Subtitle: A case-based workup of a 53-year-old woman with eczematous change of the nipple: biopsy images, Paget disease versus Bowen disease, melanoma and Toker cells, IHC panel, staging and 7 case MCQs.
Author: PathologyMCQ Editorial Board
Category: Breast Pathology
Last Updated: October 2026
Read Time: 5 minutes
At-a-Glance
- Scenario: 53-year-old woman with an eczematous, scaly nipple-areolar lesion; a biopsy was taken.
- Look for large pale intraepidermal cells with prominent nucleoli.
- Confirm with CK7 and HER2; exclude melanoma (SOX10, Melan-A) and Bowen disease (p63, CK5/6).
- Paget disease almost always signals underlying DCIS or invasive carcinoma.
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The Case
A 53-year-old woman presented with eczematous change of the nipple-areolar region that did not settle with topical treatment. A punch biopsy was performed. Study the images, then answer the case questions below.
Approach to Pagetoid Cells in the Nipple
| Diagnosis | Key morphology | CK7 | HER2 | p63 / CK5/6 | SOX10 / Melan-A |
|---|---|---|---|---|---|
| Paget disease | Large pale cells, nucleoli, mucin in some | + | + (most) | − | − |
| Toker cells | Bland small clear cells, no atypia | + | − | − | − |
| Bowen disease (SCC in situ) | Full-thickness atypia, keratinisation | − / focal | − | + | − |
| Melanoma in situ | Pagetoid melanocytes, pigment | − | − | − | + |
Also search the specimen and imaging for the underlying DCIS or invasive carcinoma. For a full review, see Paget disease of the nipple: histology and IHC →
Video
Case Questions: 7 MCQs
Case questions: 7 MCQs
Diagnosis, IHC, mimics and staging, with instant explanations.
More practice: the question banks →
Exam Pearls
- Eczematous nipple not responding to treatment = biopsy for Paget disease.
- CK7+, HER2+, p63−, SOX10−.
- Toker cells are CK7+ but bland and HER2−.
- Paget alone is staged pTis (Paget).
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Related reads: Paget disease of the nipple → · HER2 IHC scoring →
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References
- WHO Classification of Tumours Editorial Board. Breast Tumours. 5th ed. IARC; 2019.
- Lloyd J, Flanagan AM. Mammary and extramammary Paget’s disease. J Clin Pathol. 2000;53:742–9.
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