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A Translucent Nodule of the Nipple in an Elderly Male Patient

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A male patient in his 70s presented an asymptomatic, slightly eroded, translucent nodule on his right nipple (Figure, A). There was a family history of cutaneous melanoma in his 2 sisters, daughter, and nephew and breast cancer in his mother and sister. We completed genetic testing of family members and found no genetic mutations in sera samples to predispose them to melanoma skin cancer or breast cancer. The main genes tested were the breast cancer type 1 susceptibility (BRCA1), breast cancer 2–DNA repair associated (BRCA2), partner and localizer of BRCA2 (PALB2), checkpoint kinase 2 (CHEK2), and tumor protein p53 (TP53) genes. A dermoscopic examination of the patient showed a translucent lesion with arborizing vessels and erosion (Figure, B). A punch biopsy was performed.

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C. Ductal adenocarcinoma of the breast

Histological assessment of the lesion revealed a thinning of the epidermis, with a layer of hyperkeratosis and a proliferation of neoplastic cells that had created a glandular pattern in the dermis (Figure, C). There was no pagetoid cell proliferation in the epidermis (Figure, D). Immunohistochemistry staining revealed estrogen-receptor positivity, progesterone-receptor positivity, antigen KI-67 at 10%, and a human epidermal growth factor receptor 2 (Her2) score of +2. These findings were consistent with invasive ductal carcinoma of the breast. An additional clinical examination by a breast cancer specialist highlighted bilateral gynecomastia without any evidence for a palpable mass or adenopathy, although palpation by a pathologist of the specimen subsequently derived from a second resection showed a well-defined mass.

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Article Information

Corresponding Author: Ahangari Dario, MD, Department of Dermatology, Saint-Luc University Hospital, Avenue Hippocrate 10, 1200 Brussels, Belgium (darioahangari@gmail.com).

Published Online: January 8, 2020. doi:10.1001/jamadermatol.2019.4253

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information. We thank Dr Zachary Boyce, BSc, MBBS, FACD, Bulimba Dermatology Clinic and South East Dermatology Clinic, Brisbane, Australia, for proofreading this article. He was not compensated for this contribution.

References
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