What is the treatment for axillary lymphadenopathy?

Treatment of Axillary Lymphadenopathy

The treatment of axillary lymphadenopathy should be guided by the underlying cause, with ultrasound-guided incision and drainage being the first-line treatment for axillary abscesses, while sentinel lymph node biopsy (SLNB) is the preferred approach for axillary staging in breast cancer patients with clinically negative nodes. 1, 2

Diagnostic Evaluation

Initial Imaging

• Ultrasound is the recommended initial imaging modality for evaluation of axillary lymphadenopathy (highest appropriateness rating 9/9) 1
• Look for specific features on ultrasound:
  • Hypoechoic or anechoic fluid collection (if abscess)
  • Internal debris or septations
  • Surrounding hyperemia on Doppler imaging
  • Abnormal nodal morphology (cortical thickness >0.3 cm, absence of fatty hilum) 2, 1

Additional Diagnostic Testing

• For patients ≥30 years: Diagnostic mammography in conjunction with axillary ultrasound 1
• Consider ultrasound-guided core needle biopsy (preferred over FNA with sensitivity of 88% vs 74%) 2, 1
• Complete blood count with differential as baseline blood test 1
• Additional tests based on clinical suspicion:
  • CRP and ESR if infection suspected
  • ANA, Anti-Ro/SSA, and Anti-La/SSB if autoimmune disease suspected 1

Treatment Algorithm Based on Etiology

1. Infectious/Inflammatory Causes

• For axillary abscess:
  • Ultrasound-guided incision and drainage (success rate 80% vs 26% for needle aspiration alone) 1
  • Culture of purulent material to guide antibiotic therapy
  • Consider hidradenitis suppurativa in recurrent cases 1

2. Breast Cancer-Related Lymphadenopathy

• For clinically negative axilla in early breast cancer:

  • Sentinel lymph node biopsy (SLNB) is the preferred method for axillary staging 2
  • SLNB requires an experienced sentinel node team 2
  • No further axillary treatment needed if SLN has micrometastases (0.2-2.0 mm) 2

• For limited positive sentinel nodes:

  • No further axillary surgery needed if:
    • 1-2 SLNs contain metastases
    • Patient is undergoing breast-conserving surgery with tangential breast radiotherapy
    • Patient will receive adjuvant systemic therapy 2
  • Axillary radiation is a valid alternative to surgery for patients with positive SLNB 2

• For extensive nodal involvement:

  • Level I/II axillary lymph node dissection (ALND) 2
  • Consider axillary radiation as an alternative to ALND 2

3. COVID-19 Vaccine-Related Lymphadenopathy

• Conservative management with follow-up imaging 3
• Interpret in context of vaccination timing and patient's risk of metastatic disease
• Do not postpone imaging for urgent indications or treatment planning in newly diagnosed breast cancer 3

Special Considerations

• Micrometastases and isolated tumor cells are prognostically equivalent to N0 disease 2
• Routine immunohistochemistry (IHC) for evaluation of sentinel nodes is not recommended 2
• Non-healing axillary abscesses despite appropriate drainage warrant investigation for potential malignancy 1
• For patients with active breast cancer, evaluate with standard imaging protocols regardless of COVID-19 vaccination status 3

Common Pitfalls to Avoid

• Failure to perform breast imaging in patients with axillary lymphadenopathy 1
• Over-reliance on mammography alone (high false-negative rate for axillary evaluation) 1
• Missing non-breast etiologies such as systemic diseases, lymphoma, and other malignancies 1
• Failing to consider rare causes of axillary masses such as accessory breast carcinoma, sweat gland carcinoma, or Rosai-Dorfman disease 4, 5

By following this algorithmic approach to axillary lymphadenopathy treatment, clinicians can ensure appropriate management while minimizing unnecessary procedures and optimizing patient outcomes.