Paget's disease of the breast differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Preeti Singh, M.B.B.S.[2]

Overview

Due to close similarity with many skin lesions, the diagnosis of Mammary Paget’s diseas may be delayed or many cases can be misdiagnosed. Immunohistochemical staining for cytokeratin, epithelial membrane antigen (EMA) and c-erb-B2 oncoprotein is useful for the differential diagnosis. Toker cells found in the epidermis of the nipple, close to the opening of lactiferous ducts, along the basal layer of the epidermis, are morphological and immunohistochemical similar to mammary Paget's cells. In contrast to Paget's cells which are strongly associated with both Ki-67 and Her-2/c-erbB-2 and these markers are mostly used to distinguish Paget's cells from Toker cells. In case of atypical Toker cells a combination of CD138 and p53 is very helpful in distinguishing these atypical cells from Paget's cells. Paget's disease of the breast must be differentiated from atopic dermatitis, eczema, psoriasis, malignant melanoma, Bowen's disease, basal cell carcinoma, benign intraductal papilloma, nevoid hyperkeratosis of the nipple and areola (NHNA), squamous metaplasia of lactiferous ducts (SMOLD)/ Zuska's disease and pagetoid dyskeratosis.

Differential Diagnosis

• The Paget’s disease of the breast is associated with changes in the nipple-areola complex.
• Any patient presenting with changes in the nipple or areola requires surgical biopsy of the nipple-areola complex for definitive diagnosis.
• Immunohistochemical staining for cytokeratin, epithelial membrane antigen (EMA) and c-erb-B2 oncoprotein is useful for the differential diagnosis.
• Due to close similarity with many skin lesions, the diagnosis of mammary Paget’s Diseas may be delayed or many cases can be misdiagnosed.
• Toker cells found in the epidermis of the nipple, close to the opening of lactiferous ducts, along the basal layer of the epidermis, are morphological and immunohistochemical similar to mammary Paget's cells
• They are observed in about 10% of standard histological preparations of normal nipples and can be confused with Paget's disease not associated with invasive carcinoma or DICS.
• Mainly in cases of Toker cell hyperplasia with cytologic atypia, it may be difficult to distinguish them from Paget's cells.
• They are mainly distinguished from Paget's cells due to the latter having large, pleomorphic and cytologically atypical nuclei.
• CK7 and Her-2/c-erbB-2 have been proposed to be specific and sensitive markers for Paget cells.
• Toker cells are said to be consistently positive for CK7 and estrogen receptors. Ki-67 and Her-2/c-erbB-2 are rarely expressed in these cells.
• In contrast to Paget's cells which are strongly associated with both Ki-67 and Her-2/c-erbB-2 and these markers are mostly used to distinguish Paget's cells from Toker cells.
• In case of atypical Toker cells a combination of CD138 and p53 is very helpful in distinguishing these atypical cells from Paget's cells.

Paget's disease of the breast is often confused with

• Eczema
• Dermatitis of the nipple
• Lactiferous duct ectasia
• Chronic eczema
• Psoriasis
• Nipple duct adenoma
• Malignant melanoma(particularly the pigmented lesions)
• Bowen’s disease
• Superficial basal cell carcinoma
• Squamous metaplasia of lactiferous ducts (SMOLD)/ Zuska's disease
• Benign intraductal papilloma
• Nevoid hyperkeratosis of the nipple and areola (NHNA)
• Pagetoid dyskeratosis
• Mastitis
• Breast abcess

Diseases	Benign or Malignant	Etiology	Clinical manifestations						Histopathology	Gold Standard	Associated factors
			Symptoms				Physical examination
			Rash	Nipple Discharge	Erythema	Mastalgia	Breast Exam	Other
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.	+	+	±	Well-demarcated erythematous and desquamative plaques with irregular borders seen. Breast lump palpated in >50% cases.	Usually unilateral nipple is effected	The Paget cells are large round cells with abundant clear cytoplasm and atypical nuclei. The cytoplasm is often periodic-acid-Schiff (PAS) positive	Biopsy	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. Prognosis is worse in men.
Atopic dermatitis (Eczema)	Benign	Epidermal barrier dysfunction Immune dysregulation	Erythema, exudates, papules,vesicles, scales and crusts Infiltrated erythema, prurigo, scales and crusts	–	–	–	N/A	Usually bilateral nipple is effected with no accompanying induration. Centrofacial pallor Delayed blanch response Keratosis pilaris Palmar hyperlinearity Pityriasis alba Ichthyosis	Epidermal psoriasiform hyperplasia Marked intercellular edema with spongiotic vesiculation Hyperkeratosis Psoriasiform hyperplasia Dyskeratosis	Clinical examination Biopsy Immunohistochemical stain for Antiinterleukin: IL-4 Anti-IL-13 Anti-CD4 Anti-CD8 antibodies	Family history of atopy History of silicon implants or reconstruction of nipple areola complex or lactation. Personal history of atopy or extramammary Paget's disease or hematological diseases Combined usage of interferon alfa-2b and ribavirin.
Erosive adenomatosis of the nipple	Benign Neoplasm of breast lactiferous ducts.	Proliferation of the inner epithelial layer and outer, basal layer of myoepithelial cells of the lactiferous ducts the nipple.	Eczema, crusts or erosion of nipple	+	+	–	Nipple may have unencapsulated, firm granulomatous lesion . A non-tender nodule either within or under the nipple adherent to the skin, but not the breast may be palpated.	Insidious onset. Erythema may be seen prior to erosion. No lymphadenopathy.	Overlying epidermis often shows acanthosis and hyperkeratosis. Papillomatous pattern: vascular papillae project into dilated lumina and are surrounded by proliferating epithelial cells . Papillary pattern: cells proliferate into large cords with deep fissures and clefts and dense stroma.	Biopsy: Shows absence of cytological atypia	Incidence is highest in the fifth decade in women. No lymphadenopathy.
Allergic contact dermatitis	Benign	Delayed-type hypersensitivity response Skin inflammation mediated by hapten-specific T cells	Erythematous well-demarcated papules	–	–	+	N/A	Stinging and burning Localized swelling Lichenified pruritic plaques	Eosinophilic spongiosis and microvesicles Exocytosis of eosinophils and lymphocytes Chronic - Hyperkeratosis and parakeratosis	Clinical examination Biopsy	Contact with allergens in the past 1-2 days Positive family history
Psoriasis	Benign	Keratinocyte hyperproliferation Dysregulation of the immune system	Well-circumscribed, pink papules and symmetrically distributed cutaneous plaques with silvery scales.	–	+	+	N/A	Auspitz's sign (pinpoint bleeding)	Epidermal hyperplasia Parakeratosis Neutrophils microabscesses (Munro microabscesses)	Clinical examination Biopsy	Risk factors include Smoking Skin trauma Alcohol abuse Stress Cold weather Vitamin D deficiency
Malignant melanoma	Malignant	Neural crest cell derivative Development begins with disruption of nevus growth control Progression involves MAPK/ERK pathway N-RAS or BRAF oncogene also involved.	Macule Plaque with irregular border Variable size A lesion with ABCD Asymmetry Border irregularity Color variation Diameter changes Bleeding from the lesion.	±	–	–	N/A	Pigmented lesion with: Asymmetry Irregular borders Variegated color Diameter >6 mm	Nests of atypical melanocytes with asymmetry, poor circumscription of varying sizes and shapes Present in the lower epidermis and dermis	Complete full-thickness excisional biopsy of suspicious lesions with 1 to 3 mm margin of normal skin. S-100 is used to differentiate Paget's disease from melanoma. But, since 18-25% of Paget's are S-100 positive, at least two melanoma markers, such as HMB-45, S-100, or Melan-A should be used.	UV radiations Genetic predisposition Old age Male gender Family or personal history of melanoma Multiple benign or atypical nevi
Bowen’s disease	Benign can turn malignant	Solar damage Arsenic Immunosuppression (including AIDS) Viral infection (human papillomavirus or HPV) Dermatoses	Erythematous Coloured skin Patch Plaque Scaly Varying size	–	+	–	N/A	Presence of dotted and/or glomerular vessels White to yellowish surface scales Red-yellowish background	Keratinocytic dysplasia No infiltration into dermis Pleomorphic keratinocytes Hyperchromatic nuclei	Clinical examination Biopsy Immunohistochemistry: Bowen's disease can be differentiated from Paget's disease as it stains negative for CK7 and positive for CK5, CK5/6, and p63.	Slow growth over the years
Superficial basal cell carcinoma	Malignant	UV light induces inflammation of the skin. Patched 1 (PTCH1) tumor suppressor gene on chromosome 9 P53 mutations.	Erythematous Superficial scaly patch	–	+	–	N/A	Superficial fine telangiectasia Shiny white to red, translucent or opaque structureless areas Multiple small erosions.	Large, hyperchromatic, oval nuclei Minimal cytoplasm Small basaloid nodules.	Biopsy	Higher incidence in men
Squamous metaplasia of lactiferous ducts (SMOLD)/ Zuska's disease	Benign	Keratin plug blocking lactiferous duct leads to duct rupture and spillage of keratin debris in stroma Leading to chronic inflammation with giant cells surrounding ducts and squamous metaplasia	Painful erythematous subareolar mass Single fistula tract at the areolar edge. Inverted nipple may be seen.	–	+	+	Tender erythematous, subareolar mass.	Appears as an ill-defined firm area. No associated lymphadenopathy.	Squamous epithelium extending beyond the normal transition point within the duct orifice into ductal epithelium. Keratin debris can extend into duct spaces. Squamous metaplasia of the deep ducts filled with keratin debris can be seen along with areas of rupture and spillage of keratin into the surrounding stroma.	Biopsy	Strong association with smoking. Tobacco exposure or decreased level of vitamin A secondary to smoking may cause squamous metaplasia. Clinically similar to lactational mastitis but doesnot resolve with antibiotics therefore is also called recurrent subareolar abscess. Multiple surgical interventions may lead to polymicrobial, anaerobic bacterial superinfection.
Lactiferous duct ectasia / Plasma cell mastitis / Comedomastitis	Benign	Lactiferous sinuses lose their supporting elastic fibers causing accumulation of secretions. Rupture of sinuses can incite a chronic inflammatory response leading to fibrosis.	Nipple retraction	+	–	–	Palpable irregular mass that can closely resemble invasive carcinoma	Thick nipple discharge.	Multiple large ectatic ducts surrounded by a chronic inflammatory cells Giant cells, foamy histiocytes, lymphocytes, plasma cells, and pigment-laden macrophages may be seen in the surrounding stroma .	Ultrasound: Dilated lactiferous ducts Fluid-filled ducts	Most common in older women. Squamous metaplasia is not genrally seen of duct ectasia.
Nipple Adenoma / Papillary adenoma of the nipple	Benign	Circumcised adenomas arising in the large lactiferous ducts of the nipple.	Erosive or ulcerative lesion. Erythema and crusting of the nipple.	±	+	–	Multiple small palpable masses below	Usually unilateral nipple is effected	Fibrosis with distortion of the ducts that resembles pseudo invasion. Epithelial hyperplasia with a partial or total obliteration of the lumen or with intraductal papillary projections Presence of intraductal necrosis and cellular monomorphism and/or polymorphism.	Biopsy with Immunophenotyping.	Mostly occur in the fifth decade of life. Immunophenotypic analysis is essential for differentiating by documenting the presence of myoepithelial cells in adenomas (eg, p63, smooth muscle actin, or smooth muscle myosin heavy chain). Histologically similar to breast cancer. Cellular atypia and mitosis seen in 50% of cases.
Nevoid hyperkeratosis of the nipple and areola (NHNA)	Benign	Common among premenopausal women	Slow growing bluish-brown verrucous thickening of the nipple or areola.	–	–	–	The skin of the nipple and areola is thickened and hyperpigmented developing an isolated nevoid defect .	Usually bilateral nipple is effected	Acanthosis, hyperkeratosis, and papillomatosis of the epidermis	Biopsy	NHNA might be hormonal hyperkeratosis as it is shown to worsen in pregnancy. Might seperately effect the nipple or only the areola Associated with Darier’s disease, chronic acanthosis nigricans, cutaneous Tcell lymphoma, mycosis fungoides, and follicular mucinosis.
Benign Toker cell hyperplasia	Benign	Normal components of the nipple skin Appears similar to paget cells.	Normal nipple- areolar complex	–	–	–	Normal breast examination.	N/A	Toker cells have bland nuclei and abundant eosinophilic or clear cytoplasm. Occasional clusters or glands may be present. Do not generally have cellular atypia and have minimal nuclear pleomorphism.	Biopsy with Immunophenotyping.	Toker cells are immunoreactive for cytokeratin 7 and CAM5.2 but are not positive for HER2- neu.
Breast abscess	Benign	Complication of lactational mastitis in 14% of cases Common among African-American women, heavy smokers and obese patients.	Inflammation of nipple areolar complex Dimpling of nipple or inversion.	±	+	+	Localized breast edema leading to breast tenderness Swollen warm breast tissue.	Associated symptoms of fever, nausea, vomiting. Resolve after drainage/antibiotic therapy.	Mixed inflammatoryfeature by neutrophils. Granulation tissueand chronicinflammation feature caused by Gram-positive cocci.	Ultrasound: Fluid collection	Smoking history If not lactating, patient may be diabetic. History of previous breast infection
Mondors disease	Benign	Superficial phlebitis and periphlebitis of the superficial vein.	Red linear cord running from the lateral margin of the breast attached to the overlying skin.	–	+	+	Red tender cord which may last up to 4-8 weeks before spontaneously remitting leaving a puckered groove along the breast.	Usually unilateral nipple is effected No associated lymphadenopathy.	N/A–	Mammography: shows tubular density. Ultrasound: Tubular anechoic structure and multiple narrowing areas.	Predominantly seen in middle-aged women but is also seen in men. May indicate breast cancer.
Mastitis	Benign No increased risk of malignancy	Common among lactating women (first three months of breast-feeding) Periductal mastitis among smokers associated with squamous metaplasia.	Localized erythema, warmth, swelling, and pain.	±	+	±	Swollen warm breast tissue.	Associated symptoms of fever, chills, or rigor may be present. Resolve after drainage/antibiotic therapy	Breast parenchymainflammation: Acute mastitis: Staphylococcus infection Granulomatous mastitis: Tuberculosis or sarcoidosisinfection	Ultrasound: Ill-defined area with hyperechogenicity with inflamed fat lobules Skin thickening.	History of lactation including difficulty in breastfeeding, breast engorgement, or erosion of nipples.
Inflammatory Breast Cancer	Malignant	Cancer cells block the lymphatic vessels in skin covering the breast.	Localized erythema, warmth, swelling, and pain.	–	+	+	Usually unilateral Swollen warm tender erythematous breast tissue. Peau d’orange: Dimpling on the skin of the affected breast.	Generally associated with lymphadenopathy.	Dermal lymphatic invasion by tumor cells.	Core needle Biopsy	Rare disease, accounts for 0.5–2 % of invasive breast cancers . Considered locally advanced cancer. Rapid change in the appearance of the effected breast Higher cases of visceral metastases due to early and aggressive hematogenous spread.