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Abstract

This study shows that a non-suspicious mammogram (MMG) does not reliably exclude underlying malignancy in Paget's disease of the nipple (PD). Magnetic resonance imaging (MRI) was more sensitive and missed no invasive cancer, supporting complementary rather than competing roles in preoperative planning.Introduction PD is often associated with an underlying breast carcinoma, and preoperative imaging is central to surgical planning. Evidence on MRI, particularly when MMG is non-suspicious, remains limited. We evaluated the accuracy of MMG and MRI for detecting underlying malignancy in patients with PD.Patients and Methods Patients treated at Odense University Hospital between January 2011 and May 2026 were identified using the SNOMED code M85402. Preoperative MMG and MRI findings were classified as suspicious (BI-RADS≥4) or non-suspicious (BI-RADS≤3) and compared with postoperative histopathology as the reference standard. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Reporting followed the STROBE guidelines.Results All 82 patients underwent MMG and 47 (57%) underwent MRI. Underlying ductal carcinoma in situ (DCIS) or invasive ductal carcinoma (IDC) was present in 73 of 82 patients (89%). MMG had a sensitivity of 41.7% (95% CI30.2-53.9), specificity 100%, PPV 100%, and NPV 17.6%; MRI had higher sensitivity of 82.9% (95% CI 67.9-92.8) and a PPV of 87.2%. Among 51 patients with non-suspicious MMG, 42 (82%) had underlying carcinoma. MMG classified 9 invasive carcinomas as non-suspicious, whereas MRI missed none.Conclusion MRI should be considered when MMG is non-suspicious or breast-conserving surgery is planned; nipple-areola enhancement may reflect PD itself and must be interpreted clinically.