What is the management approach for an epidermoid cyst of the nipple?

Management of Epidermoid Cyst of the Nipple

Surgical excision is the definitive treatment for epidermoid cysts of the nipple, with preoperative biopsy recommended to rule out malignancy before proceeding with nipple-sparing excision and areolar reconstruction. 1

Initial Diagnostic Approach

Clinical evaluation should focus on:

• Rate of growth (rapid growth may mimic malignancy) 1
• Presence of inflammation or infection 2
• Size and exact location on the nipple-areola complex 1
• Presence of a central punctum (diagnostic hallmark of epidermoid cysts) 3, 4
• Any associated nipple discharge or skin changes 5

Imaging and Tissue Diagnosis

Ultrasound is the preferred initial imaging modality for evaluating nipple masses, showing epidermoid cysts as round to oval, well-circumscribed, avascular masses in subcutaneous tissue with posterior acoustic enhancement and lateral shadowing 4. For women under 30 years, ultrasound is the preferred initial diagnostic imaging 5.

Preoperative biopsy is essential to distinguish epidermoid cysts from breast malignancy, as these lesions can clinically mimic breast cancer when located on the areola 1. This enables limited surgical excision and nipple preservation 1.

Management Algorithm

For Non-Inflamed Cysts:

• Proceed directly to surgical excision using minimal excision technique or complete excision 1, 3, 2
• The minimal excision technique involves a 2-3 mm incision, expression of cyst contents, and extraction of the cyst wall without suture closure 2
• Complete removal of the cyst wall is mandatory to prevent recurrence 3
• Nipple-sparing surgery with areolar reconstruction using local areolar flap provides good aesthetic outcomes 1

For Inflamed Cysts:

• Postpone excision until inflammation subsides 2
• Administer a course of antibiotics first 1
• Schedule definitive surgical excision after resolution of inflammation 1, 2

Surgical Considerations

Most epidermoid cyst excisions can be performed under local anesthesia with a low complication rate of approximately 2.2% 3. The procedure is straightforward and can be learned after 3-5 precepted sessions 2.

Important technical points:

• Use gauze or splatter shield to protect from spraying cyst contents 2
• Ensure complete cyst wall removal to avoid relapse 3
• For nipple location specifically, reconstruction of the areola by local areolar flap enables optimal aesthetic results 1

Histopathologic Evaluation

Histologic evaluation is necessary only if:

• Unusual clinical findings are present 2
• Clinical suspicion of malignancy exists 2
• The lesion shows atypical features on imaging 1

The rarity of associated cancer makes routine histologic evaluation unnecessary in straightforward cases 2. However, given the nipple location and potential to mimic breast cancer, pathologic confirmation is prudent in this anatomic site 1.

Common Pitfalls to Avoid

• Do not attempt excision during active inflammation, as inflamed cysts are difficult to excise completely 2
• Failure to remove the entire cyst wall leads to recurrence 3
• Assuming malignancy without tissue diagnosis in rapidly growing nipple masses that may be benign epidermoid cysts 1
• Inadequate preoperative planning for nipple-areola reconstruction in cases requiring wider excision 1