Paget's disease of the breast differential diagnosis: Difference between revisions

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! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Other
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Other
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! rowspan="20" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Skin disorders
! rowspan="19" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Skin disorders
! style="background: #DCDCDC; padding: 5px; text-align: center;" |Paget's disease of the breast<ref name="GaspariRicci2013">{{cite journal|last1=Gaspari|first1=Eleonora|last2=Ricci|first2=Aurora|last3=Liberto|first3=Valeria|last4=Scarano|first4=Angela Lia|last5=Fornari|first5=Maria|last6=Simonetti|first6=Giovanni|title=An Unusual Case of Mammary Paget’s Disease Diagnosed Using Dynamic Contrast-Enhanced MRI|journal=Case Reports in Radiology|volume=2013|year=2013|pages=1–5|issn=2090-6862|doi=10.1155/2013/206235}}</ref><ref name="Lopes FilhoLopes2015">{{cite journal|last1=Lopes Filho|first1=Lauro Lourival|last2=Lopes|first2=Ione Maria Ribeiro Soares|last3=Lopes|first3=Lauro Rodolpho Soares|last4=Enokihara|first4=Milvia M. S. S.|last5=Michalany|first5=Alexandre Osores|last6=Matsunaga|first6=Nobuo|title=Mammary and extramammary Paget's disease|journal=Anais Brasileiros de Dermatologia|volume=90|issue=2|year=2015|pages=225–231|issn=1806-4841|doi=10.1590/abd1806-4841.20153189}}</ref>
! style="background: #DCDCDC; padding: 5px; text-align: center;" |Paget's disease of the breast<ref name="GaspariRicci2013">{{cite journal|last1=Gaspari|first1=Eleonora|last2=Ricci|first2=Aurora|last3=Liberto|first3=Valeria|last4=Scarano|first4=Angela Lia|last5=Fornari|first5=Maria|last6=Simonetti|first6=Giovanni|title=An Unusual Case of Mammary Paget’s Disease Diagnosed Using Dynamic Contrast-Enhanced MRI|journal=Case Reports in Radiology|volume=2013|year=2013|pages=1–5|issn=2090-6862|doi=10.1155/2013/206235}}</ref><ref name="Lopes FilhoLopes2015">{{cite journal|last1=Lopes Filho|first1=Lauro Lourival|last2=Lopes|first2=Ione Maria Ribeiro Soares|last3=Lopes|first3=Lauro Rodolpho Soares|last4=Enokihara|first4=Milvia M. S. S.|last5=Michalany|first5=Alexandre Osores|last6=Matsunaga|first6=Nobuo|title=Mammary and extramammary Paget's disease|journal=Anais Brasileiros de Dermatologia|volume=90|issue=2|year=2015|pages=225–231|issn=1806-4841|doi=10.1590/abd1806-4841.20153189}}</ref>
| align="center" style="background:#F5F5F5;" |[[Malignant]]
| align="center" style="background:#F5F5F5;" |[[Malignant]]
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* May positive staining against [[CEA antigen]]  and the c erbB-2 / her-2 neu oncoprotein.
* May positive staining against [[CEA antigen]]  and the c erbB-2 / her-2 neu oncoprotein.
* Prognosis is worse in men.
* Prognosis is worse in men.
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! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Extramammary Paget's disease]]
| align="center" style="background:#F5F5F5;" |[[Malignant]]
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| align="center" style="background:#F5F5F5;" |[[Biopsy]]
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! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Atopic dermatitis]]
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Atopic dermatitis]]
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| align="center" style="background:#F5F5F5;" | –
| align="center" style="background:#F5F5F5;" | –
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| align="center" style="background:#F5F5F5;" | N/A
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* Usually bilateral nipple is effected with no accompanying induration.
* Usually bilateral nipple is effected with no accompanying induration.
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* [[Dyskeratosis congenita|Dyskeratosis]]
* [[Dyskeratosis congenita|Dyskeratosis]]
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* Clinical examination
* [[Biopsy]]
*  
*  
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* Chronic - [[Hyperkeratosis]] and [[parakeratosis]]
* Chronic - [[Hyperkeratosis]] and [[parakeratosis]]
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* Clinical examination
* [[Biopsy]]
*
*
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| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |N/A
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* Pigmented lesion with:
* Asymmetry
* Irregular borders
* Variegated color
* Diameter >6 mm
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* Nests of  atypical melanocytes with asymmetry, poor circumscription of varying sizes and shapes
* Present in the lower epidermis and dermis
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* Complete full-thickness excisional [[biopsy]] of suspicious lesions with 1 to 3 mm margin of normal skin.
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* [[Ultraviolet|UV radiations]]
* [[Ultraviolet|UV radiations]]
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| align="center" style="background:#F5F5F5;" |[[Malignant]]
| align="center" style="background:#F5F5F5;" |[[Malignant]]
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* UV light induces inflammation of the skin.
* Patched 1 (PTCH1) tumor suppressor gene on chromosome 9
* [[P53]] mutations.
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* Erythematous
* Erythematous
* Superficial scaly patch
* Superficial scaly patch
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |–
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| align="center" style="background:#F5F5F5;" |+
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| align="center" style="background:#F5F5F5;" |N/A
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* Superficial fine telangiectasia
* Superficial fine telangiectasia
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* Small basaloid nodules
* Small basaloid nodules
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* [[Biopsy]]
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* Higher incidence in men
* Higher incidence in men

Revision as of 23:41, 26 February 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Preeti Singh, M.B.B.S.[2]

Overview

Paget's disease of the breast must be differentiated from atopic dermatitis, eczema, psoriasis, malignant melanoma, Bowen's disease, basal cell carcinoma, and pagetoid dyskeratosis.[1][2]

Differential Diagnosis

Paget’s disease of the breast must be differentiated from other benign and malignant processes of nipple-areola complex such as:

Paget's disease of the breast is often misdiagnosed as nipple eczema

Category Diseases Benign or Malignant Etiology Clinical manifestations Para-clinical findings Gold Standard Associated factors
Symptoms Physical examination
Histopathology
Rash Nipple Discharge Erythema Mastalgia Breast Exam Other
Skin disorders Paget's disease of the breast[1][2] Malignant Most the patients have underlying breast cancer. Ulcerated, crusted, or scaling lesion on the nipple that extends to the areolar region Serous or bloody nipple discharge may be present. + ± Usually unilateral nipple is effected
Atopic dermatitis

(Eczema)

  • Epidermal barrier dysfunction
  • Immune dysregulation
N/A
  • Clinical examination
Erosive adenomatosis of the nipple[3][4]
  • Benign
  • Neoplasm of breast lactiferous ducts
Eczema, crusts or erosion of nipple Serous or bloody nipple discharge. +
  • Papillary pattern: cells proliferate into large cords with deep fissures and clefts and dense stroma.
Biopsy: Shows absence of cytological atypia
Allergic contact dermatitis[5] Benign Erythematous well-demarcated papules + N/A
  • Clinical examination
Psoriasis Benign Well-circumscribed, pink papules and symmetrically distributed cutaneous plaques with silvery scales + + N/A Auspitz's sign (pinpoint bleeding)
  • Clinical examination
Risk factors include
Malignant melanoma Malignant
  • Macule
  • Plaque with irregular border
  • Variable size
  • A lesion with ABCD
    • Asymmetry
    • Border irregularity
    • Color variation
    • Diameterchanges
  • Bleeding from the lesion
± N/A
  • Pigmented lesion with:
  • Asymmetry
  • Irregular borders
  • Variegated color
  • Diameter >6 mm
  • Nests of atypical melanocytes with asymmetry, poor circumscription of varying sizes and shapes
  • Present in the lower epidermis and dermis
  • Complete full-thickness excisional biopsy of suspicious lesions with 1 to 3 mm margin of normal skin.
Bowen’s disease Benign can turn malignant
  • Patch
  • Plaque
  • Scaly
  • variable size
+ N/A
  • Presence of dotted and/or glomerular vessels
  • White to yellowish surface scales
  • Red-yellowish background
  • Keratinocytic dysplasia of the
  • No infiltration into dermis
  • Pleomorphic keratinocytes
  • Hyperchromatic nuclei
  • Clinical examination
  • Slow growth over the years
Superficial basal cell carcinoma Malignant
  • UV light induces inflammation of the skin.
  • Patched 1 (PTCH1) tumor suppressor gene on chromosome 9
  • P53 mutations.
  • Erythematous
  • Superficial scaly patch
+ N/A
  • Superficial fine telangiectasia
  • Shiny white to red, translucent or opaque structureless areas
  • Multiple small erosions
  • Large, hyperchromatic, oval nuclei
  • Minimal cytoplasm
  • Small basaloid nodules
  • Higher incidence in men
Squamous metaplasia of lactiferous ducts (SMOLD)/ Zuska's disease[6][7] Benign + +
Lactiferous duct ectasia / Plasma cell mastitis / Comedomastitis Benign Nipple retraction + Thick nipple discharge. Ultrasound:
Nipple Adenoma / Papillary adenoma of the nipple Benign ± +
  • Multiple small palpable masses below
  • Usually unilateral nipple is effected
Nevoid hyperkeratosis of the nipple and areola (NHNA) [8][9] Benign Slow growing bluish-brown verrucous thickening of the nipple or areola.
  • Usually bilateral nipple is effected
Biopsy
Benign Toker cell hyperplasia Benign
  • Normal components of the nipple skin
  • Appears similar to paget cells.
Normal nipple- areolar complex Normal breast examination. N/A
  • Toker cells have bland nuclei and abundant eosinophilic or clear cytoplasm. Occasional clusters or glands may be present.
  • Do not generally have cellular atypia and have minimal nuclear pleomorphism.
  • Toker cells are immunoreactive for cytokeratin 7 and CAM5.2 but are not positive for HER2- neu.
Breast abscess Benign
  • Complication of lactational mastitis in 14% of cases
  • Common among African-American women, heavy smokers and obese patients.
± + +
  • Associated symptoms of fever, nausea, vomiting.
  • Resolve after drainage/antibiotic therapy.

Ultrasound:

  • Fluid collection
  • Smoking history
  • If not lactating, patient may be diabetic.
  • History of privious breast infection
Mondors disease[10][11] Benign Superficial phlebitis and periphlebitis of the superficial vein. Red linear cord running from the lateral margin of the breast attached to the overlying skin. + +
  • Red tender cord which may last up to 4-8 weeks before spontaneously remitting leaving a puckered groove along the breast.
  • N/A–
  • Predominantly seen in middle-aged women but is also seen in men.
  • May indicate breast cancer.
Mastitis[12][13]
  • Localized erythema, warmth, swelling, and pain.
± + ±
  • Associated symptoms of fever, chills, or rigor may be present.
  • Resolve after drainage/antibiotic therapy

Breast parenchymainflammation:

Ultrasound:

  • Ill-defined area with hyperechogenicity with inflamed fat lobules
  • Skin thickening.
History of lactation including difficulty in breastfeeding, breast engorgement, or erosion of nipples.
Inflammatory Breast Cancer[14][15] Malignant Cancer cells block the lymphatic vessels in skin covering the breast
  • Localized erythema, warmth, swelling, and pain.
+ +
  • Usually unilateral
Core needle Biopsy

References

  1. 1.0 1.1 Gaspari, Eleonora; Ricci, Aurora; Liberto, Valeria; Scarano, Angela Lia; Fornari, Maria; Simonetti, Giovanni (2013). "An Unusual Case of Mammary Paget's Disease Diagnosed Using Dynamic Contrast-Enhanced MRI". Case Reports in Radiology. 2013: 1–5. doi:10.1155/2013/206235. ISSN 2090-6862.
  2. 2.0 2.1 Lopes Filho, Lauro Lourival; Lopes, Ione Maria Ribeiro Soares; Lopes, Lauro Rodolpho Soares; Enokihara, Milvia M. S. S.; Michalany, Alexandre Osores; Matsunaga, Nobuo (2015). "Mammary and extramammary Paget's disease". Anais Brasileiros de Dermatologia. 90 (2): 225–231. doi:10.1590/abd1806-4841.20153189. ISSN 1806-4841.
  3. Kumar PK, Thomas J (July 2013). "Erosive adenomatosis of the nipple masquerading as Paget's disease". Indian Dermatol Online J. 4 (3): 239–40. doi:10.4103/2229-5178.115534. PMC 3752489. PMID 23984247.
  4. Lewis HM, Ovitz ML, Golitz LE (October 1976). "Erosive adenomatosis of the nipple". Arch Dermatol. 112 (10): 1427–8. PMID 962337.
  5. Nosbaum A, Vocanson M, Rozieres A, Hennino A, Nicolas JF (2009). "Allergic and irritant contact dermatitis". Eur J Dermatol. 19 (4): 325–32. doi:10.1684/ejd.2009.0686. PMID 19447733.
  6. Gollapalli V, Liao J, Dudakovic A, Sugg SL, Scott-Conner CE, Weigel RJ (July 2010). "Risk factors for development and recurrence of primary breast abscesses". J. Am. Coll. Surg. 211 (1): 41–8. doi:10.1016/j.jamcollsurg.2010.04.007. PMID 20610247.
  7. Meguid MM, Oler A, Numann PJ, Khan S (October 1995). "Pathogenesis-based treatment of recurring subareolar breast abscesses". Surgery. 118 (4): 775–82. PMID 7570336.
  8. Mazzella C, Costa C, Fabbrocini G, Marangi GF, Russo D, Merolla F, Scalvenzi M (November 2016). "Nevoid hyperkeratosis of the nipple mimicking a pigmented basal cell carcinoma". JAAD Case Rep. 2 (6): 500–501. doi:10.1016/j.jdcr.2016.09.007. PMC 5161776. PMID 28004028.
  9. Ghanadan A, Balighi K, Khezri S, Kamyabhesari K (September 2013). "Nevoid Hyperkeratosis of the Nipple and/or Areola: Treatment with Topical Steroid". Indian J Dermatol. 58 (5): 408. doi:10.4103/0019-5154.117347. PMC 3778809. PMID 24082214.
  10. Hokama A, Fujita J (November 2010). "Mondor disease: an unusual cause of chest pain". South. Med. J. 103 (11): 1189. doi:10.1097/SMJ.0b013e3181ecfcf3. PMID 20890261.
  11. Shetty MK, Watson AB (October 2001). "Mondor's disease of the breast: sonographic and mammographic findings". AJR Am J Roentgenol. 177 (4): 893–6. doi:10.2214/ajr.177.4.1770893. PMID 11566698.
  12. Kvist LJ, Larsson BW, Hall-Lord ML, Steen A, Schalén C (April 2008). "The role of bacteria in lactational mastitis and some considerations of the use of antibiotic treatment". Int Breastfeed J. 3: 6. doi:10.1186/1746-4358-3-6. PMC 2322959. PMID 18394188.
  13. Foxman B, D'Arcy H, Gillespie B, Bobo JK, Schwartz K (January 2002). "Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States". Am. J. Epidemiol. 155 (2): 103–14. PMID 11790672.
  14. Matro JM, Li T, Cristofanilli M, Hughes ME, Ottesen RA, Weeks JC, Wong YN (February 2015). "Inflammatory breast cancer management in the national comprehensive cancer network: the disease, recurrence pattern, and outcome". Clin. Breast Cancer. 15 (1): 1–7. doi:10.1016/j.clbc.2014.05.005. PMC 4422394. PMID 25034439.
  15. Dawood S, Merajver SD, Viens P, Vermeulen PB, Swain SM, Buchholz TA, Dirix LY, Levine PH, Lucci A, Krishnamurthy S, Robertson FM, Woodward WA, Yang WT, Ueno NT, Cristofanilli M (March 2011). "International expert panel on inflammatory breast cancer: consensus statement for standardized diagnosis and treatment". Ann. Oncol. 22 (3): 515–23. doi:10.1093/annonc/mdq345. PMC 3105293. PMID 20603440.