From the Guidelines
The initial approach to managing bilateral axillary lumps should involve a thorough clinical assessment followed by bilateral axillary ultrasound as the initial imaging modality, as recommended by the American College of Radiology 1. The clinical assessment should include a detailed history focusing on symptoms like pain, duration, associated fever, weight loss, or night sweats, as well as a physical examination to assess the size, consistency, tenderness, mobility, and any overlying skin changes of the lumps.
- Key points to consider in the history include:
- Symptoms and their duration
- Associated systemic symptoms such as fever or weight loss
- History of breast cancer or other malignancies
- The physical examination should assess:
- The characteristics of the axillary lumps
- The breasts for any abnormalities
- Other lymph node regions for any enlargement Initial investigations typically include complete blood count, inflammatory markers, and the aforementioned bilateral axillary ultrasound.
- Ultrasound is preferred because it can help differentiate benign from malignant etiologies when interpretation is made in conjunction with the clinical history and laboratory results 1. Fine needle aspiration cytology (FNAC) or core needle biopsy of the lumps may be necessary for definitive diagnosis, especially if the ultrasound findings are suspicious or if there is a high clinical suspicion of malignancy 1. While waiting for results, symptomatic treatment with acetaminophen (500-1000mg every 6 hours) or ibuprofen (400-600mg every 6-8 hours) can be offered for pain relief. Bilateral axillary lumps have various potential causes including infections (like cat scratch disease or HIV), autoimmune conditions (such as rheumatoid arthritis), malignancies (lymphoma or metastatic breast cancer), and benign conditions (like lipomas), making accurate diagnosis crucial before initiating specific treatment 1.
From the Research
Initial Approach to Managing Bilateral Axillary Lumps
The initial approach to managing bilateral axillary lumps involves a thorough history and physical examination to identify the cause of lymphadenopathy 2.
Classification of Lymphadenopathy
Lymphadenopathy can be classified as localized or generalized, with generalized lymphadenopathy often indicating underlying systemic disease 2.
Evaluation of Bilateral Axillary Lumps
Patients with bilateral axillary lumps should be evaluated for etiologies typically associated with the region involved according to lymphatic drainage patterns 2.
- The workup may include:
- Blood tests
- Imaging (e.g., ultrasound, MRI)
- Biopsy (e.g., fine-needle aspiration, core needle biopsy, or open excisional biopsy)
- Risk factors for malignancy should be considered, including age older than 40 years, male sex, white race, supraclavicular location of the nodes, and presence of systemic symptoms such as fever, night sweats, and unexplained weight loss 2.
Diagnostic Imaging
Contrast-enhanced ultrasonography may be useful in distinguishing between benign and malignant lymphadenopathy, with higher diagnostic accuracy compared to conventional techniques 3.
- Ultrasound imaging can be used to evaluate superficial soft-tissue palpable lesions, including grayscale, color- and power-Doppler, spectral-Doppler, and possibly elastography facilities 4.
Biopsy and Treatment
Biopsy options include fine-needle aspiration, core needle biopsy, or open excisional biopsy 2, 5.
- The decision to perform a biopsy should be based on clinical presentation, location of the lymphadenopathy, and underlying risk factors 2.
- Treatment options may include antibiotics for acute unilateral cervical lymphadenitis, especially in children with systemic symptoms, while corticosteroids have limited usefulness in the management of unexplained lymphadenopathy 2.