What is the workup for axillary lymphadenopathy?

From the Guidelines

The workup for axillary lymphadenopathy should begin with a thorough history and physical examination, followed by imaging studies, including ultrasound of the axilla and mammography in women over 30, as recommended by the most recent guidelines 1. The initial evaluation should focus on identifying potential causes of the lymphadenopathy, including recent infections, malignancies, autoimmune conditions, medications, and exposures. A detailed medical history and physical examination are crucial in assessing the size, consistency, tenderness, mobility, and distribution of lymph nodes, as well as examining the ipsilateral breast, chest wall, and upper extremity.

Key elements of the workup include:

• Laboratory tests, such as complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, and C-reactive protein
• Specific serologic tests based on clinical suspicion, such as HIV, EBV, CMV, toxoplasmosis, or tuberculosis testing
• Imaging studies, starting with ultrasound of the axilla, which can characterize lymph node features and guide biopsy if needed
• Mammography in women over 30 to evaluate for breast malignancy, as recommended by the NCCN guidelines 1
• CT or PET scans may be indicated if systemic disease is suspected

A core needle biopsy is recommended for palpable axillary mass that is suspicious or highly suggestive on imaging 1. Fine needle aspiration or excisional biopsy of the lymph node may be necessary for definitive diagnosis, particularly when malignancy is suspected or when lymphadenopathy persists beyond 4-6 weeks without an identified cause. This systematic approach helps differentiate between benign reactive processes and more serious conditions requiring specific treatment.

From the Research

Workup for Axillary Lymphadenopathy

The workup for axillary lymphadenopathy involves a combination of clinical evaluation, imaging, and biopsy.

• The history and physical examination alone usually identify the cause of lymphadenopathy 2.
• When the cause is unknown, lymphadenopathy should be classified as localized or generalized, and patients with localized lymphadenopathy should be evaluated for etiologies typically associated with the region involved according to lymphatic drainage patterns 2.
• The workup may include:
  • Blood tests
  • Imaging, such as ultrasonography, mammography, computed tomography, and magnetic resonance imaging 3, 4
  • Biopsy, including fine-needle aspiration, core needle biopsy, or open excisional biopsy 2, 5
• Risk factors for malignancy, such as age older than 40 years, male sex, white race, supraclavicular location of the nodes, and presence of systemic symptoms, should be taken into account when determining the workup 2.
• In patients with a history of malignancy, the most common diagnoses were metastasis from the known tumor and benign change 5.
• In patients with a negative oncologic history and female patients without a history of breast cancer, the diagnosis was generally either lymphoma or benign change 5.

Imaging Findings

Imaging findings can help in the accurate diagnosis of axillary lesions, including axillary masses and axillary lymphadenopathies 3.

• Ultrasonography, mammography, computed tomography, and magnetic resonance imaging can be used to evaluate axillary lymphadenopathy 3, 4.
• The American Joint Committee on Cancer nodal staging guidelines should be taken into account when evaluating axillary lymph node staging and sentinel lymph node biopsy in patients with breast cancer 4.

Biopsy and Diagnosis

Biopsy is an important part of the workup for axillary lymphadenopathy, and can help establish a diagnosis.

• The spectrum of diagnoses in non-sentinel axillary lymph nodes includes breast carcinoma, lymphoma, melanoma, other carcinoma, sarcoma, and benign changes 5.
• Anaplastic large cell lymphoma is a rare but important diagnosis to consider, and may be mistaken for metastatic carcinoma 5.