LAUSR

Dear Dr Layfield, Paget's disease (intraepidermal nipple carcinomatous cell migration from underlying breast carcinoma) is a rare form of breast cancer occurring in 1% to 4% of patients. This lesion present as eczema-like modification of nipple's appearance with characteristic reddish/melanic pigmentation which may be analyzed using scrape smears or cutaneous punch biopsy. The extensive analysis of the literature shows thatmethodology of nipple scraping is largely underutilized and only single cases are reported. The objective of our study was to analyze the value of nipple scraping in the diagnosis of breast Paget disease retrieved from archival series in our institute. Between January 2000 and April 2018, 140 nipple scraping with clinical suspicion of Paget disease (reddish/melanic pigmentation) were performed in patients. Out of which, 62 cases were excluded because of the absence of histological correlation. Remaining 78 samples in 76 patients constitute the subject of this study. Nipple scraping was performed by one of us (J.K.) using scalpel blade and smeared on two slides (Figure 1). Both slides were stained according to May–Grunwald–Giemsa and occasionally according to Papanicolaou methods. Paget disease diagnosis was made if clustered or isolated carcinomatous cells were detected among squamous cells (Figure 2). All patients had associated breast masses, where 48 were palpable and 30 were nonpalpable. Biopsies in palpable lesions were performed under palpatory guidance and biopsies in nonpalpatory lesions were ultrasound-guided. However, all patients had histological evaluation of nipple lesion consisting on punch biopsy, lumpectomy, or total mastectomy. All patients were females and age ranged from 27 to 91 years. Cytological diagnosis of Paget disease was made in 35 (44.9%) cases (Table 1). All breast masses were evaluated histologically. There were 61 (78%) malignancies and 17 (22%) benign lesions. Malignancies were: invasive carcinomas in 46 cases (invasive ductal adenocarcinoma: 43 cases, apocrine carcinoma: two cases, lobular carcinoma: one case) and in situ ductal carcinomas in 15 cases. Benign conditions were: seven pseudotumoral adenosis, three mastitis, three nipple adenomas, and each one case of fibroadenoma, fibrocystic lesion, sebaceous hyperplasia, and ductal hyperplasia. Histologically, the presence of Paget disease was confirmed in 35 (44.9%) cases (35 patients). It occurred in 26 patients with invasive ductal carcinoma and in 9 patients with in situ ductal carcinoma. In the remaining 43 (55.1 cases (41 patients), Paget disease was not found on surgical specimen.