What are the possible causes and recommended evaluation for persistent left‑sided deep and superficial pain, six‑month left‑sided lymphadenopathy, left subcostal pain, and left breast tenderness?

Evaluation of Left-Sided Pain with Persistent Lymphadenopathy and Breast Tenderness

You need urgent clinical evaluation with age-appropriate breast imaging and assessment of your lymph nodes to exclude malignancy, given the 6-month duration of unilateral lymphadenopathy combined with focal symptoms.

Immediate Diagnostic Workup Required

Clinical Breast Examination and History

• Perform thorough clinical breast exam looking specifically for palpable masses, asymmetric thickening, nipple discharge, or skin changes, as these findings change management 1
• Document whether breast pain is focal (precisely localizable) or diffuse, and whether it relates to your menstrual cycle 1
• Focal, noncyclical breast pain requires additional evaluation to exclude underlying malignancy, even without other symptoms 1

Age-Appropriate Breast Imaging

• If you are ≥30 years old: Obtain diagnostic mammogram with or without ultrasound immediately 1, 2
• If you are <30 years old: Ultrasound is the primary imaging modality 1, 2
• The risk of breast cancer presenting with pain alone is 1.2-6.7%, but focal pain warrants imaging regardless 1

Lymph Node Evaluation

• Complete clinical evaluation to assess for other sites of adenopathy and potential non-breast causes of lymphadenopathy 1
• Six-month duration of persistent lymphadenopathy is concerning and requires tissue diagnosis if imaging shows suspicious features 1
• Obtain ultrasound of the enlarged lymph nodes with ultrasound-guided fine needle aspiration (FNA) or core needle biopsy if nodes remain palpable 1
• If FNA is inconclusive after repeated attempts, surgical excisional biopsy should be performed 3

Critical Management Based on Findings

If Breast Imaging Shows Suspicious Findings (BI-RADS 4-5)

• Core needle biopsy is mandatory for any suspicious or highly suggestive findings 1, 2
• If lymph node biopsy shows malignancy of breast origin but no breast mass is evident, obtain breast MRI 1

If Lymph Node Biopsy is Positive for Malignancy

• When cancer is identified in axillary lymph nodes, breast cancer is the most common cause, though occult breast cancer can occur 1
• Regional lymph node dissection should be considered if biopsy confirms metastatic disease 1

If Initial Imaging is Negative (BI-RADS 1-2)

• Persistent lymphadenopathy for 6 months still requires explanation even with negative breast imaging 1
• Consider non-breast causes: lymphoma, infectious processes, or systemic inflammatory conditions 1
• Surgical biopsy may significantly reduce investigation time compared to repeated needle biopsies, especially when lymphoma is suspected 3

Evaluation of Left Subcostal Pain

Musculoskeletal vs. Visceral Causes

• Left subcostal pain combined with left-sided lymphadenopathy raises concern for systemic disease including lymphoma involving bone or soft tissue 4, 5
• Extramammary causes of perceived "breast pain" include costochondritis (Tietze syndrome), intercostal nerve entrapment, or musculoskeletal chest wall conditions 1
• However, given your constellation of symptoms (persistent lymphadenopathy + multiple pain sites), systemic evaluation takes priority over assuming benign musculoskeletal causes 1

Additional Imaging if Indicated

• If lymph nodes are ≥5 cm or symptoms suggest metastatic spread, staging with CT chest/abdomen/pelvis or PET-CT may be warranted 1
• Primary bone lymphoma can present with rib pain and soft tissue mass, though this is rare 4

Common Pitfalls to Avoid

• Never dismiss persistent unilateral lymphadenopathy lasting 6 months as benign reactive nodes without tissue diagnosis 1, 3
• Do not assume breast pain is benign without imaging when it is focal and noncyclical 1, 2
• Avoid attributing all symptoms to musculoskeletal causes when lymphadenopathy is present 1
• Surgical excisional biopsy should not be delayed if needle biopsy is non-diagnostic, as this significantly reduces time to diagnosis 3

Symptomatic Management Only After Malignancy Excluded

• Once imaging and biopsies exclude malignancy, symptomatic management includes over-the-counter NSAIDs, supportive bra, ice packs or heating pads 1, 6
• Reassurance is effective for benign breast pain but should only be provided after appropriate workup 1, 6