Melanocyte colonization and pigmentation of breast carcinoma: A case report

Pigmented mammary Paget disease is a rare variant of mammary Paget disease that is often clinically misdiagnosed as a melanocytic lesion of the skin or nipple-areolar complex. Careful morphological assessment, along with the performance of adequate immunohistochemical stains, will help in achieving the right diagnosis and avoiding misdiagnosis of the entity as malignant melanoma. We report a rare case of pigmented mammary Paget disease with concomitant colonization of the underlying invasive ductal carcinoma by melanocytes mimicking melanoma.

Dense Lichenoid Inflammation in Paget Disease: A Diagnostic Pitfall

ABSTRACT

Mammary Paget disease is a rare form of breast cancer, which typically presents as an eczematous plaque on the nipple or surrounding skin. It is often a clinical diagnosis that is confirmed with skin biopsy. Histologic hallmarks of mammary Paget disease include large, pleomorphic, malignant, ductal epithelial cells within the epidermis. Chronic lichenoid inflammation may be seen in the papillary dermis but is not diagnostic. Because mammary Paget disease often overlies ductal carcinoma in situ or invasive carcinoma of the breast, prompt bilateral mammography is warranted. We report a case of Paget disease of the nipple with negative breast imaging that was originally misdiagnosed due to a dense lichenoid infiltrate obscuring the neoplasm.

Melanoma Mimicker: Pigmented Mammary Paget Disease in a Man

ABSTRACT

Male breast cancer comprises less than 1% of all breast cancer cases. Mammary Paget disease (MPD) represents a subset of breast cancer that presents with skin changes of the nipple and areola, and is frequently misdiagnosed clinically due to similarities with other disease states, leading to an average delay in diagnosis of 1 month to 2 years. Pigmented mammary Paget disease (PMPD) is an uncommon variant of MPD that clinically and histologically resembles malignant melanoma. Due to variable immunohistochemical staining patterns, analysis can be challenging and often requires interpretation of panels for accurate diagnosis. We present a rare case of PMPD in a male, originally diagnosed both clinically and histologically as malignant melanoma, to highlight the diagnostic challenges that this entity presents, and to review staining patterns which may be useful in its diagnosis.

Nipple Adenoma: A Benign Disease With a Suspicious Presentation

Nipple adenoma is a rare proliferative lesion that originates from the lactiferous ducts of the nipple. Though it is benign, the typical presentation includes suspicious symptoms-a firm nodule, crusting erosion, and/or discharge from the nipple. These findings can raise concern for malignancy and in particular, Paget's disease. We report two cases of this uncommon entity, highlighting the variable clinical presentation and keys to the diagnostic evaluation and management.

Extra-mammary Paget's disease of the penis

Paget's disease was first described in 1874 as an eczematoid changes of the nipple associated with underlying breast carcinoma. Extra-mammary Paget's disease (EMPD) is rare with involvement of the male genitalia described in small case series and management options varying according to location and extent. The diagnosis of EMPD requires a high index of clinical suspicion and close liaison with the multidisciplinary team, particularly histopathology. We present two cases of EMPD affecting the male external genitalia that highlight important learnings in the presentation, diagnosis, and management of EMPD.

Pagets sykdom i brystvorten

BACKGROUND

Paget's disease of the nipple comprises approximately 1 % of all breast cancers, and presents with unilateral eczematoid changes to the nipple, areola or surrounding skin. Symptoms can be pain, itching or stinging in the area.

CASE PRESENTATION

A female patient in her sixties presented to the skin clinic 18 months after initial detection of a rash surrounding her left nipple. Earlier ultrasound and mammography had not indicated pathology. Clinical suspicion and punch biopsies revealed a ductal carcinoma in situ. Surgical excision had to be repeated three times before the underlying malignancy was totally removed.

INTERPRETATION

Eczematoid changes in the nipple area are associated with underlying ductal carcinoma or a carcinoma in situ, and biopsies should be taken.

A peculiar case of Paget's disease of the breast

Mammary Paget's disease is a disorder of the nipple-areola complex of the breast that, while rare, is often associated with an underlying carcinoma. The typical aspect is usually an eczematoid change of the nipple or a red and ulcerative nipple's lesion or erythematous and crusted lesion, with or without mass-like lesion and infiltration and inversion of the nipple. It was described at first by Sir James Paget in 1874, [1] who classified the disease in mammary and extramammary type. The mammary type (Paget' s Breast Cancer: PBC) has rare frequency. PBC occurs in 0.5-5% of all cases of breast cancer, it affects the mouth of the excretory ducts of the nipple, which is characterized by lesion of nipple's large ducts. PBC can be a superficial lesion or a nodule-tumor and it can be associated with underlying carcinoma in situ (DCIS) in more than 95% of cases, especially in postmenopausal women. In a small percentage of cases, PBC can also be associated with an invasive breast cancer. Accuracy in the diagnostic phase, in order to distinguish PBC from others diseases is paramount and histological examination of lesion's biopsy has a crucial role. Prognosis and treatment depend on the type of underlying breast cancer and are based on the stage of cancer, but more importantly, on the prompt of an adequate multidisciplinary diagnostic pathway. KEY WORDS: Histopathological Report, Oncological Outcomes Paget's Breast Cancer.

Pigmented epidermotropic breast cancer metastases: A rare variant with a particularly unusual feature

Pigmented epidermotropic breast cancer metastases are a rarity, often clinically misdiagnosed as melanocytic lesions. Histopathologically, they show a dermal proliferation of neoplastic metastatic cells that extend to the overlying epidermis in a pattern identical to that seen in primary Paget disease (PD). Differential diagnosis should be established with entities with a similar presentation, such as pigmented mammary PD and malignant melanoma. Immunohistochemistry may be useful for this purpose. We present a new case of pigmented epidermotropic breast cancer metastases with a particularly unusual feature: the absence of dermal infiltration by neoplastic cells, thus considered as pure epidermotropic metastatic involvement.

Clinicopathological features of mammary Paget’s disease: a single-center experience in Turkey

Background/aim

Paget’s disease (PD) of the breast is a very rare presentation of breast malignancy, accounting for 1%–3% of all primary breast tumors. We aimed to evaluate and compare the clinicopathological features and clinical outcome of PD accompanied by in situ carcinoma and invasive cancer.

Materials and methods

We used the archive of our pathology laboratory retrospectively for age, sex, history of surgery, histopathological findings, treatment modalities, and follow-up information. We used the Kaplan–Meier method for survival analysis.

Results

There were 46 female patients diagnosed with PD. In 39 (84.7%) patients, invasive carcinoma accompanied PD, while 7 (15.3%) patients had ductal carcinoma in situ. The median age at diagnosis was 53.5 years. The median follow-up period was 47 months. Of the 39 invasive carcinoma, 10 (25.6%) died during the follow-up period. Invasive ductal carcinoma group had a mean overall survival of rate of 57.8 ± 6.6 months. According to univariate analysis, only the tumor type was found to impact overall survival (p < 0.001).

Conclusions

The current study displayed the tumor type as the only parameter affecting overall survival in the invasive carcinoma group. Although it was not statistically significant, breast cancers accompanied by PD were found to be predominantly advanced stage tumors, high grade, hormone receptor negative, and HER2 positive.

Expression of lipoma preferred partner in mammary and extramammary Paget disease

BACKGOUND

This study aims to identify the expression of lipoma preferred partner (LPP) in Paget disease (PD) and to further understand the pathogenesis of PD.

METHODS

Tissue microarray was used to evaluate the expression of LPP by immunohistochemistry in 40 PD patients. The results of LPP expression were combined with clinical and histopathological characteristics. Patient files were analyzed retrospectively.

RESULTS

Twenty-one cases were mammary Paget disease (MPD) and 19 extramammary Paget disease (EMPD) involving the vulva, scrotum, and penis. LPP was expressed in PD and this expression was significantly greater in MPD versus EMPD (P = .031). The expression of LPP in MPD was significantly related with age (P = .009) and expression of Ki-67 (P = .011). No statistically significant differences were observed in LPP expression as related to sex, body location, and time of PD diagnosis.

CONCLUSIONS

While LPP is expressed in both MPD and EMPD, the intensity of this expression is greater in MPD. LPP expression is positively correlated with Ki-67 and is more prevalent in middle-aged versus senior MPD patients. Further research is needed to determine its potential role in tumorigenesis and distribution.

Clinical and sonographic features of nipple lesions

BACKGROUND

The aim of this study was to present several cases of benign and malignant nipple lesions and contribute to diagnosis and differential diagnosis.

METHODS

A retrospective study was conducted on 13 patients. All of the patients were evaluated by ultrasonography, and 11 of them had pathological results. We analyzed the clinical and sonographic features.

RESULTS

There were 3 malignant lesions, 7 benign lesions, and 3 congenital nipple dysplasia, listed as follows:Malignant lesions (n = 3, 23%): Paget's disease (PD, n = 3, 23%). All of the patients with PD showed unilateral nipple erosion, discharge, and pain. The ultrasound showed abundant blood flow (n = 3, 23%); 2 patients (n = 2, 15%) had microcalcifications.Benign lesions (n = 7, 54%): Adenoma of the nipple (n = 2, 15%). One patient (n = 1, 8%) had nipple erosion and discharge. Two patients (n = 2, 15%) had a palpable nodule in the nipple. The ultrasound of both patients (n = 2, 15%) showed regular-shaped, clear border nodule with abundant blood flow (n = 2, 15%).Leiomyoma of the nipple (n = 1, 8%): This male patient was characterized by unilateral nipple enlargement and pain. The ultrasound showed a regular nodule with absent blood flow.Plasma cell mastitis (n = 2, 15%): Two patients showed unilateral nipple inversion and pain. One patient (n = 1, 8%) showed swollen and redness. The 2 patients showed a lesion in the gland around the nipple present as an irregular shape and unclear boundary hypoechoic mass.Nipple wart (n = 2, 15%): Two patients showed a unilateral soft exogenous neoplasm. Both of the patients showed a hypoechoic wart; the echo was similar to the nipple, the border was clear, and had no blood flow in the wart.Nipple Dysplasia (n = 3, 23%): Accessory nipple (n = 3, 23%). Two patients (n = 2, 15%) had accessory nipples in the subcoastal area, 1 patient (n = 1, 8%) in the areolar. All of the patients' sonographic features were the same as the nipple.The positive predict value (PPV) of the clinical symptoms: Erosion and discharge are both 75% (P < 0.05). The PPV of the US manifestations: irregular shape, indictinct margin, abundant blood flow, microcalcification, thicken skin in diagnosing malignant lesions are 60%,60%,60%,100%,100%, respectively (P < 0.05).

CONCLUSIONS

The characteristic sonographic features together with clinical symptoms contribute to the diagnosis of nipple lesions.

Unusual case of Paget disease of the nipple diagnosed by nipple scraping cytology

Paget disease of the nipple is a rare presentation of breast cancer. It is sometimes mistaken for a benign skin condition of the nipple and surrounding areola, which can significantly delay the diagnosis and treatment. In over 90% of cases there is an underlying carcinoma, either ductal carcinoma in situ (DCIS) or invasive breast cancer. We present a rare case of Paget disease of the nipple without the typical characteristics, detected by simple nipple scraping technique. A 62-year-old woman presented with a small fissure on the left nipple with scant clear nipple discharge. There were no other changes to the nipple-areola complex. The mammography and ultrasound were unremarkable. However, nipple scraping provided the immediate cytological diagnosis of Paget disease. Breast MRI with core biopsy showed high grade ductal carcinoma in situ with suggestion of microinvasion, confirmed histologically after mastectomy. Nipple scraping is a simple and inexpensive technique, which can be used in the office without anesthesia and with minimal discomfort to the patient. It could allow for significantly earlier cancer detection and treatment at the earliest stage of breast cancer. However, if the results are negative, full thickness biopsy may be needed if clinically indicated.

Paget’s disease of the breast without associated ductal carcinoma: case report and review of the literature

Objective

To present one case of Paget's disease (PD) of the breast without associated ductal carcinoma, and to conduct a review of the literature on its diagnosis and treatment.

Materials and methods

59-year-old woman with a two-year history of a chronic erythematous, ulcerated, itchy lesion in the left nipple, initially treated dermatologically with topical steroids with no improvement, finally visits a primary healthcare institution in the city of Tunja, Colombia for diagnosis. A biopsy and histochemical testing were performed to make the diagnosis and the lesion was then treated with central quadrantectomy. The post-operative pathology testing was negative for malignancy, without recurrence at one-year follow-up. A search was conducted in the PubMed, SciELO, ProQuest, ScienceDirect and Google Scholar databases using the terms "Paget´s Disease," "Breast Neoplasms," "Mammography," "Ultrasonography," Mammary," "Biopsy," and "Mastectomy," tracking bibliographic review articles, editorials, reports and clinical case series in English and Spanish, without time limitation.

Results

Overall, 11 publications were included consisting of 5 case reports, 3 case series, 1 review of the literature based on a clinical case, and 2 letters to the editor describing cases related to Paget's disease of the nipple with no associated carcinoma. The diagnosis was based on the clinical suspicion of the disease and a biopsy of the lesion. Histochemistry was useful for the differential diagnosis: treatment options ranged from mastectomy to nipple-areolar complex resection. Radiotherapy has also been used.

Conclusions

The diagnosis of Paget's disease with no associated ductal carcinoma is based on early clinical suspicion and histopathology of the nipple- areolar complex. There is no consensus regarding surgical management of this lesion. Follow-up studies of this subgroup of patients treated with radiotherapy or conservative surgery are required.

Sebaceous Carcinoma in Situ Masquerading Clinically and Histologically as Paget Disease of the Breast

Sebaceous carcinoma in situ is a poorly understood and ill-defined entity. In situ sebaceous carcinoma exhibits a similar location pattern to its invasive counterpart in that most commonly has a periorbital distribution. Review of the literature found only seven cases of extraocular sebaceous carcinoma in situ. We present a unique and challenging case of sebaceous carcinoma in situ masquerading both clinically and histologically as Paget's disease of the breast. A 61-year-old female presented to her dermatologist complaining of a 6 mm erythematous waxy papule on her medial right breast. The patient's past medical history was significant for Muir-Torre syndrome. Clinically, the differential diagnosis included Paget disease of the breast, squamous cell carcinoma, and sebaceous carcinoma. A shave biopsy revealed an atypical proliferation of large single cells limited to the epidermis infiltrating in a pagetoid pattern, as well as cohesive nests of round neoplastic cells with mild nuclear atypia, prominent nucleoli, and vacuolated cytoplasm. Histologically, the differential diagnosis included Paget's disease of the breast, squamous cell carcinoma in situ, melanoma in situ, and sebaceous carcinoma in situ. A battery of immunohistochemical stains was performed including CK7, EMA, CAM5.2, CK20, and MART-1. The lesional cells were positive for adipophilin, factor XIIIa, CK7, and EMA and were negative for CAM5.2, CK20, and MART-1 supporting a diagnosis of sebaceous carcinoma in situ. Multiple deeper sections were examined and invasion beyond the epidermis was not identified. This case adds to the paucity of information available regarding extraocular sebaceous carcinoma in situ and warns clinicians of this potential diagnostic pitfall especially in patients with Muir-Torre syndrome.

Expression of CD3, PD-L1 and CTLA-4 in mammary and extra-mammary Paget disease

BACKGROUND

Mammary and extra-mammary Paget disease is a rare form of intra-epithelial glandular neoplasm which is characteristically recurrent and necessitates multiple excisions that have an important impact on morbidity. Local immuno-modulating treatments have been applied with promising results, but the local immune markers of Paget disease have not been studied.

AIM OF THE STUDY

To investigate the local immune micro-environment of Paget disease.

MATERIALS AND METHODS

Sixty-four specimens from 41 patients, including cases with multiple recurrences and underlying primary neoplasm, have been studied for their expression of CD3, PD-L1 and CTLA-4.

RESULTS

Nineteen cases were mammary; 22 were extra-mammary and involved the vulva, the anus, the inguinal region and the lower extremity. PD-L1 was not expressed by any neoplastic lesion or the associated lymphocytes. CTLA-4 expression was found in nine cases. Higher stromal CD3 expression and moderate levels of intra-epithelial CD3 expression were present in most cases. Biopsies, subsequent excision specimens and recurrences showed the same immunohistochemical profile of CD3 and PD-L1, although there were different levels of CTLA-4 in a few cases. The underlying lesions in mammary Paget disease showed the same immunohistochemical profile as the intra-epithelial neoplastic cells. The expression of the markers did not correlate with age, sex, localization or recurrence.

CONCLUSION

Paget disease is characterized by an intense lymphocytic response, devoid of the immune-suppressive impact of the PD-L1 pathway, but with occasional CTLA-4 expression.

Transcriptome analyses reveal FOXA1 dysregulation in mammary and extramammary Paget's disease

Paget's disease (PD) is an uncommon intraepithelial adenocarcinoma with unknown pathogenesis. There are two anatomic subtypes: mammary (MPD) and extramammary (EMPD). Little is known about their molecular characteristics. Our objective was to discover novel molecular markers for PD and its subtypes. In the discovery phase, we used transcriptome analyses to uncover the most differentially expressed genes and pathways in EMPD biopsies compared with normal skin. In the validation phase, we performed immunohistochemistry analyses on the most promising marker (FOXA1) and other markers selected from a literature review (GATA3, estrogen receptor [ER], and androgen receptor [AR]) on independent biopsies of MPD (n = 86), EMPD (n = 59), and normal skin (n = 21). Transcriptome analyses revealed 210 genes differentially expressed more than 10-fold between EMPD and normal skin. These genes are involved in mammary and sweat gland development (FOXA1) and immune regulation, as well as epidermal differentiation. Immunohistochemistry staining revealed that FOXA1 was positive in 88% of both MPD and EMPD, whereas GATA3 was positive in 67% of MPD and 77% of EMPD, and ER was positive in 9% of MPD and 19% of EMPD. Finally, AR was positive in 33% of PD and 54% of EMPD. Mammary Paget's disease and EMPD share dysregulation of the glandular developmental regulator gene FOXA1, suggesting similarity in cell-specific transcriptional regulation. Further, FOXA1 may be a useful molecular target for developing PD therapies.

Clinicopathological characteristics and survival outcomes in Paget disease: a SEER population-based study

The objective of this study was to investigate the clinicopathological characteristics and survival outcomes of Paget disease (PD), Paget disease concomitant infiltrating duct carcinoma (PD-IDC), and Paget disease concomitant intraductal carcinoma (PD-DCIS). We identified 501,631 female patients from 2000 to 2013 in the Surveillance, Epidemiology, and End Results (SEER) database. These identified patients included patients with PD (n = 469), patients with PD-IDC (n = 1832), and patients with PD-DCIS (n = 1130) and infiltrating ductal carcinoma (IDC) (n = 498,076). Then, we compared the clinical characteristics of these patients with those who were diagnosed with IDC during the same period. The outcomes of these subtypes of breast carcinoma were different. Based on the overall survival, the patients with PD-IDC had the worst prognosis (5-year survival rate = 84.1%). The PD-DCIS had the best prognosis (5-year survival rate = 97.5%). Besides, among patients with Paget disease, the one who was married had a better prognosis than who were not. And, according to our research, the marital status was associated with the hormone receptor status in patients with PD-IDC. Among three subtypes of Paget disease, patients with PD-IDC had the worst prognosis. Besides, patients who were unmarried had worse outcomes. And the marital status of patients with PD-IDC is associated with hormone status. The observation underscores the importance of individualized treatment.

Analysis of 100 Cases of Paget's Disease of the Breast

Of 100 cases of Paget's disease of the breast admitted to the National Cancer Institute of Milan from 1940 to 1974, 91 were statistically evaluated. They were divided in two groups according to presence or absence of a palpable nodule. The results of surgical treatment in terms of 5 and 10 year survival rates were 59 and 44 %, respectively, with a median survival of 9 years. For the two separate subgroups, those with a palpable nodule were 38 and 22 % for 5 and 10 years, respectively, while those without a palpable nodule were 92 and 82 % for 5 and 10 years, respectively. For the two groups the median survival was 3.6 and 16.4 years, respectively. The extent of surgery should be dependent on the presence or absence of palpable nodules under the nipple. For the two groups (with and without) extended radical mastectomy and the Patey-Dawson mastectomy are recommended.

Histological Typing of Breast Tumors

The WHO Histological Classification of Breast Tumors, published in 1968 has been completely revised. This second edition provides a recommended nomenclature, definitions and code numbers for both tumors and tumor-like lesions. It aims at promoting uniformity in recording and reporting diagnoses in order to facilitate international and other comparisons.

Paget's Disease in Gynecomastia: Immunohistochemical Study of a Case

A case of Paget's disease and gynecomastia in a 70-year-old man is reported. Paget's disease was connected to an intraductal carcinoma, and the immunohistochemical study revealed similar positivity for cytokeratin A, carcinoembryonic antigen and epithelial membrane antigen in Paget cells and intraductal neoplastic cells whereas Paget cells resulted negative for cytokeratin B and C. The study using monoclonal anti-cytokeratin A (35 βH11), B (34 βE12) and C (34 βB4) could represent a good tool, supporting the theory of a ductal origin of Paget cells. A review of the literature has shown the rarity of Paget's disease in the male breast and revealed only two previous reports with an associated gynecomastia, in 2 patients with Klinefelter's syndrome and infiltrating breast carcinoma.

Paget's disease of the male breast: case report and a point of view from actual literature

INTRODUCTION

Paget disease of the nipple in man is a very rare breast cancer, and there are not standard procedures or guidelines. In any cases, a Paget's disease could hide an invasive ductal breast cancer.

CASE DESCRIPTION

We report the case of a 77-years old man affected by Alzheimer's disease, who presented to our attention because of an ulcerated palpable mass in the right nipple. A biopsy of the lesion showed "intra-epidermic proliferation of epitelioid cells, associated with linfo-plasmacellular infiltration of superficial dermis, compatible with Paget's disease (pTis)". We discussed the case in the multidisciplinary meeting and decided to subject the patient to surgery, so a right mastectomy plus sentinel lymph node biopsy (SLNB) were performed. Histo-pathological examination revealed "invasive ductal carcinoma of the breast, associated with a small component of in situ ductal carcinoma and Paget's disease of the nipple with superficial ulceration". Resection margins were free. Sentinel lymph node was negative. Biological features were as follows: ER 95%, PR 60%, Her-2/neu 1+, Ki-67 35%. The patient was discharged in the third post-operative day in good conditions. In the following weeks the patient's healing process was good and free of complications.

CONCLUSIONS

Clinical recognition of Paget's disease is very important also in man, because it can be the alarm bell for an underlying invasive ductal breast cancer, often more aggressive than in woman.

[A Case of Paget-Type Recurrence 20 Years after Breast Conserving Surgery for Invasive Ductal Carcinoma]

We report an 85-year-old female suffered Paget-type recurrence at right remnant breast. The patient had undergone breast conserving surgery(BCS)20 years ago in another hospital for invasive ductal carcinoma of the right breast(pT1N0M0, Stage I ). Her chief complain was a skin ulcer of the right nipple. The pathological diagnosis for biopsy specimen from the areola was Paget's disease. She underwent total mastectomy. Paget cells were detected pathologically in the epidermis of the nipple and nearby mammary duct connected with fibrous tissue after BCS, suggesting Paget-type recurrence of invasive breast carcinoma.

Paget disease of the male breast

Paget disease of the breast is an uncommon tumor of the nipple-areola complex that usually presents as an erythematous and erosive lesion. We report the case of a 61-year-old man that presented with a three-year history of an erythematous lesion of the right areola, first treated with topical corticosteroids without benefit. He was then referred to our dermatology department and the clinical suspicion of Paget disease was considered. The diagnosis was later confirmed by biopsy. This case report highlights the importance of clinical recognition of this entity along with other diseases that mimic these skin changes in order to allow earlier diagnosis and proper follow-up.

Pigmented lesion of the nipple - a clinicopathological challenge

Differential diagnoses of pigmented lesions of the nipple include melanocytic nevus, melanosis of the nipple, seborrheic keratosis, pigmented basal cell carcinoma, melanoma and Paget disease. The histologic exam with appropriate immunohistochemistry is a fundamental tool to achieve a correct diagnosis. We present a patient with a pigmented lesion of her right nipple revealing mammary Paget disease and elucidate diagnostic obstacles and prognostic importance of early breast cancer detection.

[Diagnosis and treatment for Paget's breast cancer: state of the art]

Breast cancer is the most common cancer in women. According to WHO experts in the world each year there are revealed from 800,000 up to 1 million new cases of breast cancer. In the structure of malignant tumors morbidity among female population, in Russia in 2012 breast cancer ranked the first place (20.7%) and remained the leading malignant pathology in women. Paget's breast cancer is a rare form of breast cancer that occurs in the mouth of the excretory ducts of the nipple, which characterized by lesion of the nipple and large ducts, often with the formation of tumor in the breast. This rare abnormality occurs in 0.5-5% of all cases of breast cancer.

Patients with nipple-areola Paget's disease and underlying invasive breast carcinoma have very poor survival: a matched cohort study

Paget's disease (PD) of the breast is a rare disease. The survival rate of PD was reported to depend on the characteristics of the underlying carcinoma. This study aimed to investigate the characteristics and survival rate of PD patients with underlying invasive breast carcinoma (IBC). Fifty-two patients were diagnosed with PD and an associated IBC from 2001 to 2005 in Fudan University Shanghai Cancer Center. Twenty-four (46.2%) had no clinical manifestation of PD and were diagnosed unexpectedly by a histologic examination. The 52 patients were all recruited in this study as the PD group. They tended to have greater chances of lymph node involvement (53.8% vs. 35.7%), lower hormone receptor expression (34.6% vs. 69.7%), higher human epidermal growth factor receptor 2 (HER2) expression (76.9% vs. 21.3%), and worse survival (5-year relapse-free survival (RFS) 52.2% vs. 86.7%, P<0.01; breast cancer-specific overall survival (OS) 62.1% vs. 91.8%, P<0.01) when compared with patients diagnosed with IBC. A matched study was then performed to investigate whether the poor survival of patients in the PD group was due to the unfavorable prognosis of the underlying IBC. One hundred and fifty-six (3∶1 ratio of controls to PD patients) patients diagnosed with IBC only were recruited into the matched group. The match was conducted according to four variables: dimension of IBC, lymph node status, hormone receptor status and HER2 status. The 5-year RFS (52.2% vs. 81.4%, P<0.01) and OS (62.1% vs. 85.9%, P<0.01) were both lower for patients in the PD group than those in the matched group. Patients with PD and underlying IBC had poor survival. Their survival was worse than that of patients with IBC of similar stage and characteristics. For patients with no clinical PD manifestation who were histologically diagnosed as PD, survival might be worse compared to patients with clinically diagnosed PD.

Paget's disease of the breast

The initial presentation of Paget's disease of the breast is an eczematous lesion, similar to contact dermatitis, in the skin of the breast at the areola and/or nipple and is refractory to usual topical treatments. It is frequent among women, especially those in their 50s and 60s. Most cases are associated with an in situ or underlying invasive breast neoplasia. The histopathology is usually diagnostic, with immunohistochemistry useful for its differentiation from melanoma and other types of tumors. Treatment should always be surgical with invasive procedures for the effective and complete removal of the breast tumor.

The routine immunohistochemical evaluation in Paget disease of the nipple

Paget disease (PD) of the nipple with coexisting intraductal (DCIS) and invasive carcinoma of the breast comprises 0.6-1.8% of all malignant epithelial neoplasms of this organ. Unlike invasive ductal carcinoma, there are many controversies concerning histological features of PD and the significance of the immunohistochemical characteristics of this neoplasm, which limits the optimal treatment protocols. Therefore, we decided to verify the immunohistochemical markers of PD basing on the retrospective analysis of postoperative material from 69 patients treated surgically. Microscopic examination revealed partial (7 cases) or total (62 cases) replacement of the squamous epithelium of the nipple with nests of atypical glandular cells spreading in an area ranging from 0.2 to 2.5 cm. DCIS coexisting with the PD lesions was present in all examined patients, and infiltrating carcinoma occurred in 31 (44.9%) patients. Both intraepidermal and DCIS components presented c-erbB2 overexpression. Positive estrogen and progesterone receptor staining was observed only in 7 (10.1%) and 2 (2.7%) tumours, respectively. Ki-67 proliferation index of PD cells ranged from 10% to 30%, whereas in DCIS it varied from 4% to 20%. The value of Ki-67 index exceeding 25% in the intraepidermal component of PD was associated with worse overall survival rate.

[A case of pagetoid carcinoma of the breast in nearly complete response by primary systemic therapy]

A 62-year-old female presented with an erosion of the left nipple. At the preoperative examination, it was diagnosed as a Pagetoid carcinoma with an invasive carcinoma. After primary systemic therapy(weekly paclitaxel/trastuzumab), we performed an operation. The only remaining Paget cell was confirmed in the resected specimen, and no other malignant cells were confirmed. There is no report that the preoperative chemotherapy for the Pagetoid carcinoma with an invasive carcinoma. The patient has had no evidence of recurrence 1. 5 years after the operation.

Current surgical approach to Paget's disease

BACKGROUND

Paget's disease constitutes between 1% and 3% of all breast malignancies, which makes defining standard surgical therapy difficult. We sought to identify preoperative factors that would select patients for successful breast conservation.

METHODS

Fifty-one patients with Paget's disease underwent surgical therapy between October 1998 and January 2010. Clinical presentation of Paget's disease, preoperative imaging, pathologic tumor characteristics, as well as surgical, radiation, and adjuvant therapies were reviewed.

RESULTS

Thirty-seven percent underwent breast conservation whereas 63% underwent mastectomy. Twelve patients presented with a palpable mass, and all were treated with mastectomy. Twenty-two patients underwent a mammogram, identifying extensive abnormality requiring mastectomy. Magnetic resonance imaging added to surgical planning in 52% of patients who participated in the study. None of our patients had a local/regional recurrence at 29 months of follow-up evaluation.

CONCLUSIONS

Paget's disease of the breast can be treated with breast conservation in a properly selected subset of patients. Successful breast conservation was achieved in patients without a palpable finding, a benign mammogram, and a normal magnetic resonance imaging scan.

[Paget's disease of the nipple and differential diagnosis]

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.

[A case of mammary Paget's disease with early systemic recurrence after operation]

A 66-year-old woman visited our hospital because of redness and erosion of her right breast, and was diagnosed with mammary Paget's disease by histological examination of erosive skin. The patient had a simple mastectomy. The pathological diagnosis was mammary Paget's disease (8x7.5 cm) showing intraductal spread. The resected skin margin was negative. Partially dermal microinvasion and lymphatic involvement were found. Immunohistochemical analysis of this tumor showed ER negative, PgR negative, and HER2 positive (3+). Eighteen months after the operation, she presented with redness of the chest wall with edema of the right arm. Incisional biopsy on the chest mass revealed a local recurrence of mammary Paget's disease. In addition, she had carcinomatous lymphangiosis in the bilateral lung, nodal metastases in the ipsilateral axillary and mediastinal space, and contralateral breast metastases on CT. She was treated with twelve courses of weekly paclitaxel in combination with trastuzumab. A complete response was obtained eleven months after initiation of chemotherapy. A rare case of early systemic recurrence of mammary Paget's disease after curative operation is reported with a review of the literature.

Misleading presentations of malignant breast diseases--role of clinical cytology

We described two examples with misleading presentations to draw attention to the role of clinical cytology as apart of multidisciplinary approach to breast lesions. In the first case--Paget's disease of the nipple, there was no obvious clinical and radiological evidence of breast cancer, while the second case--primary non-Hodgkin lymphoma of the breast imitated advanced breast carcinoma. The question is whether accurate and fast diagnoses can be made without cytological examinations. It must be kept in mind that first-hand clinical information and contact with the patient is necessary in rendering accurate cytological diagnoses.

Treatment of mammary and extramammary Paget's skin disease with topical imiquimod

BACKGROUND

Paget's disease is an uncommon epidermal cancer, affecting all skin regions wherever apocrine glands are present. It is divided into extramammary (EMPD) and mammary Paget's disease (MPD). It can be confined to the epithelium or may be associated with an underlying adenocarcinoma. The diagnosis is confirmed by skin biopsy and the treatment depends on characteristics of the underlying cancer. Surgery is the first-line treatment. Imiquimod, a topical immunomodulator, approved its efficiency in several skin neoplasms and has been shown as a safe treatment for EMPD. However, it has never been reported for the treatment of MPD.

OBSERVATIONS

We report on two cases of EMPD and MPD successfully treated with imiquimod 5% cream.

CONCLUSION

This non-surgical method may be considered as a primary treatment when Paget's disease is not associated with an underlying malignancy. The good prognosis with a long-term survival, the anatomic localization and the poor general condition of elderly people may favor imiquimod as an alternative treatment. On the other hand, it will reduce the extent of excision when it anticipates surgery.

Metachronous Paget's disease of the breast: case report

Paget breast disease is a kind of intraductal carcinoma that through an intracanalicular diffusion invades the basal epidermal layer, reaching the areola and nipple, producing a typical erythematous desquamative eczematous-like lesion. This neoplasia can remain undetected for a long time and inadequately treated as a dermatological affection. Synchronous or metachronous lesions are very uncommon. Surgical choice is conditioned by the presence of a tumor below the epidermal lesion, by its dimensions, and by the possible lymph node involvement. Surgical therapy can be radical or conservative. From our experience we think that lesion biopsy is always necessary to formulate a correct diagnosis and to schedule an appropriate therapeutic approach. In our case, a biopsy was performed first, then on the basis of the frozen section analysis a radical mastectomy with axillary third level lymph nodes dissection, because of the large dimensions of the lesion and the previous history of a methachronous lesion.

Paget's disease in contralateral breast occuring 11 years after mastectomy for invasive ductal carcinoma

Paget's disease of the breast is a rare form of breast cancer and represents only 1% to 4% of all breast cancers. It is characterized by the presence of Paget's cells in the epithelium tissue (in epidermis) and it manifests as a lesion of the nipple. In most cases, Paget's disease is associated with an underlying breast malignancy. Mastectomy has been considered the treatment of choice, but breast conservation is also being explored, in properly selected patients, depending on the underlying malignancy. We report a case of Paget's disease occurring in the contralateral breast 11 years after mastectomy for invasive ductal carcinoma but with no underlying breast malignancy.

Assessment of proliferating activity in Paget's disease of the nipple by double stain immunohistochemistry

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's disease is an intraepithelial epidermotropic migration of malignant epithelial cells originating from an underlying intraductal carcinoma. Although the immunohistochemical properties of 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 Ki-67 (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's disease and the associated intraductal carcinomas (n = 10) and/or invasive carcinomas (n = 4) were tested. The mean Ki-67 index was in Paget's 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's disease and underlying intraductal carcinomas share a close proliferating activity.

Different panels of markers should be used to predict mammary Paget's disease associated with in situ or invasive ductal carcinoma of the breast

Mammary Paget's disease (MPD) is a rare manifestation of breast carcinoma involving the nipple. Our objective was to identify molecular markers and molecular subtypes that may predict patients at high risk of developing MPD. Immunohistochemical (IHC) analyses were performed with antibodies to estrogen receptor (ER), progesterone receptor (PR), androgen receptor (AR), HER2, epidermal growth factor receptor (EGFR), and several cytokeratins (CK5/6, CK14, CK17, CK8, CK18) on representative sections of 121 cases of ductal carcinoma of the breast, including 28 cases with MPD, 81 cases with neither MPD nor nipple involvement, and 12 cases of non-MPD with nipple involvement. The rates of receptor expression and subtype distributions of 3 IHC-based molecular classifications were compared among these groups. The results showed that: (1) MPD is more likely to be associated with ER- and PR-negative ductal carcinoma in situ (DCIS), but not invasive ductal carcinoma (IDC); (2) MPD is more likely to be associated with HER2-over expression subtype DCIS, but not IDC; and (3) carcinomas with non-MPD nipple involvement differ from those with MPD, since they are more likely to be ER- and PR-positive, HER2-negative, and luminal A subtype. In summary, different panels of markers should be used to predict MPD associated with different underlying lesions; for DCIS, the ER-negative, PR-negative, and HER2-subtype and not basal-like subtype is most predictive of MPD; for IDC, the luminal B-subtype is most predictive of MPD.

[Diagnostic image (396). A woman with an eczematous nipple]

A 58-year-old woman presented with an eczematous lesion of the right nipple 6 months after a right axillary lymph node dissection that was performed due to a metastatic carcinoma. The nipple scrape smear showed malignant cells compatible with Paget's disease.

Cytologic features of primary malignant tumors of skin and adnexae

OBJECTIVE

To highlight the cytologic features of the cases seen in our institute.

STUDY DESIGN

Cases of primary malignant tumors of skin and adnexae diagnosed on cytology with histopathology confirmation were retrieved from case records of 1998-2005. Clinical presentation was noted in all the cases.

RESULTS

Thirty primary malignant tumors of skin and adnexae were analyzed. Melanoma was the most common (n=12), followed by squamous cell carcinoma (SCC) (n=5). There were 3 basal cell carcinomas and 2 cases each of sebaceous carcinoma, Paget's disease of the breast and lymphoma. There were single cases of eccrine carcinoma, malignant trichilemmal tumor, undifferentiated carcinoma and extramedullary myeloid cell tumor. All the cases of hemopoietic tumors (n=3) and the majority of the cases (4 of 7) of adnexal were seen to arise from head and neck region. Marjolin's ulcer was seen in 4 of 5 SCCs. Scrape smears were obtained from 8 patients and fine needle aspiration in 22 patients.

CONCLUSION

Cytodiagnosis of primary malignant tumors of skin and adnexae is possible based on morphology and clinical presentation.

[Diagnosis and therapy for penile cancer: a report of 46 cases with literature review]

BACKGROUND & OBJECTIVE

Penile cancer is an uncommon malignancy, which is mainly treated by surgery, radiation and chemotherapy. This study was to investigate reasonable curative methods for penile cancer.

METHODS

Medical records of 46 patients with penile cancer in the Department of Urology, The First Affiliated Hospital of Sun Yat-sen University between Jan. 1996 to Jan. 2005 were analyzed retrospectively. Forty-four patients had squamous cell carcinoma, one had Paget disease, and one had verrucous carcinoma.

RESULTS

Thirty-nine patients received partial penectomy, four received total penectomy and perineal urethrostomy, one Paget disease patient received lesion resection and skin grafting, two patients did not receive surgery. Nine out of 10 patients with positive lymph node received ilioinguinal lymphadenectomy, and five received pelvic lymphadenectomy. Forty-one cases were regularly followed up for one to 10 years. The 1-, 2-, 5- and 10- year survival rates were 95.1%, 95.1%, 82.9% and 31.7%, respectively. Prognosis of patients with pelvic lymph node metastasis was poor. Two patients who had pelvic lymph node metastasis died of lung metastasis within two years after surgery.

CONCLUSIONS

Partial penectomy is an appropriate and effective management for penile cancer. Lymph node metastasis is an important prognostic factor for penile cancer. Patients with ilioinguinal lymph node metastasis should receive lymphadenectomy as early as possible to improve the therapeutic effect. The prognosis is poor for patients with pelvic lymph node metastases.