AbstractObjectiveTo develop a nomogram and validate its use for the intraoperative evaluation of nodal metastasis using shear-wave elastography (SWE) elasticity values and nodal sizeMethodsWe constructed a nomogram to predict metastasis using ex vivo SWE values and ultrasound features of 228 axillary LNs from fifty-five patients. We validated its use in an independent cohort comprising 80 patients. In the validation cohort, a total of 217 sentinel LNs were included.ResultsWe developed the nomogram using the nodal size and elasticity values of the development cohort to predict LN metastasis; the area under the curve (AUC) was 0.856 (95% confidence interval (CI), 0.783–0.929). In the validation cohort, 15 (7%) LNs were metastatic, and 202 (93%) were non-metastatic. The mean stiffness (23.54 and 10.41 kPa,p= 0.005) and elasticity ratio (3.24 and 1.49,p= 0.028) were significantly higher in the metastatic LNs than those in the non-metastatic LNs. However, the mean size of the metastatic LNs was not significantly larger than that of the non-metastatic LNs (8.70 mm vs 7.20 mm, respectively;p= 0.123). The AUC was 0.791 (95% CI, 0.668–0.915) in the validation cohort, and the calibration plots of the nomogram showed good agreement.ConclusionsWe developed a well-validated nomogram to predict LN metastasis. This nomogram, mainly based on ex vivo SWE values, can help evaluate nodal metastasis during surgery.Key Points• A nomogram was developed based on axillary LN size and ex vivo SWE values such as mean stiffness and elasticity ratio to easily predict axillary LN metastasis during breast cancer surgery.• The constructed nomogram presented high predictive performance of sentinel LN metastasis with an independent cohort.• This nomogram can reduce unnecessary intraoperative frozen section which increases the surgical time and costs in breast cancer patients.