Paget's disease of the breast

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.

A Pictorial Exploration of Mammary Paget Disease: Insights and Perspectives

Mammary Paget disease (MPD) is a rare condition primarily affecting adult women, characterized by unilateral skin changes in the nipple-areolar complex (NAC) and frequently associated with underlying breast carcinoma. Histologically, MPD is identified by large intraepidermal epithelial cells (Paget cells) with distinct characteristics. Immunohistochemical profiles aid in distinguishing MPD from other skin conditions. Clinical evaluation and imaging techniques, including magnetic resonance imaging (MRI), are recommended if MPD is suspected, although definitive diagnosis always requires histological examination. This review delves into the historical context, epidemiology, pathogenesis, clinical manifestations, and diagnosis of MPD, emphasizing the need for early detection. The classification of MPD based on pathogenesis is explored, shedding light on its varied presentations. Treatment options, including mastectomy and breast-conserving surgery, are discussed with clear guidelines for different scenarios. Adjuvant therapies are considered, particularly in cases with underlying breast cancer. Prognostic factors are outlined, underlining the importance of early intervention. Looking to the future, emerging techniques, like liquid biopsy, new immunohistochemical and molecular markers, and artificial intelligence-based image analysis, hold the potential to transform MPD diagnosis and treatment. These innovations offer hope for early detection and improved patient care, though validation through large-scale clinical trials is needed.

A novel web-based prognostic nomogram and the features influencing the curative effect of chemotherapy and radiotherapy for Paget's disease with invasive ductal carcinoma

Paget's disease (PD) of the breast is a rare underlying malignant tumor. Approximately 50% to 60% of patients with mammary PD are concurrently diagnosed with invasive ductal carcinoma (PD-IDC), a condition associated with a worse prognosis than IDC without PD. Thus far, there has been a lack of an accurate and efficient prognostic model for PD-IDC, and the factors influencing the effectiveness of chemotherapy and radiotherapy for these patients remain unknown. In this study, we developed a web-based nomogram based on the data from the Surveillance Epidemiology and End Results (SEER) database. We subjected the model to a series of validation methods, including area under the curve (AUC) values, receiver operating characteristic curve (ROC) analysis, calibration curves, and decision curve analysis (DCA). Our results demonstrated that our model exhibited high discrimination, accuracy, and clinical applicability in predicting the overall survival (OS) of patients with PD-IDC (testing set: three- and five-year AUCs, 0.831 and 0.841, respectively). To further validate our nomogram, we used external data from both our institution and sister hospitals (external data: three- and five-year AUCs, 0.892 and 0.914, respectively). Multivariable Cox regression analysis identified several independent unfavorable prognostic factors for the OS of patients with PD-IDC, including increasing age, high grade, widowed status, higher T stages, and the presence of bone metastases. Furthermore, propensity score matching (PSM)-adjusted analysis was conducted, revealing that chemotherapy did not significantly improve the survival of patients with PD-IDC across molecular subtypes, except for those in the grade III/IV group, where it improved both OS and breast cancer-specific survival (BCSS). Additionally, our findings indicated that only patients with PD-IDC with T4 and N3 stages benefited from radiotherapy, leading to improvements in both OS and BCSS. In conclusion, we have comprehensively analyzed the clinical characteristics and prognosis of patients with PD-IDC, culminating in the development of a user-friendly web-based nomogram for predicting their survival. Our predictive model is not only highly accurate but also offers simplicity, making it accessible for healthcare providers and patients. Furthermore, our stratified analysis highlights that the pathological grade, rather than the molecular subtype, plays a pivotal role in determining the efficacy of chemotherapy in improving the prognosis for patients with PD-IDC, while radiotherapy confers survival benefits to patients with PD-IDC in T4 and N3 stages.

HER2 Negative Mammary Paget's Disease or In Situ Melanoma? A Case Report and Review of the Literature

Mammary Paget's disease (MPD) is a rare histological condition, accounting for 1-4% of female breast cancers, which may appear either independently (1.4-13% of the cases), or in association with an in situ or invasive ductal carcinoma (approximately 90% of the cases). The purpose of this article is to highlight the histopathological challenges related to the microscopical polymorphism of this disease and the utmost importance of immunohistochemistry in the thorough process of Paget's disease differential diagnosis. Moreover, the primary objective of this review of literature was to corroborate the existing data concerning the potential peculiar immunohistochemical profile that mammary Paget's disease might express. We report the case of a 44-year-old female patient, histopathologically diagnosed with HER2-negative MPD accompanying an invasive mammary carcinoma. The histopathological and immunohistochemical approach is derived from the exigency of excluding the possibility of synchronous tumors-a mammary invasive carcinoma, accompanied by another component with MPD phenotypic mimicry. The unexpected negative HER2 reaction is conducted to a primary focus on excluding a malignant melanoma in situ. The absence of MelanA and S100 immunoexpression and lack of pigmentation and clinical aspects infirmed it. Bowen's disease was invalidated by its rare presentation in the breast cutaneous tissue and the absence of individual risk factors suggestive of an existing immunosuppressive status. In the case of similar morphoimmunohistochemical aspects, significant expression of Ki-67 signals MPD, an immunoreactivity that helped distinguish the cellular population from Toker cells. The great similarity of MPD with other benign and malignant cutaneous tumors might determine delay or misdiagnosis. Thus, the utmost importance of immunohistochemistry is reflected in its prognostic significance and geared towards extending the therapeutic arsenal.

Rare Paget's Disease Associated With Breast Cancer in a 70-Year-Old Male

Male breast cancer is far less common compared to female breast cancer. Paget's disease of the breast (PDB) is a rare disease, making it even rarer in men. It often presents with eczematous patches over the nipple and areola region, mimics benign dermatological conditions, and can result in a greatly delayed diagnosis. This report presents a rare case of PDB in a 70-year-old male and includes a review of its clinical presentation, radiographic findings, histology, carcinogenic potential, and management.

Paget's disease of the breast: diagnosis and management

Paget's disease of the breast typically affects postmenopausal women and is associated with an underlying malignancy. Skin changes are a common presenting symptom, as well as a lump, nipple discharge, pain and changes to the nipple shape. Imaging options include ultrasound for women under the age of 35 years or mammogram and ultrasound for women over the age of 40 years. The definitive diagnostic investigation is a tissue core biopsy. Cases are discussed by a multidisciplinary team to decide on the optimal management strategy. Management options are typically surgical and include breast-conserving surgery or mastectomy in addition to oncoplastic techniques. Sentinel lymph node biopsy is performed in all patients undergoing surgery. Adjuvant chemotherapy, radiotherapy or endocrine therapy can be used to treat concomitant invasive disease or ductal carcinoma in situ.

Role of GATA3 as a potential adjunct marker in the differential diagnosis of Paget’s disease of the nipple

Aims

Paget’s disease of the nipple (PDN) is a rare type of cancer of the nipple-areola complex. We examined GATA3 protein expression in PDN to determine its potential value as an adjunct marker in the differential diagnosis with other nipple lesions.

Methods and results

Chart review documented clinicopathological data. H&E slides were re-evaluated and immunohistochemistry (IHC) for GATA3 was performed. Amongst 3614 breast cancer patients, 74 had PDN and 41 cases were selected for our study (mean age, 55 years). Amid PDN cases, 4 (10%) patients showed PDN alone, 22 (65%) had an underlying ductal carcinoma in situ and 15 (37%) had invasive breast carcinomas (IBC), including 11 invasive carcinoma of no special type, 2 lobular, 1 mucinous and 1 micropapillary carcinoma. Additionally, 9 cancers were classified as luminal B, 4 as HER2 overexpression and 2 as luminal A. GATA3 expression was detected in all 41 PDN cases and in all underlying cancers. Furthermore, IHC for S-100, HMB45 and Melan-A was performed in PDN-only, ensuing negative results. Positivity for cytokeratin 7 or AE1/AE3 was demonstrated in all cases and HER2 overexpression was seen in 2/4 lesions. GATA3 expression was noted in all lesions, including one CK7-negative case.

Conclusion

Our findings indicate that GATA3 is consistently expressed in PDN. Although not entirely specific, positivity for GATA3 reinforces the non-melanocytic nature of PDN and its mammary origin, thus representing a potential adjunct tool for the diagnosis of PDN in tricky situations, particularly PDN variants or unusual lesions.

Treatment of Mammary Paget Disease: A systematic review and meta-analysis of real-world data

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.

Large Mammary Paget Disease without Underlying Breast Carcinoma

Mammary Paget disease is an uncommon type of breast cancer. Redness, scaling, and thickness involving the nipple and areola are common clinical symptoms. Invasive breast cancer was found in nearly 90% of these patients. Only a few cases of mammary Paget disease with no underlying cancer have been described, with a better prognosis. Treatment options include wide excision or mastectomy. However, if the lesion is very extensive, breast reconstruction may be required. We reported a rare case of extensive Paget disease in a 65-year-old woman who had a 7-year history of a 14 × 19 cm progressively enlarging erythematous scaling lesion that covered her entire left breast. No evidence of related malignancy or metastatic lesion was seen. A left mastectomy with sentinel lymph node biopsy and immediate pedicled transverse rectus abdominis myocutaneous flap reconstruction was chosen. There is uncertainty about axillary node metastasis since multiple enlarged and palpable left axillary lymph nodes were seen. She had axillary lymph node dissection instead. A histological examination confirmed the diagnosis of Paget disease of the nipple in the absence of underlying breast cancer and there was no evidence of axillary lymph node metastasis. This article emphasizes the need to pay close attention to diagnosis, progression, and treatment of the disease.

Local recurrence of mammary Paget's disease after nipple-sparing mastectomy and implant breast reconstruction: a case report and literature review

Objective

To provide a rare case of local recurrent Paget’s disease after nipple-sparing mastectomy (NSM) with immediate breast reconstruction with 10 years of disease-free survival and to analyze the clinical and pathological characteristics.

Background

Mammary Paget’s disease can be considered a rare type of local recurrence after breast cancer treatment, both in cases of conservative surgery and NSM with immediate breast reconstruction (Lohsiriwat et al, Ann Surg Oncol 19:1850-1855, 2012). Recurrent patients who present with nipple-areolar Paget’s disease usually have unfavorable primary pathological characteristics and different latency periods. However, the recurrent status in patients with favorable primary pathological characteristics and the latency periods after NSM with immediate breast reconstruction are unclear.

Methods

First, we present a case of local recurrent Paget’s disease in a young patient diagnosed with invasive breast carcinoma at age 30 who underwent NSM with primary silicone reconstruction. Then, the keywords “Paget’s disease” and “nipple-sparing mastectomy” were selected. Articles including the local recurrence of Paget’s disease after NSM were collected from the PubMed, Springer, and OVID databases, and the acquired relevant data were analyzed. We did not restrict our search by study design or publication date.

Results

Five studies describing 31 cases of local recurrent Paget’s disease after NSM with implant breast reconstruction were included. The mean patient age reported was 45 years, and the average latency period from NSM to the local recurrence of Paget’s disease was 40.2 months. Recurrent tumor histological features were Paget’s disease with ductal carcinoma in situ (DCIS) in 16 patients (50%), Paget’s disease without DCIS in 13 patients (40.6%), and Paget’s disease with ductal intraepithelial neoplasia (DIN) in 3 patients (9.4%). The primary tumor histological feature was estrogen receptor (ER)(−)/progesterone receptor (PR)(−)/human epidermal growth factor receptor (HER-2)(+) in 21 patients (77.8%). Neither locoregional relapse nor metastatic events were found in these recurrent patients who accepted NAC excision after 4–5 years of follow-up. Our reported case showed that the patient experienced pregnancy and lactation after primary adjuvant chemotherapy and endocrine therapy. However, she developed an eczematoid lesion in the NAC 120 months after breast surgery. The histopathological examination was consistent with Paget’s disease of the breast. Complete NAC and breast silicone prosthesis removal were performed. The patient accepted no systematic or local therapy and is currently alive. It is noteworthy that the biological features of the primary tumor were ER(+), PR(+), and HER-2(−); however, the recurrent tumor changed to ER(−), PR(−), and HER-2(+).

Conclusions

The local recurrence of Paget’s disease after NSM is uncommon; it may develop at a very early age and have a very long time to recurrence, as in our patient, who presented with recurrence 10 years after primary surgery. Surgeons should be wary of local recurrence of the nipple-areola complex after NSM in patients with ER-negative and HER-2-positive primary tumors. However, patients with ER/PR-positive and HER-2-negative tumors should not be neglected; we reported a case of an ER/PR-positive and HER-2-negative primary tumor, and ER-positive recurrent cases have the longest latency period. The local recurrence rate of Paget’s disease after NSM is low, and the prognosis is good in recurrent patients who accept further extensive NAC excision. Further systematic treatment was not considered for this patient.

Nanotechnological Approaches for the Treatment of Triple-Negative Breast Cancer: A Comprehensive Review

Breast cancer is the most prevalent cancer in women around the world, having a sudden spread nowadays because of the poor sedentary lifestyle of people. Comprising several subtypes, one of the most dangerous and aggressive ones is triple-negative breast cancer or TNBC. Even though conventional surgical approaches like single and double mastectomy and preventive chemotherapeutic approaches are available, they are not selective to cancer cells and are only for symptomatic treatment. A new branch called nanotechnology has emerged in the last few decades that offers various novel characteristics, such as size in nanometric scale, enhanced adherence to multiple targeting moieties, active and passive targeting, controlled release, and site-specific targeting. Among various nanotherapeutic approaches like dendrimers, lipid-structured nanocarriers, carbon nanotubes, etc., nanoparticle targeted therapeutics can be termed the best among all for their specific cytotoxicity to cancer cells and increased bioavailability to a target site. This review focuses on the types and molecular pathways involving TNBC, existing treatment strategies, various nanotechnological approaches like exosomes, carbon nanotubes, dendrimers, lipid, and carbon-based nanocarriers, and especially various nanoparticles (NPs) like polymeric, photodynamic, peptide conjugated, antibody-conjugated, metallic, inorganic, natural product capped, and CRISPR based nanoparticles already approved for treatment or are under clinical and pre-clinical trials for TNBC.

Mammary Paget’s Disease: An Update

Simple Summary

Mammary Paget’s disease of the breast is an uncommon and often misdiagnosed breast malignancy. The review discusses the diagnosis, work-up, treatment, and prognosis of mammary Paget’s disease.

Abstract

Mammary Paget’s Disease is a non-invasive cutaneous malignancy of the breast involving the nipple-areolar complex that is commonly mistaken for benign breast conditions, leading to delay in diagnosis. This review article discusses Paget’s disease etiology, clinical presentation, differential diagnosis, diagnostic work-up, natural history and prognosis. This article also discusses evolving strategies for the surgical and non-surgical management of Paget’s disease.

Imprint cytology can be a better option for diagnosis of mammary Paget’s disease!!!: A case report with review

Mammary Paget’s disease (MPD) is a rare form of pruritic eczematous skin lesion involving the nipple areola complex usually associated with an underlying in-situ or invasive carcinoma of breast, accounting ≤ 4% of overall breast carcinoma. The patient may present with nipple discharge, eczema, plaque, or nipple destruction with or without a lump which is resistant to common remedies. Diagnosis of MPD is usually accomplished by a punch biopsy, but imprint cytology is found to be an effective modern technique yet less explored. Cytological diagnosis is advantageous over surgical excisional biopsy; advantages being easy practicability, cost-effective, quick non-invasive, and above all can lead the physician for breast-preserving surgeries in selective cases rather than more aggressive standard mastectomies. We report one such case of MPD in a 52-year-old female diagnosed on imprint cytology with the aim to emphasize that imprint cytology can be a better option to improve the treatment protocol.

Breast Cancer: A Global Concern, Diagnostic and Therapeutic Perspectives, Mechanistic Targets in Drug Development

Cancer is a complex multifactorial process, unchecked and abrupt division, and cell growth—conventional chemotherapy, along with radiotherapy, is used to treat breast cancer. Due to reduce efficacy and less survival rate, there is a particular need for the discovery of new active anticancer agents. Natural resources such as terrestrial/marine plants or organisms are a promising source for the generation of new therapeutics with improving efficacy. The screening of natural plant extracts and fractions, isolations of phytochemicals, and mechanistic study of those potential compounds play a remarkable role in the development of new therapeutic drugs with increased efficacy. Cancer is a multistage disease with complex signaling cascades. The initial study of screening whole extracts or fractions and later the isolation of secondary compounds and their mechanism of action study gives a clue of potential therapeutic agents for future drug development. The phytochemicals present in extracts/fractions produce remarkable effects due to synergistically targeting multiple signals. In this review, the molecular targets of extracts/ fractions and isolated compounds highlighted. The therapeutic agent's mechanistic targets in drug development focused involves; i) Induction of Apoptosis, ii) modulating cell cycle arrest, iii) Inhibition or suppression of invasion and metastasis and iv) various other pro-survival signaling pathways. The phytochemicals and their modified analogs identified as future potential candidates for anticancer chemotherapy.

Invasive Paget's Disease of the Breast: Rash or Recurrence?

Paget's disease of the breast is rare among breast cancers. Secondary Paget's disease of the breast presenting as local recurrence is even rarer, with limited published information on the overall prevalence. In this report, we present a case of secondary Paget's disease of the breast presenting as a pruritic rash and skin changes with normal imaging. This patient's case was unique as her presentation involved invasive Paget's disease of the breast presenting as a local recurrence, with a diffuse rash covering the entirety of the right breast including the nipple-areolar complex, pathology examination showing dermal invasion, and a 20-year time interval between her initial treatment and presentation at our institution. Furthermore, diagnostic mammogram and breast MRI revealed no underlying suspicious findings within the breast tissue. In this case, the patient benefitted from mastectomy with removal of the affected skin, resulting in a clear margin and clinically favorable outcome. The patient did well postoperatively, did not receive any systemic adjuvant treatment, and is now under surveillance. Currently, there is insufficient data on the incidence of diffuse Paget's disease of the breast with dermal invasion. It is important to recognize this atypical presentation to ensure timely diagnosis and treatment of affected patients.

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

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.

Magnetic resonance imaging in the evaluation of pathologic nipple discharge: indications and imaging findings

Pathologic nipple discharge (PND) is typically unilateral, spontaneous, involves a single duct, and is serous or bloody in appearance. In patients with PND, breast MRI can be helpful as an additional diagnostic tool when conventional imaging with mammogram and ultrasound are negative. MRI is able to detect the etiology of nipple discharge in 56-61% of cases when initial imaging with mammogram and ultrasound are negative. Advantages to using MRI in evaluation of PND include good visualization of the retroareolar breast and better evaluation of posterior lesions which may not be well evaluated on mammograms and galactograms. It is also less invasive compared to central duct excision. Papillomas and nipple adenomas are benign breast masses that can cause PND and are well visualized on MRI. Ductal ectasia, and infectious etiologies such as mastitis, abscess, and fistulas are additional benign causes of PND that are well evaluated with MRI. MRI is also excellent for evaluation of malignant causes of PND including Paget's disease, ductal carcinoma in-situ and invasive carcinoma. MRI's high negative predictive value of 87-98.2% is helpful in excluding malignant etiologies of PND.

Prevalence of mammary Paget's disease in urban China in 2016

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.

Immunohistochemistry of mammary Paget's disease. Cytokeratin 7, GATA3, and HER2 are sensitive markers

OBJECTIVES

To investigate the expression of various immunohistochemical markers in Mammary Paget's disease (MPD) and MPD-associated breast carcinoma and to evaluate their value in establishing the diagnosis.

METHODS

This retrospective descriptive study was carried out at King Faisal Specialist Hospital and Research Center and King Khalid University Hospital, Riyadh, Saudi Arabia. All MPD cases reported between January 2010 and June 2016 were selected from the surgical pathology records.  Immunohistochemical staining was carried out for cytokeratin 7 (CK7), GATA-binding protein 3 (GATA3), human epidermal growth factor receptor 2 (HER2), and estrogen, and progesterone receptors. Results: Twenty-two cases of MPD and 20 cases of MPD-associated breast carcinoma were included. CK7 was positive in 95% (21/22) cases of MPD and in all (20/20) cases of associated breast carcinoma. Similarly, GATA3 was expressed in 95% cases of both MPD (21/22) and associated breast carcinoma (19/20). Human epidermal growth factor receptor 2 was also overexpressed in 90% cases of MPD (20/22) and associated breast carcinoma (18/20). Estrogen stained positive in 27% cases of MPD (6/22) and 30% of cases of associated breast carcinoma (6/20). Progesterone receptors was not positive in any case of MPD; however, it was seen positive in 25% cases of MPD-associated breast carcinoma (5/20).

CONCLUSIONS

CK7, GATA3, and HER2 are widely expressed in MPD and MPD-associated breast carcinoma. These markers can be used for the immunohistochemical confirmation of MPD including CK7-negative cases.

Paget Disease of the Breast in Pregnancy and Lactation

Paget's disease of the breast (PDB) is a rare breast carcinoma believed to arise from an underlying in situ or invasive ductal cancer that migrates through the epidermis causing characteristic skin changes including scaling, redness, and itching of the nipple, areola, and sometimes the surrounding skin. Although Paget's may mimic benign conditions such as contact or allergic eczema and mastitis, it should remain a strong consideration in the differential diagnosis , especially in peripartum women for whom benign conditions such as bacterial mastitis from breastfeeding are common. The workup of Paget's should focus on both making the diagnosis with nipple/skin scrape cytology or punch biopsy as well as evaluating any underlying mass with mammogram, breast ultrasound , and also a core needle biopsy , if required. Treatment focuses on management of the underlying breast cancer as usual. The purpose of this chapter is to describe the presentation of PDB as well as outline an approach to its diagnosis and management, especially in the setting of pregnancy and lactation.

Case for diagnosis. Phagedenic ulcer on the thorax

Paget's disease is a rare disorder of the nipple and/or the areola that is characterized by an erythematosquamous lesion and is often associated with in situ or invasive breast carcinoma. The authors present an atypical, exuberant case that had evolved over eight years, emphasizing the importance of early diagnosis.

Biased Sampling and Causal Estimation of Health-Related Information: Laboratory-Based Experimental Research

Background

The internet is a relevant source of health-related information. The huge amount of information available on the internet forces users to engage in an active process of information selection. Previous research conducted in the field of experimental psychology showed that information selection itself may promote the development of erroneous beliefs, even if the information collected does not.

Objective

The aim of this study was to assess the relationship between information searching strategy (ie, which cues are used to guide information retrieval) and causal inferences about health while controlling for the effect of additional information features.

Methods

We adapted a standard laboratory task that has previously been used in research on contingency learning to mimic an information searching situation. Participants (N=193) were asked to gather information to determine whether a fictitious drug caused an allergic reaction. They collected individual pieces of evidence in order to support or reject the causal relationship between the two events by inspecting individual cases in which the drug was or was not used or in which the allergic reaction appeared or not. Thus, one group (cause group, n=105) was allowed to sample information based on the potential cause, whereas a second group (effect group, n=88) was allowed to sample information based on the effect. Although participants could select which medical records they wanted to check—cases in which the medicine was used or not (in the cause group) or cases in which the effect appeared or not (in the effect group)—they all received similar evidence that indicated the absence of a causal link between the drug and the reaction. After observing 40 cases, they estimated the drug–allergic reaction causal relationship.

Results

Participants used different strategies for collecting information. In some cases, participants displayed a biased sampling strategy compatible with positive testing, that is, they required a high proportion of evidence in which the drug was administered (in the cause group) or in which the allergic reaction appeared (in the effect group). Biased strategies produced an overrepresentation of certain pieces of evidence at the detriment of the representation of others, which was associated with the accuracy of causal inferences. Thus, how the information was collected (sampling strategy) demonstrated a significant effect on causal inferences (F_1,185=32.53, P<.001, η^2p=0.15) suggesting that inferences of the causal relationship between events are related to how the information is gathered.

Conclusions

Mistaken beliefs about health may arise from accurate pieces of information partially because of the way in which information is collected. Patient or person autonomy in gathering health information through the internet, for instance, may contribute to the development of false beliefs from accurate pieces of information because search strategies can be biased.

Role of diffusion-weighted imaging in prediction of nipple-areolar complex invasion by breast cancer

THE AIM OF THIS WORK

The aim of this work was to estimate the role of diffusion-weighted imaging (DWI) in predicting malignant invasion of the nipple-areolar complex (NAC) by underlying breast cancer.

MATERIAL AND METHODS

This prospective study included 70 female patients with breast cancer with a mean age of 45.8 years (range: 28-68). DWI of the breast was done for all patients. Apparent diffusion coefficient (ADC) maps were automatically constructed. The mean ADC values of NAC were independently measured by two observers who are experts in breast imaging and correlated with the results of histopathological examinations.

RESULTS

Both observers found a significantly lower ADC value of malignant NAC invasion (n = 18) when compared with free NAC (n = 52), with mean ADC value for malignant NAC invasion was 0.86 ± 0.35 × 10^-3 mm²/s and 0.84 ± 0.08 × 10^-3 mm²/s for observer one and two respectively versus mean ADC value of 1.34 ± 0.25 × 10^-3 mm²/s and 1.4 ± 0.26 × 10^-3 mm²/s for free NAC by observer one and two respectively (P-value =0.001). Observer one found that a cutoff ADC value of 1.05 × 0^-3 mm²/s can predict malignant NAC invasion with 0.975 AUC, 92.8% accuracy, 94.4% sensitivity, and 92.3% specificity. Observer two found that a cutoff ADC value of 0.95 × 10^-3 mm²/s can predict malignant NAC invasion with 0.992 AUC, 95.7% accuracy, 88.9% sensitivity, and 98.1% specificity.

CONCLUSION

DWI can predict malignant NAC invasion in patients with breast cancer.

Epidemiological, clinical and diagnostic profile of breast cancer patients treated at Potchefstroom regional hospital, South Africa, 2012-2018: an open-cohort study

Introduction

Breast cancer is the second most diagnosed cancer worldwide. We aimed to depict the diagnostic approach as well as the epidemiological and clinical profile of patients with breast cancer at Potchefstroom regional hospital, South Africa.

Methods

This descriptive open-cohort study included patients with primary invasive breast cancer, confirmed by histology results and treated at the hospital from 01 January 2012 to 31 December 2018. Data such as demographics, patient history, histology, breast clinical findings, physical mass description and diagnostic investigations were captured from hospital registries and patient files.

Result

One-hundred thirty-eight patients (mean age 56.2 (SD: 14.4) (95% CI 54.6-59.7) years) met inclusion criteria. Most patients were female (98.6%), from African (67.4%) or Caucasian (23.9%) descent. Findings included mostly left-sided breast involvement (51.8%), lesions in the upper-outer quadrant (43.1%), extensions to the skin (25.6%, N = 39), and tumour size of 2 ≤ 5 cm (49.3%), or > 5 cm (39.1%). Most patients (57.9%, N = 135) were categorised as BIRADS-5, with a ductal pattern (89.6%) (p < 0.01). Patients mostly presented in stages II to IV of disease (89.1%; p < 0.05). Late-stage (stages III-IV) at time of diagnosis (n = 84) was significantly associated with mass location (p = 0.006; Cramér's V = 0.280), tumour size (p < 0.001, Cramér's V = 0.239), and skin changes (p = 0.027, Cramér's V = 0.492).

Conclusion

Most patients consulted at a late-stage of the disease, indicating a need for the promotion of breast awareness campaigns, early detection, and timeous referral.

Paget's disease of the nipple in a Her2-positive breast cancer xenograft model

PURPOSE

Paget's disease (PD) of the breast is an uncommon disease of the nipple usually accompanied by an underlying carcinoma, often HER2 + , and accounting for 0.5-5% of all breast cancer. To date, histogenesis of PD of the breast remains controversial, as two theories-transformation and epidermotropic-have been proposed to explain this disease. Currently, animal models recapitulating PD of the nipple have not been described.

METHODS

HER2-enriched DT13 breast cancer cells were injected into the mammary fat pad of NOD scid gamma null (NSG) female mice. Immunohistochemical staining and pathological studies were performed on tumor samples, and diagnosis of PD of the nipple was confirmed by expression of proteins characteristic of Paget cells (epidermal growth factor 2 (HER2), androgen receptor (AR), cytokeratin 7 (CK7), cytokeratin 8/18 (CK8/18), and mucin 1 (MUC1)). In addition, DT13 cells grown in 2D culture and in soft agar assays were sensitive to in vitro treatment with pharmacological inhibitors targeting Her2, adenylyl cyclase, mTOR, and PI3K signaling pathways.

RESULTS

Mice developed tumors and nipple lesions that were detected exclusively on the tumor-bearing mammary fat pad. Tumor cells were positive for proteins characteristic of Paget cells. In vitro, DT13 cells were sensitive to inhibition of Her2, adenylyl cyclase, mTOR, and PI3K signaling pathways.

CONCLUSIONS

Our results suggest that injection of HER2 + DT13 cells into the mammary fat pad of NSG mice recapitulates critical aspects of the pathophysiology of PD of the nipple, supporting the epidermotropic theory as the more likely to explain the histogenesis of this disease.

Squamous Cell Carcinoma Arising within Verruca Vulgaris on the Nipple

Cutaneous squamous cell carcinoma (SCC) is a common form of skin cancer and often appears as a hard, scaly lump that occasionally ulcerates. It is usually associated with cumulative exposure to ultraviolet light, although prior scarring, chronic wounds, exposure to radiation, HPV infection, and immunosuppression are also associated risk factors. Primary SCC of the nipple is very rare and only a few cases have been reported. We present a case of a 49-year-old female with concerns of a right nipple lesion with erythema and pain. She was initially evaluated for Paget's disease with an underlying malignancy and cellulitis, but, after biopsy and investigation, she was found to have a well-differentiated SCC arising from a verruca vulgaris. Current literature does not provide distinct guidelines on management of SCC or its variants on the nipple, and the case was managed based off of SCC at other cutaneous sites as well as other cases of SCC on the nipple.

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.

Sonographic visualization of nipple blood flow can help differentiate Paget disease from benign eczematous nipple lesions

Purpose

Paget disease of the breast is a rare cancer that originates from the nipple–areolar complex. It is often overlooked and misdiagnosed as benign chronic eczema of the nipple. We aimed to retrospectively verify whether blood flow analysis using Doppler sonography was useful for detecting the presence of Paget disease.

Methods

In this retrospective study, 12 patients with pathologically proven unilateral nipple eczematous lesions (seven with Paget disease and five with simple dermatitis) were included. Nipple blood flow signal was observed using Doppler sonography, and the detected blood flow signals were quantified using digitally recorded images. Quantified blood flow ratio and pathologically examined capillary density were evaluated between affected and unaffected nipples. Findings of mammography, grayscale sonography, and contrast-enhanced magnetic resonance imaging (CE-MRI) were reviewed.

Results

In patients with Paget disease, Doppler effects in the affected nipple were more clearly visible than those in the unaffected nipple. These effects were sufficiently visible to identify Paget disease. No obvious effects were observed in the affected and unaffected nipples of simple dermatitis. The quantified blood flow ratio and pathologically examined capillary density were significantly higher for the Paget lesion than those for the non-Paget lesion. The sensitivity of CE-MRI and Doppler sonography was markedly correlated, revealing blood flow changes in the nipple lesions of Paget disease.

Conclusion

Doppler sonography visualized the proliferation of blood vessels in Paget lesions. The visualization of increased nipple blood flow using Doppler sonography is a simple and low-cost method that provides useful data for identifying Paget disease during routine medical care.

Practical consensus recommendatons for Paget's disease in breast cancer

Paget's disease of the breast is a rare type of cancer of the nipple-areola complex and that is often associated with an underlying in situ or invasive carcinoma. Diagnosis and treatment of Paget's disease is controversial. Expert oncologists discuss on the update on the approaches of Paget's disease diagnosis and its treatment options. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Dermoscopy Case of the Month

Mammary Paget's disease is a rare intraepithelial carcinoma of the nipple/areola complex often associated with ductal breast carcinoma. We report a case of a 55-year-old female patient with a classical form of mammary Paget's disease associated ductal ipsilateral breast carcinoma. Dermoscopy of Paget's disease revealed a whitish-pink area with polymorphous vessels organized in irregular nests separated by pale streak-like structures, with peripheral light brown diffuse pigmentation. Dermoscopic features described in this case are in agreement with rare previous reports and may contribute to better differentiation of mammary Paget's disease from clinically similar lesions.

Reflectance confocal microscopy of mammary Paget disease

Mammary Paget disease is the intraepidermal adenocarcinoma of the nipple area which is characterized usually by a well-demarcated eczematous plaque. Reflectance confocal microscopy (RCM), is an in vivo noninvasive diagnostic tool with a high-resolution imaging of the skin, almost comparable to conventional histology. RCM findings of Paget disease are limited in the literature. Most of the reported cases are the extramammary type. In this report, we aimed to evaluate the RCM findings of a non-pigmented mammary Paget disease in a 65 year-old woman.

Paget's Disease of Nipple in Male Breast with Cancer

Carcinoma of the male breast accounts for less than 0.5% of all cases of breast cancer. However, Paget's disease of nipple in male is extremely rare. We report on a case of Paget's disease of nipple with breast cancer in a 51-year-old gentleman. He presented with a ulcerative lesion and lump in the left breast beneath the nipple-areolar region with single mobile ipsilateral central group of axillary nodes. Modified radical mastectomy was performed. On follow up, patient was doing well with no recurrence.

Mammary and extramammary Paget's disease

Paget's disease, described by Sir James Paget in 1874, is classified as mammary and extramammary. The mammary type is rare and often associated with intraductal cancer (93-100% of cases). It is more prevalent in postmenopausal women and it appears as an eczematoid, erythematous, moist or crusted lesion, with or without fine scaling, infiltration and inversion of the nipple. It must be distinguished from erosive adenomatosis of the nipple, cutaneous extension of breast carcinoma, psoriasis, atopic dermatitis, contact dermatitis, chronic eczema, lactiferous ducts ectasia, Bowen's disease, basal cell carcinoma, melanoma and intraductal papilloma. Diagnosis is histological and prognosis and treatment depend on the type of underlying breast cancer. Extramammary Paget's disease is considered an adenocarcinoma originating from the skin or skin appendages in areas with apocrine glands. The primary location is the vulvar area, followed by the perianal region, scrotum, penis and axillae. It starts as an erythematous plaque of indolent growth, with well-defined edges, fine scaling, excoriations, exulcerations and lichenification. In most cases it is not associated with cancer, although there are publications linking it to tumors of the vulva, vagina, cervix and corpus uteri, bladder, ovary, gallbladder, liver, breast, colon and rectum. Differential diagnoses are candidiasis, psoriasis and chronic lichen simplex. Histopathology confirms the diagnosis. Before treatment begins, associated malignancies should be investigated. Surgical excision and micrographic surgery are the best treatment options, although recurrences are frequent.

Spectrum of Imaging Findings in Paget's Disease of the Breast-A Pictorial Review

PURPOSE

We aimed to demonstrate imaging features of Paget's disease of breast, which is an extremely uncommon malignancy that presents with changes in the nipple-areolar region that may or may not be associated with an underlying in situ component or invasive cancer.

METHODS AND RESULTS

Mammography is the initial investigation of choice, having a high sensitivity especially in cases where a palpable mass is present. The addition of ultrasound improves the accuracy of mammography. When both mammography and ultrasound are negative, MRI may detect an underlying mass or ductal carcinoma in situ (DCIS).

CONCLUSION

The surgical management of Paget's disease includes mastectomy with or without axillary dissection, though breast conservation surgery in the form of wide local excision can also be done in a selected group of patients. Management should be based on both clinical and imaging findings, including mammography and ultrasound, with MRI playing a crucial role in defining the extent of involvement. Teaching Points • To differentiate Paget's disease from other chronic skin conditions. • Mammographic and ultrasound findings of histopathologically established Paget's disease. • When ultrasound and mammogram are negative, MRI may detect underlying malignancy.

Challenges in Diagnosis and Management of Paget's Disease of the Breast-a Retrospective Study

Paget's disease of the breast is uncommon and patients may present with nipple discharge, eczema, plaque or nipple destruction with or without a lump. The aim of the present study was to evaluate the presentation, clinicopathological features and treatment given for patients presenting with Paget's disease of the breast. We performed a retrospective analysis of medical records of patients who were treated at our centre for Paget's disease of the breast from 2006-2011. Twenty patients were treated in this period. Twelve patients had associated lump and eight patients did not have a lump in the breast. Two patients did not have a lump or any detected abnormality in mammography. Multicentricity was present in five patients. Diagnosis of malignancy was made by fine-needle aspiration cytology for patients with palpable lump and nipple wedge biopsy for patients with no lump. Modified radical mastectomy was done in 10 patients: 2 patients underwent total mastectomy and sentinel lymph node biopsy and 8 patients underwent central quadrantectomy and sentinel lymph node biopsy. Eleven patients had invasive ductal carcinoma, one patient had ductal carcinoma in situ with foci of invasion and eight patients had ductal carcinoma in situ. Seven patients had lymph node metastases. Three patients had recurrence, one had local recurrence and two had distant recurrences. The mean follow up period was 28 months (range 15-64 months). Paget's disease of the breast is a rare entity and one needs imaging and biopsy to diagnose these patients as they have associated cancer. They can be considered for breast conservation surgery with good cosmetic and oncological results.