Paget's disease of the breast differential diagnosis: Difference between revisions

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Revision as of 22:17, 20 February 2019

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

Overview

Paget's disease of the breast must be differentiated from atopic dermatitis, eczema, psoriasis, malignant melanoma, Bowen's disease, basal cell carcinoma, and pagetoid dyskeratosis.^[1]^[2]

Differential Diagnosis

Paget’s disease of the breast must be differentiated from other benign and malignant processes of nipple-areola complex such as:^[1]^[2]

				Symptoms							Physical examination		Para-clinical findings
Category	Diseases	Benign or Malignant	Etiology	Clinical manifestations									Para-clinical findings		Gold Standard	Associated factors
				Symptoms							Physical examination		Lab Findings	Histopathology
				Rash	Nipple DIscharge	Erythema	Single/ Multiple		Involved areas	Mastalgia	Breast Exam	Other	Serum IgE	Histopathology
	Eczema	Benign		Scalp, face, trunk, postauricular, diaper area and axilla		+		–	+			Nl	Focal parakeratosis and spongiosis in epidermis Psoriasiform hyperplasia Neutrophils at the margins	Risk factors include Stress Cold, dry weather can cause flare ups Superinfection with bacteria and candida Generalized seborrheic erythroderma in immunodeficient patients
Skin disorders	Atopic dermatitis	Benign	Epidermal barrier dysfunction Immune dysregulation	Erythema, exudates, papules,vesicles, scales and crusts Infiltrated erythema, prurigo, scales and crusts		–	Multiple	+	Young children -Scalp, cheeks amd extensor surface Adolescents -flexural areas and buttock-thigh creases Adults - facial involvement and skin flexures	–		Centrofacial pallor Delayed blanch response Keratosis pilaris Palmar hyperlinearity Pityriasis alba Ichthyosis Infra-auricular and retro-auricular fissuring Nipple eczema White dermographism Perifollicular accentuation	↑	Epidermal psoriasiform hyperplasia Marked intercellular edema with spongiotic vesiculation Hyperkeratosis Psoriasiform hyperplasia Dyskeratosis		Family history of atopic dermatitis or other atopy Personal history of atopy (asthma, allergic rhinitis, food allergy) Active and passive exposure to tobacco
	Allergic contact dermatitis^[3]	Benign	Delayed-type hypersensitivity response Skin inflammation mediated by hapten-specific T cells	Erythematous well-demarcated papules		–	May be multiple after 1-2 days of exposure	+	Surrounding the area in contact with the offending agent	+		Stinging and burning Localized swelling Lichenified pruritic plaques	Nl	Eosinophilic spongiosis and microvesicles Exocytosis of eosinophils and lymphocytes Chronic - Hyperkeratosis and parakeratosis		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		+	Multiple	+	Scalp Trunk Gluteal cleft Extensor surface of elbows and knees	+		Auspitz's sign (pinpoint bleeding)	Nl	Epidermal hyperplasia Parakeratosis Neutrophils microabscesses (Munro microabscesses)		Risk factors include Smoking Skin trauma Alcohol abuse Stress Cold weather Vitamin D deficiency
	Malignant melanoma
	Bowen’s disease
	Superficial basal cell carcinoma
	Pagetoid basal cell carcinoma
	Benign intraductal papilloma
	Pagetoid dyskeratosis
	Lactiferous duct ectasia	Benign	Common among perimenopausalwomen Usually resolve spontaneously											Distention of subareolar ducts	Ultrasound: Dilated milk ducts Fluid-filled ducts
	Nipple duct adenoma
	Benign Toker cell hyperplasia
	Breast abscess	Benign								+	Localized inflammation of breast Tenderness				Ultrasound: Fluid collection
	Mondors disease
	Mastitis	Benign No increased risk of malignancy						+		±	Breast tenderness Swollen breast tissue			Breast parenchyma inflammation: Acute mastitis: Staphylococcus infection Granulomatous mastitis: Tuberculosis or sarcoidosis infection	Ultrasound: Ill-defined area with hyperechogenicity with inflamed fat lobules Skin thickening
	Inflammatory Breast Cancer

References

↑ ^1.0 ^1.1 Gaspari, Eleonora; Ricci, Aurora; Liberto, Valeria; Scarano, Angela Lia; Fornari, Maria; Simonetti, Giovanni (2013). "An Unusual Case of Mammary Paget's Disease Diagnosed Using Dynamic Contrast-Enhanced MRI". Case Reports in Radiology. 2013: 1–5. doi:10.1155/2013/206235. ISSN 2090-6862.
↑ ^2.0 ^2.1 Lopes Filho, Lauro Lourival; Lopes, Ione Maria Ribeiro Soares; Lopes, Lauro Rodolpho Soares; Enokihara, Milvia M. S. S.; Michalany, Alexandre Osores; Matsunaga, Nobuo (2015). "Mammary and extramammary Paget's disease". Anais Brasileiros de Dermatologia. 90 (2): 225–231. doi:10.1590/abd1806-4841.20153189. ISSN 1806-4841.
↑ Nosbaum A, Vocanson M, Rozieres A, Hennino A, Nicolas JF (2009). "Allergic and irritant contact dermatitis". Eur J Dermatol. 19 (4): 325–32. doi:10.1684/ejd.2009.0686. PMID 19447733.

[GaspariRicci2013-1] 1.0 ^1.1 Gaspari, Eleonora; Ricci, Aurora; Liberto, Valeria; Scarano, Angela Lia; Fornari, Maria; Simonetti, Giovanni (2013). "An Unusual Case of Mammary Paget's Disease Diagnosed Using Dynamic Contrast-Enhanced MRI". Case Reports in Radiology. 2013: 1–5. doi:10.1155/2013/206235. ISSN 2090-6862.

[Lopes_FilhoLopes2015-2] 2.0 ^2.1 Lopes Filho, Lauro Lourival; Lopes, Ione Maria Ribeiro Soares; Lopes, Lauro Rodolpho Soares; Enokihara, Milvia M. S. S.; Michalany, Alexandre Osores; Matsunaga, Nobuo (2015). "Mammary and extramammary Paget's disease". Anais Brasileiros de Dermatologia. 90 (2): 225–231. doi:10.1590/abd1806-4841.20153189. ISSN 1806-4841.

[pmid19447733-3] Nosbaum A, Vocanson M, Rozieres A, Hennino A, Nicolas JF (2009). "Allergic and irritant contact dermatitis". Eur J Dermatol. 19 (4): 325–32. doi:10.1684/ejd.2009.0686. PMID 19447733.

[1]

[2]

[3]

@@ Line 22: / Line 22: @@
 {|
-! rowspan="5" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Category
+! rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Category
-! rowspan="5" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Diseases
+! rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Diseases
-! rowspan="5" |Benign or Malignant
+! rowspan="4" |Benign or Malignant
-! rowspan="5" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Etiology
+! rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Etiology
 ! colspan="9" |Clinical manifestations
 ! colspan="2" rowspan="2" |Para-clinical findings
-| rowspan="5" |Gold Standard
+| rowspan="4" |Gold Standard
-| colspan="2" rowspan="5" style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Associated factors'''
+| colspan="2" rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Associated factors'''
 |-
-! colspan="6" rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Symptoms
+! colspan="7" rowspan="2" |Symptoms
-! colspan="3" rowspan="2" |Physical examination
+! colspan="2" rowspan="2" |Physical examination
 |-
 !Lab Findings
-! rowspan="3" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Histopathology
+! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Histopathology
 |-
-! colspan="5" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Appearance
+!Rash
-! colspan="1" rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Itching
-! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Mastalgia
-! rowspan="2" |Breast Exam
-! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Other
-! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Serum IgE
-|-
-! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Single/
-Multiple
-! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Rash
-! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Involved areas
 !Nipple
 DIscharge
-! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Erythema
+!Erythema
+!Single/
+Multiple
+!
+!Involved areas
+! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Mastalgia
+!Breast Exam
+! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Other
+! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Serum IgE
 |-
-! rowspan="22" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Skin disorders
+|
+! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Eczema]]
+|Benign
+| align="center" style="background:#F5F5F5;" |
+*
+| align="center" style="background:#F5F5F5;" | Scalp, face, trunk, postauricular, diaper area and axilla
+|
+| align="center" style="background:#F5F5F5;" | +
+| align="center" style="background:#F5F5F5;" |
+| align="center" style="background:#F5F5F5;" | –
+| align="center" style="background:#F5F5F5;" | +
+| align="center" style="background:#F5F5F5;" |
+**
+|
+| align="center" style="background:#F5F5F5;" | Nl
+| align="center" style="background:#F5F5F5;" |
+* Focal parakeratosis and spongiosis in epidermis
+* Psoriasiform [[hyperplasia]]
+* [[Neutrophils]] at the margins
+| align="center" style="background:#F5F5F5;" |Risk factors include
+* [[Stress]]
+* Cold, dry weather can cause flare ups
+* [[Superinfection]] with bacteria and [[candida]]
+Generalized seborrheic [[erythroderma]] in immunodeficient patients
+|
+|
+|
+|-
+! rowspan="21" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Skin disorders
 ! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Atopic dermatitis]]
 |Benign
@@ Line 58: / Line 85: @@
 * Epidermal barrier dysfunction
 * [[Immune]] dysregulation
-| align="center" style="background:#F5F5F5;" | Multiple
 | align="center" style="background:#F5F5F5;" |
 *[[Erythema]], [[Exudate|exudates]], [[papules]],[[vesicles]], scales and crusts
 * Infiltrated [[erythema]], [[prurigo]], scales and crusts
+|
+| align="center" style="background:#F5F5F5;" | –
+| align="center" style="background:#F5F5F5;" | Multiple
+| align="center" style="background:#F5F5F5;" | +
 | align="center" style="background:#F5F5F5;" |
 * Young children -[[Scalp]], [[cheeks]] amd [[extensor]] surface
 * [[Adolescent|Adolescents]] -flexural areas and buttock-thigh creases
 * Adults - facial involvement and skin flexures
-|
-| align="center" style="background:#F5F5F5;" | –
-| align="center" style="background:#F5F5F5;" | +
 | align="center" style="background:#F5F5F5;" | –
 |
@@ Line 103: / Line 130: @@
 * Delayed-type [[hypersensitivity]] response
 * Skin [[inflammation]] mediated by [[Haptens|hapten]]-specific T cells
-| align="center" style="background:#F5F5F5;" |May be multiple after 1-2 days of exposure
 | align="center" style="background:#F5F5F5;" | Erythematous well-demarcated [[papules]]
-| align="center" style="background:#F5F5F5;" | Surrounding the area in contact with the offending agent
 |
 | align="center" style="background:#F5F5F5;" |–
+| align="center" style="background:#F5F5F5;" |May be multiple after 1-2 days of exposure
 | align="center" style="background:#F5F5F5;" | +
+| align="center" style="background:#F5F5F5;" | Surrounding the area in contact with the offending agent
 | align="center" style="background:#F5F5F5;" | +
 |
@@ Line 124: / Line 151: @@
 * Contact with [[allergens]] in the past 1-2 days
 * Positive [[family history]]
-|-
-! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Contact dermatitis|Irritant contact dermatitis]]<ref name="pmid30293200">{{cite journal |vauthors=Bains SN, Nash P, Fonacier L |title=Irritant Contact Dermatitis |journal=Clin Rev Allergy Immunol |volume= |issue= |pages= |date=October 2018 |pmid=30293200 |doi=10.1007/s12016-018-8713-0 |url=}}</ref>
-|Benign
-| align="center" style="background:#F5F5F5;" |
-* Activation of the [[innate immune system]] by the pro-[[inflammatory]] properties of chemicals
-| align="center" style="background:#F5F5F5;" |Usually single immediately after the exposure
-| align="center" style="background:#F5F5F5;" | Well-demarcated red patch with a glazed surface
-| align="center" style="background:#F5F5F5;" | Any area in contact with the irritant
-|
-| align="center" style="background:#F5F5F5;" |–
-| align="center" style="background:#F5F5F5;" | +
-| align="center" style="background:#F5F5F5;" | +
-|
-| align="center" style="background:#F5F5F5;" |
-* [[Swelling]], [[Blister|blistering]] and scaling of the damaged area
-* Dryness
-* Thicker skin
-| align="center" style="background:#F5F5F5;" |Nl
-| align="center" style="background:#F5F5F5;" |
-* Spongiosis
-* Intraepidermal [[vesicles]] or bullae
-* [[Necrosis]] of [[keratinocytes]]
-|
-| colspan="2" align="center" style="background:#F5F5F5;" |
-* Cumulative exposure to [[irritants]]
-* Negative hypersensitivity tests
 |-
 ! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Psoriasis]]
@@ Line 156: / Line 157: @@
 * [[Keratinocyte]] hyperproliferation
 * Dysregulation of the [[immune system]]
+| align="center" style="background:#F5F5F5;" | Well-circumscribed, pink [[papules]] and symmetrically distributed cutaneous [[plaques]] with silvery scales
+|
+| align="center" style="background:#F5F5F5;" | +
 | align="center" style="background:#F5F5F5;" | Multiple
-| align="center" style="background:#F5F5F5;" | Well-circumscribed, pink [[papules]] and symmetrically distributed cutaneous [[plaques]] with silvery scales
+| align="center" style="background:#F5F5F5;" | +
 | align="center" style="background:#F5F5F5;" |
 * Scalp
@@ Line 163: / Line 167: @@
 * Gluteal cleft
 * Extensor surface of elbows and knees
-|
-| align="center" style="background:#F5F5F5;" | +
-| align="center" style="background:#F5F5F5;" | +
 | align="center" style="background:#F5F5F5;" | +
 |
@@ Line 183: / Line 184: @@
 * Cold weather
 * Vitamin D deficiency
-|-
-! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Eczema|Chronic eczema]]
-|Benign
-| align="center" style="background:#F5F5F5;" |
-*
-| align="center" style="background:#F5F5F5;" |
-| align="center" style="background:#F5F5F5;" | Scalp, face, trunk, postauricular, diaper area and axilla
-| align="center" style="background:#F5F5F5;" | +
-|
-| align="center" style="background:#F5F5F5;" | +
-| align="center" style="background:#F5F5F5;" | –
-| align="center" style="background:#F5F5F5;" |
-**
-|
-| align="center" style="background:#F5F5F5;" | Nl
-| align="center" style="background:#F5F5F5;" |
-* Focal parakeratosis and spongiosis in epidermis
-* Psoriasiform [[hyperplasia]]
-* [[Neutrophils]] at the margins
-| align="center" style="background:#F5F5F5;" |Risk factors include
-* [[Stress]]
-* Cold, dry weather can cause flare ups
-* [[Superinfection]] with bacteria and [[candida]]
-Generalized seborrheic [[erythroderma]] in immunodeficient patients
-|
-|
 |-
 ![[Melanoma|Malignant melanoma]]
@@ Line 329: / Line 303: @@
 !
 !
+* Distention of subareolar ducts
 !
+[[Ultrasound]]:
+* Dilated milk ducts
+* Fluid-filled ducts
 !
 |-
@@ Line 366: / Line 345: @@
 !
 |-
-![[Mastitis]]
+![[Breast abscess]]
 !Benign
 !
@@ Line 377: / Line 356: @@
 !+
 !
+* Localized [[inflammation]] of [[breast]]
+* [[Tenderness]]
 !
 !
 !
 !
+[[Ultrasound]]:
+* Fluid collection
 !
 |-
@@ Line 400: / Line 384: @@
 !
 |-
-![[Breast abscess]]
+![[Mastitis]]
 !
 * [[Benign]]
@@ Line 409: / Line 393: @@
 !
 !
+!+
 !
-!+
 !±
 !
@@ Line 418: / Line 402: @@
 !
 !
 [[Breast]] [[parenchyma]][[inflammation]]:
 * [[Acute]] [[mastitis]]: [[Staphylococcus]] [[infection]]
 * [[Granulomatous]] [[mastitis]]: [[Tuberculosis]] or [[sarcoidosis]][[infection]]
 !
+[[Ultrasound]]:
+* Ill-defined area with hyperechogenicity with inflamed fat lobules
+* Skin thickening
 |
+|-
+!Inflammatory Breast Cancer
+!
+!
+!
+!
+!
+!
+!
+!
+!
+!
+!
+!
+!
+!
+!
 |-

Paget's disease of the breast differential diagnosis: Difference between revisions

Revision as of 22:17, 20 February 2019

Overview

Differential Diagnosis

References

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