Symptom Finder - Axillary Mass
AXILLARY MASS
When the physician palpates a mass in the right axilla, his or her first thought is that it is a lymph node. Although in most cases this is probably right, it is a good idea to first think of the anatomy: the skin and its glands, the lymph nodes, the axillary artery, subcutaneous tissue, muscles, and ribs. Thus, in addition to an enlarged lymph node, one must consider skin conditions such as sebaceous cysts and hidradenitis suppurativa; lesions of the subcutaneous tissue such as cellulitis, lipomas, and accessory breast tissue; and axillary aneurysms and primary and metastatic tumors of
the ribs.
The lymph nodes are involved primarily by infection or malignancy. If other groups of lymph nodes are involved (e.g., anterior cervical or groin), then consider the differential under generalized lymphadenopathy
For focal lymphadenopathy, look for infection in the areas that feed the gland. There may be a minor wound of the arm or hand that has become infected or there may be an infection in the lung, breast, or back.
Tularemia often causes axillary adenopathy even though the wound in the hand is insignificant. The node may be involved with tuberculosis or a fungal infection such as actinomycosis, but there is also usually a site of infection in the lung.
If infection has been excluded, then malignancy must be considered. Hodgkin lymphoma, carcinoma of the breast, and carcinoma of the lung are the chief offenders, but lymphosarcoma and metastasis from other sites must be considered.
Approach to the Diagnosis
A unilateral tender axillary mass with an exudate is usually a sebaceous cyst or hidradenitis suppurativa. All that is required is incision and drainage, culture of the exudate, and antibiotics. After the infection has cleared, it can be excised. A unilateral, non tender mass is most likely a lymph node harboring metastasis or Hodgkin lymphoma. Lymph node biopsy is indicated. If the lymph node is associated with an infection of the breast or the arm, the swelling should subside after the infection is treated.
Bilateral axillary lymphadenopathy would be an indication for a more extensive workup
Other Useful Tests
1. Needle aspiration and culture and sensitivity of the material
retrieved (infection)
2. CBC
3. Sedimentation rate (inflammatory)
4. Chemistry panel (metastatic neoplasm, systemic infection)
5. Tuberculin test
6. Kveim test (sarcoidosis)
7. Coccidioidin skin test (coccidiomycosis)
8. Chest x-ray (tuberculosis, neoplasm)
9. Mammogram (neoplasm)
10. Lymphangiogram (Hodgkin lymphoma)
11. Angiogram (axillary aneurysm)
12. Exploratory surgery
When the physician palpates a mass in the right axilla, his or her first thought is that it is a lymph node. Although in most cases this is probably right, it is a good idea to first think of the anatomy: the skin and its glands, the lymph nodes, the axillary artery, subcutaneous tissue, muscles, and ribs. Thus, in addition to an enlarged lymph node, one must consider skin conditions such as sebaceous cysts and hidradenitis suppurativa; lesions of the subcutaneous tissue such as cellulitis, lipomas, and accessory breast tissue; and axillary aneurysms and primary and metastatic tumors of
the ribs.
The lymph nodes are involved primarily by infection or malignancy. If other groups of lymph nodes are involved (e.g., anterior cervical or groin), then consider the differential under generalized lymphadenopathy
For focal lymphadenopathy, look for infection in the areas that feed the gland. There may be a minor wound of the arm or hand that has become infected or there may be an infection in the lung, breast, or back.
Tularemia often causes axillary adenopathy even though the wound in the hand is insignificant. The node may be involved with tuberculosis or a fungal infection such as actinomycosis, but there is also usually a site of infection in the lung.
If infection has been excluded, then malignancy must be considered. Hodgkin lymphoma, carcinoma of the breast, and carcinoma of the lung are the chief offenders, but lymphosarcoma and metastasis from other sites must be considered.
Approach to the Diagnosis
A unilateral tender axillary mass with an exudate is usually a sebaceous cyst or hidradenitis suppurativa. All that is required is incision and drainage, culture of the exudate, and antibiotics. After the infection has cleared, it can be excised. A unilateral, non tender mass is most likely a lymph node harboring metastasis or Hodgkin lymphoma. Lymph node biopsy is indicated. If the lymph node is associated with an infection of the breast or the arm, the swelling should subside after the infection is treated.
Bilateral axillary lymphadenopathy would be an indication for a more extensive workup
Other Useful Tests
1. Needle aspiration and culture and sensitivity of the material
retrieved (infection)
2. CBC
3. Sedimentation rate (inflammatory)
4. Chemistry panel (metastatic neoplasm, systemic infection)
5. Tuberculin test
6. Kveim test (sarcoidosis)
7. Coccidioidin skin test (coccidiomycosis)
8. Chest x-ray (tuberculosis, neoplasm)
9. Mammogram (neoplasm)
10. Lymphangiogram (Hodgkin lymphoma)
11. Angiogram (axillary aneurysm)
12. Exploratory surgery
