What are the treatment options for a painful tender lump in the armpit?

Treatment Options for a Painful Tender Lump in the Armpit

The treatment of a painful tender lump in the armpit requires diagnostic evaluation first, followed by targeted treatment based on the underlying cause, as axillary masses are more often related to benign disorders than malignancy. 1

Diagnostic Evaluation

Initial Assessment

1. Complete clinical evaluation to assess for:
   • Other sites of adenopathy
   • Potential non-breast etiologies of adenopathy 1
   • Characteristics of the lump (size, mobility, tenderness)

Imaging Recommendations

• Age-appropriate diagnostic imaging:
  • Age ≥30 years: Ultrasound with mammogram 1
  • Age <30 years: Ultrasound only 1

Biopsy Recommendations

• Core needle biopsy (preferred) for:
  • Suspicious findings on imaging (BI-RADS 4-5) 1
  • Palpable axillary mass that persists despite negative/benign imaging 1
• Surgical excision may be considered for:
  • Suspicion of lymphoma requiring special pathologic evaluation 1
  • Indeterminate or discordant biopsy results 1

Treatment Options Based on Diagnosis

1. Benign Reactive Lymphadenopathy

• Observation with follow-up imaging every 6-12 months for 1-2 years 1
• Symptomatic management:
  • Over-the-counter pain medications
  • Warm compresses
  • Rest

2. Infectious Causes

• Antibiotics for bacterial infections 1
  • Note: Antibiotics should not delay diagnostic evaluation
• Drainage may be considered for abscess formation
• Follow-up to ensure resolution

3. Cystic Lesions

• Simple cyst:
  • Drainage may be considered for symptom relief 1
  • Clinical follow-up
• Complex cyst:
  • Core needle biopsy due to higher malignancy risk (14-23%) 2
  • Imaging follow-up every 6 months for 1-2 years if biopsy is benign 1, 2

4. Malignancy

• Breast cancer origin: Refer to NCCN Guidelines for Breast Cancer 1
  • Further evaluation with breast MRI if no breast abnormality is evident on ultrasound/mammogram
• Non-breast malignancy: Refer to appropriate guidelines for management 1

5. Inflammatory Conditions

• Non-steroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation 3
• Corticosteroids may be considered for severe inflammation
• Follow-up to monitor response to treatment

Special Considerations

Lymphedema Prevention

• All breast cancer survivors who undergo breast surgery and/or radiation are at risk for lymphedema 1
• Weight loss should be recommended for overweight or obese patients 1
• Referral to a physical therapist, occupational therapist, or lymphedema specialist for patients with clinical symptoms or swelling suggestive of lymphedema 1

Pitfalls to Avoid

1. Delaying diagnostic evaluation with antibiotics when malignancy is suspected 1
2. Assuming all axillary masses are benign - up to 7% may be malignant even in women with no personal history of breast cancer 1
3. Inadequate follow-up of benign-appearing lesions - some may require monitoring for 1-2 years to ensure stability 1
4. Overlooking rare conditions such as idiopathic granulomatous mastitis, which can mimic breast cancer 4

Key Points

• Localized axillary masses are more often benign than malignant 1
• Diagnostic evaluation should precede treatment decisions
• Core needle biopsy is preferred over fine-needle aspiration for tissue diagnosis 2
• Follow-up is essential for benign lesions to ensure stability over time