Abstract: Paget’s disease of the breast is a rare malignancy of the nipple-areola complex and accounts for 1%–4% of all breast cancers. The disease is frequently associated with an underlying in-situ or invasive carcinoma in the breast tissue that extends to the nipple and areola. Paget’s disease is characterized clinically by eczema-like inflammatory skin changes and histologically by malignant cell infiltration in the dermis (Paget’s cells). Although Paget’s presents less commonly than a palpable mass or mammography abnormality, it is an important consideration in the differential diagnosis of a persisting nipple-areola abnormality. Diagnosis may be delayed by several months or even years because of Paget’s seemingly benign appearance. The following case demonstrates this particular situation. Biopsy of a chronic wound that shows no evidence of healing over time is of paramount importance, especially in the case of a chronic breast lesion.

Address correspondence to:
Moises Menendez, MD, FACS, CWS
Wound Care Associates
411 N. Washington Ave.,Suite 5000
Dallas, TX 75246
Phone: 214-828-0702
E-mail: mmenendez@Baylorhealth.edu

   Paget’s disease (PD) of the breast is a rare malignancy of the nipple-areola complex and accounts for 1%–4% of all breast cancers.¹ The disease is frequently associated with an underlying in-situ or invasive carcinoma in the breast tissue that extends to the nipple and areola. It is characterized clinically by eczema-like inflammatory skin changes and histologically by infiltration of the dermis by malignant cells (Paget’s cells). Although less common a presentation than a palpable mass or mammography abnormality, Paget disease of the breast is an important consideration in the differential diagnosis of a persisting nipple-areola abnormality.² Because of its seemingly benign appearance, the diagnosis may be delayed by several months or even years, as in the following case. In general, it is of paramount importance to biopsy chronic wounds, which show no evidence of healing over time, especially in the case of a chronic breast wound.

Presentation

   A 75-year-old woman was referred to one of the authors at the Wound Healing Center of South Arkansas for treatment of a chronic wound in the nipple-areola complex of the left breast. Approximately 4 years prior, the patient was referred to the authors for care of a breast lesion, which was suspected to be malignant. She had changed primary care physicians when her condition had not improved. At that time, several biopsies were performed once the clinical suspicion of PD was entertained; however, the pathological impression showed only chronic inflammation with no evidence of malignancy. The patient was subsequently lost to follow up, and was seen by two separate dermatologists within that period.

   The patient’s comorbidities included rheumatoid arthritis, arterial hypertension, adult-onset diabetes, and obesity. She underwent multiple surgeries on the right shoulder that rendered her with significantly limited range of motion. Her past surgical history also included a cholecystectomy and a hysterectomy. Her medications included corticosteroids, antihypertensives, and oral diabetic agents. Physical examination found chronic rheumatoid changes on the joints with severe limitation in range of motion of the right shoulder and elbow, and moderate obesity. Examination of the left breast showed areas of eczematoid changes around the nipple-areolar complex. There was marked erythema with crusting of the surface of the skin. A moderate amount of bleeding was produced by inspection and palpation. The most striking feature was obliteration of the nipple compared to the contralateral breast (Figure 1). At times, the wound appeared to form an eschar (Figure 2). There were no palpable breast masses or axillary/supraclavicular adenopathy.