Paget's disease of the breast differential diagnosis

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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:[1][2]

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 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. +
  • 50% of the cases of Paget’s disease of the breast are associated with a palpable underlying mass.
  • 90% of the cases will have an invasive intraductal carcinoma of the breast.
  • May positive staining against CEA antigen and the c erbB-2 / her-2 neu oncoprotein.
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

Bleeding from the lesion may be present

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 Common among premenopausal women slow growing brown pigmentation and verrucous thickening of the nipple or areola. Usually bilateral nipple is effected Acanthosis, hyperkeratosis, and papillomatosis of the epidermis Biopsy
Benign Toker cell hyperplasia
Breast abscess Benign +

Ultrasound:

  • Fluid collection
Mondors disease
Mastitis ±

Breast parenchymainflammation:

Ultrasound:

  • Ill-defined area with hyperechogenicity with inflamed fat lobules
  • Skin thickening
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.