Management of Suspicious Axillary Mass in a 35-Year-Old Male
Proceed immediately with ultrasound-guided core needle biopsy of the 3.2 cm hypoechoic lesion after completing diagnostic mammography to exclude an occult breast primary. 1
Immediate Next Steps
Complete the Imaging Work-Up First
Obtain diagnostic mammography (or digital breast tomosynthesis) before any tissue sampling, even in this male patient. 1 This is mandatory to search for an occult breast primary, as male breast cancer accounts for approximately 3-5% of axillary metastases from unknown primaries. 1
The imaging work-up must be completed in a single visit before biopsy. 1 Post-biopsy changes (hematoma, inflammation) will obscure subsequent mammographic and MRI findings, potentially delaying diagnosis. 1
Why This Lesion Requires Urgent Tissue Diagnosis
The ultrasound findings are highly concerning for malignancy based on multiple high-risk features:
- The 3.2 cm size exceeds the 1 cm threshold strongly associated with malignancy. 1
- Irregular borders raise concern for invasive disease or matted nodes. 1
- Cortical thickening of 0.4 cm in the adjacent lymph node exceeds the 0.3 cm threshold, which carries a 90-93% positive predictive value for malignancy. 1
- The presence of multiple lesions (the hypoechoic mass plus the anechoic focus) suggests multifocal disease. 1
Tissue Diagnosis Strategy
Biopsy Technique
Perform ultrasound-guided core needle biopsy of the largest (3.2 cm) hypoechoic lesion. 1 Core biopsy is essential because it preserves tissue architecture needed for lymphoma diagnosis and provides sufficient material for immunohistochemistry and receptor testing. 1
Do not use fine-needle aspiration as the initial diagnostic technique. 1 FNA cannot provide the architectural detail required for lymphoma classification or receptor status assessment, which are critical for treatment planning. 1
Differential Diagnosis in This Male Patient
The most likely diagnoses include:
- Non-Hodgkin lymphoma, which commonly presents as axillary masses and requires core biopsy with immunophenotyping. 1
- Occult male breast cancer with axillary metastasis (3-5% of axillary metastases from unknown primaries). 1
- Metastatic adenocarcinoma from another primary site. 1
- Reactive adenopathy is unlikely given the size >2 cm, irregular margins, and cortical thickening. 1
If Mammography is Negative but Pathology Confirms Malignancy
- Order contrast-enhanced breast MRI. 1 MRI detects occult breast cancer in approximately 70% of cases with suspicious axillary lymphadenopathy and negative conventional imaging. 1, 2
Staging After Malignancy Confirmation
- Obtain contrast-enhanced CT of the chest, abdomen, and pelvis to evaluate for distant metastases and to search for alternative primary sites. 1 This is especially important for adenocarcinoma of unknown primary or suspected lymphoma. 1
Critical Pitfalls to Avoid
Never perform biopsy before completing the full imaging work-up. 1 Post-biopsy changes will obscure mammographic and MRI findings, potentially missing an occult primary. 1
Do not delay histologic confirmation with empiric antibiotics or observation. 1 The size, irregular borders, and cortical thickening make benign reactive adenopathy extremely unlikely, and delay postpones treatment of potentially aggressive malignancies. 1
Do not rely solely on ultrasound findings to exclude malignancy. 1 While ultrasound sensitivity ranges from 26-94%, tissue diagnosis remains essential when imaging morphology is suspicious. 1, 3
If Axillary Metastasis is Confirmed Without Identified Primary (T0 N1-3 M0)
Surgical options include: