How to manage axillary lymph node tenderness?

Management of Axillary Lymph Node Tenderness

The management of axillary lymph node tenderness depends critically on the underlying cause: if related to breast cancer staging or treatment, proceed with sentinel lymph node biopsy for clinically negative nodes or ultrasound-guided biopsy for suspicious nodes; if tenderness develops post-operatively, initiate early referral to specialized lymphedema therapy and treat any signs of infection promptly with antibiotics. 1, 2, 3

Initial Diagnostic Evaluation

For unexplained axillary lymph node tenderness, particularly in patients without known breast cancer:

• Perform axillary ultrasound to characterize lymph node morphology, specifically assessing cortical thickness, uniformity, size, shape (round vs. oval), and vascularity patterns 3, 4
• If ultrasound reveals suspicious features (thickened cortex, loss of fatty hilum, abnormal vascularity), obtain tissue diagnosis via ultrasound-guided fine needle aspiration (FNA) or core biopsy 3, 4
• Consider PET/CT if there is concern for lymphoma or other non-breast malignancy 3
• If initial biopsy is benign but clinical suspicion remains, perform ultrasound monitoring every 6 months for 1-2 years and re-biopsy if lymph node characteristics change 3

Management in Breast Cancer Context

For patients with known or suspected breast cancer:

• Sentinel lymph node biopsy (SLNB) is the standard staging approach for clinically negative axillary lymph nodes, as it delivers significantly less morbidity (shoulder stiffness, pain, arm swelling) compared to complete axillary lymph node dissection (ALND) 1
• SLNB achieves high identification rates (97%) with acceptably low false-negative rates (5-10%) and favorable axillary recurrence rates (<1% isolated recurrence) 1
• For clinically or radiographically suspicious nodes, obtain pathologic confirmation using ultrasound-guided FNA or core biopsy before proceeding to ALND 1

Key surgical principles:

• Micrometastases (0.2-2.0 mm) or isolated tumor cells in treatment-naïve sentinel nodes are prognostically equivalent to N0 disease and do not require further axillary treatment unless neoadjuvant therapy was given 1
• Routine immunohistochemistry or PCR for sentinel node evaluation is not recommended in patients unexposed to neoadjuvant chemotherapy 1

Post-Operative Complications and Their Management

Lymphedema (occurs in 3-5% after surgery alone, up to 40% when combined with radiotherapy):

• Early detection and intervention are critical as lymphedema may be reversible or more effectively managed with early physiotherapy 2, 5
• Refer patients with clinical symptoms or swelling suggestive of lymphedema to a physical therapist, occupational therapist, or certified lymphedema specialist 2
• Initiate complete decongestive therapy consisting of manual lymphatic drainage, compression therapy, exercise, skin care, and education for self-management 2
• This physiotherapy and compression therapy must be regularly repeated to maximize treatment effect 2

Infection prevention and management:

• Advise patients who have undergone axillary clearance to avoid cannulation, venesection, and blood pressure monitoring in the ipsilateral arm 1
• Start antibiotic treatment promptly for potentially infected wounds on the ipsilateral arm 1, 2
• Prompt treatment of infections is essential as recurrent infections increase the risk of lymphedema progression 2, 5

Axillary web syndrome (AWS):

• AWS refers to fibrotic bands or "cords" developing in the axilla after axillary lymph node dissection 6
• While self-limited in most cases, it causes significant morbidity 6
• Physiotherapy appears beneficial for management 6

Common Symptoms and Their Prevalence

Long-term complications 2-5 years post-axillary dissection include:

• Numbness (35% of patients), more common in younger patients and those with smoking history 7
• Pain (30% of patients), associated with younger age 7
• Arm swelling (15% of patients), associated with younger age and greater body surface area 7
• Limitation of arm movement (8% of patients), positively associated with adjuvant tamoxifen therapy 7
• Episodes of infection or inflammation (8% of patients), more frequent with radiation therapy 7

Critical Pitfalls to Avoid

• Do not delay treatment: Delaying intervention for lymphedema leads to progression and increased risk of complications 2
• Do not restrict all physical activity: Contrary to historical advice, supervised progressive resistance training has been shown to be safe and may be beneficial 2
• Do not use diuretics: Diuretics are generally ineffective for lymphedema management 2
• Do not perform routine immunohistochemistry: This should not be used in clinical decision-making for sentinel nodes in patients not receiving neoadjuvant therapy 1

Advanced Treatment Considerations

• If conservative treatment for lymphedema is insufficient, consider referral for microsurgical procedures, which have shown effectiveness 2
• For patients with obesity (BMI >30 kg/m²), refer to a registered dietitian for weight management counseling, as obesity is a significant risk factor for lymphedema development and progression 2, 5
• Once lymphedema is established, treatment by trained therapists using compression bandaging, manual lymphatic drainage, and graduated compression garments is essential 1