Nipple adenoma in a female patient presenting with persistent erythema of the right nipple skin: case report, review of the literature, clinical implications, and relevancy to health care providers who evaluate and treat patients with dermatologic conditions of the breast skin

Nipple Adenoma: Systematic Review of Literature

Background

Nipple adenomas (NAs) are rare benign proliferative tumors presenting as palpable nodules, erosive lesions, or nipple discharge, mimicking other conditions. This systematic review categorizes cases into sole NA (ONA) or co-diagnoses with other conditions (CONA) to enhance clinical recognition, diagnosis, and treatment efficacy.

Methods

Following PRISMA guidelines, a PubMed search was conducted for NA. Inclusion criteria covered original research, excluding reviews or other breast diseases. Bias risk was assessed through a thorough search, authors independently evaluated studies, and data were synthesized using varied measures. Subgroups ONA and CONA were formed. Analyses were conducted in Excel and R, complemented by a qualitative review due to case report predominance. Biases in case reports were transparently addressed.

Results

Of the 86 studies, 387 cases were analyzed, showing 10.34% with co-diagnoses of malignant or premalignant conditions. Mean age was 44, with a female predominance (97%). ONA (347 cases) and CONA (40 cases) subgroups exhibited variations in symptoms, physical findings, and imaging. Treatment modalities included excision (51.39%), biopsy alone (11.1%), and mastectomy (8.6%). Mean follow-up of 56.73 months revealed recurrence (2.87%) and malignancy development (1.79%), notably in CONA cases (33.33%).

Conclusions

This study provides insights into the broader age range of NA and its associations. Higher co-diagnosis rates were correlated with older age, highlighting the necessity for thorough investigation, with excision as the primary treatment. Follow-up emphasizes the significance of identifying and monitoring CONA cases, which pose a higher malignancy risk. Recurrence is presumed to be linked to proper lesion excision and co-diagnosis.

'Eczematous' dermatitis of the nipple: clinical and histopathological differential diagnosis of Paget disease

The nipple can be affected by many malignant and benign entities. A wide variety of diseases including Paget disease, atopic dermatitis and nipple candidiasis can cause eczema-like changes in the nipple. In cases of diagnostic uncertainty, tissue sampling may be indicated. A true eczematous lesion, such as atopic dermatitis, typically shows a spongiotic dermatitis pattern. Paget disease, on the other hand, presents with infiltration of the nipple epidermis by neoplastic cells. The presence of atypical cells scattered in the epidermis in a pagetoid pattern opens up a histopathological differential diagnosis encompassing squamous cell carcinoma in situ and malignant melanoma, among others. Immunohistochemistry is commonly used to render a diagnosis. The objective of this article is to discuss Paget disease and highlight relevant clinical and histopathological differential diagnoses.

Unusual presentation of intraductal papilloma on the nipple: A case report

INTRODUCTION AND SIGNIFICANCE

Intraductal papilloma (IDP) is a benign breast lesion characterized by a small, delicate wart-like growth found within the milk ducts. Typically located centrally behind the nipple, IDP often presents with a serous, serosanguinous, or bloody discharge from the nipple, making it a common cause of abnormal nipple discharge. Differential diagnosis is crucial as it can be mistaken for other conditions such as pigmented Paget's disease and pigmented basal cell carcinoma.

CASE PRESENTATION

This case study depicts a 35-year-old female with a painless, pigmented mass on the nipple of her right breast that had been present for four months. Physical examination revealed a well-defined blue nodule measuring 13 × 8 mm. Although mammography and ultrasound did not detect any abnormalities in the breast tissue, a biopsy confirmed the diagnosis of intraductal papilloma. The lesion was surgically excised under local anesthesia without complications.

CLINICAL DISCUSSION

In this case, IDP presented as a blue nodule near the nipple. Despite the patient's young age and unique presentation, the diagnosis of intraductal papilloma was made based on the identified risk factors for breast tumors. Differential diagnoses considered included mammary Paget disease, nipple duct adenoma, and erosive adenomatosis of the nipple.

CONCLUSION

This case report underscores the uncommon occurrence of IDP manifesting on the nipple. A thorough evaluation incorporating medical history, physical examination, imaging studies, and cytological analysis is essential for an accurate diagnosis and to exclude malignancy. Surgical excision was successful in removing the lesion.

Nipple Adenoma: A Benign Disease With a Suspicious Presentation

Nipple adenoma is a rare proliferative lesion that originates from the lactiferous ducts of the nipple. Though it is benign, the typical presentation includes suspicious symptoms-a firm nodule, crusting erosion, and/or discharge from the nipple. These findings can raise concern for malignancy and in particular, Paget's disease. We report two cases of this uncommon entity, highlighting the variable clinical presentation and keys to the diagnostic evaluation and management.

Nipple Lesions of the Breast: An Update on Morphologic Features, Immunohistochemical Findings and Differential Diagnosis

Because of the unique anatomic structure of the nipple, a few specific breast lesions occur only at this site. Large lactiferous sinuses may be involved by inflammatory conditions such as squamous metaplasia of lactiferous ducts and ductal ectasia or be the site of uncommon superficial epithelial neoplasms such as nipple adenoma or syringomatous tumor of the nipple. Paget disease of the nipple may be secondary to intraepidermal extension of ductal carcinoma in situ in the underlying lactiferous ducts or develop from malignant transformation of Toker cells. Invasive breast cancer may also arise primarily in the nipple. Most of these conditions present as a palpable mass and/or skin changes with or without nipple discharge. Due to the delicate location and often relatively small size of nipple lesions, biopsy specimens are often superficial and fragmented, and the interpretation is challenging. Knowledge of the morphologic and immunophenotypic features of nipple lesions is essential in making the correct diagnosis. Information on the molecular alterations underpinning nipple neoplasms is currently very limited.

Therapeutische Besonderheiten bei Erkrankungen der Mamillenhaut

Die Mamillenregion ist durch besondere anatomische Verhältnisse charakterisiert und lässt sich aus dermatologischer Perspektive in Brusthaut, Haut des Brustwarzenhofes (Areola) und Haut der Brustwarze (Papilla mammae) unterteilen. Im klinischen Zusammenhang sind die Brustwarzen häufig während der Stillzeit durch mechanische Beanspruchung, Milieuänderung mit Mazeration durch den Milchfluss sowie durch mikrobielle Erreger alteriert. Zudem besteht hier die Gefahr der Entwicklung einer Mastitis puerperalis. Außerhalb der Schwangerschaft und Stillzeit finden sich gelegentlich an der Mamillenhaut Ekzemerkrankungen, häufig bei atopischer Disposition (atopisches Mamillenekzem) oder als irritatives Kontaktekzem („joggers nipple“). Seltener werden allergische Kontaktekzeme auf Konservierungsstoffe von Topika oder Metallen (Piercings) beobachtet. Auch im Rahmen einer Skabiesinfestation wird eine Beteiligung der Mamillen, insbesondere bei Frauen, regelmäßig beobachtet. Von großer klinischer Bedeutung sind seltene, präinvasive Läsionen eines Mammakarzinoms oder der Morbus Paget der Mamille vom extramammären Typ. Durch die besonderen anatomischen Gegebenheiten ist es naheliegend, dass bei der Anwendung von Topika sich auch spezifische Penetrationsbedingungen ableiten. Experimentelle Untersuchungen an Humanhaut ex vivo legen nahe, dass in Abhängigkeit von der Molmasse und der Löslichkeit des Arzneistoffs sowie des eingesetzten Vehikelsystems eine deutliche Zunahme der kutanen Bioverfügbarkeit, insbesondere an der Brustwarze selbst durch den transpapillären Diffusionsweg, auftreten kann. Dies sollte insbesondere bei der topischen Anwendung von Arzneistoffen mit bekanntem dosisabhängigem Nebenwirkungspotenzial (z. B. Glukokortikoiden) beachtet werden. Allerdings fehlt dafür bisher eine klinische Evidenz.

Nipple Adenoma: Correlation of Imaging Findings and Histopathology

Nipple adenomas (NAs) are benign neoplasms composed of papillary hyperplasia of the epithelium of the major lactiferous ducts. Patients with NA may report bloody nipple discharge and clinically may resemble Paget disease, raising concern for malignancy. Mammographically, NAs are often occult. US can show a hypervascular circumscribed mass centered within the nipple with varying echogenicity. Diagnosis is usually made on punch biopsy or excision, but breast radiologists should be aware of this entity. Malignancy can be found elsewhere in the ipsilateral or contralateral breast, or very rarely may directly extend to involve an NA, but published experience with concurrent malignancies is small. We describe the radiologic-pathologic correlation of NAs.

An Improved Nomogram to Reduce False-Positive Biopsy Rates of Breast Imaging Reporting and Data System Ultrasonography Category 4A Lesions

BACKGROUND

The NCCN clinical guidelines recommended core needle biopsy for breast lesions classified as Breast Imaging Reporting and Data System (BI-RADS) 4, while category 4A lesions are only 2-10% likely to be malignant. Thus, a large number of biopsies of BI-RADS 4A lesions were ultimately determined to be benign, and those unnecessary biopsies may incur additional costs and pains. However, it is important to emphasize that the current risk prediction model focuses primarily on the details and complex risk features of US or MG findings, which may be difficult to apply in order to benefit from the model. To stratify and manage BI-RADS 4A lesions effectively and efficiently, a more effective and practical predictive model must be developed.

METHODS

We retrospectively analyzed 465 patients with BI-RADS ultrasonography (US) category 4A lesions, diagnosed between January 2019 and July 2019 in Tianjin Medical University Cancer Institute and Hospital and National Clinical Research Center for Cancer. Univariate and multivariate logistic regression analyses were conducted to identify risk factors. To stratify and predict the malignancy of BI-RADS 4A lesions, a nomogram combining the risk factors was constructed based on the multivariate logistic regression results. In order to determine the predictive performance of our predictive model, we used the concordance index (C-index), calibration curve, and receiver operating characteristic (ROC), and the decision curve analysis (DCA) to assess the clinical benefits.

RESULTS

Based on our analysis, 16.3% (76 out of 465) of patients were pathologically diagnosed with malignant lesions, while 83.6% (389 out of 465) were diagnosed with benign lesions. According to univariate and multivariate logistic regression analysis, age (OR = 3.414, 95%CI:1.849-6.303), nipple discharge (OR = .326, 95%CI:0.157-.835), palpable lesions (OR = 1.907, 95%CI:1.004-3.621), uncircumscribed margin (US) (OR = 1.732, 95%CI:1.033-2.905), calcification (mammography, MG) (OR = 2.384, 95%CI:1.366-4.161), BI-RADS(MG) (OR = 5.345, 95%CI:2.934-9.736) were incorporated into the predictive nomogram (C-index = .773). There was good agreement between the predicted risk and the observed probability of recurrence. Furthermore, we determined that 153 was the best cutoff score for distinguishing between patients in the low- and high-risk groups. Malignant lesions were significantly more prevalent in high-risk patients than in low-risk patients.

CONCLUSION

Based on clinical, US, and MG features, we present a predictive nomogram to reliably predict the malignancy risk of BI-RADS(US) 4A lesions, which may assist clinicians in the selection of patients at low risk of malignancy and reduce the number of false-positive biopsies.

Pathological and imaging features of Paget's disease and nipple adenoma: a comparative study

BACKGROUND

Both Paget's disease (PD) and nipple adenoma (NA) are rare lesions occurred on nipple and share some similarities in clinical manifestations, but there are have different pathological manifestations and imaging findings. This study analyzed the clinicopathological and imaging features of PD in nipple and NA to improve our knowledge about these two diseases and to provide guidance for clinical diagnosis and treatment.

METHODS

Retrospectively analyzed 99 female patients confirmed by surgery and pathology from January 2014 to December 2018. The features of imaging examination included 95 cases of breast ultrasound, 83 cases of breast X-ray and 24 cases of magnetic resonance imaging (MRI) were analyzed and compered the detection rate and diagnostic accuracy.

RESULTS

The 99 patients consisted of 76 patients with PD and 23 patients with NA. Despite the similarity of clinical manifestations between PD and NA, the pathological features of these diseases were completely different. Differences in various imaging manifestations were found to facilitate differential diagnosis. Breast X-ray and ultrasound can discover the nipple areola changes such as mass and calcification, but some cases still show negative. Breast MRI can clearly show the areola lesions of nipple PD and NA, accurately evaluate the degree and size of breast lesions, and help clinicians choose appropriate and personalized diagnosis and treatment methods.

CONCLUSIONS

The combination of multiple breast imaging examinations (including X-ray, ultrasound, and MRI) can improve the diagnosis of PD and NA and play a guiding role in the options for clinical treatment.

5-Aminolevulinic acid induced photodynamic therapy (ALA-PDT) for erosive adenomatosis of the nipple: A case report

Erosive adenomatosis of the nipple (EAN) is an uncommon, benign neoplasm that involves the nipple. Traditional treatments include complete surgical excision, limited forms of complete surgical excision and Mohs micrographic surgery. Here, we report a case of a 40-year-old woman with a 2-year history of asymptomatic erosion, papillomatous hyperplasia and intermittent serosanguineous discharge on her right nipple. Histopathological examination confirmed the diagnosis of EAN. She was treated with 5-aminolevulinic acid induced photodynamic therapy (ALA-PDT) for 2 sessions with 2 weeks intervals. No recurrence occurred within 6 months. Therefore, our report suggested that ALA-PDT is a possible method to treat EAN, especially in patients who have the need of breastfeeding and cosmetic appearance, but this needs to be examined in a larger clinical trial.

Cryosurgery as a Minimally Invasive Alternative Treatment for a Patient with Erosive Adenomatosis of the Nipple

Erosive adenomatosis of the nipple (EAN), also known as nipple adenoma, florid papillomatosis, or papillary adenoma of the nipple, is a benign neoplasm originating from a lactiferous duct of the breast. Although the potential for malignant change is invariably negligible, the nature of the disease is quite intractable despite several treatment methods. Surgical excision is known as the treatment of choice, but this invasive approach is generally not acceptable to the vast majority of patients due to the cosmetic outcomes. Cryosurgery could be an alternative choice to preserve the structure of the nipple-areola complex, though its application has not been studied due to the paucity of cases. A 22-year-old female presented with a unilateral, crater-like erosion of the left nipple with serosanguineous discharge. The skin biopsy revealed proliferation of tubular structures, which corresponded to EAN. She was treated with 4 sessions of cryosurgery (open cryospray with liquid nitrogen) over 6 months, and the skin lesion resolved completely without any recurrence for 12 months. Although further study is required to determine the optimal treatment regimen for EAN, cryosurgery should be considered as an effective option to surgical excision.

Dermoscopy of nipple adenoma

Characteristic finding of nipple adenoma (NA) in dermoscopy (red dots in linear, radial, or semicircular patterns) can help in accurate clinicopathologic diagnosis of NA vs other inflammatory, benign, and especially malignant nipple lesions.

Nipple Ultrasound: A Pictorial Essay

Ultrasound (US) is an attractive diagnostic approach to identify both common and uncommon nipple pathologies, such as duct ectasia, nipple abscess, nipple leiomyoma, nipple adenoma, fibroepithelial polyp, ductal carcinoma in situ (restricted to nipple), invasive carcinoma, and Paget's disease. US is the reliable first-line imaging technique to assess nipple pathologies. It is useful to identify and characterize nipple lesions. Additionally, we have presented the mammography and MRI outcomes correlated with histopathologic features for the relevant cases.

Erosive Adenomatosis of the Nipple: A Clinical Diagnostic Challenge

Erosive adenomatosis of the nipple (EAN) is a rare benign neoplasm of the nipple. The entity is generally characterized by erosion, serous discharge (serous and/or sanguineous), nodularity, swelling, itching and erythema of the nipple. It may be confused with mammary Paget’s disease of the nipple and obtain over-treatment. We reported a patient with typical clinical and histopathological features. Clinicians should consider EAN as one of the differential diagnosis in patients with erosions on the nipple.

Invasive Breast Carcinoma Arising in a Nipple Adenoma After 15 Years: Report of a Rare Case and Literature Review

Nipple adenoma (NA) is a rare benign breast neoplasm that seldom co-exists with breast carcinoma (BC). Majority of these BC are separate from NA, and their origin from NA is an extremely rare event. We herein describe a case of 65-year-old female who had a painless lump for 15 years which increased in size and ulcerated for last six months. Microscopic examination of the wedge biopsy of nipple showed features of NA at superficial aspect and invasive carcinoma from it at the deeper aspect. The patient underwent mastectomy and axillary clearance, which revealed a 4-cm invasive breast carcinoma, no special type with axillary lymph node involvement. The patient received adjuvant chemotherapy, radiotherapy and adjuvant hormonal therapy. The patient is alive and disease-free after 36 months.

NA should be carefully evaluated for co-existent BC because it completely changes the treatment plan and prognosis. 

Clinical and sonographic features of nipple lesions

BACKGROUND

The aim of this study was to present several cases of benign and malignant nipple lesions and contribute to diagnosis and differential diagnosis.

METHODS

A retrospective study was conducted on 13 patients. All of the patients were evaluated by ultrasonography, and 11 of them had pathological results. We analyzed the clinical and sonographic features.

RESULTS

There were 3 malignant lesions, 7 benign lesions, and 3 congenital nipple dysplasia, listed as follows:Malignant lesions (n = 3, 23%): Paget's disease (PD, n = 3, 23%). All of the patients with PD showed unilateral nipple erosion, discharge, and pain. The ultrasound showed abundant blood flow (n = 3, 23%); 2 patients (n = 2, 15%) had microcalcifications.Benign lesions (n = 7, 54%): Adenoma of the nipple (n = 2, 15%). One patient (n = 1, 8%) had nipple erosion and discharge. Two patients (n = 2, 15%) had a palpable nodule in the nipple. The ultrasound of both patients (n = 2, 15%) showed regular-shaped, clear border nodule with abundant blood flow (n = 2, 15%).Leiomyoma of the nipple (n = 1, 8%): This male patient was characterized by unilateral nipple enlargement and pain. The ultrasound showed a regular nodule with absent blood flow.Plasma cell mastitis (n = 2, 15%): Two patients showed unilateral nipple inversion and pain. One patient (n = 1, 8%) showed swollen and redness. The 2 patients showed a lesion in the gland around the nipple present as an irregular shape and unclear boundary hypoechoic mass.Nipple wart (n = 2, 15%): Two patients showed a unilateral soft exogenous neoplasm. Both of the patients showed a hypoechoic wart; the echo was similar to the nipple, the border was clear, and had no blood flow in the wart.Nipple Dysplasia (n = 3, 23%): Accessory nipple (n = 3, 23%). Two patients (n = 2, 15%) had accessory nipples in the subcoastal area, 1 patient (n = 1, 8%) in the areolar. All of the patients' sonographic features were the same as the nipple.The positive predict value (PPV) of the clinical symptoms: Erosion and discharge are both 75% (P < 0.05). The PPV of the US manifestations: irregular shape, indictinct margin, abundant blood flow, microcalcification, thicken skin in diagnosing malignant lesions are 60%,60%,60%,100%,100%, respectively (P < 0.05).

CONCLUSIONS

The characteristic sonographic features together with clinical symptoms contribute to the diagnosis of nipple lesions.

[Erosive adenomatosis of the nipple in an adolescent girl: A case report]

Erosive adenomatosis of the nipple is a rare benign lesion arising from the lactiferous sinuses. A 14-year-old girl with a nipple-pricked, left nipple lesion that had been evolving for 15 days with purulent discharge was referred to breast consultation. An oozing eczema-like nipple lesion with a yellowish discharge which secondarily took on the appearance of an ulcerated tumor was observed. Breast ultrasound found no abnormality. An excision of the lesion was performed. The diagnosis of erosive adenomatosis of the nipple was given on histological examination. This rare benign proliferative lesion has an excellent prognosis and is important to recognize as its care differs from that of differential diagnostic entities.

Dermoscopy of Adnexal Tumors

Cutaneous adnexal tumors include lesions with apocrine, eccrine, follicular, sebaceous, and mixed differentiation. Most are benign and sporadic, although malignant forms are occasionally observed and some cases develop in the setting of inherited syndromes. These tumors often cause immense diagnostic difficulty. Dermoscopy is a noninvasive technique that has greatly improved the diagnostic accuracy of different skin lesions, including these tumors. We provide a review of the literature on the dermoscopic structures and patterns associated with adnexal tumors. Most patterns associated with this kind of tumor are nonspecific and are observed in other nonadnexal tumors, especially in basal cell carcinomas.

Nipple adenoma in a 2-year-old boy

Nipple adenoma is an uncommon proliferative process of the breast and predominantly occurs in women aged 40-50. Its incidence is extremely low in men, and it has not been reported in a boy. Although nipple adenoma is rare and benign, being familiar with it is important because it clinically resembles Paget disease and histologically adenocarcinoma. We report a case of nipple adenoma in a boy.

MOHS micrographic surgery for treating erosive adenoma of the nipple: a case report and review of the literature

BACKGROUND

Erosive adenoma of the nipple (EAN) is a benign condition that involves major ducts of the nipple. Its clinical presentation may resemble other disorders. Complete removal of the nipple is often suggested because of frequent relapse. However, adverse cosmetic and functional results have prompted clinicians to look for other more conservative options.

AIMS

To present a case of EAN successfully treated using Mohs micrographic surgery (MMS) and summarize differential diagnosis and treatment.

MATERIALS AND METHODS

A 40-year-old woman with EAN was diagnosed by immunohistochemical markers after clinical suspicion. We have reviewed other cases treated with MMS in the literature.

RESULTS

In this patient, lesion size was 0.8 cm and the margin specimen was 1 × 0.9 × 0.2 cm, with EAN as histopathologic diagnosis. No atypia or malignancy was reported. Final esthetic outcome was reached with only one session, under local anesthesia and on an outpatient basis.

DISCUSSION

Dermatologic lesions appearing on the nipple's surface should be closely followed. Paget's disease, carcinoma or proliferative lesions like EAN have to be considered, and such conditions require different surgical approaches. Traditional complete removal of the nipple is performed in many cases, but it may result in over-treatment and unfavorable cosmetic outcome. MMS is frequently used in dermatologic surgery to treat malignant lesions with a high cure rate, avoiding excess tissue excision and leading to better patient satisfaction.

CONCLUSION

EAN can be successfully treated by minimal resection, especially if early diagnosis is done. MMS offers a better aesthetic outcome than traditional total excision.