Breast carcinoma (multicentric multifocal in mammary Paget disease)

Case contributed by Nur Ahida Md Ahir


Bloody right nipple discharge associated with skin excoriation. Wedge biopsy of nipple showed Paget disease.

Patient Data

Age: 55 years
Gender: Female

Heterogenous dense breast parenchymal pattern (type C).   
There is an opacity noted at the right lower inner quadrant near to the chest wall with associated pleomorphic microcalcifications. Adjacent scattered uniform macrocalcifications also seen at right lower inner quadrant.
No architectural distortion seen.
Few shotty axillary nodes with preserved central fatty hilum noted.


Biopsy-proven Paget disease with associated mammographic findings suspicious malignant breast lower inner quadrant lesion with microcalcifications - BIRADS IVc

An ill-defined microlobulated hypoechoic lesion with microcalcifications at 5 o'clock position of the right breast 3 cm from the nipple suspicious of malignancy.

Ultrasound guided biopsy was performed.

HPE: Invasive Ductal Carcinoma

Breast density pattern: type C (heterogenous dense breast fibroglandular pattern).
Background enhancement: mild to moderate.

Right breast:
There is a spiculated lesion of the lower inner quadrant which shows low to intermediate signal intensity on T1WI, T2WI, heterogenously enhanced post contrast and restricted diffusion on DWI. It measures 1.4 x 1.5 cm.
Presence of abnormal dilated vessels adjacent to the lesion suggestive of neovascularity.
Multiple enhancing smaller satellite lesions seen adjacent to the above describe lesion and extending along the duct distribution to the nipple.
Multifocal enhancing right axillary lymphadenopathy. Overlying skin and nipple-areolar complex are also enhanced.

Features are in keeping with multicentric multifocal malignant right breast lesions with metastatic axillary lymphadenopathy. BIRADS 6 (HPE proven).

Case Discussion

Typical signs of Paget disease are erythema, eczema, scaling, erosion, ulceration and retraction of the nipple-areolar complex that may mislead to a diagnosis of a benign dermatological lesion.

In this case, there was a high index of suspicion toward underlying breast malignancy as patient also had a bloody nipple discharge.

The common histological type of breast carcinoma in Paget disease is DCIS which is a centrally-located tumor. However a peripherally-located tumor (as in this case), commonly have multifocal multicentric lesions because tumors spread along the ducts and show invasive carcinoma. The other histological type is microinvasive carcinoma.

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