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Guirguis MS, Arribas EM, Kapoor MM, Patel MM, Perez F, Nia ES, Ding Q, Moseley TW, Adrada BE. Multimodality Imaging of Benign and Malignant Diseases of the Nipple-Areolar Complex. Radiographics 2024; 44:e230113. [PMID: 38483829 DOI: 10.1148/rg.230113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
The nipple-areolar complex (NAC), a unique anatomic structure of the breast, encompasses the terminal intramammary ducts and skin appendages. Several benign and malignant diseases can arise within the NAC. As several conditions have overlapping symptoms and imaging findings, understanding the distinctive nipple anatomy, as well as the clinical and imaging features of each NAC disease process, is essential. A multimodality imaging approach is optimal in the presence or absence of clinical symptoms. The authors review the ductal anatomy and anomalies, including congenital abnormalities and nipple retraction. They then discuss the causes of nipple discharge and highlight best practices for the imaging workup of pathologic nipple discharge, a common condition that can pose a diagnostic challenge and may be the presenting symptom of breast cancer. The imaging modalities used to evaluate and differentiate benign conditions (eg, dermatologic conditions, epidermal inclusion cyst, mammary ductal ectasia, periductal mastitis, and nonpuerperal abscess), benign tumors (eg, papilloma, nipple adenoma, and syringomatous tumor of the nipple), and malignant conditions (eg, breast cancer and Paget disease of the breast) are reviewed. Breast MRI is the current preferred imaging modality used to evaluate for NAC involvement by breast cancer and select suitable candidates for nipple-sparing mastectomy. Different biopsy techniques (US -guided biopsy and stereotactic biopsy) for sampling NAC masses and calcifications are described. This multimodality imaging approach ensures an accurate diagnosis, enabling optimal clinical management and patient outcomes. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
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Affiliation(s)
- Mary S Guirguis
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Elsa M Arribas
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Megha M Kapoor
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Miral M Patel
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Frances Perez
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Emily S Nia
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Qingqing Ding
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Tanya W Moseley
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Beatriz E Adrada
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
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Pelorca RJF, de Oliveira-Junior I, da Costa Vieira RA. Oncoplastic surgery for Paget's disease of the breast. Front Oncol 2023; 13:1151932. [PMID: 37265790 PMCID: PMC10231681 DOI: 10.3389/fonc.2023.1151932] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/02/2023] [Indexed: 06/03/2023] Open
Abstract
Introduction Paget's disease of the breast (PDB) is a rare nipple entity associated with multifocality. Due to its location, resection of the entire nipple-areolar complex is necessary. Historically central quadrantectomy and mastectomy have the surgical treatments of choice. The feasibility of oncoplastic breast surgery (OBS) for PDB is unknown. Methods This was a retrospective study performed in a Brazilian oncological hospital. We evaluated the factors related to the performance of OBS in PDB. In addition, the impact of OBS on local recurrence and survival was analysed. Comparisons were made between groups using the chi-square test, Mann-Whitney U test, and Kaplan-Meier method. To assess the impact factor of the variables on the performance of OBS, logistic regression was performed. Results Eighty-five patients were evaluated. OBS was performed in 69.4% (n=59), and of these, 16 (27.2%) were symmetrized with contralateral surgery. Mastectomy without reconstruction was performed in 28.3% of the patients. The primary procedure performed was mastectomy with reconstruction (n=38; 44.7%), and the preferential technique for immediate reconstruction was skin-sparing mastectomy with prosthesis; for late reconstruction, the preferred technique was using the latissimus dorsi. Breast conserving-surgery was performed in 27.0% (n=23), primarily using the plug-flap technique (OBS). Age was associated with the use of OBS; as patients aged 40-49 exhibited a higher rate of OBS (p = 0.002; odds ratio 3.22). OBS did not influence local recurrence (p=1.000), overall survival (p=0.185), or cancer-specific survival (p=0.418). Conclusion OBS improves options related to surgical treatment in PDB without affecting local recurrence or survival rates.
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Affiliation(s)
- Rafael José Fábio Pelorca
- Programa de Pós-Graduação em Tocoginecologia, Faculdade de Medicina de Botucatu, Botucatu, SP, Brazil
| | - Idam de Oliveira-Junior
- Programa de Pós-Graduação em Tocoginecologia, Faculdade de Medicina de Botucatu, Botucatu, SP, Brazil
- Programa de Pós-Graduação em Oncologia, Barretos Cancer Hospital, Barretos, SP, Brazil
- Departamento de Mastologia e Reconstrução Mamária, Barretos Cancer Hospital, Barretos, SP, Brazil
| | - René Aloisio da Costa Vieira
- Programa de Pós-Graduação em Tocoginecologia, Faculdade de Medicina de Botucatu, Botucatu, SP, Brazil
- Programa de Pós-Graduação em Oncologia, Barretos Cancer Hospital, Barretos, SP, Brazil
- Departamento de Cirurgia Oncológica, Divisão de Mastologia, Hospital de Câncer de Muriaé, Muriaé, MG, Brazil
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Lin CW, Chiang MH, Tam KW. Treatment of Mammary Paget Disease: A systematic review and meta-analysis of real-world data. Int J Surg 2022; 107:106964. [PMID: 36309195 DOI: 10.1016/j.ijsu.2022.106964] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 09/10/2022] [Accepted: 10/11/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Because the lesions of mammary Paget disease (MPD) are often limited to the nipple-areolar complex, the extension of optimal tumor excision is inconclusive. Moreover, the risk of potential tumor upstaging is unknown; therefore, the application of sentinel lymph node biopsy (SLNB) is required for analysis. We systematically reviewed the real-world data to evaluate the optimal treatment and potential predictors of poorer prognosis for MPD. METHODS The PubMed, Embase, and Cochrane Library databases were searched for relevant studies. Clinical studies were included if they evaluated the outcome of positive rates of SLNB, prognostic risk factors of MPD, and survival outcomes of treatments of interest for MPD, including mastectomy, breast-conserving surgery (BCS) with radiotherapy, and BCS alone. RESULTS A total of 38 studies with 24,062 patients were retrieved. Compared with BCS alone (21.2%), mastectomy (5.9%; P < 0.001) and BCS with radiotherapy (8; P = 0.001) had significantly lower local recurrence rates. Patients with palpable tumors (30.2%) had significantly worse prognoses than those with impalpable (3.4%) tumors in metastasis (P < 0.001), and significantly higher local recurrence rates were observed in patients with underlying invasive carcinoma (6.7%) than those with noninvasive carcinoma (4.5%; P = 0.032). The positive rate of SLNB was 17% (95% CI: 0.115-0.226). CONCLUSION Except for MPD alone, BCS alone is not recommended for treating MPD with invasive ductal carcinoma and MPD with ductal carcinoma in situ. Moreover, a palpable mass, underlying invasive carcinoma, and positive lymph node status may lead to a poorer prognosis, which may be taken into consideration for the application of SLNB.
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Affiliation(s)
- Cheng-Wei Lin
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
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Luu Thi TH, Eichner A, Wohlrab J. Therapeutische Besonderheiten bei Erkrankungen der Mamillenhaut. DIE DERMATOLOGIE 2022; 73:873-879. [PMID: 35925215 PMCID: PMC9592625 DOI: 10.1007/s00105-022-05031-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/22/2022] [Indexed: 11/25/2022]
Abstract
Die Mamillenregion ist durch besondere anatomische Verhältnisse charakterisiert und lässt sich aus dermatologischer Perspektive in Brusthaut, Haut des Brustwarzenhofes (Areola) und Haut der Brustwarze (Papilla mammae) unterteilen. Im klinischen Zusammenhang sind die Brustwarzen häufig während der Stillzeit durch mechanische Beanspruchung, Milieuänderung mit Mazeration durch den Milchfluss sowie durch mikrobielle Erreger alteriert. Zudem besteht hier die Gefahr der Entwicklung einer Mastitis puerperalis. Außerhalb der Schwangerschaft und Stillzeit finden sich gelegentlich an der Mamillenhaut Ekzemerkrankungen, häufig bei atopischer Disposition (atopisches Mamillenekzem) oder als irritatives Kontaktekzem („joggers nipple“). Seltener werden allergische Kontaktekzeme auf Konservierungsstoffe von Topika oder Metallen (Piercings) beobachtet. Auch im Rahmen einer Skabiesinfestation wird eine Beteiligung der Mamillen, insbesondere bei Frauen, regelmäßig beobachtet. Von großer klinischer Bedeutung sind seltene, präinvasive Läsionen eines Mammakarzinoms oder der Morbus Paget der Mamille vom extramammären Typ. Durch die besonderen anatomischen Gegebenheiten ist es naheliegend, dass bei der Anwendung von Topika sich auch spezifische Penetrationsbedingungen ableiten. Experimentelle Untersuchungen an Humanhaut ex vivo legen nahe, dass in Abhängigkeit von der Molmasse und der Löslichkeit des Arzneistoffs sowie des eingesetzten Vehikelsystems eine deutliche Zunahme der kutanen Bioverfügbarkeit, insbesondere an der Brustwarze selbst durch den transpapillären Diffusionsweg, auftreten kann. Dies sollte insbesondere bei der topischen Anwendung von Arzneistoffen mit bekanntem dosisabhängigem Nebenwirkungspotenzial (z. B. Glukokortikoiden) beachtet werden. Allerdings fehlt dafür bisher eine klinische Evidenz.
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Affiliation(s)
- Thanh Huong Luu Thi
- Universitätsklinik für Dermatologie und Venerologie, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Str. 40, 06097, Halle (Saale), Deutschland
| | - Adina Eichner
- Institut für angewandte Dermatopharmazie, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Johannes Wohlrab
- Universitätsklinik für Dermatologie und Venerologie, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Str. 40, 06097, Halle (Saale), Deutschland.
- Institut für angewandte Dermatopharmazie, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland.
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Han BY, Xu XL, Zhu XZ, Han XC, Hu X, Ling H. Clinicopathological Characteristics and Survival Outcomes of Mammary Paget’s Disease: A Retrospective Study Based on a Chinese Population. Cancer Manag Res 2022; 14:237-247. [PMID: 35125891 PMCID: PMC8807864 DOI: 10.2147/cmar.s338788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 12/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background Mammary Paget’s disease (PD) is a rare type of breast cancer. Most cases of PD are presented with underlying ductal carcinoma in situ (DCIS) or invasive breast carcinoma (IDC). This study aimed to investigate the clinicopathological characteristics and survival outcomes of PD patients. Materials and Methods A total of 406 patients diagnosed with PD with IDC/DCIS at Fudan University Shanghai Cancer Center (FUSCC) were recruited as the PD group, 1218 patients diagnosed with IDC/DCIS alone during the same period were selected as the non-PD group, and the clinicopathological results of these two groups were compared. The Surveillance, Epidemiology, and End Results (SEER) database was used to investigate the clinicopathological features between PD and non-PD patients for validation. Results Compared with the non-PD group, the PD group was much more likely to have larger (≥2 cm: 43.1% vs 35.5%, P < 0.001), less hormone receptor (HR)-positive (68.5% vs 26.6%, P < 0.001), more human epidermal growth factor receptor-2 (HER-2)-positive (70.7% vs 27.5%, P < 0.001) and higher Ki-67 proportion (51.5% vs 42.5%, P < 0.001) tumors. The HER-2 overexpression subtype accounted for the largest proportion in the PD-IDC group and the lowest proportion in the non-PD-IDC group (54% vs 8%, P < 0.01). Moreover, the PD group had significantly worse disease-free survival (DFS) than the non-PD group (5-year DFS: 91.8% vs 97.3%, P = 0.001), and the SEER database showed a similar trend. Univariate and multivariate Cox regression analyses demonstrated that PD was an independent poor-risk factor. Our matched study showed that the PD group had worse survival than the non-PD group after excluding age, HR, HER-2, tumor size and lymph node status. Conclusion PD with IDC/DCIS is associated with more aggressive tumor characteristics and worse survival outcomes. More than half of PD breast cancers are HER-2 overexpression subtype. PD is an independent poor-risk factor for breast cancer survival.
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Affiliation(s)
- Bo-Yue Han
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200032, People’s Republic of China
- Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200032, People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People’s Republic of China
| | - Xiao-Li Xu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People’s Republic of China
- Department of Pathology, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200032, People’s Republic of China
| | - Xiu-Zhi Zhu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200032, People’s Republic of China
- Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200032, People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People’s Republic of China
| | - Xiang-Chen Han
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200032, People’s Republic of China
- Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200032, People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People’s Republic of China
| | - Xin Hu
- Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200032, People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People’s Republic of China
- Correspondence: Xin Hu; Hong Ling, Tel +86 18017317652; +86 18017312656, Email ;
| | - Hong Ling
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200032, People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People’s Republic of China
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Hu T, Chen Z, Hou M, Lin K. Overall and cancer-specific survival in patients with breast Paget disease: A population-based study. Exp Biol Med (Maywood) 2021; 247:187-199. [PMID: 34842487 DOI: 10.1177/15353702211056264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Paget disease of the breast is an uncommon malignant tumor with an inferior outcome. Therefore, establishing nomograms to predict the survival outcomes of breast Paget disease patients is urgent. Clinicopathological and follow-up data of breast Paget disease patients diagnosed between 2010 and 2016 were retrieved through the Surveillance, Epidemiology, and End Result (SEER) database. The significant factors were screened out, and then those factors were utilized to build two valuable nomograms. The discriminative ability of nomograms was investigated using concordance-index (C-index), while the predictive accuracy and benefits were evaluated using calibration curves and decision curve analysis. Finally, a total of 417 breast Paget disease patients were enrolled. Tumor grade, histological type, American Joint Committee on Cancer (AJCC) stage, surgery, chemotherapy, and marital status were confirmed as independent overall survival (OS)-related factors; tumor grade, histological type, AJCC stage, and age were associated with independent cancer-specific survival (CSS)-related factors. The values of the C-index for OS nomogram acquired were 0.827 and 0.745 for training and validation cohorts, respectively. Meanwhile, the corresponding values of the C-index to CSS nomogram were 0.890 and 0.655, respectively. The calibration curves and decision curve analysis indicated that both nomograms had an excellent performance. Finally, the nomogram-based risk stratification system indicated that all breast Paget disease patients could be classified into low- and high-risk groups and showed distinct outcomes. In conclusion, two valuable nomograms incorporating various clinicopathological indicators were established for breast Paget disease patients. These prognostic nomograms provide accurate prognostic assessment for breast Paget disease patients and help clinicians select appropriate treatment strategies.
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Affiliation(s)
- Tingting Hu
- Department of Chemoradiation Oncology, 89657The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Zhiyuan Chen
- Department of Microbiology and Immunology, School of Basic Medical Sciences, 26453Wenzhou Medical University, Wenzhou 325000, China
| | - Meng Hou
- Department of Chemoradiation Oncology, 89657The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Kezhi Lin
- Experimental Center of Basic Medicine, 26453Wenzhou Medical University, Wenzhou 325000, China
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Nori J, Bicchierai G, Amato F, De Benedetto D, Boeri C, Vanzi E, Di Naro F, Bianchi S, Miele V. A new technique for the histological diagnosis of Paget's disease of the breast using a semiautomated core needle biopsy with a 14-gauge needle. Radiol Med 2021; 126:936-945. [PMID: 33900526 DOI: 10.1007/s11547-021-01358-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/14/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of our work is to illustrate a new technique for the histological diagnosis of Paget's disease (PD) using a core needle biopsy with a semiautomated 14-gauge needle called nipple-core needle biopsy (N-CNB). We report 3 years' experience in our senology unit. MATERIALS AND METHODS Twenty-six women with 26 clinical of nipple-areola complex (NAC) changes with suspected PD and subjected to core needle biopsy using our new 14G semiautomated needle technique were included in our study group. Institutional review board approval was obtained for this retrospective analysis. A semiautomated biopsy gun with a 14-gauge, 15-cm-long needle was used for this new procedure. After a subcutaneous injection of anesthetic and spray-ice application to the NAC, the 14G needle was opened with the cradle exposed and positioned on the NAC with considerable pressure exerted on the same. The cradle was then closed by triggering the needle spring, and 2-4 core samples were withdrawn by moving the needle position each time. Clinical, instrumental and histological differences between the lesions that gave benign results after N-CNB and those that resulted PD were analyzed by applying the Fisher's exact test. RESULTS After N-CNB, 13/26 lesions were found to be PD (50%) while 13/26 alterations were benign (50%). No malignant lesions were detected during the follow-up in patients with benign N-CNB results. The diagnosis of PD obtained with N-CNB was confirmed in all 13 cases by means of a histological analysis of the surgical specimens. No significant post-biopsy complications were recorded. Patients with PD more frequently presented nipple retraction (ρ = 0.0407) and associated suspicious (i.e., BI-RADS 4 and 5) mammographic (ρ = 0.0006) findings compared to patients whose N-CNB had given benign results and the difference was statistically significant. CONCLUSIONS In conclusion, with this novel technique, we were able to obtain an easy, painless, major complication-free and accurate diagnosis of PD of the NAC using a semiautomated core needle biopsy with a 14-gauge needle.
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Affiliation(s)
- Jacopo Nori
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, Florence, Italy
| | - Giulia Bicchierai
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, Florence, Italy.
| | - Francesco Amato
- Radiology Department, Ospedale San Giovanni Di Dio, Agrigento, Italy
| | - Diego De Benedetto
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, Florence, Italy
| | - Cecilia Boeri
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, Florence, Italy
| | - Ermanno Vanzi
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, Florence, Italy
| | - Federica Di Naro
- Diagnostic Senology Unit, Azienda Ospedaliero-Universitaria Careggi, Largo G. A. Brambilla 3, 50134, Florence, Italy
| | - Simonetta Bianchi
- Division of Pathological Anatomy, University of Florence, Florence, Italy
| | - Vittorio Miele
- Emergency Radiology Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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Abstract
No national data have been available on descriptive epidemiology of mammary Paget's disease (MPD) in China. This population-based study aimed to estimate the prevalence of MPD and its pattens by sex, age and area in China. We conducted a population-based study using data in 2016 from China's Urban Employee Basic Medical Insurance and Urban Resident Basic Medical Insurance, covering approximately 0.43 billion residents. MPD cases were identified based on the diagnostic names and codes in claim data. A total of 825 patients of confirmed diagnosis of MPD were found during the study period. The prevalence of MPD in 2016 was 0.42 per 100,000 population (95% CI 0.19 to 0.73), with marked female predominance. The prevalence rates peaked at 40-59 years and ≥ 80 years in females and males, respectively. The prevalence rates varied among different regions, ranging from 0.06 (95% CI 0.00 to 0.23) in Northeast China to 1.21 (95% CI 0.07 to 3.72) in Northwest China. MPD showed marked female predominance in China. Chinese female patients were much younger, with lower prevalence than that in the United States. Obvious sex difference in the age pattern of MPD prevalence was also observed in China.
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Diagnosis, Management, and Percutaneous Sampling of Nipple-Areolar Calcifications: How Radiologists Can Help Patients Avoid the Operating Room. AJR Am J Roentgenol 2020; 216:48-56. [PMID: 33170739 DOI: 10.2214/ajr.20.23046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Both benign and malignant causes of calcifications in the nipple-areolar complex exist. BI-RADS terminology applies to the description and classification of nipple-areolar calcifications in the same way it does to calcifications elsewhere in the breast. Minimally invasive sampling can be performed safely and accurately with ultrasound-guided techniques, with a few technical modifications. CONCLUSION This article provides insight regarding the management algorithm and image-guided interventional techniques for sampling nipple-areolar calcifications as an essential competency for breast imaging practices.
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Wong SM, Freedman RA, Sagara Y, Stamell EF, Desantis SD, Barry WT, Golshan M. The effect of Paget disease on axillary lymph node metastases and survival in invasive ductal carcinoma. Cancer 2015; 121:4333-40. [PMID: 26376021 DOI: 10.1002/cncr.29687] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 08/14/2015] [Accepted: 08/24/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND The objective of this study was to examine the effect of Paget disease (PD) on axillary lymph node metastases and survival in patients who had concomitant invasive ductal carcinoma (PD-IDC). METHODS The Surveillance, Epidemiology, and End Results (SEER) database was used to identify women who were diagnosed with PD-IDC from 2000 to 2011, comparing baseline demographic and tumor characteristics with those who were diagnosed with IDC alone during the same period. Multivariable logistic regression was used to examine the association of PD-IDC with axillary lymph node metastasis, and breast cancer-specific survival and overall survival were compared between the PD-IDC and IDC groups using the Kaplan-Meier method and Cox proportional hazards regression. RESULTS The study cohort included 1102 patients with PD-IDC and 302,242 controls with IDC alone. PD-IDC tumors were more likely to be centrally located (26.9% vs 5.5%; P < .001), high grade (63.5% vs 40.3%; P < .001), >2 cm in greatest dimension (47.1% vs 35.7%; P < .001), and estrogen/progesterone receptor-negative (45.2% vs 22.1%; P < .001). In adjusted analyses, patients with PD-IDC had higher odds of axillary lymph node metastasis (odds ratio, 1.83; P < .001). The unadjusted 10-year breast cancer-specific and overall survival rates were lower for the PD-IDC group compared with the IDC-alone group, although, after adjusting for disease stage, tumor characteristics, and local therapy, no significant differences in mortality risk were observed between the 2 groups (hazard ratio, 0.91; P = .24). CONCLUSIONS PD-IDC is associated with an increased risk of axillary lymph node metastasis, but not with inferior survival, compared with IDC alone after adjustment for other disease factors.
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Affiliation(s)
- Stephanie M Wong
- Harvard School of Public Health, Boston, Massachusetts.,Department of Surgery, McGill University Health Center, Montreal, Quebec, Canada
| | - Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Yasuaki Sagara
- Department of Surgery, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Emily F Stamell
- Harvard School of Public Health, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Stephen D Desantis
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Surgery, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - William T Barry
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mehra Golshan
- Department of Surgery, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
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11
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Helme S, Harvey K, Agrawal A. Breast-conserving surgery in patients with Paget's disease. Br J Surg 2015; 102:1167-74. [DOI: 10.1002/bjs.9863] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 12/06/2014] [Accepted: 04/20/2015] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Paget's disease of the breast is a rare condition that is associated with underlying breast cancer in the majority of patients. The conventional treatment for Paget's disease has been mastectomy, but there is an increasing trend to consider breast-conserving surgery (BCS) in selected patients. Owing to the uncommon nature of the disease, research studies tend to be small and retrospective. This systematic review presents the published evidence regarding BCS for patients with Paget's disease with a focus on patient selection and oncological safety.
Methods
A search of Ovid and PubMed databases was conducted to identify all papers published regarding BCS for Paget's disease.
Results
The search identified 172 papers of which 43 were clinically relevant. BCS is a safe alternative to mastectomy, provided a clear surgical margin is achieved and adjuvant radiotherapy used. However, patients with Paget's disease should be assumed to have underlying breast cancer, and these cancers tend to have poor biological profiles. When BCS is considered, careful preoperative investigation should be undertaken to identify the presence and extent of an underlying cancer. These cancers can be mammographically occult, multifocal or multicentric. Although the evidence is limited, there may be a role for MRI in selecting patients with Paget's disease for BCS.
Conclusion
Patients with Paget's disease are candidates for breast conservation with appropriate preoperative investigations. Oncological outcomes are equivalent to those of mastectomy if surgical margins are achieved and adjuvant radiotherapy is given.
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Affiliation(s)
- S Helme
- Breast Department, Queen Alexandra Hospital, Portsmouth, UK
| | - K Harvey
- Breast Department, Queen Alexandra Hospital, Portsmouth, UK
| | - A Agrawal
- Breast Department, Queen Alexandra Hospital, Portsmouth, UK
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12
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Sandoval-Leon AC, Drews-Elger K, Gomez-Fernandez CR, Yepes MM, Lippman ME. Paget’s disease of the nipple. Breast Cancer Res Treat 2013; 141:1-12. [DOI: 10.1007/s10549-013-2661-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 08/02/2013] [Indexed: 11/24/2022]
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13
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Vani B, Thejaswini M, Srinivasamurthy V, Rao MS. Pigmented Paget's disease of nipple: A diagnostic challenge on cytology. J Cytol 2013; 30:68-70. [PMID: 23661948 PMCID: PMC3643369 DOI: 10.4103/0970-9371.107521] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Paget's disease is a rare form of breast cancer often associated with an underlying ductal carcinoma in situ or invasive cancer. A 47-year-old female patient presented with bleeding from the left nipple since 4 months. Imprint smears from the lesion showed pleomorphic malignant epithelial cells in singles and in small clusters, many of them containing dark brown cytoplasmic pigment granules. There was no palpable breast lump or axillary lymph node enlargement. Based on the physical examination and cytological features, a diagnosis of malignant melanoma with a differential of Paget's disease of the nipple was made. Biopsy showed features of Paget's disease and immunohistochemistry was positive for HER-2/neu, negative for HMB-45 and S-100, thus confirming the diagnosis. This case has been reported to emphasize the fact that Paget's cells can contain imbibed brown cytoplasmic pigment and should not be mistaken for melanoma cells on cytology smears.
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Affiliation(s)
- Br Vani
- Department of Pathology, ESIC Medical College and PGIMSR, Rajajinagar, Bangalore, India
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14
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Rzaca M, Tarkowski R. Paget's disease of the nipple treated successfully with cryosurgery: a series of cases report. Cryobiology 2013; 67:30-3. [PMID: 23665146 DOI: 10.1016/j.cryobiol.2013.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 04/14/2013] [Accepted: 04/19/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Paget's disease of the nipple is a rare form of breast malignancy. Underlying breast cancer, either in situ or invasive accompanies lesions of the nipple in most of the cases. The connection between both entities and their exact origin remains unclear. Nevertheless, underlying ductal breast cancer is often confined to the central, subareolar part of the breast. Radical mastectomy, although successful, seems to be too mutilating treatment in the era of breast sparing surgery. Studies describing breast conserving surgery performed without adjuvant treatment are rare and the patients not numerous. Due to low incidence of the disease, there are no randomised trials conducted which could show the optimal method of treatment. MATERIALS AND METHODS We performed cryosurgery of the affected nipple-areola complex (NAC) in treatment of six patients with Paget's disease of the nipple who presented general contraindications or lack of consent for surgery. RESULTS With a follow up ranging from 60 to 121 months (average 94) we obtained very good results in terms of disease specific survival: there were two cases of recurrent disease, confined to the scar and treated successfully with cryosurgery again; four patients are alive without disease. Death was not related to cancer in the remained two cases. CONCLUSIONS Cryotherapy is successful form of treatment of localised Paget's disease of the nipple--especially in face of contraindications for surgery or lack of patient's agreement for operational treatment.
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Affiliation(s)
- M Rzaca
- Regional Specialist Hospital, Department of Surgical Oncology, ul Kamieńskiego 73A, 51-124 Wrocław, Poland.
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15
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Zheng S, Song QK, Zhao L, Huang R, Sun L, Li J, Fan JH, Zhang BN, Yang HJ, Xu F, Zhang B, Qiao YL. Characteristics of mammary Paget's disease in China: a national-wide multicenter retrospective study during 1999-2008. Asian Pac J Cancer Prev 2013; 13:1887-93. [PMID: 22901142 DOI: 10.7314/apjcp.2012.13.5.1887] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The aim of this study was to detail characteristics of mammary Paget's disease (PD) representing the whole population in China. A total of 4211 female breast cancer inpatients at seven tertiary hospitals from seven representative geographical regions of China were collected randomly during 1999 to 2008. Data for demography, risk factors, diagnostic imaging test, physical examination and pathologic characters were surveyed and biomarker status was tested by immunohistochemistry. The differences of demography and risk factors between PD with breast cancer and other lesions were compared using Chi-square test or t-test, with attention to physical examination and pathological characters. The percentage of PD was 1.6% (68/4211) in all breast cancers. The mean age at diagnosis was 48.1, and 63.2% (43/68) patients were premenopausal. There is no difference in demography and risk factors between PD with breast cancer and other breast cancer (P>0.05). The main pattern of PD in physical exam and pathologic pattern were patients presenting with a palpable mass in breast (65/68, 95.6%) and PD with underlying invasive cancer (82.4%, 56/68) respectively. The rate of multifocal disease was 7.4% (5/68). PD with invasive breast cancer showed larger tumor size, more multifocal disease, lower ER and PR expression and higher HER2 overexpression than those in other invasive breast cancer (P<0.05). These results suggested that PD in China is a concomitant disease of breast cancer, and that PD with underlying invasive cancer has more multiple foci and more aggressive behavior compared with other breast invasive cancer. We address the urgent needs for establishing diagnostic and therapeutic guidelines for mammary PD in China.
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Affiliation(s)
- Shan Zheng
- Department of Pathology, Center of Breast Disease, Cancer Institute and Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Lohsiriwat V, Martella S, Rietjens M, Botteri E, Rotmensz N, Mastropasqua MG, Garusi C, De Lorenzi F, Manconi A, Sommario M, Barbieri B, Cassilha M, Minotti I, Petit JY. Paget’s Disease as a Local Recurrence after Nipple-Sparing Mastectomy: Clinical Presentation, Treatment, Outcome, and Risk Factor Analysis. Ann Surg Oncol 2012; 19:1850-5. [DOI: 10.1245/s10434-012-2226-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Indexed: 11/18/2022]
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18
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Abstract
This case describes new onset mammary Paget disease arising in the background of Darier disease. Clinically and histologically, lesions of Darier disease can mask the lesions of mammary Paget disease. A high index of suspicion is necessary to diagnose Paget disease in a patient with Darier disease, for a potentially fatal disease could easily be missed.
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Geffroy D, Doutriaux-Dumoulins I, Labbe-Devilliers C, Meingan P, Houdebine S, Sagan C, Dejode M, Ricaud-Couprie M. [Paget's disease of the nipple and differential diagnosis]. ACTA ACUST UNITED AC 2011; 92:889-98. [PMID: 22000610 DOI: 10.1016/j.jradio.2011.07.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Revised: 11/17/2010] [Accepted: 07/01/2011] [Indexed: 11/19/2022]
Abstract
Clinical evaluation of the nipple-areolar complex is a routine component of the breast screening examination. All persistent unilateral nipple lesion should be viewed with suspicion and Paget's disease of the nipple should be considered. The diagnosis is established by nipple scrape cytology. It is a rare variant of ductal carcinoma in situ. The breast imaging work-up should include a search for an underlying malignancy, present in over 80% of cases, not infrequently multifocal. Preoperative MRI is useful if breast conservative surgery is contemplated because of the high rate of occult malignancy on mammograms and ultrasound. Erosive adenomatosis of the nipple is a benign process that may simulate Paget's disease isolated to the nipple. Less frequently, pagetoid basal cell carcinoma, Bowen's disease and melanoma may be more difficult to differentiate clinically and share the unilateral and chronic features of Paget's disease. Biopsy is needed for diagnosis. Cutaneous extension of a breast cancer is rare but should be suspected in patients with retraction and/or fixed nipple. Eczema is characterized by the bilateral nature of the process, the absence of nipple deformity, the presence of flare-ups and the favorable response to local steroid therapy.
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Affiliation(s)
- D Geffroy
- Centre René-Gauducheau, service d'imagerie médicale, institut de cancérologie de l'Ouest, boulevard Jacques-Monod, 44805 Saint-Herblain cedex, France.
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20
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Onoe S, Kinoshita T, Tamura N, Nagao T, Kuno H, Hojo T, Akashi-Tanaka S, Tsuda H. Feasibility of breast conserving surgery for Paget's disease. Breast 2011; 20:515-8. [PMID: 21689938 DOI: 10.1016/j.breast.2011.05.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 05/04/2011] [Accepted: 05/29/2011] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The standard treatment for Paget's disease of the breast is mastectomy. Since it is frequently associated with underlying carcinoma, many surgeons are reluctant to choose breast conserving surgery for Paget's disease. PATIENTS AND METHODS We retrospectively analyzed a series of 59 patients with Paget's disease who had undergone mastectomy at the National Cancer Center Hospital between 1963 and 2009. RESULTS In 55 of 59 cases (93%) there was underlying carcinoma in the ipsilateral breast. Clinically, 27 (46%) patients had no evidence of other tumors, but 23 (85%) had underlying histopathologically confirmed carcinoma. Based on the data from this subset, cone excision with a 3-cm radius and a 4-cm radius could completely resect any underlying malignancy in 74% and 85% of patients, respectively. CONCLUSION As Paget's disease is frequently accompanied by underlying intraductal and/or invasive carcinoma, patients should be carefully selected for breast conserving surgery.
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Affiliation(s)
- Shunsuke Onoe
- Breast Cancer Group, Surgical Oncology Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
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21
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Ehst BD, Minzer-Conzetti K, Swerdlin A, Devere TS. Cutaneous manifestations of internal malignancy. Curr Probl Surg 2010; 47:384-445. [PMID: 20363406 DOI: 10.1067/j.cpsurg.2010.01.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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22
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Noel JC, Fayt I, Buxant F. Proliferating activity in paget disease of the nipple. Pathol Oncol Res 2009; 16:7-10. [PMID: 20016962 DOI: 10.1007/s12253-009-9179-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Accepted: 05/19/2009] [Indexed: 11/28/2022]
Abstract
Paget disease of the nipple is a rare disease characterized by the presence of malignant glandular cells within the squamous epithelium of the nipple. The most common hypothesis to explain the development of Paget disease is an intraepithelial epidermotropic migration of malignant epithelial cells originating from an underlying intraductal carcinoma. If the immunohistochemical properties of the Paget cells in the nipple have been extensively studied, their proliferating characteristics remain paradoxically poorly studied. In the present study we have investigated the proliferating activity of Paget cells in the nipple by using double stain immunohistochemistry with both Ki67 (a protein which is expressed in all active parts of the cell cycle) and cytokeratin 7 (a highly sensitive marker of Paget cells). Ten cases of Paget disease and in their associated intraductal carcinomas (n = 10) and/or invasive carcinomas (n = 4) were tested. The mean Ki67 index was in Paget disease (26% +/- 10), in intraductal carcinomas (23% +/- 8) and/or in invasive carcinomas (20% +/- 8) (p > 0,05). This is the first report to convincingly demonstrate by specific double stain immunohistochemistry that Paget disease and underlying intraductal carcinomas share a close proliferating activity.
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Affiliation(s)
- Jean-Christophe Noel
- Departments of Pathology, Erasme Hospital, Free University of Brussels, 808 route de Lennik, 1070, Brussels, Belgium.
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23
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Song Y, Wang Z, Xu H, Yue Z, Xing C. Paget's disease is associated with eleven cancerous regions: a case report and therapeutic strategy. ACTA ACUST UNITED AC 2009; 29:677-8. [PMID: 19821109 DOI: 10.1007/s11596-009-0529-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Indexed: 10/19/2022]
Abstract
Paget's disease of the breast is an uncommon disorder that accounts for 1% to 3% of all mammary tumors. The incidence of underlying carcinoma associated with Paget's disease has been reported in 82% to 100% of cases. The finding of underlying carcinoma reaches almost 100% when a palpable lump is also present. In this rare case, we described a patient presenting with Paget's disease but no palpable lump. However, we found 11 independent regions which were all invasive ductal carcinoma after the operation. Considering this patient, we should pay more attention to a multifocal and multicentric breast carcinoma associated with Paget's disease. Furthermore, we believe the mammography examination and a modified radical mastectomy are the most appropriate treatments for this population in clinical practice.
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Affiliation(s)
- Yongxi Song
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, China.
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24
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25
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Abstract
Paget's disease of the nipple is an unusual epidermal presentation of underlying breast cancer. It presents as eczematous change or erythematous ulceration, but may also be an incidental histological finding in a mastectomy specimen. Approximately half of the underlying cancers are invasive, the remainder being ductal carcinoma in situ, and only rarely is there no associated malignancy. Routine clinical and mammographic assessment may significantly underestimate the extent of disease, but MRI may increase the sensitivity in detecting occult malignancy. Mastectomy maximizes local control; however, selected cases can be treated by nipple conisation with radiotherapy. Sentinel node biopsy is the standard of care for axillary staging in the clinically and ultrasonically node-negative case. Almost all invasive cases overexpress human EGF receptor-2 and, therefore, are likely to benefit from adjuvant chemotherapy and herceptin.
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Affiliation(s)
- Seema Seetharam
- Seema Seetharam, MBBS, MRCS, Hedley Atkins Breast Unit, Guy's Hospital, London SE1 9RT, UK, Tel.: +44 207 188 4239, Fax: +44 207 188 4239,
| | - Ian S Fentiman
- Ian S Fentiman, MD, DSc, FRCS, Hedley Atkins Breast Unit, Guy's Hospital, London SE1 9RT, UK, Tel.: +44 207 188 4239, Fax: +44 207 188 4239,
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Affiliation(s)
- Kristin L Cox
- Virginia Clinton Kelley/FFANY Breast Fellowship, Komen Interdisciplinary Breast Fellowship, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Nicholson BT, Harvey JA, Cohen MA. Nipple-areolar complex: normal anatomy and benign and malignant processes. Radiographics 2009; 29:509-23. [PMID: 19325062 DOI: 10.1148/rg.292085128] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The nipple-areolar complex may be affected by many normal variations in embryologic development and breast maturation as well as by abnormal processes of a benign or malignant nature. Benign processes that may affect the nipple-areolar complex include eczema, duct ectasia, periductal mastitis, adenomas, papillomas, leiomyomas, and abscesses; malignant processes include Paget disease, lymphoma, and invasive and noninvasive breast cancers. Radiologists should be aware of the best methods for evaluating each of these entities: Many disorders of the nipple-areolar complex are unique or differ in important ways from those that occur elsewhere in the breast, and they require a diagnostically specific imaging evaluation. Patients may present with benign developmental variations; inversion, retraction, or enlargement of the nipple, which may have either a benign or a malignant cause; a palpable mass; nipple discharge; skin changes in and around the nipple; infection with resultant nipple changes or a subareolar mass; or abnormal findings at routine mammographic screening. Further diagnostic imaging may include repeat mammography, breast ultrasonography, galactography, and magnetic resonance imaging. When skin changes are present, a clinical evaluation by the patient's primary care physician, dermatologist, or surgeon should be part of the diagnostic work-up.
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Affiliation(s)
- Brandi T Nicholson
- Department of Radiology, University of Virginia, Charlottesville, VA 22908, USA.
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Abstract
This article discusses several solid organ and hematologic neoplasms that can metastasize to the skin. Special emphasis is placed on the most frequent solid and hematological malignancies that have cutaneous metastases, including breast cancer, melanoma, lung cancer, colon cancer, and leukemia. In addition, mammary and extramammary Paget's disease are further discussed as examples of direct extension of primary tumors to the skin.
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Affiliation(s)
- Gabriela Rolz-Cruz
- Clinical Unit for Research Trials in Skin, Department of Dermatology, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA 02115, USA
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Caliskan M, Gatti G, Sosnovskikh I, Rotmensz N, Botteri E, Musmeci S, Rosali dos Santos G, Viale G, Luini A. Paget's disease of the breast: the experience of the European Institute of Oncology and review of the literature. Breast Cancer Res Treat 2008; 112:513-21. [PMID: 18240020 DOI: 10.1007/s10549-007-9880-5] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 12/19/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND Paget's disease of the breast is an uncommon presentation of breast malignancy, accounting for 1-3% of all the breast tumors and presents in different histopathologic patterns: in association with an underlying invasive or non invasive carcinoma, or without any underlying neoplasia. In the literature, different methods are used for the treatment. Mastectomy with or without axillary dissection has been considered as the standard treatment procedure for many years. Several studies have already shown that breast conservation with radiation therapy is an oncologically safe option. Regarding the axillary approach, several studies have documented the presence of positive sentinel lymph node even in Paget's disease alone. The objective of this study was to retrospectively analyze outcome of patients affected by Paget's breast disease and to define our institutional experience. PATIENTS AND METHODS Between May 1996 and February 2003, 114 patients with confirmed Paget's disease of the breast were retrieved and underwent surgery at the European Institute of Oncology of Milan, Italy. The median age of the patients was 54 years at the time of the diagnosis. In our study, the histopathological examination of the operated specimen revealed one hundred seven patients with Paget's disease associated with an underlying invasive or non invasive carcinoma, and seven patients without underlying carcinoma. Patients underwent either conservative breast surgery or mastectomy, with or without sentinel lymph node biopsy and/or axillary surgery. Each patient was evaluated after surgery at a multidisciplinary meeting to selecting systemic therapy. RESULTS Seven patients had "pure" Paget's disease of the breast and one hundred seven had the disease associated with an underlying carcinoma. As surgical techniques 71 mastectomies and 43 breast conserving surgeries have been performed. Complete axillary dissection was done in patients with clinically positive lymph node and/or sentinel lymph node biopsy positive. Sentinel lymph node biopsy was performed in nineteen patients with invasive component and five were positive and underwent axillary dissection. Eleven sentinel lymph node biopsies were done in patients with non invasive component and none of them was positive. Adjuvant systemic therapies were based on the final tumor, node and metastasis stage: thirty patients received adjuvant chemotherapy alone, fourteen received endocrine treatment alone, twenty-six patients were evaluated to receive both chemo and endocrine therapy. The median duration of follow up was 73 months and was updated in the last 6 months. Five patients developed local recurrence, one had regional recurrence, another two had loco-regional recurrences and fourteen had distant metastasis as a first event. Malignancy-related deaths were censored in the statistical analyses cancer for and due to another tumor in eleven patients. Additionally, deaths were not related to malignancy totally in thirteen patients. CONCLUSIONS Screening examination and imaging techniques are fundamental. Breast conserving surgery combined with breast irradiation for patients with invasive and non invasive breast carcinoma has become the treatment of first choice. All surgical conservative approaches should include the complete nipple-areolar complex and margins of resected specimen free of tumor. Thanks to the evolution of the conservative approach, good cosmetic result can be obtained. To be informed about the axillary lymph node status and to avoid the patient to have a second surgical approach, sentinel lymph node biopsy should be performed.
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Affiliation(s)
- Mujgan Caliskan
- Division of Breast Surgery, European Institute of Oncology, Milan, Italy
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MRI Identifies Otherwise Occult Disease in Select Patients with Paget Disease of the Nipple. J Am Coll Surg 2008; 206:316-21. [DOI: 10.1016/j.jamcollsurg.2007.07.046] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2007] [Revised: 07/19/2007] [Accepted: 07/20/2007] [Indexed: 11/20/2022]
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Louwman MWJ, Vriezen M, van Beek MWPM, Nolthenius-Puylaert MCBJET, van der Sangen MJC, Roumen RM, Kiemeney LALM, Coebergh JWW. Uncommon breast tumors in perspective: incidence, treatment and survival in the Netherlands. Int J Cancer 2007; 121:127-35. [PMID: 17330844 DOI: 10.1002/ijc.22625] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The relatively small group of patients with breast tumors other than the ductal, lobular or mixed ducto-lobular types, has reached nonnegligible numbers due to the ongoing increase in the incidence of breast cancer. We investigated stage and grade distribution of uncommon breast tumors using the nation-wide Netherlands Cancer Registry (population 16.5 million) and incidence patterns, treatment and long-term survival (up to 19 years) using the regional Eindhoven Cancer Registry (population 2.4 million). Incidence of all uncommon breast tumors together was 9.2/100,000 person years (age-standardized, ESR). The proportion of stage I tumors was 70% among patients with tubular (n = 3,456) and 40-50% for mucinous (n = 3,482), papillary (n = 1,078), cribriform (n = 503) and neuroendocrine (n = 76) tumors, contrasting to 27, 28 and 36%, respectively among patients with Signet ring cell cancer (n = 75), Paget's disease (n = 818) and the common invasive ductal carcinomas (n = 121,656). A better age-, stage-, and grade-adjusted prognosis was observed for patients with lobular (death risk ratio 0.8, 95%CI: 0.7-0.9), mucinous (0.5, 0.3-0.9), medullary (0.5, 0.3-0.9) and tubular (0.4, 0.2-0.6) carcinoma or phyllodes tumor (0.02, 0.0-0.2), compared with invasive ductal carcinomas. For patients with papillary (0.6, 0.2-1.6) and cribriform (0.1, 0.0-5.1) tumors better prognosis was not statistically significant. In conclusion, histologic type was an essential determinant of survival for about 10% of all newly diagnosed women with invasive breast cancer. Because patients with mucinous, tubular, medullary and phyllodes tumors have such a good prognosis, less aggressive treatment should be considered in some cases whereby specific guidelines are becoming increasingly desirable. Communication to patients with these specific histological types should reflect this.
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Affiliation(s)
- Marieke W J Louwman
- Eindhoven Cancer Registry, Comprehensive Cancer Centre South IKZ, Eindhoven, The Netherlands.
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Haddad N, Ollivier L, Tardivon A, Thibault F, El Khoury C, Neuenschwander S. Apport de l’IRM dans la maladie de Paget du sein. ACTA ACUST UNITED AC 2007; 88:579-84. [PMID: 17464257 DOI: 10.1016/s0221-0363(07)89858-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Evaluate the usefulness of MRI in local staging of Paget disease of the breast. MATERIALS AND METHODS Clinical, radiological (mammographies, MRI), and histological data were analyzed in six female patients presenting Paget disease of the breast. The criteria for analysis in MRI were the following: morphology of the aureola-nipple plaque (thickening, regularity of the contour) and the type of enhancement after injection of contrast medium (signal intensity/time curve), detection of abnormal enhancing in the mammary gland, and ganglion areas. RESULTS None of the patients presented a palpable mass or a suspicious anomaly on mammography. On MRI, the aureola-nipple plaque was morphologically abnormal in four cases, with suspicious enhancement in two cases (two cases of ductal carcinoma in situ) and normal enhancement in two cases (one case of ductal carcinoma in situ). In the two other cases, the aureola-nipple plaque was normal (one case of ductal carcinoma in situ). Distant abnormal enhancement of the aureola-nipple plaque was noted in two cases (one case of ductal carcinoma in situ and one benign lesion). CONCLUSION The MRI aspect of the aureola-nipple plaque in Paget disease shows little concordance with the histological results. MRI can be useful in detecting distant lesions when there is no clinical sign nor a suspicious mammography.
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Affiliation(s)
- N Haddad
- Service de Radiologie, Institut Curie, 26 rue d'Ulm, 75248 Paris Cedex 05, France.
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Günhan-Bilgen I, Oktay A. Paget's disease of the breast: Clinical, mammographic, sonographic and pathologic findings in 52 cases. Eur J Radiol 2006; 60:256-63. [PMID: 16887314 DOI: 10.1016/j.ejrad.2006.06.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2006] [Revised: 06/27/2006] [Accepted: 06/28/2006] [Indexed: 11/19/2022]
Abstract
PURPOSE To determine and quantitate radiologic characteristics of Paget's disease of the breast and to report clinical and pathologic findings. MATERIALS AND METHODS A retrospective review of records of 2872 women who received a diagnosis of breast carcinoma between January 1988 and January 2006 revealed 52 histologically proved Paget's disease of the breast. Analysis included history, findings at physical examination, mammography and sonography (US) and histologic type of Paget's disease. RESULTS At physical examination, palpable mass (n=33, 63%), nipple erythema-eczema-ulceration (n=17, 33%) and blood-stained nipple discharge (n=5, 10%) were noted. Among 17 patients who had clinically evident Paget's disease, the mammographic findings were isolated microcalcifications in 3 (18%), mass associated with microcalcifications in 5 (29%), mass in 2 (12%) and negative in 7 (41%) patients. In the 35 patients with clinically inevident Paget's disease, these mammographic findings were 43% (n=15), 34% (n=12), 20% (n=7) and 3% (n=1), respectively. US depicted 43 masses in 35 patients, all of which were lobulated or irregularly contoured, mostly (n=41, 95%) without posterior acoustic shadowing. The cancer was clinically occult in 10% (n=5), mammographically occult in 15% (n=8) and radiologically occult in 13% (n=7) of the 52 patients. Histologically, the tumor was multifocal and/or multicentric in 11 (21%) patients. CONCLUSION The clinical features of Paget's disease are characteristic and should alert the clinician to the likelihood of an underlying carcinoma, which should be evaluated radiologically. However, as Paget's disease is primarily a clinical diagnosis and mammograms may be negative, screening programs without clinical examination may result with delay in diagnosis. As a result, both clinical and imaging findings are complementary and should be correlated to confirm or exclude a diagnosis of Paget's disease.
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Affiliation(s)
- Işil Günhan-Bilgen
- Ege University Hospital, Department of Radiology, Bornova 35100, Izmir, Turkey.
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Zeng HA, Cartun R, Ricci A. Potential Diagnostic Utility of CDX-2 Immunophenotyping in Extramammary Paget's Disease. Appl Immunohistochem Mol Morphol 2005; 13:342-6. [PMID: 16280663 DOI: 10.1097/01.pai.0000163989.12896.d2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Extramammary Paget's disease (EMPD) is a rare condition whose importance is amplified by its association with either cutaneous or internal malignancy. Recently it has been shown that EMPD is not a single disease but can be divided into cutaneous and endodermal subtypes. The authors studied 12 new cases of immunohistochemically well-characterized EMPD, including HER-2/neu and CDX-2 immunophenotyping. The latter represents a novel application of this nuclear transcription factor, considered to be a relatively specific IHC marker for gastrointestinal-type epithelium. Cutaneous EMPD, accounting for 10 of the 12 (83%) cases, was CDX2-/HER2+; endodermal EMPD, accounting for 2 of the 12 (17%) cases, was CDX2+/HER2-. Four of the 12 cases (33%) were associated with a malignancy (two cutaneous adenocarcinomas, two colorectal carcinomas). The two cases of cutaneous adenocarcinoma occurred in the cutaneous group (2/10 [20%]), while the two cases of rectal carcinoma (one invasive, one in situ) occurred in the endodermal group (2/2 [100%]). Since EMPD subtypes have specific implications with regard to cancer risk, immunophenotyping should be performed in all cases. CDX-2 immunoreactivity may be useful in the subtyping of EMPD.
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Affiliation(s)
- Hao Audrey Zeng
- Department of Pathology and Laboratory Medicine, Hartford Hospital, CT 06102, USA
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Kawase K, Dimaio DJ, Tucker SL, Buchholz TA, Ross MI, Feig BW, Kuerer HM, Meric-Bernstam F, Babiera G, Ames FC, Singletary SE, Hunt KK. Paget’s Disease of the Breast: There Is a Role for Breast-Conserving Therapy. Ann Surg Oncol 2005; 12:391-7. [PMID: 15915373 DOI: 10.1245/aso.2005.05.026] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2004] [Accepted: 01/05/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND The optimal surgical management of Paget's disease of the breast remains to be defined. Mastectomy has been the standard of care, but several institutions have recently advocated breast-conserving surgery, particularly for patients with minimal disease. In an effort to develop rational treatment guidelines, we examined our institutional experience with Paget's disease of the breast. METHODS Patients with Paget's disease of the breast who had surgical therapy at our institution between 1949 and 1993 were reviewed. In addition to patient and tumor characteristics, charts were reviewed for treatment modalities, locoregional recurrence patterns, and survival. Subgroups were compared for differences in survival in both univariate and multivariate analyses. RESULTS A total of 104 patients met the study criteria. The most common presenting symptoms were nipple discharge and eczematous changes of the nipple/areola complex. Ninety-seven patients (93.2%) had an underlying invasive or noninvasive cancer associated with Paget's disease. Ninety-two patients (88.5%) underwent mastectomy, and 12 (11.5%) had a breast-conserving procedure. On univariate analysis, patients with age <60 years at diagnosis, stage II disease, positive lymph nodes, invasive disease, or a palpable mass had significantly lower 10-year disease-specific and recurrence-free survival. There were four locoregional recurrences (three after mastectomy and one after breast conservation). There were no significant differences in overall, disease-specific, or recurrence-free survival according to the type of surgery. CONCLUSIONS Paget's disease of the breast is almost always associated with an underlying breast cancer. Breast-conserving approaches result in local control and survival rates similar to those achieved with mastectomy.
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Affiliation(s)
- Kazumi Kawase
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 444, Houston, Texas 77030, USA
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Echevarria JJ, Lopez-Ruiz JA, Martin D, Imaz I, Martin M. Usefulness of MRI in detecting occult breast cancer associated with Paget's disease of the nipple–areolar complex. Br J Radiol 2004; 77:1036-9. [PMID: 15569646 DOI: 10.1259/bjr/94607773] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
MRI allows for the detection of mammographically and clinically occult breast neoplasms. We analysed the ability of MRI to detect occult breast cancer in three patients with Paget's disease of the nipple-areolar complex, proven histologically. In all three cases we observed differences in the morphological and dynamic features of healthy and pathological nipples, and we also found enhancement foci in breast tissue, with suspicious kinetic and morphological characteristics, which in the case of two patients corresponded to ductal carcinoma in situ. The detection and location with MRI of underlying neoplastic foci may be of help in choosing the most reasonable and conservative treatment in these patients.
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Affiliation(s)
- J J Echevarria
- Section of Breast Imaging of the Department of Radiology, Galdakao Hospital, Barrio Labeaga s/n 48960 Galdakao, Vizcaya, Spain
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Nicoletti G, Scevola S, Ruggiero R, Coghi AM, Toussoun GS. Gigantic Paget disease of the breast. Breast 2004; 13:425-7. [PMID: 15454200 DOI: 10.1016/j.breast.2003.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2003] [Revised: 10/22/2003] [Accepted: 11/25/2003] [Indexed: 11/25/2022] Open
Abstract
A rare case of gigantic Paget disease is presented. Surgical treatment and reconstructive issues are discussed in detail.
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Affiliation(s)
- G Nicoletti
- Plastic and Reconstructive Surgery Unit, University of Pavia, Fondazione Salvatore Maugeri, Via Ferrata 8, Pavia 27100, Italy.
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Abstract
Paget's disease of the breast is a relatively rare condition, accounting for 1% to 3% of primary breast cancers. It is associated with an underlying carcinoma, invasive or noninvasive (ductal carcinoma in situ), in most of the cases. Primary treatment is surgical with adjuvant therapy being dictated by the stage and nature of the underlying tumor. Modified radical mastectomy is the standard of care with breast conservation appropriate in a select group of patients with Paget's disease. This select group includes patients that are diagnosed with nipple-areola changes alone without evidence of a palpable mass or mammographic abnormality. In this group of patients, breast conservation offers local recurrence rates comparable to rates in patients with invasive or noninvasive cancers. In patients diagnosed with associated palpable masses or mammographic abnormalities suggestive of cancer, the recurrence rates are higher and mastectomy is warranted.
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Affiliation(s)
- Elizabeth Marcus
- Division of Breast Oncology, John H. Stroger, Jr. Hospital of Cook County, Rush University, 1900 West Polk, Room 601, Chicago, IL 60612, USA.
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Anderson JM, Ariga R, Govil H, Bloom KJ, Francescatti D, Reddy VB, Gould VE, Gattuso P. Assessment of Her-2/Neu status by immunohistochemistry and fluorescence in situ hybridization in mammary Paget disease and underlying carcinoma. Appl Immunohistochem Mol Morphol 2003; 11:120-4. [PMID: 12777994 DOI: 10.1097/00129039-200306000-00005] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
HER-2/Neu overexpression is seen in 20% to 30% of invasive breast carcinomas and has been reported in as many as 80% of high-grade infiltrating carcinomas. Earlier studies have suggested that 100% of the tumor cells in mammary Paget disease show overexpression of HER-2 protein. We undertook this study to assess HER-2 status of mammary Paget disease and of the underlying breast carcinoma, when present, by immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH). Formalin-fixed, paraffin-embedded tissue from 20 cases of mammary Paget disease were analyzed for HER-2 status by IHC and FISH. IHC for estrogen receptor (ER) was also performed. The patients ranged in age from 34 to 88 years, with a mean age of 62 years. Eighty percent of the cases showed strong overexpression (3+) of HER-2 protein by IHC, and all of these cases showed more than 5-fold amplification of the HER-2 gene by FISH. The remaining 4 cases, which were negative for HER-2/Neu by IHC, showed no amplification by FISH. All of the latter cases expressed ER, whereas no case that overexpressed HER-2 expressed ER. Sixteen cases had an underlying tumor, which was in situ in 6 cases. The underlying tumors were identical to the Paget disease with respect to their HER-2/Neu overexpression by both IHC and FISH. HER-2 overexpression was identified in 80% of our cases of Paget disease. There was 100% concordance between HER-2 protein overexpression by immunohistochemistry and gene amplification in both the Paget and the underlying tumor. Moreover, all of the cases negative for HER-2 overexpression expressed ER, whereas those positive for HER-2 did not.
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Affiliation(s)
- Joseph M Anderson
- Department of Pathology, Rush Medical College, Chicago, Illinois 60612, USA
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