Evaluation of Perimenopausal Female with Breast and Axillary Symptoms

Initial Diagnostic Workup

The National Comprehensive Cancer Network recommends urgent bilateral diagnostic mammography with or without ultrasound to rule out Paget's disease of the breast in patients with unilateral breast itching, as this symptom is a red flag for malignancy 1
Breast imaging should be performed first, as the combination of unilateral breast itching with ipsilateral axillary symptoms raises concern for serious pathology, according to the National Comprehensive Cancer Network 1
The American College of Radiology recommends obtaining bilateral diagnostic mammography with or without ultrasound as the initial imaging study 1
The itching symptom specifically raises suspicion for Paget's disease, which presents with eczema of the nipple or areola, bleeding, ulceration, and itching of the nipple, as stated by the National Comprehensive Cancer Network 1
Paget's disease is frequently occult on mammography, so a negative mammogram does not exclude the diagnosis, according to the National Comprehensive Cancer Network 1

If imaging shows BI-RADS category 1-3, the National Comprehensive Cancer Network recommends performing punch biopsy of the affected breast skin or nipple biopsy 1
The National Comprehensive Cancer Network advises not to delay biopsy based on normal imaging, as Paget's disease can be mammographically occult 1
If biopsy results are benign, the National Comprehensive Cancer Network suggests reassessing clinical-pathologic correlation and considering breast MRI, repeat biopsy, and consultation with a breast specialist 1

The National Comprehensive Cancer Network recommends performing axillary ultrasound to assess for lymphadenopathy, as this is the primary modality for evaluating axillary nodes 2 3
The American College of Radiology suggests looking for morphologically abnormal lymph nodes with abnormal cortical thickness, loss of fatty hilum, or abnormal vascularity 2
If suspicious nodes are identified on ultrasound, the National Comprehensive Cancer Network advises performing ultrasound-guided core needle biopsy for definitive diagnosis 2 3

The National Comprehensive Cancer Network warns against dismissing unilateral breast itching as a benign dermatologic condition without imaging and potential biopsy, as Paget's disease diagnosis is often delayed due to confusion with benign conditions 1
The National Comprehensive Cancer Network cautions against attributing axillary symptoms to simple body odor until breast malignancy with axillary metastases has been excluded 1 2
The American College of Radiology advises against relying on clinical breast examination alone, as sensitivity and specificity are limited for detecting both breast cancer and axillary disease 3
The National Comprehensive Cancer Network recommends not allowing antibiotics to delay diagnostic evaluation if given empirically for suspected infection 1