Imaging updates to breast cancer lymph node management

Metastatic lymph node involvement in breast cancer is a key deter-minant of the overall stage of disease and prognosis. Historically, lymph node status was determined by surgery first, with adjuvant treatments determined based on the results of the final surgical pathologic analysis.While this sequence is still applicable in many cases, neoadjuvant systemic treatment (NST) is increasingly be-ing administered as the initial treatment. In cases that demonstrate good therapeutic response to drug therapies, NST may permit the option to perform less radical surgeries subsequently. Current breast cancer treatment has become multidisciplinary, with overlapping roles from the different disciplines. As surgery may be postponed, imaging and image-guided lymph node interventions have gained importance as the primary means of lymph node as-sessment. Imaging enables evaluation of all regional nodal basins, including locations where surgery is not usually performed. By dif-ferentiating limited versus extensive nodal involvement, imaging findings help determine whether initial treatment should be surgical or medical. If medical treatment with NST is indicated, imaging is performed to monitor the in vivo nodal response to drug therapy and ultimately to help determine the surgical technique to perform on the basis of the final imaging findings after NST. The authors discuss the imaging features of nodal metastases and the indications and techniques for the various image-guided procedures. The rela-tive usefulness and shortcomings of the various imaging examina-tions are reviewed to discuss how they can be applied when biopsy results are not available. The role of imaging in the multidisci-plinary team approach is emphasized based on past clinical trials of lymph node management and recent evolving knowledge of breast cancer staging.