What is the best course of action for an elderly female patient with a history of bilateral breast reduction surgery two years ago, presenting with persistent retracted nipples and chronic itch sensation?

Evaluation and Management of Persistent Nipple Retraction with Chronic Itch After Breast Reduction

This patient requires urgent evaluation with bilateral diagnostic mammography and ultrasound to exclude Paget disease of the nipple, followed by punch biopsy of the nipple if imaging is negative but symptoms persist, as chronic nipple itching with skin changes can represent underlying malignancy in 80-90% of Paget disease cases. 1

Critical Malignancy Exclusion

The combination of persistent nipple retraction and chronic itch sensation is concerning for Paget disease, which frequently presents with nipple itching and is often misdiagnosed as benign dermatologic conditions 1. Key concerns include:

• Underlying breast cancer is present in 80-90% of Paget disease cases, which may be either ductal carcinoma in situ (DCIS) or invasive carcinoma 1
• Symptom chronicity does not exclude malignancy, as Paget disease can have a waxing and waning course 1
• Pure Paget disease is frequently occult on mammography, meaning negative imaging does not exclude the diagnosis 1

Recommended Diagnostic Algorithm

Initial Imaging Evaluation

Step 1: Bilateral diagnostic mammography with ultrasound 1

• Perform thorough clinical breast examination looking for masses, skin changes, or persistent nipple abnormalities 1
• Special ultrasound attention to the retroareolar region using standoff pad or abundant warm gel 2
• Apply peripheral compression and rolled-nipple techniques for optimal visualization 2

Tissue Diagnosis Based on Imaging Results

If imaging shows BI-RADS 1-3 (negative/benign/probably benign):

• Punch biopsy of the nipple should still be performed given clinical suspicion, as normal imaging does not exclude Paget disease 1
• The National Comprehensive Cancer Network emphasizes that "nipple excoriation, scaling, and eczema should increase clinical suspicion of Paget's disease" 1

If imaging shows BI-RADS 4-5 lesions:

• Proceed directly to image-guided core needle biopsy for tissue diagnosis 2

If biopsy is benign but clinical suspicion remains:

• Consider breast MRI, repeat biopsy, and consultation with a breast specialist 1

Post-Surgical Considerations

While evaluating for malignancy, recognize that post-reduction complications can contribute to symptoms:

• Nipple sensation changes are common after breast reduction, with variable recovery patterns depending on surgical technique 3, 4
• Partial areolar necrosis occurs in 3.1% of breast reduction patients, which could contribute to chronic symptoms 5
• Chronic traction injury to intercostal nerves in women with prior gigantomastia may persist despite surgical correction 3

However, the two-year interval since surgery makes acute surgical complications unlikely, and the chronic itch sensation specifically raises concern for Paget disease rather than routine post-operative changes 1.

Critical Pitfalls to Avoid

• Do not attribute symptoms solely to post-surgical changes without excluding malignancy, as Paget disease diagnosis is frequently delayed due to confusion with benign conditions 1
• Do not rely on mammography alone, as sensitivity for detecting underlying malignancy in Paget disease is limited 1
• Do not dismiss resolved or intermittent symptoms, as the American College of Radiology and National Comprehensive Cancer Network emphasize that symptom resolution does not exclude underlying malignancy 1

Follow-Up Strategy

If initial workup is negative:

• Re-evaluate in 3-6 months with repeat clinical examination 6
• Maintain low threshold for repeat imaging or biopsy if symptoms persist or worsen 1
• Instruct patient to report development of spontaneous nipple discharge, particularly if bloody or serous 6, 2