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This study evaluated IO-USG\u2019s dual role in preventing unnecessary axillary lymph node dissection (ALND) and identifying additional nodal metastases missed by sentinel lymph node biopsy (SLNB).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This retrospective cohort study included 314 consecutive patients with invasive breast cancer who underwent SLNB with IO-USG evaluation between January 2019 and December 2023. IO-USG was performed after SLNB to identify suspicious non-sentinel nodes. Patients were categorized into SLNB-only, targeted axillary dissection (TAD), or ALND based on combined SLNB and IO-USG findings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Of 314 patients, 113 (36%) received neoadjuvant chemotherapy and 201 (64%) underwent upfront surgery. Final surgical management comprised SLNB-only in 244 (77.7%), TAD in 46 (14.7%), and ALND in 24 (7.6%) patients. Among 89 SLNB-positive patients, 68 (76.4%) avoided ALND through IO-USG guidance. IO-USG identified additional axillary metastases in 4 of 225 SLNB-negative patients (1.8%). Molecular subtype analysis revealed no IO-USG positivity in triple-negative cases (0\/25), while HR+\/HER2- tumors comprised 82.6% of IO-USG-positive cases. At a median follow-up of 33.2 months, no axillary recurrences occurred.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>IO-USG may support personalized axillary management, helping avoid ALND in 76.4% of node-positive patients while identifying additional axillary metastases in 1.8% of SLNB-negative cases. As a complementary technique to standard SLNB, it appears to provide selective utility based on tumor biology.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration<\/jats:title>\n                    <jats:p>Not applicable.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12957-026-04223-8","type":"journal-article","created":{"date-parts":[[2026,1,28]],"date-time":"2026-01-28T09:48:45Z","timestamp":1769593725000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Dual role of intraoperative ultrasound in axillary surgery: enhanced detection and surgical de-escalation in breast cancer"],"prefix":"10.1186","volume":"24","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2341-3572","authenticated-orcid":false,"given":"Adnan","family":"G\u00fcndo\u011fdu","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1108-8752","authenticated-orcid":false,"given":"Merve","family":"Akta\u015f","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-8046-8490","authenticated-orcid":false,"given":"Sangar","family":"Abdullah","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0568-706X","authenticated-orcid":false,"given":"Ayhan","family":"Alpar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8700-3447","authenticated-orcid":false,"given":"K\u00fcbra","family":"Ertekin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6645-2267","authenticated-orcid":false,"given":"Feyza","family":"Ba\u015far","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8861-5223","authenticated-orcid":false,"given":"Damiano","family":"Gentile","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8418-0234","authenticated-orcid":false,"given":"Osman Cem","family":"Y\u0131lmaz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,1,28]]},"reference":[{"key":"4223_CR1","doi-asserted-by":"crossref","unstructured":"Magnoni F, Galimberti V, Corso G, Intra M, Sacchini V, Veronesi P, editors. 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