A normal node has a thin, uniform hypoechoic cortex and a fatty hilum; eccentric cortical thickening over 3 mm, a lost hilum or a round shape are the features that earn a needle.
Orient first
- Nodal status stages breast cancer and decides axillary surgery.
- Reactive nodes after vaccination (COVID-19 and others) or infection are common — history matters.
- A biopsied positive node should be clipped before neoadjuvant therapy.
Acquire the study
- High-frequency linear probe from the axillary tail to level I–II, with the arm abducted; colour Doppler; ultrasound-guided core biopsy or FNA of the most abnormal node.
The manoeuvre
- Survey level I, then level II behind pectoralis minor, then infraclavicular and supraclavicular nodes if abnormal.
- Each suspicious node: short axis in mm, cortical thickness in mm, cortical shape (uniform vs eccentric), fatty hilum present or absent.
- Colour Doppler: hilar vs peripheral (non-hilar) vascularity.
- Choose the most abnormal node for biopsy; state its position (level, distance from the skin).
- Record clip placement.
What confirms it
- Metastasis on core biopsy or FNA of the targeted node.
What licenses you to exclude it
- Nodes with a uniform cortex under 3 mm and a preserved fatty hilum are benign-appearing; ultrasound cannot exclude micrometastases.
The classic misread
- Biopsying the easiest node instead of the most abnormal one.
- Calling post-vaccination nodes metastatic without the history.