What could be causing my left-sided chest pain that worsens with bending, shortness of breath, chest and neck pain, early satiety, and swollen lymph nodes under my axilla?

Urgent Evaluation for Malignancy Required

Your constellation of symptoms—left-sided chest pain worsening with bending, shortness of breath, early satiety, and multiple enlarged lymph nodes in the axilla and popliteal regions—demands immediate evaluation for underlying malignancy, most likely lymphoma or metastatic cancer with mediastinal involvement. 1, 2

Critical Red Flags Present

Your symptom pattern contains multiple concerning features that distinguish this from benign causes:

• Hard, swollen lymph nodes in multiple regions (axillary and popliteal) strongly suggest systemic disease rather than localized infection 1
• Early satiety indicates possible abdominal mass effect or mediastinal compression affecting the esophagus 1
• Positional chest pain (worse with bending) combined with shortness of breath suggests mediastinal mass with possible vascular or airway compression 1, 2
• Neck pain accompanying chest symptoms raises concern for superior vena cava syndrome or extensive mediastinal adenopathy 1, 2

Most Likely Diagnoses to Rule Out

Lymphoma (Primary Concern)

Hodgkin's or non-Hodgkin's lymphoma is the leading consideration given your age-appropriate risk profile and presentation with multiple lymph node regions involved plus mediastinal symptoms. 1, 3

• Large mediastinal masses with cervical/axillary lymphadenopathy are classic for Hodgkin's lymphoma 3
• The combination of chest pain, shortness of breath, and early satiety suggests bulky mediastinal disease compressing adjacent structures 1
• Multiple lymph node regions involved (axillary and popliteal) indicates at least stage II disease 3

Lung Cancer with Metastatic Spread

Lung cancer must be excluded, particularly given the mediastinal symptoms and multiple lymph node involvement. 1, 2

• Chest pain, dyspnea, and early satiety can result from primary lung tumor with mediastinal extension 1
• Axillary lymphadenopathy occurs with lung cancer metastases 1
• Superior vena cava syndrome from lung cancer causes facial/neck swelling and can manifest as systemic venous congestion 2

Metastatic Breast Cancer

Given axillary lymphadenopathy, breast cancer with thoracic spread requires consideration, though less likely without breast mass history. 4

Immediate Diagnostic Workup Required

You need urgent imaging and tissue diagnosis within 48-72 hours:

1. Contrast-enhanced chest CT to evaluate mediastinal mass, lymphadenopathy extent, and vascular compression 1, 2

   • Will identify mediastinal widening, hilar masses, and assess for SVC syndrome 1, 2
   • Can characterize lymph node size, texture, and distribution 1

2. Excisional lymph node biopsy of the most accessible enlarged node (likely axillary) 1, 3

   • Fresh tissue sent in saline for flow cytometry and immunophenotyping 1, 3
   • Essential for distinguishing lymphoma subtypes from metastatic carcinoma 3
   • Core needle biopsy is insufficient—excisional biopsy is mandatory 3

3. Complete staging workup once diagnosis established:

   • PET/CT from skull base to mid-thigh if lymphoma confirmed 3
   • Bone marrow biopsy may be needed depending on PET findings 3
   • Cardiac and pulmonary function testing before chemotherapy 3

Why Benign Causes Are Unlikely

The guideline evidence clearly distinguishes your presentation from benign conditions: 1

• Pain that varies with position and breathing typically indicates less severe musculoskeletal or pleuritic causes 1
• However, your multiple hard lymph nodes override this reassurance 1
• Sarcoidosis causes symmetric mediastinal adenopathy but rarely presents with hard peripheral nodes 5
• Tuberculosis causes mediastinal lymphadenopathy but typically in different demographic contexts 5, 6

Critical Time-Sensitive Actions

Do not delay seeking emergency evaluation:

• Present to emergency department or urgent care today for initial assessment 1
• Request immediate chest imaging and referral to oncology or hematology 1
• If you develop facial swelling, severe dyspnea, or chest pain at rest, call 911 immediately—these indicate superior vena cava syndrome requiring emergent intervention 2

The presence of hard lymph nodes in multiple sites with mediastinal symptoms represents advanced disease requiring immediate diagnosis and treatment. 1, 2, 3 Delays in diagnosis worsen outcomes for both lymphoma and lung cancer, where early intervention significantly impacts survival. 1, 3