Breast Skin Changes/Nipple Retraction ~ Algorithm 5
Breast Cancer Diagnostic Algorithms for Primary Care Providers
(Third Edition, June 2005)
A thorough
history and CBE are important in the assessment
of the patient who presents with skin changes
(e.g. inflammation, scaling) or skin/nipple
retraction.
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Introduction to the work-up of Breast Skin Changes/Nipple Retraction ~ Algorithm 5
A thorough history and CBE are important in the assessment of the patient who presents with skin changes (e.g. inflammation, scaling) or skin/nipple retraction. Important questions to consider include:
- How long has the change been present?
- Is there an associated palpable mass or mammographic abnormality?
- Is it a unilateral finding?
Timing of onset of nipple retraction is of paramount importance; congenital nipple inversion is insignificant, whereas recent nipple retraction has more serious implications. Unilateral nipple retraction, even slight, is also more suspicious than bilateral nipple inversion.
Skin changes that may signify carcinoma include skin erythema, retraction, dimpling, nipple excoriation or crustiness. Asymmetry of the breasts that indicate a recent change should be noted along with other findings, particularly any masses. Inflammatory breast cancer (IBC) symptoms include diffuse erythema, edema involving more than two-thirds of the breast, peau d’orange, tenderness, induration, warmth, enlargement of the breast, and diffuseness (or absence) of a tumor on palpation (Cristofamilli, 2004).
Signs of inflammation can be treated with a 10-day course of antibiotics that cover aerobic and anerobic skin bacteria (typical of those in the mouth and vagina), but if not completely (100%) resolved, inflammatory carcinoma must be suspected and diagnostic imaging is required. A possible treatment regimen could be cephalexin plus metronidazole. Nipple retraction can be managed in the case of suspected periductal mastitis or deep tissue infections. A lack of a complete (100%) response requires further diagnostic imaging work-up.
There are many dermatologic causes of red, oozing and crusted nipples, including psoriasis, seborrheic dermatitis, contact dermatitis, neurodermatitis and atopic dermatitis. Eczema can be localized or can involve the complete nipple-areolar complex and must be distinguished from the non-eczematous conditions of Paget's disease of the nipple. Because Paget’s disease is a very serious but commonly missed diagnosis, a thorough history and physical examination are important for every patient who presents with skin and/or nipple changes of the breast. Paget’s disease comprises 1-3% of all primary breast cancers (Marcus, 2004) . Paget’s disease is manifested by progressive eczematoid changes of the areola with persistent soreness or itching (Lev-Schelouch, 2003). A mass is often associated with Paget's disease (NCI, 2002) and those p atients with a palpable mass have a worse survival rate than do patients with a nonpalpable mass (Fu, 2001).
| Usually bilateral |
Unilateral |
| Intermittent history with rapid evolution |
Continuous history with slow progression |
| Moist |
Moist or dry |
| Indefinite edge |
Irregular but definite edge |
| Nipple may be spared |
Nipple always involved and disappears in advanced cases |
| Itching common |
Itching common |
From Hughes LE et al. Benign Disorders and Diseases of the Breast: Concepts and Clinical Management. London, Ballière Tindell, 1989.
Despite some of these clinical differences, it is important to consider Paget's disease until proven otherwise. Nipple scaling may respond to a short course of topical steroids, but a follow-up appointment is critical to assess responsiveness. Sometimes Paget's will transiently respond to steroid cream, so if used, follow-up exam is required. Paget’s disease with a palpable breast mass is likely to be accompanied by an invasive ductal carcinoma and has a poor prognosis (Sun Q, 2003).
Diagnostic imaging is the first line investigation when there are skin or nipple changes, even if no mass is palpable on CBE. However, a negative diagnostic imaging work-up for a clinical abnormality of the breast must not preclude referral to a breast specialist. Patients with any nipple complaint require further evaluation.
Flowchart Notes and Footer
NOTE 5A: There is some controversy over the use of a topical steroid cream for nipple symptoms indicative of Paget’s disease. Some surgeons now advocate referral for examination and possible biopsy prior to any use of steroid cream.
Footer:
*Diagnostic Imaging Evaluation should be accompanied by standard screening mammography of both breasts if screening mammography has not been conducted within the recommended timeframe. Diagnostic Imaging Evaluation will often include diagnostic mammogram and breast ultrasound, but can also include any radiographic imaging procedure recommended by the radiologist. A final BI-RADS category will be assigned to the case based on the results of all diagnostic imaging procedures. Women should return to routine screening once the diagnostic and/or treatment cycle is completed.
References
Cristofanilli, M., Singletary, E. S., Hortobagyi, G. N. (2004). Inflammatory breast carcinoma: the sphinx of breast cancer research. Journal of Clinical Oncology , 22, 381-383.
Fu, W., Mittel, V. K., Young, S. (2001). Paget disease of the breast: analysis of 41 patients. American Journal of Clinical Oncology, 24(4), 397-400.
Hughes, L. E., Mansel, R. E., Webster, D. T.J. (2000). Benign disorders and diseases of the breast – concepts and clinical management (2nd ed.). New York: WB Saunders.
Lev-Schelouch, D., Sperber, F., Gat, A., Klausner, J., Gutman, M. (2003). Paget's disease of the breast [Electronic Version]. Harefuah , 142(6), 433-437, 485.
Marcus, E. (2004). The management of Paget's disease of the breast. Current Treatment Options in Oncology, 5(2), 153-60.
National Cancer Institute. (2002). Cancer Facts. Paget's disease of the breast: questions and answers. [Brochure]. Author.
Sun, Q., Zhou, Y. D., Huang, H.Y. (2003). Diagnosis and treatment of Paget's disease of the breast: report of 33 cases. Zhongguo Yi Xue Ke Xue Yuan Xue Bao, 25(1), 93-95.
Updated: November, 2007. |
