:::: FOR OUR REFERRING PHYSICIANS : NEWSLETTER :.

Pagets vs Eczema

Dear Colleagues:

Having seen a recent case of Paget’s disease of the nipple followed for several months as “eczema”, it seemed appropriate to draw attention to the diagnosis and management of this relatively uncommon but important manifestation of breast cancer.

I hope you find the accompanying discussion about Paget’s disease useful.  As always, my colleagues and I are available to answer your questions, provide consultations and meet the breast imaging needs of your patients.

Sincerely,

G.W. Eklund, M.D., FACR

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Paget ’s disease vs. Eczema of the nipple

G.W. Eklund, M.D., FACR, Medical Director
Pacific Breast Center

What is Paget’s disease?

Paget’s disease of the nipple is an uncommon form of breast cancer (<5% of all breast cancers) that is almost always associated with an underlying breast cancer (invasive or intraductal carcinoma).  Paget’s may occur in women of all ages and may rarely be seen in males. Malignant cells from the underlying lesion migrate down the ducts to the nipple surface. In rare cases, the nipple surface is involved without an identifiable underlying lesion.

What is the clinical presentation of Paget’s disease?

Patients with Paget’s disease present with redness and scaling or eczema-like changes on the nipple surface. Early in the course of the disease, there may be only itching or burning with signs of mild irritation that may be mistakenly attributed to an external irritant. Some cases may respond temporarily to topical treatment, contributing to delays in diagnosis, which are not uncommonly 6 to 12 months. Although Paget’s disease can affect the nipple and areola, it is unusual to see the areola affected without involvement of the nipple. Eczema, on the other hand, typically involves the areola with scaling, itching and redness.  Advanced cases of Paget’s may show ulceration or erosion of the nipple surface with or without involvement of the areola.

How is the diagnosis of Paget’s disease confirmed?

Diagnosis of Paget’s disease is established through skin biopsy of the affected area and the microscopic demonstration of Paget cells in the epithelial layer of the skin.

How is Paget’s disease treated?

Treatment is surgical, usually followed with radiation and possibly chemotherapy. If an identified underlying lesion can be confirmed with breast imaging and the patient is a candidate for breast conservation, removal of the nipple/areolar complex is followed with lumpectomy and radiation. If no underlying lesion is detectable by imaging, mastectomy is usually performed.

What are the “take-home messages”about Paget’s disease?

Paget’s disease must be considered for all cases of eczema-like nipple changes, regardless of patient age or apparent improvement with topical treatments.

• The complaint of nipple itching should prompt careful breast physical examination with inspection of the nipple surface with comparison to the contralateral nipple.
• Any palpable abnormalities or evidence of reddening, scaling or erosion of the nipple should prompt referral for diagnostic breast imaging studies to assess palpable concerns and search for clinically occult lesions.
• Clinical findings consistent with Paget’s disease which have negative mammographic findings should be further evaluated with breast MRI or Gamma Imaging to search for lesions that may be mammographically occult.
• Nipple skin biopsy is required for confirmation.

Suggested reading:

• Marcus E. The management of Paget’s disease of the breast. Current Treatment Options in Oncology 2004; 5:153–160
• Kaelin CM. Paget’s Disease. In Harris JR, Lippman ME, Morrow M, Osborne CK, editors. Diseases of the Breast. 3rd ed. Philadelphia: Lippincott Williams and Wilkins, 2004.