From the Guidelines
The best next imaging test for a 68-year-old female with incidentally discovered axillary reactive lymph nodes on shoulder MRI, no known cancer, and a negative mammogram from a year ago would be a current bilateral diagnostic mammogram with possible ultrasound, as recommended by the National Comprehensive Cancer Network (NCCN) guidelines 1. This approach allows for comprehensive evaluation of both breasts and axillary regions to identify any potential breast malignancy that could explain the lymphadenopathy. Given the patient's age and the finding of axillary lymph node enlargement, breast cancer must be ruled out as a primary concern, even with a previously negative mammogram.
If the mammogram is negative, targeted ultrasound of the axillary region would help characterize the lymph nodes further, assessing features like cortical thickening, loss of fatty hilum, or abnormal vascularity that might suggest malignancy, as suggested by the American College of Radiology (ACR) appropriateness criteria for imaging of the axilla 1. Depending on these findings, additional steps might include axillary lymph node biopsy if suspicious features are present, or consideration of other causes of reactive lymphadenopathy such as infection or inflammatory conditions.
The timing is important here - a mammogram from a year ago is not recent enough to exclude a developing breast malignancy that might now be manifesting as axillary lymphadenopathy. According to the NCCN guidelines for breast cancer screening and diagnosis, version 3.2018, diagnostic follow-up for a patient with a negative mammogram and ultrasound findings suggestive of malignancy would include consideration of breast MRI or consultation with a breast specialist 1.
Key considerations in this case include:
- The patient's age and the potential for breast cancer
- The finding of axillary lymph node enlargement on shoulder MRI
- The need for comprehensive evaluation of both breasts and axillary regions
- The importance of ruling out breast cancer as a primary concern
- The potential for other causes of reactive lymphadenopathy, such as infection or inflammatory conditions.
Overall, a current bilateral diagnostic mammogram with possible ultrasound is the best next step in evaluating this patient's axillary reactive lymph nodes, given the potential for breast cancer and the need for comprehensive evaluation of both breasts and axillary regions.
From the Research
Next Steps for Axillary Reactive Lymph Nodes
Given the presence of axillary reactive lymph nodes in a 68-year-old female with no known cancer and a negative mammogram a year ago, the next steps should focus on determining the cause of the lymph node enlargement.
Imaging Tests:
- Breast MRI: This is a sensitive tool for detecting occult breast cancer, especially in cases where mammography and ultrasound are negative 2. It can identify breast carcinomas that were not visible on initial mammography and sonography.
- Ultrasound of the axilla: This can help in characterizing the lymph nodes and guiding biopsies if necessary.
Lab Tests and Biopsies:
- Fine needle aspiration or core needle biopsy of the lymph nodes: These methods are sufficient for clarifying the nature of the lymph node enlargement in most cases 3.
- Blood tests: May be ordered to check for infectious diseases or inflammatory markers, depending on the clinical suspicion.
Considerations:
- The presence of axillary reactive lymph nodes does not necessarily indicate breast cancer; there are various benign and malignant causes 4.
- Dermatopathic lymphadenopathy, a benign condition associated with skin conditions, should be considered in the differential diagnosis 5.
- Routine axillary scanning may not be recommended for patients with negative mammography and breast ultrasound, especially without a history of cancer 6.
Decision Making
The decision to proceed with additional imaging or lab tests should be based on a thorough clinical evaluation, including a detailed medical history and physical examination. The patient's risk factors for breast cancer, history of skin conditions, and presence of any systemic symptoms should guide the choice of next steps.