Monday, March 30, 2015

Pagets disease of the nipple

Posted by Pulasthi Senaratna

Pagets disease of the nipple

A 65 year old lady presents with a lesion affecting her right breast. On examination she has a weeping, crusting lesion overling the right nipple, the areolar region is not involved. There is no palpable mass lesion in the breast, there is a palpable axillary lymph node. The patients general practitioner has tried treating the lesion with 1% hydrocortisone cream, with no success. What is the most likely diagnosis?

  

A.

Infection with Staphylococcus aureus

 

 

B.

Pagets disease of the nipple

  

C.

Phyllodes tumour

  

D.

Nipple eczema

  

E.

Basal cell carcinoma

 

A weeping, crusty lesion such as this is most likely to represent Pagets disease of the nipple (especially since the areolar region is spared). Although no mass lesion is palpable, a proportion of patients will still have an underlying invasive malignancy (hence the lymphadenopathy).

 

Pagets disease of the nipple

Pagets disease is an eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer. In half of these patients, it is associated with an underlying mass lesion and 90% of such patients will have an invasive carcinoma. 30% of patients without a mass lesion will still be found to have an underlying carcinoma. The remainder will have carcinoma in situ.
Pagets disease differs from eczema of the nipple in that it involves the nipple primarily and only latterly spreads to the areolar (the opposite occurs in eczema).
Diagnosis is made by punch biopsy, mammography and ultrasound of the breast.
Treatment will depend on the underlying lesion.