Aspiration Biopsy Technique Research Articles

SILICONE FINE-NEEDLE ASPIRATION RETINAL BIOPSY: A Novel Surgical Technique for Vitreoretinal Lymphoma.

To describe a 41-gauge silicone fine-needle aspiration biopsy (S-FNAB) technique and assess its value in diagnosing primary vitreoretinal lymphoma (PVRL). Retrospective review of seven consecutive patients who underwent vitreous biopsy (VB) and 41-gauge S-FNAB of retinal/subretinal lesions in a single tertiary center between January 2012 and March 2023. Of seven patients, S-FNAB confirmed the diagnosis of PVRL in six patients. In five of those patients, both VB and retinal/subretinal S-FNAB (performed at the same procedure) yielded positive results, with the retinal thickness at the biopsy site as small as 231 µm. Four of these five patients had one or more previous negative VB. In one patient, S-FNAB yielded positive results despite a negative VB. Silicone fine-needle aspiration biopsy failed to confirm positive VB for PVRL in the remaining patient. The time from symptom onset to diagnosis of PVRL ranged from 18 days to 26 months. There were no severe complications associated with the procedure. Silicone fine-needle aspiration biopsy might be a valuable method for obtaining a sufficient sample of viable cells to diagnose PVRL. It can be performed as a primary procedure along with VB. Further studies are warranted to determine where this technique could be most advantageous.

Mapping Thyroid Changes in Size and Position During Enlargement in Adult Mice With Hyperthyroidism.

The thyroid in Graves' disease undergoes a considerable divergence in size and position from the normal anatomy. However, knowledge of the pathological anatomy related to the change, which is required before planned surgical or local intervention, or diagnosis, is neglected. To investigate Graves' disease, we established a model of mice that successfully mimicked all the signs presented in the clinic. Under a long-term immunization (35 weeks), the animals displayed large heterogeneity in thyroid size, such as the cases of natural occurrence. These thyroids in the model were sized into various phases and registered. A blend of the registered thyroids and the thyroid and tracheal cartilage landmarks led to the production of site-dependent incidence graphs of thyroid in the front view and on the section for each phase. The merger of the incidence graphs of all the phases resulted in thyroid phase-dependent topography. The depicted graphs illustrate the fine localization of the thyroid in various sizes and their dynamic changes during enlargement, which may facilitate currently used fine-needle aspiration biopsy and ultrasonography-guided biopsy techniques. Familiarity with this knowledge might avoid misclassifying an abnormality as normal, or vice versa, and be helpful for imaging diagnosis and local surgery therapy in Graves' disease.

Use of Fine Needle Aspiration Biopsy in Diagnosis Oral and Maxillo-Facial Tumors

The Technique of fine needle aspiration biopsy (F.N.A.B.) was evaluated in the field of maxillofacial surgery. For this purpose comparison of cyt ological results with the conventional histo pathological results were take place. Seventy-two specimens were obtained by F.N.A.B. from 60 patients with age range from 3-84 years of both sexes, 11.7% of the patients had previous history of diagnosed malignant tumors. Cytological results show 40 cases(55.5%) were benign tumor, 27 cases (37.5 %) were malignant, 3 cases (4.2 %) unsatisfactory for diagnosis and 2 cases (2.8 %) were suspicious to be malignant. The statistical analysis showed that F.N.A.B. had sensitivity (92.6%), specificity (100%), positive predictive value (92.3%), and accuracy rate (96%).

Comparison of low-cost phantoms for ultrasound-guided fine-needle aspiration biopsy training.

Phantoms and simulators are widely accepted methods to gain valuable experience and confidence for inexperienced trainees prior to seeing their patient and for refining their skills. A phantom model that is durable, simple, and inexpensive to produce and use would be ideal to train practitioners in ultrasound-guided fine-needle aspiration biopsy (USFNA) technique. In this study, we systematically compared several low-cost phantom models including gelatin, extra firm tofu, canned cooked pork, ballistics gel, and chicken breast for their haptic properties, echogenicity, teaching utility, and overall performance based on a Likert scale (1-5; 5 = best). Nine cytopathologists and cytopathology fellows who perform FNA regularly evaluated these models and completed the survey. The gelatin phantom, with a gelatin to water ratio of 1:8 by weight, was found to be the best for USFNA practice and overall performance, followed by the 1:10 gelatin phantom. Tofu and chicken breast phantoms were also good low-cost alternatives that needed only a few minutes of total preparation time. Low-cost, homemade phantoms can serve as excellent alternatives to commercial phantoms for practicing and teaching USFNA.

Rotation aiding technique for endobronchial ultrasound-guided transbronchial needle aspiration biopsy of intrathoracic lymph nodes: A complementary approach to the conventional jabbing method.

BackgroundThis study aimed to compare the lymph node core tissue lengths obtained via mediastinal or hilar lymphadenopathy using the complementary “rotation aiding” and conventional Jab technique.MethodsWe prospectively measured the lymph node core tissue length in patients who sequentially underwent the Jab and rotation aiding (RA) techniques between October 2012 and December 2014. Wilcoxon signed‐rank test was used to compare the core tissue length and grade of diagnostic cells obtained by each technique. McNemar's test was used to compare the proportion of adequate cellularity (≥grade 2) between the aspiration techniques.ResultsThe core tissue length of 61 lymph nodes from 43 patients (mean age: 63 years, range: 16–86 years) was analyzed. Pathological findings were consistent with malignant lesions in 25 (41%) patients and benign lesions in 36 (59%). The most common diagnosis in benign lymph nodes was reactive, followed by tuberculosis and sarcoidosis. We obtained longer core tissue with RA technique than with the Jab technique (83.2 ± 12.7 vs. 60.1 ± 10.1 mm; p = 0.02). There was a significant increase in cellularity grade and proportion of ≥grade 2 cells with the RA technique than with the Jab technique (2.39 ± 1.08 vs. 1.84 ± 1.14; p < 0.001, 78.7% vs. 52.5%; p = 0.002), regardless of the pathological diagnosis.ConclusionsRA technique facilitated more lymph node samples in terms of core tissue length and cellularity than the Jab technique.

A novel combined animal tissue model for freehand and ultrasound-guided fine needle aspiration biopsy and smear preparation techniques training.

A variety of models are used for fine needle aspiration biopsy (FNAB) and smear preparation techniques training: human, animal and silicon models or combined models. We present fresh animal tissues as models for freehand and ultrasound (US)-guided FNAB technique training, enabling an integrated approach from tumour detection to smear evaluation. We introduced a novel combined animal tissue model using dietary animal meat with covering skin as a substrate. Animal liver tissue of various sizes, representing tumour, was inserted into the various layers of the substrate (subcutaneous fat, muscle tissue, proximity of bone). Freehand and US-guided FNAB smear preparation, including fixation, was then performed and assessed. The use of a combined animal tissue model for 6 freehand and 3 US-guided FNAB sessions showed a statistically significant improvement in the US-guided FNAB retrieval of liver tissue (Fisher's exact test, p = .0216), in smear preparation technique reflected in a decrease in the number of too thick smears after freehand FNAB (Fisher's exact test, p = .0070), in the overall number of smears satisfactory for evaluation by US-guided FNAB (Fisher's exact test, p = .0206) and in the number of flawless smears obtained in the freehand FNAB training sessions (Fisher's exact test, p = .0020). A unique advantage of the presented model encompassing various layers of animal tissues with covering skin, offers an integrated approach for FNAB training from "tumour" detection, puncture precision, to smear preparation and cytological evaluation for a wider audience and does not compromise patient safety.

Extraskeletal myxoid chondrosarcoma: combining cytopathology with molecular testing to achieve diagnostic accuracy

Advances in the genetics of soft tissue neoplasia have allowed for the diagnostic recognition of specific tumor types from small biopsy specimens, including those procured using the fine needle aspiration (FNA) biopsy technique. Extraskeletal myxoid chondrosarcoma (EMC) is a malignant mesenchymal neoplasm characterized by NR4A3 and, less specifically, by EWSR1 gene rearrangements. A series of EMC cytologic specimens was examined to demonstrate the diagnostic value of incorporating fluorescence in situ hybridization (FISH) testing in cytologic cases of suspected EMC. A search was made of our cytopathology and surgical pathology databases for cases diagnosed as EMC. FNA biopsy cytology, exfoliative cytology, imprint cytology, and FISH analysis were performed and examined using standard techniques. A total of 16 cases of EMC were retrieved from 15 patients (male/female ratio, 2.8:1; mean age, 62 years). Of the 15 patients, 10 were new patients with primary tumors, 2 had locally recurrent tumors, and 4 had metastases. The sites included the extremities in 10 cases, the trunk in 4, serous effusion in 1, and a mediastinal lymph node in 1 case. The specific cytologic diagnoses were EMC (14 cases; 88%), suspicious for EMC (n = 1), and malignant cells (n = 1). All cases for which FISH testing was successfully used were specifically recognized as EMC. Aspirates and imprint smears consisted of uniformly rounded cells set in an opaque myxoid/chondromyxoid stroma (less abundant and more diaphanous in the effusion sample), sometimes arranged in short anastomosing cords. FNA of 1 case of an EMC cellular variant mimicked a malignant small rounded cell tumor. EMC can be added to the growing list of soft tissue neoplasms that are specifically recognizable using cytopathology, coupled with judicious application of ancillary molecular testing.

Whirling technique for thyroid fine needle aspiration biopsy: a preliminary study of effectiveness and safety.

PurposeThis study was aimed to compare thyroid fine needle aspiration biopsy (FNAB) techniques (conventional vs. whirling) in terms of cell harvesting ability ex vivo, the unsatisfactory rate and complication rate in vivo, and multi-operator performance in a phantom study.MethodsIn the ex vivo study, cell counts per background at ×100 magnification were compared between both techniques. In the in vivo study, 70 patients who underwent whirling FNAB from July 2019 to November 2019 were retrospectively compared to 140 matched patients who underwent conventional FNAB from January 2018 to November 2019 regarding the unsatisfactory rate and complication rate. As a subgroup analysis, thyroid nodules in difficult biopsy situations (nodule diameter <10 mm and location within 3 mm from major anatomical structures) were compared. In the phantom study, eight operators with varying experience recorded levels of dexterity and needle tip visualization, and their preferences for both techniques.ResultsIn the ex vivo study, cell counts were comparable between both techniques in all thyroid nodule mimickers (80.0% vs. 87.5%, P=0.178). In the in vivo study, the unsatisfactory rate was comparable between the two groups (15.7% vs. 12.9%, P=0.859). In the subgroup analysis, the whirling technique demonstrated a lower unsatisfactory rate (5.9% vs. 24.2%, P=0.045) and a lower complication rate (0% vs. 6.1%, P=0.553). In the phantom study, the whirling technique demonstrated better dexterity and needle tip visualization and was preferred by all operators.ConclusionThis newly proposed whirling technique for thyroid FNAB may be effective and safe, especially in difficult biopsy situations.

Computed Tomography- Guided Bone Marrow Aspiration and Trephine (Core) Biopsy for Hematologists and Oncologists

Computed tomography (CT) with or without fluoroscopy has evolved as a very useful tool in medical science and is used as an instrument for sampling a solid organ tissue (biopsy), body fluid, or a tumor mass suspected of malignancy. In this system the aspiration and biopsy needle can be visualized by the physician practitioner on a CT scan and help assist in the accurate localization of the target tissue. Because of the problems associated with accurately locating the posterior iliac crest with surface anatomic landmarks and conventional palpation (considered as a blind method) we have used the technique of CT-guided bone marrow aspiration and bone marrow trephine (core) biopsy in patients diagnosed with various hematological malignancies. We found the technique is extremely useful in accurately locating the posterior iliac crest particularly in obese patients. This procedure facilitates an adequate aspiration of a marrow suspension (liquid marrow) and extraction of an excellent core sample each time and is more surgically precise than when access to the target bone (iliac crest) is based only on palpation of external landmarks (blind method).

Preoperative morphological diagnosis of axillary lymph nodes in a breast center consultation service: evaluation of fine-needle aspiration and core biopsy techniques.

Preoperative routine examination of axillary lymph nodes (ALN) in breast cancer patients is carried out physically and by ultrasound imaging; unsuspicious nodes will lead to a sentinel node (SN) procedure, suspicious ones require axillary dissection (AD). Pre-operative biopsy techniques like fine needle aspiration (FNA) or core biopsy (CB) may reduce the number of false "suspicious" cases and prevent overtreatment. We evaluated the effectiveness of both biopsy techniques. After physical and ultrasound examination 241 suspicious ALNs were found in 214 patients. Ultrasound-guided FNA and/or CB procedures were chosen randomly, resulting in 138 FNA and 86 CB. In 17 further events both FNA and CB were employed. The samples were examined in our Cytology lab or in the Pathology Department and the findings correlated with post-operative histological lymph node reports. Patients with histologically proven breast cancer underwent sentinel node biopsy, cytologically or histologically positive FNA/CB-findings prompted ALN dissection. Out of 155 FNA samples 34 were not representative (21.9%), 89 showed no tumor cells (57.4%), 30 showed positive tumor cells (19.4%), leaving two missing. All 103 CB showed representative material, positive in 62 (60.2%) and negative in 41 (39.8%) cases. Correlation with histological reports revealed a statistically non-significant advantage for CB over FNA regarding total accuracy (92.9% vs. 78.3%) and sensitivity (92% vs. 73.7%). Preoperative CB and alternative FNA are valuable complementary methods of predicting ALN involvement in breast cancer patients and may spare the patient unnecessary ALN dissection.

Lymph node cytopathology: Essential ancillary studies as applied to lymphoproliferative neoplasms.

Ancillary testing is absolutely integral to the correct recognition and classification of lymphoid neoplasms as procured with the fine-needle aspiration (FNA) biopsy technique. In patients with a newly diagnosed lymphoid neoplasm, immunophenotyping with flow cytometry, immunohistochemistry, or both is a standard that is currently expected by oncologists before any form of therapy is initiated. This is often the case also for patients with recurrent/relapsed disease. The cellular material obtained with FNA is perfectly suited to meet this demand. That said, the exceptional complexity of modern-day lymphoma classification often precludes definitive subclassification in a subset of lymphomas for a variety of reasons with the FNA biopsy technique, even with the application of ancillary tests. These include a requirement for definitive knowledge of the nodal architecture (eg, Hodgkin lymphoma), of the histologic grade via the counting of cells per microscopic field (follicular lymphoma), and of molecular findings (often unobtainable because of limitations of cellularity). The application of molecular tests to lymph node aspirates continues to evolve but is still largely confined to specialized medical centers. The intent of this article is to briefly review the diagnostic approach and algorithm for handling lymph node aspirates at the authors' own laboratory. This article highlights what the authors and others consider to be essential ancillary tests and discusses their respective advantages and shortcomings. It lists limited and extended antibody panels and molecular tests that the authors have found helpful not only for correctly recognizing lymphoma with FNA cytopathology but also for subtyping lymphomas whenever possible.

Fine-Needle Aspiration Biopsy in Orbital Lesions: A Retrospective Study of 225 Cases

To describe and analyze results from the fine-needle aspiration biopsy (FNAB) technique, used as a diagnostic tool, in patients with orbital lesions. Retrospective case series. setting: Institutional (Karolinska Hospital, Stockholm). 207 patients with 210 orbital lesions. 225 FNABs of the orbit. Successful diagnosis from FNAB. Of the 210 orbital lesions evaluated with FNAB, a successful cytologic diagnosis was achieved in 176 (84%). In more than half of the orbital lesions (54%), the FNAB diagnosis in addition to imaging appearance, clinical appearance, and clinical history provided sufficient information for treatment, and the patient did not require an incisional or excisional biopsy. Ninety-seven patients underwent additional excisional or incisional biopsy; FNAB diagnoses and the histopathologic diagnoses corresponded in 87% of the cases with an intraclass correlation coefficient of 0.84 (95% confidence interval [CI] 0.76-0.90). The difference was statistically significant between the ability to make a successful cytologic FNAB diagnosis in palpable lesions vs nonpalpable lesions (successful diagnosis in 90% [CI= 85%-95%] vs 75% [CI= 66%-84%];P<.01). Neither the orbital quadrant location, nor the radiologic appearance (diffuse vs encapsulated), nor size of the lesion affected the success of FNAB diagnoses (all P > .7). There was a complication in 6 cases (3%). All complications were temporary and none led to permanent damage. FNAB proved effective and exceedingly safe. With the current healthcare climate of minimally invasive surgery and cost control, FNAB should be considered as a valid alternative to open surgery in the evaluation and management of orbital lesions.

Epidermoid/Dermoid cysts mimicking odontogenic infections: review of literature

Introduction: Dermoid/Epidermoid cysts are rare pathologic lesions that may involve the floor of the mouth. Infection and inflammation of the cyst can produce a clinical picture very similar to the submandibular and submental abscesses with odontogenic origin. Dermoid/epidermoid cysts are on the floor of the mouth with submental or submandibular component can be mistaken for odontogenic infections. Methods: Four biopsy proven dermoid/epidermoid cysts operated in the Mashhad University of Medical Sciences, Ghaem hospital (2012-2013), were reviewed. Results: Four patients, including two classic cases and two infected dermoid/epidermoid cysts, were erroneously diagnosed as odontogenic infection. Discussion: The lesions located solely below mylohyoid muscle need to be removed through anextraoral approach but the lesions above the mylohyoid muscle or those that have both supra- and infra-mylohyoid components can be removed through an intraoral incision.Conclusion: Dermoid/epidermoid cysts should be considered in the differential diagnosis of submental/submandibular swellings. In the absence of an odontogenic cause of infection, fine-needle aspiration biopsy and appropriate imaging evaluation techniques with sonography, CT or MRI are mandatory for correct diagnosis and surgical treatment planning. The clinicians should be very cautious to differentiate odontogenic infections from infected dermoid/epidermoid cysts.

Ultrasound-guided thyroid nodule fine-needle biopsies--comparison of sample adequacy with different sampling techniques, different needle sizes, and with/without onsite cytological analysis.

The aim of this study was to compare the diagnostic adequacy of thyroid samples obtained by aspiration or capillary biopsy techniques, with 22 or 27 gauge needles, and with or without on-site cytological analysis (OCA). Four hundred patients with thyroid nodules underwent ultrasound (US)-guided fine-needle biopsies. Patients were divided into eight groups according to needle size (22 vs. 27 gauge), biopsy technique (aspiration vs. capillary), and whether or not OCA was performed. Sample adequacy rates were calculated for each group and subgroups and compared using chi-square tests. When all nodes were evaluated (n = 400), the adequacy rate was significantly greater with the capillary than with the aspiration technique (97% vs. 91.5%, p = 0.032) and when OCA was than was not performed (97% vs. 91.5%, p = 0.032). When only solid nodules were evaluated (n = 205) the adequacy rate was also significantly greater with the capillary than with the aspiration technique (98.9% vs. 89.7%, p = 0.008) and when OCA was than was not performed (97.9% vs. 89.6%, p = 0.014). In contrast, the adequacy rate was similar for 22 and 27 gauge needles (94.2% vs. 93.1%, p = 0.733). Optimal results were obtained with the capillary technique and OCA. The capillary technique and OCA should be the preferred approach in thyroid nodule biopsy, optimising adequacy rates and patient comfort.

A novel technique for CT-guided transthoracic biopsy of lung lesions: improved biopsy accuracy and safety.

To present the diagnostic accuracy and safety of a novel technique for CT-guided transthoracic needle aspiration biopsy (TNAB) of lung lesions suspected of malignancy. A novel technique for coaxial CT-guided TNAB is reported in this single-centre, retrospective study. A 22-gauge guide wire is used to accurately locate the lesion prior to biopsy. The technique enables penetration of lung lesions in various locations with less risk of harm to adjacent organs. Malignant and benign diagnoses were confirmed by histology or radiologic resolution. Clinical features of 181 patients included 59% men. Mean lesion size was 24 ± 14.9 mm with a mean depth of 13.6 ± 18.3 mm. Among 160 (88.4%) confirmed malignancies, 151 (94.4%) were diagnosed with TNAB. Among the 13 (7.2%) confirmed benign diagnoses, 11 (84.6%) received a specific, benign diagnosis with TNAB. The overall diagnostic accuracy of CT-TNAB was 93.6% among all confirmed diagnoses (173/181). Complications included 48 (26.5%) with pneumothorax, of which 77.8% resolved spontaneously, 20% by aspiration and 2.2% required chest drain insertion. Intrapulmonary haemorrhage was observed in 3.9% and hemoptysis in 6.0% without clinical significance. The guide wire technique provides a novel method for needle biopsy of lung lesions with improved accuracy and safety. Lung cancer screening has increased the detection of lung lesions. The guide wire technique is a novel method to biopsy lung lesions. The guide wire technique for lung biopsy demonstrates improved accuracy and safety. The chest tube insertion rate is reduced with aspiration during the procedure.

RESTATEMENT OF INDICATIONS FOR THYROID NODULES BIOPSY

The ultrasonic signs or focal formations have a defining value for indication of fine-needle aspiration biopsy of thyroid nodules. The size and dynamics of growth aren't so important. The evaluation of indications for performing a thyroid nodules biopsy was made in 6403 patients. It was proved that the size of thyroid nodules hadn't any value for the indications and technique of aspiration biopsy. It was stated that a subjectivity assessment, many errors and parameters variety took place in clinical and ultrasound examination in the case of thyroid nodules changes. Indications for biopsy based on the size of nodules hadn't any theoretical or practical value. The indications according to TIRADS system are reasonable. Their application considerably improved obtaining an informative material and increased the probability of thyroid tumor detection.

Seasonal fluctuations in the steady-state mRNA levels of suppressor of cytokine signaling-3 (SOCS-3) in the mammary gland of lactating and non-lactating ewes

Prolactin (PRL) is a hormone that plays a crucial role during pregnancy and lactation. The Janus kinase/signal transducer and activator of transcription (JAK/STAT) pathway, which is an important pathway in signal transduction from PRL to target cells, can be modulated by various factors, including suppressor of cytokine signaling-3 (SOCS-3). PRL may increase and decrease SOCS-3 expression, and its actions are mostly dependent on additional factors such as the photoperiod. There is also evidence for a relationship between suckling and SOCS-3 expression in the mammary gland. The aim of this study was to examine the influence of seasonality and physiological status on SOCS-3 expression levels in ovine mammary glands. Mammary gland fragments were obtained from 18 Polish Longwool ewes, and the fine-needle aspiration biopsy technique was used on 4 groups of animals under specific physiological and photoperiodic conditions: non-lactating ewes during long days (LD; n=6), ewes on day 30 (n=6) or day 56 of lactation (n=6) and non-lactating ewes during short days (SD; n=6). SOCS-3 mRNA levels were measured by real-time PCR. The results of this study confirmed that SOCS-3 mRNA expression in sheep is dependent on the season and stage of lactation. The highest expression of the examined factors was noted in the mammary glands of non-lactating sheep during SD, and the lowest levels were observed in ewes on day 30 of lactation. The transcript levels observed in the tissues collected from non-lactating sheep during SD and LD were higher (74% and 41%, respectively) compared with the expression observed on day 30 of lactation. On day 56 of lactation, the SOCS-3 mRNA level was similar to that observed in the udders of non-lactating sheep during LD. These results indicate that SOCS-3 could play an integrating role between hormones and other factors that are involved in the physiological functions of the mammary gland.

Diagnostic accuracy and clinical utility of biopsy in musculoskeletal lesions: A comparison of fine‐needle aspiration, core, and open biopsy techniques

Selection of biopsy technique for musculoskeletal lesions is complex. Fine-needle aspiration (FNA) is uncommonly used due to concerns regarding accuracy. We compared diagnostic accuracy of FNA, core, and open biopsy in a series of musculoskeletal lesions. Records of the University of Utah were searched for biopsy and resection specimens of musculoskeletal lesions. Results of corresponding imaging studies were obtained. Biopsy and FNA diagnoses were correlated with resection diagnoses. For each technique, diagnostic accuracy, utility, and frequency of subsequent biopsy were calculated. Open biopsy had the highest diagnostic accuracy (89%) followed by FNA (82%) and core biopsy (78%). Clinically significant errors occurred with all methods. The likelihood of an open biopsy being performed was affected by prior performance of an FNA or core biopsy and by diagnostic imaging and FNA results.

Thoracoscopic Needle Aspiration Biopsy for a Centrally Located Solitary Pulmonary Nodule

Thoracoscopic needle aspiration is a good alternative for a centrally-located solitary pulmonary nodule (SPN) suspected of being lung cancer without severe pleural adhesion. The authors report the technique of thoracoscopic needle aspiration biopsy in a SPN just in the medial aspect of the truncus anterior pulmonary artery and the right upper lobe bronchus.

Imagerie préopératoire de l’extension ganglionnaire initiale et locorégionale des cancers du sein

Although its use is underestimated, the lymph node area should be thoroughly investigated prior to treatment so that the right course of therapy can be selected, especially axillary surgical procedures, which may occasionally be performed after neoadjuvant chemotherapy. Ultrasonography plays a pivotal role in this assessment, as the high resolution waves enable metastatic tumours larger than 3 mm to be investigated, while aspiration biopsy techniques can confirm this spread in nearly 80% to 90% of cases. Evidence of pre-operative spread to the lymph nodes means that the surgeon no longer needs to perform a sentinel lymph node biopsy, which requires expensive equipment and a specialist team. When spread to the lymph nodes is proven or highly suspected, layered imaging techniques (computerised axial tomography and/or magnetic resonance imaging) will enable this spread to be quantified so that the extent of surgery and the amount of radiotherapy can be determined. Positron emission tomography is being developed and may also help in lymph node staging. No technique has a sufficiently high detection failure rate, which means that surgical investigation will never be required; however, the sentinel lymph node biopsy should be carried out only for patients considered as not needing surgery or radiotherapy after an extensive ultrasound investigation. The expected benefits and current limitations of the imaging techniques are being developed.