Pathologic-radiologic correlation in evaluation of retroareolar margin in nipple-sparing mastectomy

Mammary Paget's Disease Mimicking Benign and Malignant Dermatological Conditions: Clinical Challenges and Diagnostic Considerations

Mammary Paget's disease (MPD) or Paget's disease of the breast is a rare dermatological malignancy of the nipple-areolar complex that manifests with a spectrum of symptoms spanning from itching and redness to more severe indications such as breast lump, nipple-areolar complex destruction, or nipple discharge. It is predominantly associated with an underlying ductal carcinoma in situ or invasive ductal carcinoma. MPD often masquerades as other benign and malignant dermatological conditions, including eczema, atopic dermatitis, psoriasis, and squamous and basal cell carcinomas, leading to delayed diagnosis and inappropriate treatment. Only one-third of the patients present with a palpable lump; therefore, advanced age with chronic and unilateral lesions should raise concern for MPD. Our review article presents case reports of MPD imitating other skin conditions and underscores the key findings of clinical features and diagnostic workup to help differentiate the condition. A literature review revealed that studies emphasize caution regarding the sole use of mammography and ultrasound in diagnosing MPD, particularly in cases lacking a palpable lump. This highlights the MRI as a superior and more accurate imaging tool. However, any suspicious lesion must be biopsied to allow histopathological and immunohistochemical examination, since there are some cases where MRI findings were negative in the presence of a biopsy-proven MPD. This highlights the need for clinicians to investigate any suspicious lesion of the nipple or breast using the complete triple assessment approach to exclude an underlying malignancy. It is imperative to establish therapeutic guidelines to approach any nipple lesion to minimize the risk of misdiagnosing any underlying cancer, which can be potentially fatal if left alone.

How to accurately preoperative screen nipple-sparing mastectomy candidate-a nomogram for predicting nipple-areola complex involvement risk in breast cancer patients

BACKGROUND

Nipple-sparing mastectomy (NSM) offers superior cosmetic outcomes and has been gaining wide acceptance. It has always been difficult to objectively quantify the risk of nipple-areola complex involvement (NACi). The goal was to develop a prediction model for clinical application.

METHODS

Patients who had a total mastectomy (TM) between January 2016 and January 2020 at a single institute formed the development cohort (n = 578) and those who had NSM + immediate breast reconstruction (IBR) between January 2020 and January 2021 formed the validation cohort (n = 112). The prediction model was developed using univariate and multivariate logistic regression studies. Based on NACi risk variables identified in the development cohort, a nomogram was created and evaluated in the validation cohort. Meanwhile, stratified analysis was performed based on the model's risk levels and was combined with intraoperative frozen pathology (IFP) to optimize the model.

RESULTS

Tumor central location, clinical tumor size (CTS) > 4.0 cm, tumor-nipple distance (TND) ≤ 1.0 cm, clinical nodal status positive (cN +), and KI-67 ≥ 20% were revealed to be good predictive indicators for NACi. A nomogram based on these major clinicopathologic variables was employed to quantify preoperative NACi risk. The accuracy was verified internally and externally. The diagnostic accuracy of IFP was 92.9%, sensitivity was 64.3%, and specificity was 96.9% in the validation group. Stratified analysis was then performed based on model risk. The diagnostic accuracy rates of IFP and NACiPM in low-risk, intermediate-risk, and high-risk respectively were 96.0%, 93.3%, 83.9%, 61.3%, 66.7%, and 83.3%.

CONCLUSION

We created a visual nomogram to predict NACi risk in breast cancer patients. The NACiPM can be used to distinguish the low, intermediate, and high risk of NAC before surgery. Combined with IFP, we can develop a decision-making system for the implementation of NSM.

The utility of intraoperative retroareolar margin frozen section assessment and the management of atypical epithelial proliferative lesions at the retroareolar margin in nipple-sparing mastectomies

OBJECTIVES

Nipple-sparing mastectomy (NSM) has become more frequently utilized due to superior psychological and cosmetic outcomes. The aim of this study was to evaluate the accuracy and utility of intraoperative frozen section evaluation of the retroareolar margin (RAM) in NSM. The management of atypical epithelial proliferative lesions at the RAM was also reviewed and discussed.

METHODS

A single institution, retrospective analysis was performed on all therapeutic NSM patients with intraoperative evaluation of the RAM from 2014 to 2018. Patient demographics, tumor characteristics, pathologic assessment of the RAM, surgical management, and clinical follow-up were reviewed.

RESULTS

Seventy-four nipple-sparing mastectomies with intraoperative evaluation of RAMs were identified. Concordance was 95% between frozen and permanent section diagnoses with 4 cases representing false negatives and no false positives. There were no instances of nipple-areolar complex (NAC) recurrence in all cases with preserved NACs (mean follow up: 750 days). In the 9 cases where NACs were excised based on intraoperative RAM evaluation, the findings in the excised NACs were negative in 6 and ductal carcinoma in situ in 3 cases. Postoperative measurement of the tumor to nipple distance was the only statistically significant variable associated with a positive RAM by multivariable logistic regression (OR 0.475; 95% CI 0.238-0.946).

CONCLUSIONS

Intraoperative RAM evaluation demonstrated high concordance with permanent histology. Negative RAM, including atypical epithelial proliferative lesions, led to NAC preservation without recurrence. Positive RAM alone did not predict NAC involvement, although pagetoid spread of ductal carcinoma in situ along nipple ducts may predict NAC positivity.

A novel MRI-based predictive index can identify patients suitable for preservation of the nipple-areola complex in breast reconstructive surgery

INTRODUCTION

Accurately predicting nipple-areola complex (NAC) involvement in breast cancer is necessary for identifying patients who may be candidates for a nipple-sparing mastectomy. Although multiple risk factors are indicated in the guidelines, it is difficult to predict NAC involvement (NAC-i) preoperatively even if these factors are evaluated individually. This study aimed to develop a more accurate and practical preoperative NAC-i prediction model using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

All tumors in 252 patients were evaluated using postcontrast T1-weighted subtraction on MRI.

RESULTS

The receiver operating characteristic curves identified cut-off values for tumor size and tumor-to-nipple distance (TND) as 4 cm and 1.2 cm, respectively. Multivariate analysis demonstrated that TND (p < 0.001), ductal enhancement extending to the nipple (DEEN) (p < 0.001), and nipple enhancement (NE) (p = 0.005) were independent clinical risk factors for pathological NAC-i. A formula was constructed using odds ratios for these three independent preoperative risk factors in multivariate analysis: the MRI-based NAC-i predictive index (mNACPI) = TND × 4 + DEEN × 3 + NE × 1. A total score of ≤4 points was defined as low risk and ≥5 points as high risk. NAC-i rates were 2.4% in the low-risk group and 89.4% in the high-risk group; a significant correlation was observed between the risk group and permanent pathological NAC-i (p < 0.001). Assuming that the NAC was preserved in low-risk patients and resected in high-risk patients, NAC-i was verified using the mNACPI.

CONCLUSION

mNACPI may contribute greatly to the improvement of selecting suitable patients for NAC preservation in breast reconstructive surgery while maintaining oncological safety.

Mammary Paget's Disease of the Nipple: Relatively Common but Still Unknown to Many

Mammary Paget’s disease is clinically defined as skin inflammation of the nipple area and is an adenocarcinoma of the epidermis of the nipple. The pathogenesis of mammary Paget’s disease is relatively unknown; nonetheless, there are two popular theories that support the underlying carcinoma and de novo carcinogenesis. For the attending medical practitioner, mammary Paget’s disease poses a diagnostic and therapeutic dilemma, especially in the absence of a clinically palpable breast mass. We report a rare case of a 48-year-old Malay woman who presented at Hospital Universiti Sains Malaysia, Kelantan, Malaysia with the symptom of skin erosion on the left nipple and unresponsiveness to multiple topical treatments. A full evaluation and assessment of the patient were conducted, and mammary Paget’s disease was diagnosed.

Preservation of the nipple-areola complex in skin-sparing mastectomy for early breast cancer

PURPOSE

Skin-sparing mastectomy (SSM) enables a radical cure of breast cancer while overcoming the cosmetic issues related to surgery. We review our experience of performing SSMs and assess whether preservation of the nipple-areola complex (NAC) could have been an option for some patients who underwent SSM.

METHODS

The subjects of this retrospective study were women who underwent SSM that utilized four incision types; namely, the so-called tennis racket incision, a periareolar and midaxillary incision, an areola-sparing and midaxillary incision, and a small transverse elliptical incision. We assessed whether preservation of the NAC would have been an option in SSM, based on histologic examination of three serial cut surfaces of the specimen around the nipple, ruling out the option when evidence of the malignant lesion/s was found in at least one of the following locations: in the nipple, within a 1-cm radius from the base of the nipple, or within 1 cm from the surface of the NAC.

RESULTS

We performed 193 SSMs. The cumulative 10-year local disease-free survival rate was 98%, with 89% of patients reporting levels of satisfaction with the reconstructed breast, of excellent, very good, or good. We evaluated that 70 of the 193 procedures could have been performed as nipple-sparing mastectomy (NSM).

CONCLUSIONS

The outcomes of SSM in this series were excellent and NSM might have been an option for about one-third of the patients.

Nipple Preservation in Breast Cancer Associated with Nipple Discharge

BACKGROUND

Breast carcinoma presented with nipple discharge is a rare condition. There is theoretical concern about preserving nipple in these patients since the risk of nipple-areolar complex involvement may be greater, but not many studies in the literature have addressed on this issue. The aim of the current study was to determine the incidence and outcome of nipple preservation in breast cancer associated with nipple discharge.

METHODS

Medical records of patients who were diagnosed to have breast carcinoma and presented with nipple discharge from May 2009 to October 2014 were retrospectively reviewed.

RESULTS

Sixty patients presented with nipple discharge were diagnosed with breast cancer, which represent 3.8 % of all patients who underwent breast cancer surgery in our unit during the study period. Forty-six patients (76.7 %) had nipple discharge as their only symptom, while the rest also presented with breast mass clinically or radiologically. All patients had mammogram and ultrasound performed, and 53.3 and 63.3 % respectively showed suspicious findings. Forty-one out of 46 (89.1 %) nipple discharge cytology were inadequate or benign. Thirty-two microdochectomy were performed. Routine frozen section was utilized intra-operatively to ensure clear margins. The most common histology was ductal carcinoma in situ (DCIS) (n = 29, 48.3 %), followed by DCIS with invasive ductal carcinoma (n = 23, 38.3 %). Regarding treatment, 26 patients (43.3 %) had nipple preserved, including 21 breast conservative surgery and five nipple-sparing mastectomies. Overall, no local or systemic recurrence was observed at a median follow-up of 27 months. Ten out of 34 (29.4 %) mastectomy specimens showed NAC involvement on pathology. By comparing patients with NAC preserved to patients with NAC removed, no significant preoperative predictors were identified.

CONCLUSION

Breast carcinoma patients who present with nipple discharge usually have early-stage cancer. Presence of nipple discharge is not equivalent to NAC involvement. Nipple preservation can be oncologically safe if negative margins are ascertained.

Paget's Breast Disease: A Case Report and Review of the Literature

Paget’s disease of the breast is a rare cancer. This typical clinical case illustrates the different epidemiological, clinical, histological, therapeutic, and evolving aspects of the disease. We report a case of Paget’s disease in a 43-year-old woman who presented eczema of the nipple. Mammography and ultrasounds did reveal a lesion in situ. The patient was scheduled for mastectomy and sentinel node biopsy. She had chosen a radical bilateral surgery. The histological diagnosis was Paget’s disease of the breast with a carcinoma in situ. There was no metastasis in either of the sentinel nodes. Paget’s disease must be considered with the presence of a persistent eczematous involvement of the nipple, which does not respond to local treatment. Ultrasounds, mammography, and magnetic resonance imaging can allow searching an underlying cancer and guiding the surgical management. There is no evidence at this time that one of the two surgical techniques (conservative or mastectomy) would improve survival. The prognosis depends on the presence of a palpable mass and the invasiveness of the cancer.