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Epidermal ulceration was not identified. Final histopathologic evaluation confirmed nipple adenoma.
Dermatoscopic examination i. One such benign breast entity is nipple adenoma NA. NA is a very uncommon condition of the breast, primarily seen in middle-aged women, and representing a benign proliferative process of lactiferous ducts of the nipple [ 2 — ]. Dermatoscopic evaluation of the nipple lesion showed linear, cherry-red structures thought to be representative of neoplastic tubular luminal openings of the NA. Interestingly, the dermatoscopic photography of the patient presented in our current case report demonstrated red serpiginous and annular structures rather than linear cherry-red structures as reported by Takashima et al.
Try out PMC Labs and tell us what you think. The patient has continued regularly scheduled follow-up with her dermatologist and her surgical oncologist. Subsequently, one month later, a larger 6 mm punch biopsy was performed by a breast surgical oncologist to the same region of the right breast and histopathologic evaluation was reported to show adenosis and associated usual type ductal hyperplasia, consistent with subareolar duct papillomatosis.
However, it has also been reported in men [ 21214 Flint free the nipple, 2031449096, ], as well as throughout childhood [ 8699]. NA most typically presents in women in their 4th and 5th decades of life [ 2652 ]. The purpose of our current case report is to present a comprehensive review of the available data on nipple adenoma, as well as provide useful information to health care providers including dermatologists, breast health specialists, and other health care providers who evaluate patients with dermatologic conditions of the breast skin for appropriately clinically recognizing, diagnosing, and treating patients with nipple adenoma.
However, nipple tissue biopsy with histopathological evaluation and confirmation prior to complete lesion excision is highly recommended. New diagnostic tools include dermatoscopic examination i.
The purpose of our current case report is to present a comprehensive review of the available data on NA, as well as provide useful information to health care providers including dermatologists, breast health specialists, and other health care providers who evaluate patients with dermatologic conditions of the breast skin for appropriately clinically recognizing, diagnosing, and treating patients with NA. A 53 year old Caucasian female with a past medical history of right eye choroidal melanoma presented with a one year history of erythema and induration of the skin at the junction of the inferior aspect of the right nipple profile and surrounding areolar skin Fig.
The patient had subsequently been treated with the application of topical steroids and topical antibiotics to the right nipple profile and surrounding areolar skin for the duration of approximately 5 months, and showed no clinical improvement. At the current time, some 31 months after her definitive surgical therapy to her right breast, the patient remains without any evidence of any recurrent process within her right breast. However, digital mammography should always be considered for ruling out any mammographic abnormalities in the underlying breast tissue when a patient presents with any ificant nipple symptomatology.
It is well documented that incidental breast cancer has been detected at the time of the excision of a NA [ 28122426274849525357677587, ]. Ozaki et al. A nipple biopsy confirmation and subsequent complete surgical excision remain the gold standard for diagnosis and treatment of NA. However, more recently, alternate approaches have been suggested. When a NA grows from the nipple stroma and into the overlying dermis and epidermis or erodes through the epidermis, more limited forms of surgical excision, such as the nipple splitting enucleation technique, should not be considered.
Eusebi and Lester reported that 24 of The gold standard for making the most definitive final diagnosis of NA is histopathologic examination of a completely excised lesion [ 3 — ]. Recently, 5-hydroxymethylcytosine, an epigenetic modifier, has been suggested as a putative marker for NA [ ]. Since nipple adenoma represents a benign proliferative process of the nipple, complete surgical excision is curative. The patient presented in our current case report had both histologic evidence of adenosis and hyperplasia, most consistent with a mixed type of NA.
It is our own personal opinion that most NAs will histologically display features in common across more than one of the aforementioned subtypes. All four of these NA cases showed a small to large papillary cluster of epithelial cells, round to oval nuclei, and with Flint free the nipple of the four cases also having attached myoepithelial cells. Immunohistochemical studies supporting the diagnosis of nipple adenoma.
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However, the coexistence of nipple adenoma and ipsilateral or contralateral breast cancer is well reported in the literature. According to the WHO Classification of Tumours of the Breast [ 2 ], the 4 most common recognized histological subtypes of NA are: 1 adenosis type; 2 epithelial hyperplasia or papillomatosis type; 3 sclerosing papillomatosis or pseudo-infiltrating type; and 4 mixed type.
An initial 3 mm punch biopsy of the skin at the junction of the inferior aspect of the right nipple profile and surrounding areolar skin was obtained by a dermatologist and histopathologic evaluation Flint free the nipple reported to show subareolar sclerosing duct hyperplasia without abnormalities of the skin. Repeat diagnostic digital mammography was performed on the patient during her evaluation by the breast surgical oncologist, and showed stable, benign-appearing right breast calcifications, and no suspicious mammographic findings within the right subareolar region or elsewhere within the right breast.
It should be emphasized that any patient with a history of NA should be encouraged to maintain regular breast follow-up with continuation of annual clinical breast exams by their healthcare providers and annual digital screening mammography after successful NA removal.
No atypia or malignancy was identified within either of the two sequential skin punch biopsy specimens. No palpable intraparenchymal breast masses were detected on clinical breast examination within either breast.
Initial clinical appearance of right nipple. The patient was subsequently taken to the operating room Fig. Surgical excision.
There was no histologic evidence of atypia or malignancy identified within the submitted specimen at the time of histopathologic evaluation. However, more limited forms of complete surgical excision of the entire NA have been reported using a wedge resection technique [ 9394], as well as a nipple splitting enucleation technique via a trans-nipple longitudinal incision made down through the long axis of the nipple profile to expose and extract the NA [ 80, ]. In the sclerosing papillomatosis type, a pseudo-infiltrating pattern is distinguished by a prominence of proliferating epithelium into the stroma.
The major histologic features of NAs are that they represent a ductal proliferation of glandlike structures within the stroma of the nipple, and generally have fairly well circumscribed borders but without encapsulation [ 815232652].
Flint free the nipple bilateral digital mammogram performed approximately seven months before presentation was within normal limits. The potential for a direct causal link or association of nipple adenoma and breast cancer cannot be fully excluded. Likewise, Mohs micrographic surgery has been reported to be successfully used for NA excision and is thought to be curative [ 768498 ]. Learn More.
In light of these staggering breast cancer statistics, it is important to recognize benign breast conditions including conditions affecting the skin of the breast which can clinically and histologically mimic malignant conditions of the breast.
Lastly, cryotherapy has been reported as a novel technique for eradication of a NA [ 74 ].
Development of the human breast
Alternate treatment interventions include Mohs micrographic surgery [ 768498 ], nipple splitting enucleation of the NA [ 80, ], and cryotherapy [ 74 ]. Since NA represents a benign proliferative process of the nipple, complete surgical excision is curative.
InTakashima et al. Thus, the histological subtyping of NAs is somewhat arbitrary secondary to shared histologic features that can be seen within any given NA, and the resultant clinical relevance of the histological subtyping of NAs remains in question. As such, patients may have symptoms for many months to many years before presenting to a health care provider for evaluation.
Breast magnetic resonance imaging has also been reported to allow for characterization of NA [ 8195]. Histopathologic evaluation by a breast-specific pathologist of hematoxylin and eosin stained sections from the right central breast resection specimen revealed a well-circumscribed, compact proliferation of tubular glands within the nipple stroma and nipple skin dermis Fig.
The lesion appeared centered in the reticular dermis, with focal extension into the papillary dermis. Cytokeratin CK7 highlights the ductal epithelium and support the diagnosis. While most cases of NA are unilateral, there have been rare reports of bilateral disease [ 2228 ].
Lastly, cases of NA have even rarely been reported to have arisen from a supernumerary mammary gland location [ 37, ]. Historically, NA has been known by a variety of other names in the literature, including nipple duct adenoma, papillary adenoma of the nipple, florid papillomatosis of the nipple, florid adenomatosis of the nipple, erosive adenomatosis of the nipple, papillomatosis of the nipple, subareolar sclerosing duct hyperplasia of the nipple, subareolar duct papillomatosis of the nipple, and superficial papillary adenomatosis of the nipple.
The patient is doing well 31 months after her definitive surgical therapy.
Imaging studies, including mammography and breast ultrasound are generally unable to provide adequate information for confirming the presence of NA due to the similarity in tissue density of the nipple to the surrounding skin and the underlying breast tissue [ ]. In such cases, complete excision of all involved nipple skin should be undertaken to assure complete lesion removal and to minimize the risk of local recurrence of the NA with the remaining nipple profile.
While most of these incidental breast cancers are found at the time of the initial NA excision, there are rare cases in which breast cancer has been reported at the site where a NA was ly biopsied or excised [ 2243653]. It is universally agreed upon that complete surgical excision of the entire NA is important for preventing local recurrence [ 3 — ].
Histologically, NA can appear similar to other breast conditions including syringomatous adenoma of the nipple, intraductal papilloma, adenomyoepithelioma, ductal carcinoma in situ, and invasive ductal carcinoma as well as several dermatologic lesions including syringoma of the skin, hidradenoma papilliferum, and syringocystadenoma papilliferum [ 215232652, ]. Skin punch biopsies showed subareolar duct papillomatosis.
Adenosis, cystic dilation, ductal hyperplasia, papillary hyperplasia, apocrine metaplasia, squamous metaplasia, and keratin cysts can be seen to varying degrees in NAs. Immunohistochemical stains can be useful to highlight the presence of two cell layers i. They differentiated an adenoma of the nipple as a separate process from that of ductal papillomatosis of the nipple [ 15 ].
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It is highly impactful on treatment planning, prognostication, and the resultant financial and psychosocial consequences. Histologic examination of the excised right nipple tissue. James Cancer Hospital and Richard J. Nipple adenoma is a very uncommon, benign proliferative process of lactiferous ducts of the nipple. The patient elected to undergo complete surgical excision with right central breast resection. Breast ultrasound has been reported by some to be a potential useful tool for identifying NA, as based upon the findings of homogenous echogenicity and hypervascularity [ 79,], while others have found its use limited and inconclusive [ ].
At medium power, an adenosis pattern with proliferation of benign tubular glands was seen Fig. At high power, several glands showed usual type ductal hyperplasia and apocrine metaplasia Fig. A medium power hematoxylin and eosin stained section Fig. Therefore, a final pathologic diagnosis of NA was given.
As in our particular case, complete surgical excision has traditionally been accomplished by resection surgical excision of the right nipple profile, adjacent surrounding areolar skin, and superficial underlying breast and subcutaneous tissues [ 38, ]. The overlying epidermis showed acanthosis, but was not directly involved by the lesion itself. Resultantly, the literature on NA has been somewhat limited, and has primarily consisted of multiple case reports and small case series, although a few larger case series do exist [ 3 — ]. The potential for local recurrence of NA is always a concern with utilization of any of these more limited forms of complete lesion removal.
Lastly, the mixed type may show features of any of the other three aforementioned subtypes. The accurate diagnosis of breast diseases is of paramount importance to both patients and clinicians. NA is a benign proliferative process of lactiferous ducts of the nipple [ 2 — ].