Nipple Biopsy is the Next Best Step
The correct answer is C: Nipple biopsy. A scaly, oozing nipple lesion that persists for weeks requires tissue diagnosis to exclude Paget disease of the nipple, which represents ductal carcinoma in situ (DCIS) extending into the nipple epidermis and is found in over 80% of cases with persistent unilateral nipple lesions. 1
Why Biopsy is Mandatory Despite Normal Imaging
Normal imaging does not exclude malignancy in nipple lesions. Paget disease can present with isolated nipple changes without detectable underlying masses or imaging abnormalities in a significant proportion of cases. 1
The clinical presentation is highly suspicious. A persistent unilateral scaly, oozing nipple lesion lasting weeks is the classic presentation of Paget disease, which requires histologic confirmation. 2, 1
Mammography and ultrasound have limited sensitivity for nipple-specific pathology. These modalities are designed to detect parenchymal lesions, not intraepidermal malignancies like Paget disease that may exist without an underlying mass. 1
Why Other Options Are Inappropriate
Topical Steroid Cream (Option B) is Dangerous
Empiric treatment without tissue diagnosis risks missing cancer. Eczema of the nipple is a differential diagnosis for Paget disease, but the two cannot be reliably distinguished clinically. 1
Steroid application may temporarily improve symptoms while allowing malignancy to progress. This creates a false sense of reassurance and delays definitive diagnosis. 1
The standard of care mandates biopsy before treatment. In any patient with a persistent unilateral nipple lesion, tissue sampling is required to exclude Paget disease. 1
Dermatology Referral (Option A) is Suboptimal
This introduces unnecessary delay in cancer diagnosis. While dermatologists can perform biopsies, the patient should proceed directly to tissue diagnosis rather than adding another consultation step. 1
Breast surgeons or breast specialists are better equipped to manage this presentation. They can coordinate immediate biopsy and subsequent breast imaging (including MRI if malignancy is confirmed) to assess for multifocal disease. 1
The Specific Biopsy Approach
Punch biopsy or wedge biopsy of the nipple lesion itself is required. The sample must include the abnormal nipple skin to capture the intraepidermal malignant cells characteristic of Paget disease. 2, 1
Core needle biopsy of breast parenchyma is insufficient. The pathology in Paget disease involves the nipple epidermis, not necessarily the underlying breast tissue. 2
Post-Biopsy Management Algorithm
If Paget disease is confirmed: Breast MRI is indicated to detect underlying DCIS or invasive cancer (present in >80% of cases) and assess for multifocal disease, especially if breast-conserving surgery is planned. 1
If benign (eczema or erosive adenomatosis): Appropriate topical therapy can then be initiated with confidence. 1
If biopsy is non-diagnostic or discordant: Repeat biopsy or excisional biopsy is necessary until concordance between clinical presentation and pathology is achieved. 3
Critical Pitfall to Avoid
Never assume a nipple lesion is benign based on normal imaging alone. The absence of a palpable mass and normal mammogram/ultrasound does not exclude Paget disease, which can exist as an isolated finding in the nipple epidermis without detectable parenchymal abnormalities. 1 Delaying biopsy to trial topical treatments or await specialist consultation allows potential malignancy to progress and represents a significant medicolegal risk.