Cases corner – 39 yr old with a lump in the axilla

19th November 2019

Yolanda, a 39yr old woman, presents to you with a 6 week history of a lump in her left axilla. She reports she first noticed this when in the shower but assumed it was due to an ingrown hair. Yolanda reports the lump is painless, has not changed in size and she denies any discharge from the lump. She has not noticed any change to either of her breasts and is otherwise feeling well. She denies any fevers or weight loss. Yolanda has no significant past medical history or family history, has never smoked and rarely drinks alcohol.

On examination, there is a 1.5cm lesion that is hard and non-mobile in her left axilla. The area is not tender on palpation with no overlying erythema. Nil of note is found when examining the right axilla. A breast examination finds diffuse nodularity of both left and right breast, but no discrete lesion is found. There is no cervical or inguinal lymphadenopathy. Her observations are all normal.

What would you do next?

  1. Adopt a watch and wait response and review the lesion in 4 weeks
  2. Order a routine ultrasound scan
  3. Order an urgent ultrasound scan
  4. Order an urgent ultrasound scan and blood tests (including full blood count)
  5. Refer the patient via a breast 2 week wait pathway

Yolanda has presented with an unexplained lump in her axilla. This presentation raises the suspicion of an underlying breast cancer. NICE guidelines suggest:

  • Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:
    • with skin changes that suggest breast cancer, or
    • Aged 30 and over with an unexplained lump in the axilla. [new 2015]

As you can see the recommendation to refer a patient aged over 30 with an unexplained lump in the axilla was added to the NICE guidelines in 2015. NICE referral criteria for suspected breast cancer also includes the following:

  • Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:
    • aged 30 and over and have an unexplained breast lump with or without pain, or
    • aged 50 and over with any of the following symptoms in one nipple only:
      • discharge
      • retraction
      • other changes of concern. [new 2015]