Evaluation and Management of Axillary Lymph Node Tenderness

Initial Clinical Assessment

The National Comprehensive Cancer Network recommends a complete clinical evaluation to assess for other sites of adenopathy, history of recent infections, vaccinations, or trauma, and signs suggesting lymphoma, for patients presenting with isolated axillary lymph node tenderness and no other symptoms 1
The assessment should also consider breast implants, which can cause benign axillary lymphadenopathy 1

The American College of Radiology recommends diagnostic mammography or digital breast tomosynthesis as the initial examination for patients ≥30 years old, with axillary ultrasound performed complementary to mammography at the same visit 2, 1
For patients <30 years old, the National Comprehensive Cancer Network recommends ultrasound as the initial and primary examination 1
The American College of Radiology suggests that mammography may identify occult breast cancer that has metastasized to the axilla or detect silicone in axillary nodes from implant leakage 2, 1

The American College of Radiology recommends characterizing cortical thickness and uniformity, size and shape, and vascularity pattern on ultrasound, as these features can predict malignancy 4, 2
A "snowstorm" appearance on ultrasound can indicate silicone adenitis in patients with breast implants 2

The National Comprehensive Cancer Network recommends clinical management as appropriate based on level of clinical suspicion if imaging is negative/benign, with consideration of observation with clinical follow-up or repeat imaging in 4-6 weeks if symptoms persist or worsen 1
If imaging shows morphologically abnormal lymph nodes, the National Comprehensive Cancer Network recommends ultrasound-guided core needle biopsy for definitive diagnosis, with core needle biopsy preferred over fine needle aspiration 1, 4

The American College of Radiology suggests that PET/CT should be considered if there is concern for lymphoma or other non-breast malignancy, and CT chest/abdomen/pelvis may be warranted if metastatic disease from an unknown primary is suspected 4, 2
MRI without contrast has limited value for isolated axillary adenopathy evaluation, as ultrasound more readily diagnoses the common causes 2