February 2004

2.

Diagnosis: Erosive adenomatosis of the nipple

Histopathology: A shave biopsy showed a florid ductal proliferation with intraductal papillomatosis in the superficial dermis. Focal areas of apocrine metaplasia were seen. The dermal tissue was in some areas unremarkable and in others had a fibrotic appearance. (Figure 2 )

Discussion: Erosive adenomatosis occurs in middle aged or older woman, but has been reported in adult males and a female child. Patients complain of serous or bloody nipple discharge, dermatitis, pruitus and tenderness. On physical exam the nipple is erythematous, edematous, and covered by crust, and therefore may be confused with Paget's disease. Palpation reveals a freely movable mass in the nipple, which is usually .5 to 1.5 cm in size. The nipple may exhibit telengectasia, and epidermal and dermal thickenings. Axillary lymphadenopathy is not found. Most often erosive adenomatosis is unilateral but can be bilateral. It can also occur in supernummary nipples. Erosive adenomatosis usually occurs in middle aged to older woman but can occur in any age. The first symptoms are noticed approximately 21 months from the diagnosis. (3).

Histologically it may be confused with low-grade breast carcinoma. It is usually well-circumscribed, nonencapsulated lesion with an adenomatous configuration. Papillary projections into the lumen are seen and may show cystic changes. Apocrine secretory cells usually line the epithelium, and there is commonly a backing of myoepithelial cells. (4) It is imperative that these tumors are differentiated from carcinoma to avoid unnecessary masectomy. Erosive adenomatosis of the nipple while a benign entity, in the past has rarely been associated with a malignant degeneration or with comcomitant breast malignancy. One male patient had Paget's disease and a history of erosive adenomatosis of the nipple with subsequent low-grade malignant changes. The patient was successfully treated with local excision.(5) Another author reported 2 patients with a erosive adenomatosis who developed mammary carcinoma. (6) Most authors suggest that these carcinomas are merely coincidental, not precancerous. (1,5,7)

Treatment includes local excision, tumorectomy, liquid nitrogen and Mohs. An extensive excision can be psychologically devastating for a patient. In addition recurrence rates are high and most likely secondary to incomplete excision. We performed Mohs micrographic surgery on our patient which allows for complete excision of this contiguously growing neoplasm by carefully examining the tissue margin. Seven months after Mohs, there is no evidence of recurrence.

References:
1. Kuflik EG. Erosive adenomatosis of the nipple treated with cryotherapy. AmAcad Dermatol 1998;38:270-1.
2. Lammie GA, Millis RR. Ductal adenoma thebreast-a review of fifteen cases, fifteencases.Human Pathol 1989;20(9):903-8.
3. Bourlond J, Bourland-Reinert L. Erosive adenomatosis of the nipple. Dermatol 1992;185:319-24.
4.Weedon D. Skin Pathology. New York:Churchill Livingstone; 2002.p.887.
5. Burdick C, Rinehart RM, Matsumoto T, et al. Nipple adenoma and Paget's disease
in a man. Arch Surg 1965;91:835-8.
6.Bhagavan BS. Patchegsky A, Koss LG: Florid subareolar duct papillomatosis
(nipple adenoma) and mammary carcinoma: Report of three cases. Hum Pathol
1973;4:289-95.
7. Higginbotham LH, Mikhail GR. Erosive Adenomatosis of the Nipple. J Dermatol Surg Onc. 1986:12:514-516.

This case was provided by Drs. Julia Ho and Roberta Sengelmann