As the primary provider, what are the next steps for a female patient with a 4.7 cm invasive ductal carcinoma of the right breast (BI‑RADS 5) with approximately 8 cm inflammatory‑type involvement, skin thickening, nipple retraction, and a suspicious 1.1 cm right axillary lymph node, after core needle biopsy confirming cancer?

Primary Care Next Steps for Confirmed Invasive Ductal Carcinoma with Inflammatory Features

Your immediate priority is to ensure urgent multidisciplinary oncology care coordination, complete staging workup, and obtain skin punch biopsies to confirm or exclude inflammatory breast cancer, as this distinction fundamentally alters treatment approach and prognosis. 1

Immediate Actions Required

1. Confirm Inflammatory Breast Cancer Diagnosis

• Arrange skin punch biopsy (minimum of two specimens) from the erythematous/edematous areas to document dermal lymphovascular tumor emboli, which is the pathological hallmark of inflammatory breast cancer (IBC). 1
• This patient meets clinical criteria for IBC: rapid onset (<6 months), skin thickening, nipple retraction, and involvement suggesting >1/3 of breast with inflammatory changes. 1
• The skin biopsy is strongly recommended even though dermal lymphatic invasion is not required for IBC diagnosis—its presence confirms true IBC versus pseudo-IBC, which have dramatically different prognoses. 1

2. Complete Staging Workup Immediately

• Order CT chest/abdomen/pelvis and bone scan for systemic staging. 1
• All women with suspected IBC require systemic staging studies before treatment initiation. 1
• PET/CT is not routinely recommended for IBC staging per international consensus guidelines. 1

3. Obtain Additional Tissue Characterization

• Ensure the core biopsy specimen is tested for ER, PR, and HER2 status if not already completed. 1
• Proceed with ultrasound-guided biopsy of the suspicious 1.1 cm right axillary lymph node as previously recommended. 1
• This provides critical staging information and confirms nodal involvement before initiating neoadjuvant chemotherapy. 1

Urgent Referrals and Coordination

Multidisciplinary Team Assembly

• Expedite referrals to medical oncology, surgical oncology, and radiation oncology within 1-2 business days. 1
• A multidisciplinary approach is mandatory for IBC management given its aggressive nature and complex treatment algorithm. 1
• Coordinate a tumor board presentation or joint consultation if available at your institution. 1

Treatment Paradigm for IBC

• The standard treatment sequence is: neoadjuvant chemotherapy → modified radical mastectomy → postmastectomy radiation. 1
• Primary systemic chemotherapy with anthracycline and taxane is the initial treatment, with anti-HER2 therapy added if HER2-positive. 1
• Modified radical mastectomy is the only acceptable surgical approach following neoadjuvant therapy—breast conservation is contraindicated in IBC. 1
• Immediate breast reconstruction is not recommended; delayed reconstruction may be considered. 1

Critical Caveats and Common Pitfalls

Distinguishing True IBC from Pseudo-IBC

• True IBC has a rapidly fatal course if untreated, while pseudo-IBC has favorable outcomes despite large tumor size. 2
• Dermal lymphatic emboli are found in only 61% of true IBC cases, so their absence does not exclude the diagnosis. 2
• Pseudo-IBC (11% of inflammatory presentations) has no dermal involvement, minimal lymph node involvement, and requires different treatment. 2
• This distinction is why the skin punch biopsy and axillary node biopsy are essential before finalizing the treatment plan. 1, 2

Avoiding Diagnostic Delays

• IBC is frequently misdiagnosed as mastitis, leading to dangerous treatment delays. 3, 4, 5
• History of mastitis not responding to ≥1 week of antibiotics should raise immediate suspicion for IBC. 1, 3
• This patient's presentation with BI-RADS 5 findings and confirmed invasive ductal carcinoma makes the diagnosis clear, but skin biopsy confirmation remains important for treatment planning. 1

Radiation Therapy Considerations

• Postmastectomy radiation is mandatory, with dose escalation to 66 Gy recommended for patients who are >45 years old, have close/positive margins, ≥4 positive lymph nodes post-chemotherapy, or poor response to neoadjuvant treatment. 1

Documentation and Patient Communication

• Document that results and urgent oncology referrals have been discussed with the patient. 1
• Explain the aggressive nature of this cancer subtype and the importance of rapid treatment initiation. 1
• Ensure the patient understands that neoadjuvant chemotherapy will begin before surgery, which differs from typical breast cancer management. 1
• Provide written information about IBC and connect the patient with support resources given the psychological impact of this diagnosis. 1