary tumor (18)F-FDG uptake on preoperative PET/CT for predicting intratumoral lymphatic invasion and axillary nodal metastasis. Breast Cancer. 23(5):712-7, 2016 Sep.
75.	Catalano OA, Horn GL, Signore A, et al. PET/MR in invasive ductal breast cancer: correlation between imaging markers and histological phenotype. Br J Cancer. 116(7):893-902, 2017 Mar 28.
76.	Diao W, Tian F, Jia Z. The prognostic value of SUVmax measuring on primary lesion and ALN by 18F-FDG PET or PET/CT in patients with breast cancer. [Review]. Eur J Radiol. 105:1-7, 2018 Aug.
77.	Ozgur Aytac H, Colacoglu T, Nihal Nursal G, et al. Predictors determining the status of axilla in breast cancer: Where is PET/CT on that?. J. Balk. Union Oncol.. 20(5):1295-303, 2015 Sep-Oct.
78.	Fujii T, Yajima R, Tatsuki H, Kuwano H. Prediction of Extracapsular Invasion at Metastatic Sentinel Nodes and Non-sentinel Lymph Nodal Metastases by FDG-PET in Cases with Breast Cancer. Anticancer Res. 36(4):1785-9, 2016 Apr.
79.	van Nijnatten TJA, Ploumen EH, Schipper RJ, et al. Routine use of standard breast MRI compared to axillary ultrasound for differentiating between no, limited and advanced axillary nodal disease in newly diagnosed breast cancer patients. Eur J Radiol. 85(12):2288-2294, 2016 Dec.
80.	Xing H, Song CL, Li WJ. Meta analysis of lymph node metastasis of breast cancer patients: Clinical value of DWI and ADC value. Eur J Radiol. 85(6):1132-7, 2016 Jun.
81.	Abe H, Schmidt RA, Kulkarni K, Sennett CA, Mueller JS, Newstead GM. Axillary lymph nodes suspicious for breast cancer metastasis: sampling with US-guided 14-gauge core-needle biopsy--clinical experience in 100 patients. Radiology 2009;250:41-9.
82.	Alvarez S, Anorbe E, Alcorta P, Lopez F, Alonso I, Cortes J. Role of sonography in the diagnosis of axillary lymph node metastases in breast cancer: a systematic review. AJR Am J Roentgenol 2006;186:1342-8.
83.	Pilewskie M, Jochelson M, Gooch JC, Patil S, Stempel M, Morrow M. Is Preoperative Axillary Imaging Beneficial in Identifying Clinically Node-Negative Patients Requiring Axillary Lymph Node Dissection?. J Am Coll Surg. 222(2):138-45, 2016 Feb.
84.	Lee B, Lim AK, Krell J, et al. The efficacy of axillary ultrasound in the detection of nodal metastasis in breast cancer. AJR Am J Roentgenol 2013;200:W314-20.
85.	Cools-Lartigue J, Sinclair A, Trabulsi N, et al. Preoperative axillary ultrasound and fine-needle aspiration biopsy in the diagnosis of axillary metastases in patients with breast cancer: predictors of accuracy and future implications. Ann Surg Oncol. 20(3):819-27, 2013 Mar.
86.	Balasubramanian I, Fleming CA, Corrigan MA, Redmond HP, Kerin MJ, Lowery AJ. Meta-analysis of the diagnostic accuracy of ultrasound-guided fine-needle aspiration and core needle biopsy in diagnosing axillary lymph node metastasis. Br J Surg. 105(10):1244-1253, 2018 09.
87.	Le-Petross HT, McCall LM, Hunt KK, et al. Axillary Ultrasound Identifies Residual Nodal Disease After Chemotherapy: Results From the American College of Surgeons Oncology Group Z1071 Trial (Alliance). AJR Am J Roentgenol. 210(3):669-676, 2018 Mar.
88.	Ertan K, Linsler C, di Liberto A, Ong MF, Solomayer E, Endrikat J. Axillary ultrasound for breast cancer staging: an attempt to identify clinical/histopathological factors impacting diagnostic performance. Breast Cancer (Auckl). 7:35-40, 2013.
89.	Kaur N, Sharma P, Garg A, Tandon A. Accuracy of individual descriptors and grading of nodal involvement by axillary ultrasound in patients of breast cancer. Int J Breast Cancer 2013;2013:930596.
90.	Elmore LC, Appleton CM, Zhou G, Margenthaler JA. Axillary ultrasound in patients with clinically node-negative breast cancer: which features are predictive of disease?. J Surg Res. 184(1):234-40, 2013 Sep.
91.	Boland MR, Ni Cearbhaill R, Fitzpatrick K, et al. A Positive Node on Ultrasound-Guided Fine Needle Aspiration Predicts Higher Nodal Burden Than a Positive Sentinel Lymph Node Biopsy in Breast Carcinoma. World J Surg. 40(9):2157-62, 2016 Sep.
92.	Senkus E, Kyriakides S, Ohno S, et al. Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology. 26 Suppl 5:v8-30, 2015 Sep.
93.	Wahl RL, Siegel BA, Coleman RE, Gatsonis CG. Prospective multicenter study of axillary nodal staging by positron emission tomography in breast cancer: a report of the staging breast cancer with PET Study Group. J Clin Oncol. 2004;22(2):277-285.
94.	Riedl CC, Slobod E, Jochelson M, et al. Retrospective analysis of 18F-FDG PET/CT for staging asymptomatic breast cancer patients younger than 40 years. J Nucl Med. 55(10):1578-83, 2014 Oct.
95.	Ulaner GA, Castillo R, Goldman DA, et al. (18)F-FDG-PET/CT for systemic staging of newly diagnosed triple-negative breast cancer. Eur J Nucl Med Mol Imaging 2016;43:1937-44.
96.	Lyman GH, Temin S, Edge SB, et al. Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 32(13):1365-83, 2014 May 01.
97.	Expert Panel on Breast Imaging:, Slanetz PJ, Moy L, et al. ACR Appropriateness Criteria R Monitoring Response to Neoadjuvant Systemic Therapy for Breast Cancer. J. Am. Coll. Radiol.. 14(11S):S462-S475, 2017 Nov.
98.	Wecsler JS, Tereffe W, Pedersen RC, et al. Lymph node status in inflammatory breast cancer. Breast Cancer Res Treat 2015;151:113-20.
99.	An YS, Kang DK, Jung Y, Kim TH. Volume-based metabolic parameter of breast cancer on preoperative 18F-FDG PET/CT could predict axillary lymph node metastasis. Medicine (Baltimore). 96(45):e8557, 2017 Nov.
100.	Dunnwald LK, Doot RK, Specht JM, et al. PET tumor metabolism in locally advanced breast cancer patients undergoing neoadjuvant chemotherapy: value of static versus kinetic measures of fluorodeoxyglucose uptake. Clin Cancer Res 2011;17:2400-9.
101.	Keam B, Im SA, Koh Y, et al. Early metabolic response using FDG PET/CT and molecular phenotypes of breast cancer treated with neoadjuvant chemotherapy. BMC Cancer 2011;11:452.
102.	Groheux D, Espie M, Giacchetti S, Hindie E. Performance of FDG PET/CT in the clinical management of breast cancer. [Review]. Radiology. 266(2):388-405, 2013 Feb.
103.	Cho N, Moon WK, Han W, Park IA, Cho J, Noh DY. Preoperative sonographic classification of axillary lymph nodes in patients with breast cancer: node-to-node correlation with surgical histology and sentinel node biopsy results. AJR Am J Roentgenol 2009;193:1731-7.
104.	Garcia-Ortega MJ, Benito MA, Vahamonde EF, Torres PR, Velasco AB, Paredes MM. Pretreatment axillary ultrasonography and core biopsy in patients with suspected breast cancer: diagnostic accuracy and impact on management. Eur J Radiol. 79(1):64-72, 2011 Jul.
105.	Lim GH, Upadhyaya VS, Acosta HA, Lim JMA, Allen JC Jr, Leong LCH. Preoperative predictors of high and low axillary nodal burden in Z0011 eligible breast cancer patients with a positive lymph node needle biopsy result. Eur J Surg Oncol. 44(7):945-950, 2018 07.
106.	Cancer research campaign (King's/Cambridge) trial for early breast cancer. A detailed update at the tenth year. Cancer Research Campaign Working Party. Lancet 1980;2:55-60.
107.	Fisher B, Montague E, Redmond C, et al. Comparison of radical mastectomy with alternative treatments for primary breast cancer. A first report of results from a prospective randomized clinical trial. Cancer 1977;39:2827-39.
108.	Anderson TL, Glazebrook KN, Murphy BL, Viers LD, Hieken TJ. Cross-sectional imaging to evaluate the extent of regional nodal disease in breast cancer patients undergoing neoadjuvant systemic therapy. Eur J Radiol. 89:163-168, 2017 Apr.
109.	Candelaria RP, Bassett RL, Symmans WF, et al. Performance of Mid-Treatment Breast Ultrasound and Axillary Ultrasound in Predicting Response to Neoadjuvant Chemotherapy by Breast Cancer Subtype. Oncologist. 22(4):394-401, 2017 04.
110.	Hennessy BT, Hortobagyi GN, Rouzier R, et al. Outcome after pathologic complete eradication of cytologically proven breast cancer axillary node metastases following primary chemotherapy. J Clin Oncol 2005;23:9304-11.
111.	Hunt KK, Yi M, Mittendorf EA, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy is accurate and reduces the need for axillary dissection in breast cancer patients. Ann Surg 2009;250:558-66.
112.	Fayanju OM, Ren Y, Thomas SM, et al. The Clinical Significance of Breast-only and Node-only Pathologic Complete Response (pCR) After Neoadjuvant Chemotherapy (NACT): A Review of 20,000 Breast Cancer Patients in the National Cancer Data Base (NCDB). Ann Surg 2018;268:591-601.
113.	Park J, Chae EY, Cha JH, et al. Comparison of mammography, digital breast tomosynthesis, automated breast ultrasound, magnetic resonance imaging in evaluation of residual tumor after neoadjuvant chemotherapy. Eur J Radiol. 108:261-268, 2018 Nov.
114.	Cheng X, Li Y, Liu B, Xu Z, Bao L, Wang J. 18F-FDG PET/CT and PET for evaluation of pathological response to neoadjuvant chemotherapy in breast cancer: a meta-analysis. Acta Radiol. 53(6):615-27, 2012 Jul.
115.	Liu Q, Wang C, Li P, Liu J, Huang G, Song S. The Role of (18)F-FDG PET/CT and MRI in Assessing Pathological Complete Response to Neoadjuvant Chemotherapy in Patients with Breast Cancer: A Systematic Review and Meta-Analysis. [Review]. Biomed Res Int. 2016:3746232, 2016.
116.	Mghanga FP, Lan X, Bakari KH, Li C, Zhang Y. Fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography in monitoring the response of breast cancer to neoadjuvant chemotherapy: a meta-analysis. Clin Breast Cancer. 13(4):271-9, 2013 Aug.
117.	Tian F, Shen G, Deng Y, Diao W, Jia Z. The accuracy of 18F-FDG PET/CT in predicting the pathological response to neoadjuvant chemotherapy in patients with breast cancer: a meta-analysis and systematic review. [Review]. Eur Radiol. 27(11):4786-4796, 2017 Nov.
118.	Wang Y, Zhang C, Liu J, Huang G. Is 18F-FDG PET accurate to predict neoadjuvant therapy response in breast cancer? A meta-analysis. Breast Cancer Res Treat. 131(2):357-69, 2012 Jan.
119.	Jung N, Kim HJ, Jung JH, et al. Restaging the axilla after neo-adjuvant chemotherapy for breast cancer: Predictive factors for residual metastatic lymph node disease with negative imaging findings. Breast J 2019;25:196-201.
120.	Wu S, Wang Y, Li J, et al. Subtype-Guided (18)F-FDG PET/CT in Tailoring Axillary Surgery Among Patients with Node-Positive Breast Cancer Treated with Neoadjuvant Chemotherapy: A Feasibility Study. Oncologist 2019.
121.	Steiman J, Soran A, McAuliffe P, et al. Predictive value of axillary nodal imaging by magnetic resonance imaging based on breast cancer subtype after neoadjuvant chemotherapy. J Surg Res. 204(1):237-41, 2016 07.
122.	Javid S, Segara D, Lotfi P, Raza S, Golshan M. Can breast MRI predict axillary lymph node metastasis in women undergoing neoadjuvant chemotherapy. Ann Surg Oncol. 2010;17(7):1841-1846.
123.	Zhou P, Wei Y, Chen G, Guo L, Yan D, Wang Y. Axillary lymph node metastasis detection by magnetic resonance imaging in patients with breast cancer: A meta-analysis. Thorac Cancer. 9(8):989-996, 2018 08.
124.	Marinovich ML, Houssami N, Macaskill P, et al. Meta-analysis of magnetic resonance imaging in detecting residual breast cancer after neoadjuvant therapy. [Review]. J Natl Cancer Inst. 105(5):321-33, 2013 Mar 06.
125.	Hylton NM. Residual Disease after Neoadjuvant Therapy for Breast Cancer: Can MRI Help? Radiology 2018;289:335-36.
126.	McGuire KP, Toro-Burguete J, Dang H, et al. MRI staging after neoadjuvant chemotherapy for breast cancer: does tumor biology affect accuracy? Ann Surg Oncol. 2011;18(11):3149-3154.
127.	Straver ME, Loo CE, Rutgers EJ, et al. MRI-model to guide the surgical treatment in breast cancer patients after neoadjuvant chemotherapy. Ann Surg. 2010;251(4):701-707.
128.	Zhang X, Wang D, Liu Z, et al. The diagnostic accuracy of magnetic resonance imaging in predicting pathologic complete response after neoadjuvant chemotherapy in patients with different molecular subtypes of breast cancer. Quant Imaging Med Surg 2020;10:197-210.
129.	Boughey JC, Ballman KV, Hunt KK, et al. Axillary Ultrasound After Neoadjuvant Chemotherapy and Its Impact on Sentinel Lymph Node Surgery: Results From the American College of Surgeons Oncology Group Z1071 Trial (Alliance). J Clin Oncol. 33(30):3386-93, 2015 Oct 20.
130.	Kelly AM, Dwamena B, Cronin P, Carlos RC. Breast cancer sentinel node identification and classification after neoadjuvant chemotherapy-systematic review and meta analysis. Acad Radiol 2009;16:551-63.
131.	Choudhery S, Simmons C, Harper L, Lee CU. Tomosynthesis-Guided Needle Localization of Breast and Axillary Lesions: Our Initial Experience. AJR Am J Roentgenol 2019;212:943-46.
132.	Li H, Yao L, Jin P, et al. MRI and PET/CT for evaluation of the pathological response to neoadjuvant chemotherapy in breast cancer: A systematic review and meta-analysis. [Review]. BREAST. 40:106-115, 2018 Aug.
133.	Sheikhbahaei S, Trahan TJ, Xiao J, et al. FDG-PET/CT and MRI for Evaluation of Pathologic Response to Neoadjuvant Chemotherapy in Patients With Breast Cancer: A Meta-Analysis of Diagnostic Accuracy Studies. Oncologist. 21(8):931-9, 2016 08.
134.	Schipper RJ, Moossdorff M, Beets-Tan RGH, Smidt ML, Lobbes MBI. Noninvasive nodal restaging in clinically node positive breast cancer patients after neoadjuvant systemic therapy: a systematic review. [Review]. Eur J Radiol. 84(1):41-47, 2015 Jan.
135.	Buchbender C, Kuemmel S, Hoffmann O, et al. FDG-PET/CT for the early prediction of histopathological complete response to neoadjuvant chemotherapy in breast cancer patients: initial results. Acta Radiol. 53(6):628-36, 2012 Jul.
136.	Kolesnikov-Gauthier H, Vanlemmens L, Baranzelli MC, et al. Predictive value of neoadjuvant chemotherapy failure in breast cancer using FDG-PET after the first course. Breast Cancer Res Treat. 131(2):517-25, 2012 Jan.
137.	Kim SY, Cho N, Park IA, et al. Dynamic Contrast-enhanced Breast MRI for Evaluating Residual Tumor Size after Neoadjuvant Chemotherapy. Radiology. 289(2):327-334, 2018 11.
138.	Banys-Paluchowski M, Gruber IV, Hartkopf A, et al. Axillary ultrasound for prediction of response to neoadjuvant therapy in the context of surgical strategies to axillary dissection in primary breast cancer: a systematic review of the current literature. Archives of Gynecology & Obstetrics. 301(2):341-353, 2020 02.
139.	Peppe A, Wilson R, Pope R, Downey K, Rusby J. The use of ultrasound in the clinical re-staging of the axilla after neoadjuvant chemotherapy (NACT). BREAST. 35:104-108, 2017 Oct.
140.	Helfgott R, Mittlbock M, Miesbauer M, et al. The influence of breast cancer subtypes on axillary ultrasound accuracy: A retrospective single center analysis of 583 women. Eur J Surg Oncol. 45(4):538-543, 2019 04.
141.	Stein RG, Wollschlager D, Kreienberg R, et al. The impact of breast cancer biological subtyping on tumor size assessment by ultrasound and mammography - a retrospective multicenter cohort study of 6543 primary breast cancer patients. BMC Cancer. 16:459, 2016 07 13.
142.	Nwaogu IY, Yan Y, Appleton CM, Cyr AE, Margenthaler JA. Predictors of false negative axillary ultrasound in breast cancer. J Surg Res. 198(2):351-4, 2015 Oct.
143.	Hieken TJ, Boughey JC, Jones KN, Shah SS, Glazebrook KN. Imaging response and residual metastatic axillary lymph node disease after neoadjuvant chemotherapy for primary breast cancer. Ann Surg Oncol. 20(10):3199-204, 2013 Oct.
144.	McGale P, Taylor C, Correa C, et al. Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet. 2014;383(9935):2127-2135.
145.	Nielsen HM, Overgaard M, Grau C, Jensen AR, Overgaard J. Study of failure pattern among high-risk breast cancer patients with or without postmastectomy radiotherapy in addition to adjuvant systemic therapy: long-term results from the Danish Breast Cancer Cooperative Group DBCG 82 b and c randomized studies. J Clin Oncol 2006;24:2268-75.
146.	Wakeam E, Acuna SA, Keshavjee S. Chest Wall Resection for Recurrent Breast Cancer in the Modern Era: A Systematic Review and Meta-analysis. Ann Surg 2018;267:646-55.
147.	Bouganim N, Tsvetkova E, Clemons M, Amir E. Evolution of sites of recurrence after early breast cancer over the last 20 years: implications for patient care and future research. Breast Cancer Res Treat 2013;139:603-6.
148.	Spronk I, Schellevis FG, Burgers JS, de Bock GH, Korevaar JC. Incidence of isolated local breast cancer recurrence and contralateral breast cancer: A systematic review. Breast 2018;39:70-79.
149.	Pan H, Gray R, Braybrooke J, et al. 20-Year Risks of Breast-Cancer Recurrence after Stopping Endocrine Therapy at 5 Years. N Engl J Med 2017;377:1836-46.
150.	Stuart-Harris R, Dahlstrom JE, Gupta R, Zhang Y, Craft P, Shadbolt B. Recurrence in early breast cancer: Analysis of data from 3,765 Australian women treated between 1997 and 2015. BREAST. 44:153-159, 2019 Apr.
151.	Wapnir IL, Price KN, Anderson SJ, et al. Efficacy of Chemotherapy for ER-Negative and ER-Positive Isolated Locoregional Recurrence of Breast Cancer: Final Analysis of the CALOR Trial. J Clin Oncol 2018;36:1073-79.
152.	Park S, Koo JS, Kim MS, et al. Characteristics and outcomes according to molecular subtypes of breast cancer as classified by a panel of four biomarkers using immunohistochemistry. Breast 2012;21:50-7.
153.	Clarke M, Collins R, Darby S, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005;366(9503):2087-2106.
154.	Thill M, Jackisch C, Janni W, et al. AGO Recommendations for the Diagnosis and Treatment of Patients with Locally Advanced and Metastatic Breast Cancer: Update 2019. Breast Care (Basel) 2019;14:247-55.
155.	Xiao Y, Wang L, Jiang X, She W, He L, Hu G. Diagnostic efficacy of 18F-FDG-PET or PET/CT in breast cancer with suspected recurrence: a systematic review and meta-analysis. [Review]. Nucl Med Commun. 37(11):1180-8, 2016 Nov.
156.	Lehman CD, Lee JM, DeMartini WB, et al. Screening MRI in Women With a Personal History of Breast Cancer. Journal of the National Cancer Institute. 108(3), 2016 Mar.
157.	Wernli KJ, Ichikawa L, Kerlikowske K, et al. Surveillance Breast MRI and Mammography: Comparison in Women with a Personal History of Breast Cancer. Radiology. 292(2):311-318, 2019 08.Radiology. 292(2):311-318, 2019 08.
158.	Choi EJ, Choi H, Choi SA, Youk JH. Dynamic contrast-enhanced breast magnetic resonance imaging for the prediction of early and late recurrences in breast cancer. Medicine (Baltimore). 95(48):e5330, 2016 Nov.
159.	Kolb TM, Lichy J, Newhouse JH. Comparison of the performance of screening mammography, physical examination, and breast US and evaluation of factors that influence them: an analysis of 27,825 patient evaluations. Radiology. 225(1):165-75, 2002 Oct.
160.	Berg WA, Zhang Z, Lehrer D, et al. Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA. 307(13):1394-404, 2012 Apr 04.
161.	Dibble EH, Lourenco AP, Baird GL, Ward RC, Maynard AS, Mainiero MB. Comparison of digital mammography and digital breast tomosynthesis in the detection of architectural distortion. European Radiology. 28(1):3-10, 2018 Jan.
162.	Valente SA, Levine GM, Silverstein MJ, et al. Accuracy of predicting axillary lymph node positivity by physical examination, mammography, ultrasonography, and magnetic resonance imaging. Ann Surg Oncol. 19(6):1825-30, 2012 Jun.
163.	Ciatto S, Brancato B, Risso G, et al. Accuracy of fine needle aspiration cytology (FNAC) of axillary lymph nodes as a triage test in breast cancer staging. Breast Cancer Res Treat 2007;103:85-91.
164.	Deurloo EE, Tanis PJ, Gilhuijs KG, et al. Reduction in the number of sentinel lymph node procedures by preoperative ultrasonography of the axilla in breast cancer. Eur J Cancer 2003;39:1068-73.
165.	Sapino A, Cassoni P, Zanon E, et al. Ultrasonographically-guided fine-needle aspiration of axillary lymph nodes: role in breast cancer management. Br J Cancer 2003;88:702-6.
166.	American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.

Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination