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Question

Difficulty: HardBreast Disorders

A 54-year-old postmenopausal woman comes to the clinic due to a 3-month history of an itchy, flaking rash on her left nipple and areola. She states that the rash initially began as a small red patch but has gradually spread and thickened. She applied an over-the-counter hydrocortisone cream twice daily for 4 weeks with no improvement. She has no personal or family history of breast cancer. On physical examination, there is a unilateral, well-demarcated, erythematous, scaly plaque confined to the left nipple-areolar complex with small areas of superficial crusting and ulceration. The nipple appears slightly flattened. Palpation of the left breast yields no distinct masses. Axillary lymph nodes are not palpable. Bilateral diagnostic mammography reveals no abnormalities. Which of the following is the most appropriate next step in management?

  1. Punch biopsy of the skin lesionAnswer
  2. B
    Breast magnetic resonance imaging
  3. C
    Oral cephalexin therapy
  4. D
    Trial of topical high-potency corticosteroids
  5. E
    Core needle biopsy of the retroareolar tissue

Answer

Punch biopsy of the skin lesion is the most appropriate next step to diagnose suspected Paget disease of the breast.
This patient presents with a unilateral, pruritic, scaly, and crusting erythematous plaque on the nipple-areolar complex that is refractory to low-potency topical corticosteroids. This presentation is highly suspicious for Paget disease of the breast, a rare malignancy characterized by the migration of malignant glandular cells (Paget cells) through the lactiferous ducts to the nipple epidermis. The most appropriate next step in management is a full-thickness skin biopsy (such as a punch biopsy) of the affected area to establish a histopathologic diagnosis. Even with a negative mammogram and no palpable mass, biopsy is mandatory because a significant percentage of patients with Paget disease have an underlying ductal carcinoma in situ (DCIS) or invasive carcinoma that is occult on mammography.

Step-by-Step Solution

1
Identify the key clinical features
Unilateral, persistent, pruritic and scaling nipple rash in a postmenopausal woman that is refractory to topical corticosteroids.
Differentiates malignant from benign etiology.
2
Determine the most likely diagnosis
Paget disease of the breast.
The failure of empirical treatment for a unilateral eczema-like lesion points toward a neoplastic process involving the nipple epidermis.
3
Select the most appropriate diagnostic test
Punch biopsy of the affected skin.
A full-thickness skin biopsy is required to identify intraepidermal Paget cells and establish the diagnosis, regardless of mammography findings.

Key Concept

Diagnosis of Paget disease of the breast requires a full-thickness skin biopsy (e.g., punch biopsy) of the affected nipple-areolar complex, especially when conservative therapy fails.
Estimated Time:1m 30s
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Topics

Breast Disorders

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