What is the diagnosis and recommended treatment for a patient with left-sided breast and chest pain, accompanied by a burning sensation triggered by deep breathing, and two palpable lymph nodes under the axilla for the past six months?

Urgent Diagnostic Workup for Suspected Inflammatory Breast Cancer or Malignancy

This patient requires immediate diagnostic imaging with mammography and ultrasound of the breast and axilla, followed by core needle biopsy of any suspicious findings, as the 6-month duration of symptoms with persistent axillary lymphadenopathy raises significant concern for inflammatory breast cancer or other breast malignancy. 1

Critical Red Flags Present

This clinical presentation contains multiple concerning features that mandate urgent evaluation:

• Duration of 6 months or less with persistent symptoms is a defining characteristic of inflammatory breast cancer 2, 1
• Burning sensation and pain wrapping around to the back may indicate extensive disease involvement
• Persistent axillary lymphadenopathy for 6 months is highly suspicious for malignancy, particularly when bilateral or unilateral with breast symptoms 2
• Pleuritic pain (triggered by deep breathing) suggests possible chest wall involvement or advanced disease

Immediate Diagnostic Algorithm

Step 1: Clinical Examination

Perform focused breast examination looking for:

• Erythema occupying at least one-third of the breast (diagnostic criterion for inflammatory breast cancer) 2, 1
• Peau d'orange (orange peel skin texture) 1
• Asymmetry compared to contralateral breast 1
• Skin dimpling or attachment to deep fascia 1
• Nipple retraction, crusting, or flattening 2
• Palpable breast mass (may or may not be present) 2

Step 2: Imaging Studies

Obtain diagnostic mammography with ultrasound of both breasts and bilateral axillae immediately 2, 3:

• Mammography evaluates for underlying mass, architectural distortion, and microcalcifications 3
• Ultrasound characterizes any masses (solid vs cystic) and evaluates axillary lymph node morphology 2, 3
• Axillary ultrasound can identify morphologically abnormal lymph nodes not detected on physical examination 3

Step 3: Tissue Diagnosis

If imaging shows suspicious findings (BI-RADS 4 or 5), proceed immediately with core needle biopsy 2, 3:

• Core needle biopsy is strongly preferred over fine needle aspiration because it provides adequate tissue for histologic diagnosis and receptor testing (ER/PR, HER2) 2, 3
• Skin punch biopsy (at least two) should be obtained if inflammatory breast cancer is suspected, even if breast imaging is negative 2
• Biopsy suspicious axillary lymph nodes under ultrasound guidance 2

Step 4: Staging if Malignancy Confirmed

If biopsy confirms invasive carcinoma:

• CT chest/abdomen/pelvis and bone scan for systemic staging 2
• Test all tumors for hormone receptors (ER/PR) and HER2 status 2

Critical Pitfall to Avoid

Do NOT treat this as simple mastitis with a trial of antibiotics if the patient has no clear infectious symptoms (fever, warmth, recent lactation). A history of mastitis not responding to at least 1 week of antibiotics is a red flag for inflammatory breast cancer 2, 1. The NCCN guidelines allow a short 7-10 day antibiotic trial only if there is LOW clinical suspicion for cancer and HIGH suspicion for infection 2. Given the 6-month duration and persistent lymphadenopathy, this patient does not meet criteria for empiric antibiotic treatment.

Alternative Diagnoses to Consider

While malignancy is the primary concern, the differential includes:

• Inflammatory breast cancer (most concerning given symptom duration and lymphadenopathy) 2, 1
• Non-inflammatory breast cancer with nodal metastases 2, 4
• Lymphoma (can present with axillary lymphadenopathy and chest symptoms) 5
• Costochondritis or musculoskeletal pain (less likely given persistent lymphadenopathy)
• Benign axillary lymph node inclusions (rare, diagnosis of exclusion) 6

Treatment Implications if Inflammatory Breast Cancer Confirmed

If inflammatory breast cancer is diagnosed, the standard treatment sequence is 2:

1. Primary systemic chemotherapy (anthracycline + taxane; add anti-HER2 therapy if HER2-positive)
2. Modified radical mastectomy (breast conservation is not appropriate)
3. Post-mastectomy radiation therapy (dose escalated to 66 Gy in high-risk patients)

A multidisciplinary approach involving medical oncology, surgical oncology, and radiation oncology is mandatory 2.

Timeline for Action

This workup should be completed within 1-2 weeks maximum. The 6-month symptom duration already represents significant delay, and inflammatory breast cancer is an aggressive malignancy with rapid progression. Same-week imaging and biopsy should be the goal 1.