Nipple Biopsy (Paget’s or Other Disease)

Description

Nipple biopsy is usually performed under local anesthesia, but sedation or general

anesthesia is occasionally used. The aim of the nipple biopsy is to exclude carcinoma.

Paget’s disease is in situ carcinoma of the nipple characterized by erythema,

scaling, or ulceration of the nipple, which is often associated with an underlying

breast carcinoma (95 %).
The usual differential diagnosis is eczema. The diagnosis

is often delayed due to trial of eczema treatments. A full-thickness incisional

or punch biopsy is used. A preoperative mammogram and ultrasound are used to

investigate underlying breast parenchymal pathology. There is division of opinion

over the origin of Paget’s clear cells varying from a direct extension of an underlying

in situ or invasive carcinoma to a physically separate focus of in situ carcinoma

arising in the nipple isolated from any underlying carcinoma. It may represent wide

ductal system “fi eld” change. In the majority of cases, the carcinoma, if present, is

located within a few centimeters of the nipple-areolar complex. It can be diffi cult to

identify the location of the carcinoma and it may be only an in situ carcinoma. An

alternative approach is to take a small amount of underlying breast tissue at the time

of nipple biopsy. If the workup does not demonstrate any radiographic abnormality

and the nipple biopsy demonstrates Paget’s disease, then an MRI can be obtained to

further evaluate the breast parenchyma. If no other lesion can be identifi ed, then the

patient has the option of proceeding with a central lumpectomy in order to attempt

to capture the carcinoma or the patient may want to proceed with a mastectomy

with or without immediate reconstruction. An underlying breast carcinoma may not

be present, so some surgeons adopt an expectant management plan, with regular

imaging, often using several modalities.

Anatomical Points

Nipple shape can vary considerably dictating the ease and cosmetic results. Some

10–12 individual ducts open onto the nipple. Occasionally, a duct may open at the

side or base of the nipple or even within the areola. The nipple may be inverted and

require eversion, increasing the diffi culty of biopsy. Anatomic studies have identifi

ed branches of the lateral cutaneous branch of the fourth intercostal nerve entering

the peri-areolar area most consistently at the lower lateral position (4 o’clock on left

and the 8 o’clock on right breast). Care should be taken to avoid incisions in those

areas, if possible.

Perspective

First described in 1874 by Sir James Paget as a “disease of the mammary

areola preceding cancer in the mammary gland,” we now understand the Paget

cells to be cancerous cells, even if they are in situ. If a signifi cant part of the nipple

is removed, nipple deformity may result. Rarely, if lactation or discharge occurs,

ductal leakage can occur from ducts misdirected in the postoperative scar tissue. It

is often diffi cult to make a diagnosis of Paget’s disease and adequate tissue must be

obtained. Full-thickness biopsy is required. Biopsy of the underlying breast tissue

as well as the suspicious nipple skin is often helpful. If a diagnosis is not secured,

but Paget’s is still suspected, the patient should be followed closely and re-biopsied

if required.

Major Complications

The major complications of nipple biopsy are nipple deformity and infection. The

nature of Paget’s disease makes failure to diagnose not uncommon.

Open nipple biopsy is indicated to rule out Paget’s disease. Paget’s disease, if

identifi ed, represents a form of nipple involvement by pagetoid cells and an effort

should be made to identify whether an underlying breast carcinoma is present and

the location. Hematoma formation, infection, and paresthesia of the nipple are

uncommon with the nipple biopsy.