Axillary Ultrasound in the Evaluation of Breast Cancer Patients

Rodrigo Arrangoiz MS, MD, FACS, FSSO
Normal Axillary Lymph Node
  • A normal axillary lymph node (Image):
    • Is elliptical in shape (or bean shaped), and has a narrow, symmetrical, hypoechoic cortex surrounding an isoechoic to hyperechoic fatty hilum (mediastinum)
    • The cortex of a normal node is composed largely of lymphatic tissue and fluid-filled cortical sinuses:
      • Thus the hypoechoic echogenicity
    • The hilum contains alternating medullary cords and sinusoids that have innumerable acoustic interfaces:
      • Thus the higher degree of echogenicity
Metastatic Axillary Lymph Node. Another presentation of a metastatic node is an asymmetric cortex where the tumor can be seen invading the hilum with convex indentations that look like “rat bites”
Lymph node completely replaced with metastatic carcinoma obliterating the fatty hilum. Doppler shows more than a single blood vessel supplying the node.
  • When a lymph node is completely replaced with metastatic cancer:
    • It will be rounded, hypoechoic, and the hilum will be completely obliterated (Image)
    • Before the node reaches the stage of complete replacement:
      • It can have an asymmetric, thickened cortex, with an eccentric hilum (Image)
  • Another presentation of a metastatic node:
    • Is an asymmetric cortex where the tumor can be seen invading the hilum with convex indentations that look like “rat bites” (First Image)
  • A metastatic node can also have severe compression of a central hilum resulting in a slit-like central hyperechoic band (Image)
Severe compression of the hilum by metastatic carcinoma resulting in a “slit-like” central hilum
Lymph nodes with eccentric hila and asymmetric, thickened cortices.
  • Reactive nodes can be difficult to distinguish from metastatic nodes (Image)
Reactive node.
  • In general, benign causes of nodal enlargement:
    • Tend to thicken the cortex diffusely
  • In addition, it is not uncommon to have a metastatic node adjacent to a normal node:
  • But all nodes in a region tend to be reactive when the cause is benign
  • Finally, a reactive node has blood supply on Doppler examination through a single hilum, whereas metastatic nodes tend to have multiple transcapsular vessels
  • References
  • Rahbar H, Partridge SC, Javid SH, Lehman CD. Imaging axillary lymph nodes in patients with newly diagnosed breast cancer. Curr Probl Diagn Radiol. 2012;41(5):149-158.
  • Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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