Purpose of Review <p>This review summarizes the recently reported SOUND and related trials results evaluating the implications of axillary imaging on the management of breast cancer patients. </p> Recent Findings <p>Nodal staging in breast cancer management is important for prognosis and treatment planning since lymph node metastasis indicate a higher risk. For the most part, sentinel lymph node biopsy in the axilla has replaced standard lymph node dissection for early-stage breast cancer staging, as shown by the ACSOG Z0011 and CALGB 9343 trials, which showed no significant difference in disease-free and overall survival. Axillary ultrasound is now routine, valued for its accuracy and biopsy guidance, despite varied sensitivity and specificity. When ultrasound of the axilla is combined with needle biopsy, the staging accuracy is enhanced. Recent trials, including NAUTILUS, BOOG 2013-08, SOUND, and INSEMA, investigate excluding axillary surgery in patients who are clinically node-negative and showed no decrement in disease-free survival. MRI, though evolving rapidly, presents mixed results in axillary lymph node evaluation. While promising in certain contexts, MRI shows no significant advantage over ultrasound for routine preoperative evaluation of the axilla in breast cancer patients.</p> Summary <p>The SOUND and INSEMA trials showed that avoiding axillary surgery in appropriate breast cancer patients can be safe without impacting disease-free survival. This shift is consistent with the Choosing Wisely Guidelines, suggesting that advanced imaging techniques and standardized criteria can reduce the need for invasive procedures while at the same achieving enhanced patient results.</p>