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Question

Difficulty: MediumBreast Disorders

A 59-year-old woman comes to the clinic due to a persistent, itchy rash on her right breast that has been present for the past 4 months. She initially thought it was dry skin and applied over-the-counter moisturizers and a low-potency topical hydrocortisone cream for several weeks, but the lesion has progressively worsened. On physical examination, there is an erythematous, sharply demarcated, scaling, and crusted plaque restricted to the right nipple and extending slightly onto the areola. The right nipple appears partially inverted. Palpation reveals no discrete underlying breast mass, and axillary lymph nodes are not palpable. Bilateral mammography performed today shows no distinct masses or suspicious microcalcifications. Which of the following is the most appropriate next step in management?

  1. Punch biopsy of the nipple-areolar complexAnswer
  2. B
    Prescription of a high-potency topical corticosteroid
  3. C
    Empiric treatment with an oral antibiotic targeting Staphylococcus aureus
  4. D
    Swab of the nipple for bacterial and fungal cultures
  5. E
    Magnetic resonance imaging (MRI) of the breasts

Answer

Punch biopsy of the nipple-areolar complex is the most appropriate next step in management.
The correct answer is a punch biopsy of the nipple-areolar complex. This patient's persistent, unilateral, eczematous, and scaling nipple rash that is refractory to topical corticosteroids is highly suspicious for Paget disease of the breast. Paget disease is a rare intraepithelial adenocarcinoma of the nipple epidermis, almost always associated with an underlying in situ or invasive breast malignancy. Even in the absence of a palpable mass or suspicious mammographic findings, the definitive diagnostic step for a suspected Paget lesion is a full-thickness skin biopsy (such as a punch biopsy) of the nipple to identify malignant intraepithelial cells.

Step-by-Step Solution

1
Analyze the clinical presentation.
The patient has a 4-month history of a persistent, unilateral, eczematous, and scaling nipple rash that has not responded to conservative topical therapies.
Identifying the chronic and refractory nature of the lesion helps rule out simple benign dermatologic conditions.
2
Correlate the findings with potential breast pathologies.
A scaling, crusted plaque on the nipple accompanied by nipple inversion is the classic clinical presentation of Paget disease of the breast.
Recognizing the pathognomonic signs of Paget disease is essential for guiding the diagnostic workup.
3
Determine the most appropriate next step in management.
A full-thickness tissue biopsy of the skin lesion is required.
Even with negative mammography, a persistent unilateral nipple lesion must be biopsied to histologically confirm the presence of malignant intraepithelial cells.

Key Concept

Any persistent, unilateral, eczematous, or scaling lesion of the nipple-areolar complex that does not respond to topical treatments must be biopsied to rule out Paget disease of the breast.
Estimated Time:1m 0s
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Topics

Breast Disorders

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