Q. What does an asymptomatic palpable lump in the armpit suggest?
Hello doctor,
This query pertains to a palpable axilla lump in the armpit of a middle-aged female. The lump is painless and firm, without any skin redness or irritation from the past one and half months. The armpit area has not been shaved for seven months, further reducing skin irritation. The person is genetically susceptible to breast and lymphatic malignancy with a recent kidney infection on the same side. The lesion measures 1.1 x 0.6 x 1.1 mm and has increased vascularity. What is your opinion?
Thank you.
Hello,
Welcome to icliniq.com.
The report (attachment removed to protect the patient's identity) shows a well-defined round to oval hypervascular heterogeneously hypoechoic lesion of size 11.9 x 6.1 mm containing cystic areas located in the deep subcutaneous plane in the right axilla. The lesion shows posterior acoustic enhancement. The outer margins of the lesion are slightly irregular. A small round echogenic speck is noted within the lesion, suggesting calcification. A linear track-like structure is seen extending outwards from the lesion. The lesion is anterior to the muscle plane. The rest of the visible axillary parenchyma appears normal.
A lesion, predominantly cystic, is located in the subcutaneous plane with a track extending from it. The most likely diagnosis would be a sebaceous or epidermal cyst (solely based on these ultrasound images). Sebaceous cysts or epidermal cysts usually show no vascularity on doppler, but with associated superadded infection, vascularity can be seen. My only concern is that with so much vascularity that might be due to inflammation, the patient should have had some history of fever, pain, and tenderness in the axillary region. But no such history is not there.
Also, had there been no track and with the presence of internal vascularity as seen in the lesion and genetic susceptibility to breast or lymphatic cancer, an axillary lymph node would be a differential too.
So, I have the following queries:
1) Has there been any history of the above symptoms over the last 1.5 months?
2) The track can be seen only in one sag image, was it seen in other sections too?
3) Were the breasts scanned?
Further imaging, such as an MRI (magnetic resonance imaging), would help narrow down the diagnosis. The final say would be with an FNAC (fine needle aspiration cytology) biopsy of the lesion.
Hope this helps.
Thank you.
Hello doctor,
To answer your questions:
1. There was no fever in the last 1.5 months (apart from what was related to the kidney infection on the same side). There has never been any pain, redness, or infection at the site of the axillary lump
2. I have attached an image with a track labeled as well. It appears less defined. Does it look like a tract to you?
3. The breasts were not scanned.
I dismissed the lump for the first month as I figured it was a distant reactive lymph node from the kidney infection, so your differential diagnosis is plausible. However, our radiologists at the local hospital indicated a sebaceous cyst as well, but, with no clinical information, incorrectly speculated the cause as a surface infection, inflammation, and ingrown hair from shaving. Do you see vascularity inside the lesion, or is it solely surrounding the lesion?
Thank you.
Hello,
Welcome back to icliniq.com.
The track needs to be more defined in the present image and look more convincing. Ultrasound is an operator-dependent modality, and the quality of images taken depends on the patient's habitus and the technician's expertise or experience. Therefore interpreting still images taken by someone else is always challenging for radiologists. That is why imaging findings should always be correlated clinically. About your query on vascularity, there is evidence of vascularity within the lesion and at its periphery. You can approach the problem in the following ways:
1) In case the lump is not bothering you, get a follow-up ultrasound at six months to see if the size of the lesion increases or decreases and to document other changes in its morphology. I would also suggest looking at the breasts at that time to have a baseline record that the breasts are okay.
2) The other approach would be to get it removed if you want to. This would give you peace of mind once it is gone. But again, there is no urgency. You can think about all the possibilities and discuss them with your doctor.
Thank you.
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