What are the next steps in diagnosing a patient with thickened and darkened left breast tissue, suggestive of peau d'orange (inflammatory breast cancer) or dystrophic calcification (calcification due to trauma or surgery)?

From the Guidelines

For a patient with thickened/darkened left breast tissue, the next diagnostic steps should include a thorough clinical breast examination, bilateral mammography, and ultrasound imaging, as recommended by the National Comprehensive Cancer Network (NCCN) guidelines 1. These imaging studies will help characterize the abnormality and determine if it represents inflammatory breast cancer, mastitis, or another condition. The diagnostic approach aims to distinguish between benign conditions like mastitis or dermatological issues and malignant processes that require urgent intervention. Additional diagnostic procedures may include a skin punch biopsy if inflammatory breast cancer is suspected, or core needle biopsy of any suspicious masses identified on imaging, as suggested by the American College of Radiology (ACR) Appropriateness Criteria 1. Blood tests to assess for infection markers may be appropriate if mastitis is suspected. MRI might be indicated if conventional imaging is inconclusive or to better define the extent of disease, as recommended by the international expert panel on inflammatory breast cancer 1. The patient should be referred to a breast specialist or surgeon for comprehensive evaluation. Prompt diagnosis is essential as thickened/darkened breast tissue can represent inflammatory breast cancer, which is aggressive and requires immediate treatment. Some key points to consider in the diagnostic workup include:

• The use of BI-RADS categories to classify imaging findings and guide further management 1
• The importance of clinical correlation and physical examination in evaluating palpable breast masses 1
• The role of imaging modalities such as mammography, ultrasound, and MRI in characterizing breast abnormalities 1
• The need for tissue diagnosis and biopsy in cases where imaging findings are suspicious or inconclusive 1

From the Research

Next Steps in Diagnosis for Patient with Thickened/Darkened Left Breast Tissue

• The patient's symptoms suggest a palpable breast abnormality, which requires further evaluation 2
• The first step in diagnosis would be to perform an ultrasound, as it is a highly effective imaging tool for guiding the evaluation of women with palpable breast abnormalities 2
• If the patient is under 30 years old, pregnant, or lactating, ultrasound should be the primary imaging tool 2
• For women 40 years old and older, mammography followed by ultrasound is recommended 2
• If the ultrasound findings are suspicious, a fine needle aspiration (FNA) or core needle biopsy (CNB) may be performed to obtain a tissue sample for histological examination 3, 4, 5
• CNB has been shown to have higher sensitivity than FNA in detecting malignancy, especially in special types of breast cancer such as invasive lobular carcinoma and apocrine carcinoma 3
• The choice between FNA and CNB depends on the specific clinical situation and the availability of resources 4, 5
• Axillary ultrasound and FNA or CNB of axillary lymph nodes may also be performed to evaluate for lymph node metastases 6, 5