Abstract: Objective: To compare the diagnostic efficacy of two-dimensional (2D) ultrasonography and to modify realtime tissue elastography (RTE) scoring method for suspected axillary lymph node metastasis of breast cancer patients. Methods: Elastosonography and 2D ultrasonography were performed on 97 suspected axillary lymph nodes of 92 confirmed breast cancer patients. Scores of sizes, long-to short-axis ratio (L/S), cortical thickness, and lymph node hilum (H/L) were summed as the score of each lymph node at 2D ultrasonography, while a five-point scale was adopted for RTE scoring. The RTE evaluation method is determined based on the percentage and distribution of the hypoechoic regions in the lymph nodes, and is divided into the presence or absence of lymphatic portal structure for 5-point evaluation. The combined score of each lymph node was obtained by summing the score at 2D ultrasonography and that at RTE scoring. The strain ratio (SR) was calculated by comparison of the average strain of the lymph node with that of the surrounding tissue at the same depth. Diagnostic efficacies of 2D ultrasonography, RTE, the combined method and SR were compared through the receiver operating characteristic curve (ROC). Results: There were 97 axillary lymph nodes, including 45 non-metastatic (46.4%) and 52 metastatic nodes (53.6%). The sensitivity, specificity and accuracy of two-dimensional ultrasound were 92%, 73% and 83% respectively; RTE were 78%, 93% and 86% respectively; combined diagnostic assessments were 88%, 96% and 92% respectively; and the strain ratios are 87%, 76% and 81%, respectively. Two-dimensional ultrasound was more sensitive than RTE (92% vs 78%, P = 0.039), while the specificity of RTE was superior to two-dimensional ultrasound (93% vs 73%, P = 0.012). The combined diagnosis had the highest area under the curve (AUC = 0.963), so the diagnostic efficiency was the highest. Conclusion: RTE is highly specific for evaluating the presence or absence of axillary lymph node metastasis. Combined application of 2D ultrasonography with elastosonography can improve the diagnostic efficacy for metastatic axillary lymph node in breast cancer.