What could be causing pain and burning under the breast radiating from front to back, swollen left axillary (axilla) lymph nodes for 6 months, and hypertension (elevated blood pressure) in a patient?

Urgent Diagnostic Workup Required for Suspected Breast Malignancy

This patient requires immediate age-appropriate diagnostic imaging (diagnostic mammogram with ultrasound if ≥30 years, ultrasound alone if <30 years) followed by core needle biopsy of the axillary lymph nodes to exclude malignancy. 1

Why This Presentation is High-Risk

This clinical picture is clinically significant and demands urgent evaluation because it combines three concerning features:

• Focal, unilateral breast pain that radiates in a dermatomal pattern (front to back) 1
• Persistent axillary lymphadenopathy for 6 months 1
• The combination substantially increases malignancy risk beyond the 2.3-4.6% cancer detection rate for focal breast pain alone 1

Critical distinction: This is NOT benign cyclical mastalgia, which is bilateral or diffuse, temporally related to menstrual cycles, and not associated with lymphadenopathy 2, 3. Focal, persistent, unilateral pain with axillary adenopathy requires immediate workup 1.

Differential Diagnosis (In Order of Priority)

1. Breast Cancer with Axillary Metastases (Most Urgent)

• Invasive lobular carcinoma and anaplastic carcinoma can present with pain as a primary symptom 1
• Occult breast cancer occurs in patients with isolated axillary masses, with 9 of 17 cancer cases having occult breast primary 1
• Malignant lymph nodes are typically extremely enlarged, homogeneous, separated, and lack hilar fatty degeneration 4

2. Inflammatory/Infectious Causes

• Bacterial infection can cause axillary lymphadenopathy 4
• Granulomatous mastitis or sarcoidosis (though typically presents with mass rather than just pain) 5

3. Dermatopathic Lymphadenopathy

• Associated with cutaneous conditions, can cause asymptomatic axillary enlargement 6
• Benign process but requires exclusion of malignancy first 6

4. Lymphedema-Related Changes

• Can cause pain ranging from mild discomfort to overt pain 2
• However, 6-month duration of lymphadenopathy without prior breast surgery/radiation makes this less likely 2

Immediate Diagnostic Algorithm

Step 1: Imaging (Within Days)

• If patient ≥30 years: Diagnostic mammogram with ultrasound 1
• If patient <30 years: Ultrasound alone 1
• Look for suspicious findings (BI-RADS 4 or 5 lesions) 1

Step 2: Biopsy Decision

• If BI-RADS 4 or 5: Immediate core needle biopsy is mandatory 1
• If BI-RADS 1 or 2 BUT high clinical suspicion: Do NOT rely on negative imaging alone—proceed to biopsy of axillary lymph nodes 1
• All lymph nodes >1 cm without fatty infiltration should be biopsied (excluding obvious mastitis/dermatitis) 4

Step 3: Pathology Confirmation

• Core needle biopsy is essential because mammography cannot differentiate between malignant and benign lymph node enlargement 4
• Only pathology can definitively determine the cause of lymphadenopathy 4

Address the Hypertension Simultaneously

The blood pressure of 149/104 requires management but should not delay cancer workup:

• This represents Stage 2 hypertension
• Initiate antihypertensive therapy per standard guidelines
• However, do not allow BP management to delay the urgent breast/axillary evaluation

Common Pitfalls to Avoid

• Never dismiss focal breast pain with lymphadenopathy as benign mastalgia 2, 1
• Never rely on negative imaging alone when clinical suspicion is high 1
• Never delay biopsy for "watchful waiting" given the 6-month duration already 1
• Never assume lymphadenopathy is reactive without tissue diagnosis 4

Symptomatic Management (Only After Malignancy Excluded)

If malignancy is definitively excluded:

• Over-the-counter NSAIDs (ibuprofen) for pain control 1, 3
• Well-fitted supportive bra 3
• Consider physical therapy if musculoskeletal component identified 3

The priority is immediate diagnostic workup—symptomatic treatment is secondary until cancer is excluded. 1