title: The role of combined assessment in preoperative axillary staging.
abstract: BACKGROUND
  Axillary lymph node status is the most significant single prognostic factor in breast cancer, and preoperative axillary staging is essential in determining lymph node status. Axillary ultrasound scan (AUS) is the gold standard modality in preoperative staging. However, triple assessment-including clinical examination and radiological assessment with fine needle aspiration (FNA) with or without core biopsy-ensures high sensitivity.
  
  
  METHODS
  Our study included 219 women diagnosed with invasive breast cancer between 2009 and 2010. All patients underwent a preoperative staging AUS that was graded from normal (U1) to malignant (U5). All patients with ultrasound scans graded U3 (indeterminate) and above underwent FNA that was graded from C1 (inadequate for diagnosis) to C5 (malignant). Patients diagnosed preoperatively with metastatic lymph nodes were offered axillary lymph node clearance. The rest of the patients were offered sentinel lymph node biopsy.
  
  
  RESULTS
  The 219 women were diagnosed with 228 invasive breast cancers. The mean age was 60 years (range 29-90 years). The final histology report showed metastatic axillary lymph nodes in 49 (21.5%) cases. Of these 49 cases, 22 were diagnosed preoperatively with metastatic axillary lymph node and were elected for axillary lymph node clearance, and 27 were elected for sentinel lymph node biopsy that revealed metastatic lymph nodes. AUS showed abnormal (U3/U4/U5) axillary lymph nodes in 30 of 49 (61.2%) cancer cases with an overall accuracy of 91.6%.
  
  
  CONCLUSIONS
  Combined triple assessment increases the sensitivity, negative predictive value, and overall accuracy of preoperative staging of the axilla.
authors.affiliation: Breast Unit, Queen Elizabeth Hospital - Surgery, Gateshead, United Kingdom.
authors.forename: Hazem
authors.initials: H
authors.lastname: Khout
authors.affiliation: Breast Unit, Queen Elizabeth Hospital - Surgery, Gateshead, United Kingdom.
authors.forename: Catherine
authors.initials: C
authors.lastname: Richardson
authors.affiliation: Breast Unit, Queen Elizabeth Hospital - Surgery, Gateshead, United Kingdom.
authors.forename: Hamid
authors.initials: H
authors.lastname: Toghyan
authors.affiliation: Breast Unit, Queen Elizabeth Hospital - Surgery, Gateshead, United Kingdom.
authors.forename: Tarannum
authors.initials: T
authors.lastname: Fasih
keywords: Biopsy—fine needle; breast neoplasms; sentinel lymph node biopsy; ultrasonography