Paget's disease of the breast differential diagnosis

Revision as of 02:10, 25 February 2019 by Preeti Singh (talk | contribs)
Jump to navigation Jump to search

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
Extramammary Paget's disease Malignant Biopsy
Atopic dermatitis

(Eczema)

  • Epidermal barrier dysfunction
  • Immune dysregulation
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 +
Psoriasis Benign Well-circumscribed, pink papules and symmetrically distributed cutaneous plaques with silvery scales + + 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
±
Bowen’s disease Benign can turn malignant
  • Erythematous
  • Skin colored
  • Patch
  • Plaque
  • scaly
  • variable size
  • Presence of dotted and/or glomerular vessels
  • White to yellowish surface scales
  • Red-yellowish background
  • Keratinocytic dysplasia of the epidermis
  • No infiltration into dermis
  • Pleomorphic keratinocytes
  • Hyperchromatic nuclei
  • Slow growth over the years
Superficial basal cell carcinoma Malignant
  • Erythematous
  • Superficial scaly patch
  • 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
Benign intraductal papilloma
Pagetoid dyskeratosis
Lactiferous duct ectasia Benign
  • Usually resolve spontaneously
Ultrasound:
  • Dilated milk ducts
  • Fluid-filled ducts
Nevoid hyperkeratosis of the nipple and areola (NHNA) [6][7] Benign Slow growing bluish-brown verrucous thickening of the nipple or areola.
  • Usually bilateral nipple is effected
Biopsy
Benign Toker cell hyperplasia
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[8][9] 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.
  • Usually unilateral nipple is effected
  • No associated lymphadenopathy.
  • N/A–
  • Predominantly seen in middle-aged women but is also seen in men.
  • May indicate breast cancer.
Mastitis
  • 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 Malignant 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. 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.
  7. 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.
  8. 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.
  9. 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.