Diverse Radiologic Presentations of Paget's Disease of the Breast: From Subtle to Striking Findings

Objectives Paget's disease of the breast is a rare condition that is often associated with underlying malignancy. Given the subtle mammographic findings, a multimodal imaging approach is essential for an early diagnosis. The objective of this study was to describe the clinical, multimodality imaging, and histopathological spectrum of histopathologically confirmed mammary Paget's disease in eight patients. Materials and methods This is a descriptive study of eight histopathologically confirmed patients with Paget's disease of the breast, identified over a 10-year period (2015-2025) at a tertiary care center in India. Imaging modalities analyzed included mammography, ultrasonography, MRI, and positron emission tomography-computed tomography (PET-CT), with clinical and pathological correlation. Results The patients' ages ranged from 27 to 75 years, with one case of bilateral disease. Nipple ulceration was the predominant symptom in six patients (75%), followed by breast lump in two patients (25%). Mammography was performed in five patients (63%) and showed irregular equal-density mass, round circumscribed nodule, fine pleomorphic calcifications, skin thickening, nipple retraction, and axillary lymphadenopathy; notably, all mammograms in this study had features suggestive of malignancy, in contrast to previous studies. Ultrasonography was performed in seven patients (88%); irregular hetero-echoic masses, thickened nipple-areola complexes with internal vascularity, ductal involvement, heterogeneous parenchyma with calcifications, and axillary lymphadenopathy were common. MRI was performed in three patients (38%) and showed irregular enhancing lesions, satellite nodules, ductal involvement, nonmass enhancement, and nipple erosion. PET-CT was performed in two patients (25%) and showed fluorodeoxyglucose (FDG)-avid ill-defined lesions with associated lymphadenopathy. One multifocal disease pattern was identified on MRI, and one multicentric disease pattern was identified on mammography. Surgical management included modified radical mastectomy in five patients (63%), simple mastectomy in two patients (25%), and wide local excision in one patient (12%). Histopathological analysis revealed Paget's disease with underlying invasive mammary carcinoma in four patients (50%), ductal carcinoma in situ (DCIS) in two patients (25%), and isolated Paget's disease with no underlying malignancy in two patients (25%). Conclusion Paget's disease presents with subtle radiological features. Hence, a multimodality imaging strategy may improve characterization and assessment of disease extent and help in planning treatment.