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

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* [[Biopsy]]
* [[Biopsy]]


* Immunohistochemical stain for:
* Immunohistochemical stain for Anti[[interleukin]]:
:*Anti[[interleukin]] [[Interleukin 4|(IL)-4]]
:*[[Interleukin 4|IL-4]]
:*Anti-[[Interleukin 13|IL-13]]  
:*Anti-[[Interleukin 13|IL-13]]  
:*Anti-[[CD4]]   
:*Anti-[[CD4]]   
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* [[Benign]]
* [[Benign]]
* Neoplasm of breast lactiferous ducts
* Neoplasm of breast lactiferous ducts
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* [[Proliferation]] of the inner  [[Epithelial|epithelial layer]] and outer, [[basal layer]] of [[myoepithelial cells]] of the [[Lactiferous duct|lactiferous ducts]]  the [[nipple]].
* [[Proliferation]] of the inner  [[Epithelial|epithelial layer]] and outer, [[basal layer]] of [[myoepithelial cells]] of the [[Lactiferous duct|lactiferous ducts]]  the [[nipple]].
| align="center" style="background:#F5F5F5;" |[[Eczema]], crusts or erosion of nipple
| align="left" style="background:#F5F5F5;" |[[Eczema]], crusts or erosion of nipple
| align="center" style="background:#F5F5F5;" |Serous or bloody [[nipple discharge]].
| align="left" style="background:#F5F5F5;" |Serous or bloody [[nipple discharge]].
| 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;" |
| align="left" style="background:#F5F5F5;" |
* [[Nipple]] may have unencapsulated, firm  [[Granuloma|granulomatous lesion]] .
* [[Nipple]] may have unencapsulated, firm  [[Granuloma|granulomatous lesion]] .
* A non-tender [[nodule]] either within or under the [[nipple]] adherent to the [[skin]], but not the [[breast]] may be palpated.  
* A non-tender [[nodule]] either within or under the [[nipple]] adherent to the [[skin]], but not the [[breast]] may be palpated.  
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Insidious onset.
* Insidious onset.
* [[Erythema]] may be seen prior to [[erosion]].
* [[Erythema]] may be seen prior to [[erosion]].
* No  [[lymphadenopathy]].
* No  [[lymphadenopathy]].
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Overlying epidermis often shows [[acanthosis]] and [[hyperkeratosis]].  
* Overlying epidermis often shows [[acanthosis]] and [[hyperkeratosis]].  
* Papillomatous pattern: [[vascular]] papillae project into dilated [[lumina]] and are surrounded by [[Epithelial cells|proliferating epithelial cells]] .
* Papillomatous pattern: [[vascular]] papillae project into dilated [[lumina]] and are surrounded by [[Epithelial cells|proliferating epithelial cells]] .
* [[Papilla|Papillary]] pattern:  [[cells]] proliferate into large cords with deep fissures and clefts and dense [[stroma]].
* [[Papilla|Papillary]] pattern:  [[cells]] proliferate into large cords with deep fissures and clefts and dense [[stroma]].
| align="center" style="background:#F5F5F5;" |[[Biopsy]]: Shows absence of [[Atypia|cytological atypia]]
| align="left" style="background:#F5F5F5;" |[[Biopsy]]: Shows absence of [[Atypia|cytological atypia]]
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* [[Incidence]] is highest in the fifth decade in women.
* [[Incidence]] is highest in the fifth decade in women.
* No  [[lymphadenopathy]].
* No  [[lymphadenopathy]].
|-
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Contact dermatitis|Allergic contact dermatitis]]<ref name="pmid19447733">{{cite journal |vauthors=Nosbaum A, Vocanson M, Rozieres A, Hennino A, Nicolas JF |title=Allergic and irritant contact dermatitis |journal=Eur J Dermatol |volume=19 |issue=4 |pages=325–32 |date=2009 |pmid=19447733 |doi=10.1684/ejd.2009.0686 |url=}}</ref>
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Contact dermatitis|Allergic contact dermatitis]]<ref name="pmid19447733">{{cite journal |vauthors=Nosbaum A, Vocanson M, Rozieres A, Hennino A, Nicolas JF |title=Allergic and irritant contact dermatitis |journal=Eur J Dermatol |volume=19 |issue=4 |pages=325–32 |date=2009 |pmid=19447733 |doi=10.1684/ejd.2009.0686 |url=}}</ref>
| align="center" style="background:#F5F5F5;" |[[Benign]]
| align="left" style="background:#F5F5F5;" |[[Benign]]
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Delayed-type [[hypersensitivity]] response
* Delayed-type [[hypersensitivity]] response
* Skin [[inflammation]] mediated by [[Haptens|hapten]]-specific T cells
* Skin [[inflammation]] mediated by [[Haptens|hapten]]-specific T cells
| align="center" style="background:#F5F5F5;" | Erythematous well-demarcated [[papules]]
| align="left" style="background:#F5F5F5;" | Erythematous well-demarcated [[papules]]
| 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;" | +
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" |N/A
| align="center" style="background:#F5F5F5;" |N/A
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Stinging and burning
* Stinging and burning
* Localized [[swelling]]
* Localized [[swelling]]
* [[Lichenification|Lichenified]] [[Itch|pruritic]] [[plaques]]
* [[Lichenification|Lichenified]] [[Itch|pruritic]] [[plaques]]
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* [[Eosinophilic]] spongiosis and [[microvesicles]]
* [[Eosinophilic]] spongiosis and [[microvesicles]]
* [[Exocytosis]] of [[eosinophils]] and [[lymphocytes]]  
* [[Exocytosis]] of [[eosinophils]] and [[lymphocytes]]  
* Chronic - [[Hyperkeratosis]] and [[parakeratosis]]
* Chronic - [[Hyperkeratosis]] and [[parakeratosis]]
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Clinical examination
* Clinical examination
* [[Biopsy]]
* [[Biopsy]]
*
| align="center" style="background:#F5F5F5;" |
| align="center" style="background:#F5F5F5;" |
* Contact with [[allergens]] in the past 1-2 days
* Contact with [[allergens]] in the past 1-2 days
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|-
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Psoriasis]]<ref name="pmid20107724">{{cite journal |vauthors=Ljosaa TM, Rustoen T, Mörk C, Stubhaug A, Miaskowski C, Paul SM, Wahl AK |title=Skin pain and discomfort in psoriasis: an exploratory study of symptom prevalence and characteristics |journal=Acta Derm. Venereol. |volume=90 |issue=1 |pages=39–45 |date=2010 |pmid=20107724 |doi=10.2340/00015555-0764 |url=}}</ref><ref name="pmid1390163">{{cite journal |vauthors=Naldi L, Parazzini F, Brevi A, Peserico A, Veller Fornasa C, Grosso G, Rossi E, Marinaro P, Polenghi MM, Finzi A |title=Family history, smoking habits, alcohol consumption and risk of psoriasis |journal=Br. J. Dermatol. |volume=127 |issue=3 |pages=212–7 |date=September 1992 |pmid=1390163 |doi= |url=}}</ref>
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Psoriasis]]<ref name="pmid20107724">{{cite journal |vauthors=Ljosaa TM, Rustoen T, Mörk C, Stubhaug A, Miaskowski C, Paul SM, Wahl AK |title=Skin pain and discomfort in psoriasis: an exploratory study of symptom prevalence and characteristics |journal=Acta Derm. Venereol. |volume=90 |issue=1 |pages=39–45 |date=2010 |pmid=20107724 |doi=10.2340/00015555-0764 |url=}}</ref><ref name="pmid1390163">{{cite journal |vauthors=Naldi L, Parazzini F, Brevi A, Peserico A, Veller Fornasa C, Grosso G, Rossi E, Marinaro P, Polenghi MM, Finzi A |title=Family history, smoking habits, alcohol consumption and risk of psoriasis |journal=Br. J. Dermatol. |volume=127 |issue=3 |pages=212–7 |date=September 1992 |pmid=1390163 |doi= |url=}}</ref>
| align="center" style="background:#F5F5F5;" |[[Benign]]
| align="left" style="background:#F5F5F5;" |[[Benign]]
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* [[Keratinocyte]] hyperproliferation
* [[Keratinocyte]] hyperproliferation
* Dysregulation of the [[immune system]]
* Dysregulation of the [[immune system]]
| align="center" style="background:#F5F5F5;" | Well-circumscribed, pink [[papules]] and symmetrically distributed cutaneous [[plaques]] with silvery scales
| align="left" style="background:#F5F5F5;" | Well-circumscribed, pink [[papules]] and symmetrically distributed cutaneous [[plaques]] with silvery scales
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | +
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| align="center" style="background:#F5F5F5;" | N/A
| align="center" style="background:#F5F5F5;" | N/A
| align="center" style="background:#F5F5F5;" |[[Auspitz's sign]]  (pinpoint bleeding)
| align="left" style="background:#F5F5F5;" |[[Auspitz's sign]]  (pinpoint bleeding)
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* [[Epidermal]] [[hyperplasia]]
* [[Epidermal]] [[hyperplasia]]
* Parakeratosis
* Parakeratosis
* [[Neutrophils]] microabscesses (Munro microabscesses)
* [[Neutrophils]] microabscesses (Munro microabscesses)
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Clinical examination
* Clinical examination
* [[Biopsy]]
* [[Biopsy]]
|Risk factors include
|Risk factors include
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|-
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Melanoma|Malignant melanoma]]
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Melanoma|Malignant melanoma]]
| align="center" style="background:#F5F5F5;" |[[Malignant]]
| align="left" style="background:#F5F5F5;" |[[Malignant]]
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* [[Neural crest cell]] derivative
* [[Neural crest cell]] derivative
* Development begins with disruption of [[nevus]] growth control
* Development begins with disruption of [[nevus]] growth control
* Progression involves [[MAPK/ERK pathway]]
* Progression involves [[MAPK/ERK pathway]]
* [[RAS|N-RAS]] or [[BRAF]] [[oncogene]]<nowiki/>also involved
* [[RAS|N-RAS]] or [[BRAF]] [[oncogene]]<nowiki/>also involved
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Macule
* Macule
* Plaque with irregular border
* Plaque with irregular border
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| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |N/A
| align="center" style="background:#F5F5F5;" |N/A
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Pigmented lesion with:  
* Pigmented lesion with:  
* Asymmetry
* Asymmetry
* Irregular borders
* Irregular borders
* Variegated color
* Variegated color
* Diameter >6 mm
* Diameter >6 mm
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Nests of  atypical melanocytes with asymmetry, poor circumscription of varying sizes and shapes
* Nests of  atypical melanocytes with asymmetry, poor circumscription of varying sizes and shapes
* Present in the lower epidermis and dermis
* Present in the lower epidermis and dermis
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Complete full-thickness excisional [[biopsy]] of suspicious lesions with 1 to 3 mm margin of normal skin.
* Complete full-thickness excisional [[biopsy]] of suspicious lesions with 1 to 3 mm margin of normal skin.
| align="left" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
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|-
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Bowen’s disease]]
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Bowen’s disease]]
| align="center" style="background:#F5F5F5;" |[[Benign]] can turn [[malignant]]
| align="left" style="background:#F5F5F5;" |[[Benign]] can turn [[malignant]]
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Solar damage
* Solar damage
* [[Arsenic]]  
* [[Arsenic]]  
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* [[Viral]] [[infection]] ([[human papillomavirus]] or [[HPV]])  
* [[Viral]] [[infection]] ([[human papillomavirus]] or [[HPV]])  
* [[Skin disease|Dermatoses]]
* [[Skin disease|Dermatoses]]
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* [[Erythema|Erythematous]]
* [[Erythema|Erythematous]]
* Skin colored
* Skin colored
* Patch
* Patch
* Plaque
* Plaque
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| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |N/A
| align="center" style="background:#F5F5F5;" |N/A
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Presence of dotted and/or glomerular vessels
* Presence of dotted and/or glomerular vessels
* White to yellowish surface scales
* White to yellowish surface scales
* Red-yellowish background
* Red-yellowish background
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Keratinocytic dysplasia of the  
* Keratinocytic dysplasia of the  
*  
*  
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* Pleomorphic keratinocytes
* Pleomorphic keratinocytes
* Hyperchromatic nuclei
* Hyperchromatic nuclei
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Clinical examination
* Clinical examination


* [[Biopsy]]
* [[Biopsy]]
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Slow growth over the years
* Slow growth over the years
|-
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Basal cell carcinoma|Superficial basal cell carcinoma]]<ref name="pmid11668245">{{cite journal |vauthors=Yamamoto H, Ito Y, Hayashi T, Urano N, Kato T, Kimura Y, Tanigawa T, Endo W, Kurokawa E, Kikkawa N, Taniguchi H |title=A case of basal cell carcinoma of the nipple and areola with intraductal spread |journal=Breast Cancer |volume=8 |issue=3 |pages=229–33 |date=2001 |pmid=11668245 |doi= |url=}}</ref><ref name="pmid30057838">{{cite journal |vauthors=Ulanja MB, Taha ME, Al-Mashhadani AA, Al-Tekreeti MM, Elliot C, Ambika S |title=Basal Cell Carcinoma of the Female Breast Masquerading as Invasive Primary Breast Carcinoma: An Uncommon Presentation Site |journal=Case Rep Oncol Med |volume=2018 |issue= |pages=5302185 |date=2018 |pmid=30057838 |pmc=6051126 |doi=10.1155/2018/5302185 |url=}}</ref>
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Basal cell carcinoma|Superficial basal cell carcinoma]]<ref name="pmid11668245">{{cite journal |vauthors=Yamamoto H, Ito Y, Hayashi T, Urano N, Kato T, Kimura Y, Tanigawa T, Endo W, Kurokawa E, Kikkawa N, Taniguchi H |title=A case of basal cell carcinoma of the nipple and areola with intraductal spread |journal=Breast Cancer |volume=8 |issue=3 |pages=229–33 |date=2001 |pmid=11668245 |doi= |url=}}</ref><ref name="pmid30057838">{{cite journal |vauthors=Ulanja MB, Taha ME, Al-Mashhadani AA, Al-Tekreeti MM, Elliot C, Ambika S |title=Basal Cell Carcinoma of the Female Breast Masquerading as Invasive Primary Breast Carcinoma: An Uncommon Presentation Site |journal=Case Rep Oncol Med |volume=2018 |issue= |pages=5302185 |date=2018 |pmid=30057838 |pmc=6051126 |doi=10.1155/2018/5302185 |url=}}</ref>
| align="center" style="background:#F5F5F5;" |[[Malignant]]
| align="left" style="background:#F5F5F5;" |[[Malignant]]
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* UV light induces inflammation of the skin.
* UV light induces inflammation of the skin.
* Patched 1 (PTCH1) tumor suppressor gene on chromosome 9  
* Patched 1 (PTCH1) tumor suppressor gene on chromosome 9  
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| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |N/A
| align="center" style="background:#F5F5F5;" |N/A
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Superficial fine telangiectasia
* Superficial fine telangiectasia
* Shiny white to red, translucent or opaque structureless areas
* Shiny white to red, translucent or opaque structureless areas
* Multiple small erosions
* Multiple small erosions
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Large, hyperchromatic, oval nuclei
* Large, hyperchromatic, oval nuclei
* Minimal cytoplasm
* Minimal cytoplasm
* Small basaloid nodules
* Small basaloid nodules
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* [[Biopsy]]
* [[Biopsy]]
| align="center" style="background:#F5F5F5;" |
| align="center" style="background:#F5F5F5;" |
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|-
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |Squamous metaplasia of lactiferous ducts (SMOLD)/  [[Zuska's disease]]<ref name="pmid20610247">{{cite journal |vauthors=Gollapalli V, Liao J, Dudakovic A, Sugg SL, Scott-Conner CE, Weigel RJ |title=Risk factors for development and recurrence of primary breast abscesses |journal=J. Am. Coll. Surg. |volume=211 |issue=1 |pages=41–8 |date=July 2010 |pmid=20610247 |doi=10.1016/j.jamcollsurg.2010.04.007 |url=}}</ref><ref name="pmid7570336">{{cite journal |vauthors=Meguid MM, Oler A, Numann PJ, Khan S |title=Pathogenesis-based treatment of recurring subareolar breast abscesses |journal=Surgery |volume=118 |issue=4 |pages=775–82 |date=October 1995 |pmid=7570336 |doi= |url=}}</ref>
! style="background: #DCDCDC; padding: 5px; text-align: center;" |Squamous metaplasia of lactiferous ducts (SMOLD)/  [[Zuska's disease]]<ref name="pmid20610247">{{cite journal |vauthors=Gollapalli V, Liao J, Dudakovic A, Sugg SL, Scott-Conner CE, Weigel RJ |title=Risk factors for development and recurrence of primary breast abscesses |journal=J. Am. Coll. Surg. |volume=211 |issue=1 |pages=41–8 |date=July 2010 |pmid=20610247 |doi=10.1016/j.jamcollsurg.2010.04.007 |url=}}</ref><ref name="pmid7570336">{{cite journal |vauthors=Meguid MM, Oler A, Numann PJ, Khan S |title=Pathogenesis-based treatment of recurring subareolar breast abscesses |journal=Surgery |volume=118 |issue=4 |pages=775–82 |date=October 1995 |pmid=7570336 |doi= |url=}}</ref>
| align="center" style="background:#F5F5F5;" |[[Benign]]
| align="left" style="background:#F5F5F5;" |[[Benign]]
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* [[Keratin]] plug blocking [[lactiferous duct]] leads to [[duct]] rupture and spillage of [[keratin]] debris in [[stroma]]  
* [[Keratin]] plug blocking [[lactiferous duct]] leads to [[duct]] rupture and spillage of [[keratin]] debris in [[stroma]]  
* Leading to [[chronic inflammation]] with [[giant cells]] surrounding ducts and  [[squamous metaplasia]]
* Leading to [[chronic inflammation]] with [[giant cells]] surrounding ducts and  [[squamous metaplasia]]
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Painful [[erythematous]] [[Subareolar abscess|subareolar mass]]  
* Painful [[erythematous]] [[Subareolar abscess|subareolar mass]]  
* Single [[Fistula|fistula tract]] at the [[Areolar tissue|areolar]] edge.
* Single [[Fistula|fistula tract]] at the [[Areolar tissue|areolar]] edge.
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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;" |
| align="left" style="background:#F5F5F5;" |
* [[Tenderness (medicine)|Tender]] [[Erythema|erythematous]], [[Subareolar abscess|subareolar]] [[mass]].
* [[Tenderness (medicine)|Tender]] [[Erythema|erythematous]], [[Subareolar abscess|subareolar]] [[mass]].
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Appears as an ill-defined firm area.
* Appears as an ill-defined firm area.
* No associated [[lymphadenopathy]].
* No associated [[lymphadenopathy]].
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* [[Squamous epithelium]] extending beyond the normal transition point within the [[Duct carcinoma|duct]] orifice into ductal [[epithelium]].
* [[Squamous epithelium]] extending beyond the normal transition point within the [[Duct carcinoma|duct]] orifice into ductal [[epithelium]].
* [[Keratin]] debris can extend into duct spaces.  
* [[Keratin]] debris can extend into duct spaces.  
* [[Squamous metaplasia]] of the deep [[ducts]] filled with [[keratin]] debris can be seen along with areas of rupture and spillage of [[keratin]] into the surrounding [[stroma]].
* [[Squamous metaplasia]] of the deep [[ducts]] filled with [[keratin]] debris can be seen along with areas of rupture and spillage of [[keratin]] into the surrounding [[stroma]].
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* [[Biopsy]]
* [[Biopsy]]
| align="center" style="background:#F5F5F5;" |
| align="left" style="background:#F5F5F5;" |
* Strong association with [[smoking]].
* Strong association with [[smoking]].
* [[Tobacco]] exposure or decreased level of [[vitamin A]] secondary to [[smoking]] may cause [[squamous metaplasia]].
* [[Tobacco]] exposure or decreased level of [[vitamin A]] secondary to [[smoking]] may cause [[squamous metaplasia]].

Revision as of 15:15, 27 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

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

(Eczema)[3][4]

  • Epidermal barrier dysfunction
  • Immune dysregulation
N/A
  • Clinical examination
Erosive adenomatosis of the nipple[5][6]
  • Benign
  • Neoplasm of breast lactiferous ducts
Eczema, crusts or erosion of nipple Serous or bloody nipple discharge. + Biopsy: Shows absence of cytological atypia
Allergic contact dermatitis[7] Benign Erythematous well-demarcated papules + N/A
Psoriasis[8][9] Benign Well-circumscribed, pink papules and symmetrically distributed cutaneous plaques with silvery scales + + N/A Auspitz's sign (pinpoint bleeding) 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 + 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[10][11] Malignant
  • UV light induces inflammation of the skin.
  • Patched 1 (PTCH1) tumor suppressor gene on chromosome 9
  • P53 mutations.
+ 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[12][13] 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) [14][15] 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[16][17] 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[18][19]
  • 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[20][21] Malignant Cancer cells block the lymphatic vessels in skin covering the breast
  • Localized erythema, warmth, swelling, and pain.
+ +
  • Usually unilateral
Core needle Biopsy

References

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