How should dark flat pigmented lesions on the areola be evaluated and managed?

Evaluation and Management of Dark Flat Pigmented Lesions on the Areola

Dark flat pigmented lesions on the areola should undergo full-thickness surgical biopsy (not excision) to exclude melanoma and Paget's disease, as melanosis of the nipple-areola complex is likely the most common benign cause but cannot be reliably distinguished from malignancy on clinical grounds alone. 1

Initial Clinical Assessment

Key Warning Signs Requiring Urgent Evaluation

Assess for melanoma using the ABCDE criteria, which are standard for evaluating any pigmented lesion 2:

• Asymmetry of the lesion 2
• Border irregularity 2
• Color heterogeneity (multiple shades of brown, black, or other colors) 2
• Diameter ≥7 mm (though early melanomas can be smaller) 2
• Evolution (recent change in size, shape, or color) - this must coexist with at least one preceding criterion 2

Additional concerning features include 2:

• Change in size, shape, or color (the three major signs) 2
• Inflammation, sensory change (itching), crusting, or bleeding (minor signs) 2

Specific Considerations for Areolar Lesions

Paget's disease of the nipple must be excluded, as it commonly presents with pigmentation, eczema, bleeding, ulceration, or itching of the nipple-areola complex, with an associated breast cancer present in 80-90% of cases 2. The associated cancers may be DCIS or invasive and are not necessarily adjacent to the nipple 2.

Melanosis of the nipple-areola is likely the most common cause of pigmentation at this site and is significantly underreported in medical literature 1. However, it cannot be reliably distinguished from melanoma or pigmented Paget's disease without histopathology 1, 3.

Dermoscopic Evaluation

Dermoscopy by an experienced physician enhances diagnostic accuracy and should be performed when available 2. For areolar melanosis, dermoscopic features may include 1, 4:

• Light to dark brown cobblestone pigmentation with ring-like structures 1
• Reticulation pattern 1
• Reticular-like pattern specifically associated with areolar melanosis 4
• Structureless pattern with blue hue (suggests melanophages in upper dermis) 4

Concerning dermoscopic features suggesting melanoma include 1:

• Blue-white veil 1
• Irregular centered black dots 1
• Black blotches 5

Critical caveat: Dermoscopy should only be used by trained clinicians familiar with the technique, as accuracy depends on experience 2. Even with dermoscopy, histopathology remains the gold standard 5, 6.

Diagnostic Approach

Mandatory Evaluation Steps

1. Complete history documenting 2:

   • Duration of the lesion 2
   • Any change in size, color, or shape 2
   • Associated symptoms (itching, bleeding, pain) 2

2. Physical examination including 2:

   • Site and maximum diameter measurement 2
   • Elevation (flat, palpable, nodular) 2
   • Description of margins (regular vs irregular) and pigmentation pattern 2
   • Complete breast examination to identify any associated breast mass or abnormality 2
   • Regional lymph node examination (axillary nodes) 7

3. Diagnostic breast imaging (mammography ± ultrasound) is recommended when evaluating pigmented lesions of the nipple-areola complex to identify any underlying breast pathology 2

4. Breast MRI is recommended if biopsy confirms Paget's disease to define extent of disease and identify additional lesions 2

Biopsy Technique

Full-thickness surgical biopsy (not excision) is the appropriate initial approach for suspected benign melanosis, as this allows histologic confirmation while avoiding unnecessary wide excision of benign lesions 1. The biopsy should include 2:

• Full thickness of epidermis 2
• At least a portion of any clinically involved nipple-areola complex 2

If melanoma is suspected based on clinical or dermoscopic features, complete excisional biopsy with a 2 mm margin of normal skin is standard practice 2, 7. The rationale for complete excision includes 2:

• Risk of misdiagnosis if melanocytic lesion is only partially examined 2
• Examination of entire lesion necessary to assess all histological parameters, particularly maximum thickness 2
• If benign, no further treatment needed 2

Use a scalpel rather than laser or electrocautery, as tissue destruction compromises final diagnosis and assessment of histological prognostic factors 2.

Critical Pitfalls to Avoid

• Never assume a pigmented areolar lesion is benign without histologic confirmation, as melanoma, pigmented Paget's disease, and pigmented breast carcinoma can all present as pigmented lesions at this site 1, 3

• Do not perform partial biopsy or shave biopsy of suspected melanoma, as this risks misdiagnosis and prevents accurate assessment of Breslow thickness 2

• Do not delay biopsy in patients with any concerning features (ABCDE criteria, symptoms, or evolution), as early diagnosis is critical for melanoma prognosis 2

• Avoid using dermoscopy alone to exclude malignancy without histopathologic confirmation, particularly in clinically equivocal lesions 4, 5, 6

• Do not forget to evaluate the entire breast and regional lymph nodes, as Paget's disease is associated with underlying breast cancer in the majority of cases 2

Histopathologic Requirements

The pathology request must include 2:

• Patient age, sex, and exact anatomic site 2
• Type of surgical procedure performed 2
• Complete macroscopic description and specimen dimensions 2

For melanoma, the histopathology report must document 2:

• Breslow thickness (measured to nearest 0.1 mm from granular layer to tumor base) 2
• Presence of ulceration 2
• Clearance of surgical margins 2
• Clark level, mitotic rate, regression, and lymphovascular invasion 2