Breast carcinoma (multicentric multifocal in mammary Paget's disease)

Case contributed by Dr Nur Ahida Md Ahir

Presentation

Bloody right nipple discharge associated with skin excoriation. Wedge biopsy of nipple shown Paget's 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.

Impression:

Biopsy proven Paget's 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 at lower inner quadrant which show low to intermediate signal intensity on T1WI, T2WI, heterogenously enhanced post contrast and restricted diffusion on DWI. It measures 1.4 cm 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.
Multiple enhancing right axillary lympahdenopathies. Overlying skin and nipple-areolar complex are also enhanced.

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

Case Discussion

Typical signs of Paget's disease are erythema, eczema, scaling, erosion, ulceration and retraction of nipple areolar complex that may misled the diagnosis of benign dermatological lesion.

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

The common histological type of breast carcinoma in Paget's disease is DCIS which is centrally located tumour. However for peripherally located tumour (as in this case), commonly have multifocal multicentric lesions because tumours spread along the ducts and show histological type of Invasive Carcinoma. The other histological type is microinvasive carcinoma.

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Case information

rID: 50966
Case created: 31st Jan 2017
Last edited: 5th Jun 2017
Systems: Breast, Oncology
Inclusion in quiz mode: Included

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