Fine-needle aspiration of axillary lymph nodes: a change of paradigm in the approach to axillary compromise?

Radiol Bras. 2016 Jan/Fev;49(1):IX Breast cancer is the most common malignant tumor in women. Recently, the Brazilian radiological literature has been extremely concerned with the relevance of the role played by imaging methods in the improvement of breast cancer diagnosis. In the last decades, the treatment for breast cancer has undergone major changes, with more conservative surgeries demonstrating no influence on overall survival. However, despite the recent developments, axillary compromise still remains as the most relevant isolated prognostic factor. Additionally, it may determine the indication for the most appropriate treatment such as chemotherapy and radiotherapy in a significant number of patients. Until recently, sentinel lymph node biopsy has been a game changer in the assessment of the axilla and definition of the necessity of axillary dissection. The latter, however, was responsible for the major part of the morbidity associated with breast cancer surgery. Avoiding such a measure in cases where it is unnecessary, i.e. in cases of negative sentinel lymph node was the main focus of the oncologic breast surgery over the last decades. Thus, the application of a minimally invasive, simple and effective diagnostic method in the prediction of axillary compromise could be helpful to reduce the surgical time, so the surgeon could avoid the sentinel lymph node biopsy, proceeding directly to axillary dissection. Would it be so simple? Such a rationale would be perfect up to four years ago, before the publication of the clinical essays ACOSOG Z0011 and AMAROS. Such studies have demonstrated that patients eligible for conservative surgery (T1-T2), with less than three positive lymph nodes and submitted to axillary dissection, presented the same survival and local management as those who had not undergone dissection. Then, on the basis of the ACOSOG Z0011 and AMAROS results, in which situations could the findings by Rocha et al. be useful? The great relevance of the study developed by Rocha et al. is in the high degree of sensitivity of fine needle aspiration biopsy (FNAB) observed in cases of lymph nodes considered to be suspicious and indeterminate (87.1%), allowing to avoid the sentinel lymph node procedure in 70.1% of patients. And, in the cases where