Paget's disease of the breast: Presentation, treatment, and outcomes in a modern cohort

BACKGROUND

Surgical management for Paget's disease (PD) of the breast is controversial. This study aims to assess outcomes of PD patients based on procedure type and determine the reliability of imaging in estimating disease extent.

METHODS

A retrospective review analyzed clinicopathologic data of PD patients between 2009 and 2022. Pre-operative imaging size (PIS) was compared to post-operative pathology size (PPS) looking at concordance.

RESULTS

Thirty patients had PD, 21 underwent total mastectomy (TM) and 9 breast conserving surgery (BCS). Seventeen patients (56.7 ​%) had a final diagnosis of invasive cancer (14 ​TM, 3 BCS), with no local recurrences. Only 6/19 (31.6 ​%) patients with positive findings on ultrasound/mammogram had concordance between PIS and PPS. There were no breast/chest wall recurrences with a median follow up of 35.9 months.

CONCLUSION

Ultrasound and mammogram had poor concordance with pathological size. BCS is feasible in select patients. MRI may help guide management.

[A Case of Invasive Ductal Carcinoma with Paget's Disease of the Breast]

Paget's disease of the breast is usually localized in the nipple epidermis and lactiferous duct located near the nipple. Here, we report a rare case of synchronous breast carcinoma with Paget's disease and invasive ductal carcinoma. A 50-year-old woman was admitted to our hospital because of abnormalities in screening mammography findings. Ultrasonography(US) findings showed a 2.4×1.3×1.6 cm sized hypoechoic lesion in a region of the left mammary gland. Computed tomography (CT)findings did not reveal distant metastasis. Magnetic resonance imaging(MRI)revealed an approximately 2.2 cm sized irregular tumor. The pretreatment diagnosis was left non-invasive ductal carcinoma(cTisN0M0, Stage 0), and surgery was performed. The tumor was found in the range of 40.2×15.0 mm, many of which were breast ductal growth. An infiltrated image was confirmed at multiple sites, but the maximum size was 2.5×1.5 mm. Pathological findings of the main lesion revealed papillotubular carcinoma. Agglomeration of heterotypic cells with abundant cytoplasm was observed in the epidermis of the papilla. The final diagnosis was invasive breast cancer(pT1aN3M0, Stage Ⅲc, Luminal HER2)coexisting with Paget's disease.

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.

[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.

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 of the breast: Clinical, mammographic, sonographic and pathologic findings in 52 cases

PURPOSE

To determine and quantitate radiologic characteristics of Paget's disease of the breast and to report clinical and pathologic findings.

MATERIALS AND METHODS

A retrospective review of records of 2872 women who received a diagnosis of breast carcinoma between January 1988 and January 2006 revealed 52 histologically proved Paget's disease of the breast. Analysis included history, findings at physical examination, mammography and sonography (US) and histologic type of Paget's disease.

RESULTS

At physical examination, palpable mass (n=33, 63%), nipple erythema-eczema-ulceration (n=17, 33%) and blood-stained nipple discharge (n=5, 10%) were noted. Among 17 patients who had clinically evident Paget's disease, the mammographic findings were isolated microcalcifications in 3 (18%), mass associated with microcalcifications in 5 (29%), mass in 2 (12%) and negative in 7 (41%) patients. In the 35 patients with clinically inevident Paget's disease, these mammographic findings were 43% (n=15), 34% (n=12), 20% (n=7) and 3% (n=1), respectively. US depicted 43 masses in 35 patients, all of which were lobulated or irregularly contoured, mostly (n=41, 95%) without posterior acoustic shadowing. The cancer was clinically occult in 10% (n=5), mammographically occult in 15% (n=8) and radiologically occult in 13% (n=7) of the 52 patients. Histologically, the tumor was multifocal and/or multicentric in 11 (21%) patients.

CONCLUSION

The clinical features of Paget's disease are characteristic and should alert the clinician to the likelihood of an underlying carcinoma, which should be evaluated radiologically. However, as Paget's disease is primarily a clinical diagnosis and mammograms may be negative, screening programs without clinical examination may result with delay in diagnosis. As a result, both clinical and imaging findings are complementary and should be correlated to confirm or exclude a diagnosis of Paget's disease.

Paget's disease of the nipple diagnosed by MRI

BACKGROUND

Paget's disease of the breast is a rare manifestation of breast carcinoma.

CASE REPORT

The patient presented with a red lesion of the left nipple-areola complex. Breast physical examination, ultrasonography and mammography were normal bilaterally. Magnetic resonance imaging (MRI) correctly depicted Paget's disease of the nipple. Before surgery the patient underwent biopsy of the lesion that showed Paget's disease of the breast associated with an underlying ductal carcinoma in situ. The patient underwent left mastectomy and unilateral axillary lymph node dissection. The patient refused the breast-conserving surgery because she was afraid that she could have a recurrence of the carcinoma. Microscopy of the lesion confirmed the MRI diagnosis.

CONCLUSION

MRI was very useful and accurate to diagnose Paget's disease of the breast without palpable mass, ultrasonographic and mammographic findings.

[Is mammography useful in Paget's disease of the breast?]

PURPOSE

Interest of the mammogram in Paget's disease of the breast, especially for a therapeutic decision in otherwise asymptomatic women with Paget's disease, who would be candidates for conservative treatment.

MATERIALS AND METHODS

61 women with histological Paget's disease of the nipple, treated by mastectomy, were retrospectively analyzed with clinical, radiological and pathological correlations.

RESULTS

An underlying carcinoma was found in 60 cases (98.4%), atypical epithelial hyperplasia in one. In the 24 women without breast palpable mass, 17 (71%) had a normal mammogram, 12 (50%) had carcinoma with an invasive component, 14 (58%) had a cancer at a distance from the nipple, 17 (71%) had a multifocal carcinoma. All 37 women with a palpable mass had a pathological mammogram, 36 of them had carcinoma with an invasive component, 35 (95%) a cancer at a distance from the nipple, 31 (84%) a multifocal carcinoma.

CONCLUSION

Mammogram is of limited value in management of Paget's disease of the breast for women without breast palpable mass; it can not predict the site of malignancy, nor the invasive component.

99mTc-MIBI scan in mammary Pagets disease: a case report

Technetium-99m methoxyisobutylisonitrile (99mTc-MIBI) uptake is known to be increased in breast cancer because of increased blood flow from angiogenesis and heightened metabolism. We performed a 99mTc-MIBI scan in a patient with mammary Paget's disease. The patient had underlying invasive cancer in the same side of the breast. 99mTc-MIBI scan exhibited a scintigraphic image of the uptake from the invasive cancer lesion located deeply in the breast toward the epidermis. 99mTc-MIBI showed an uptake in the deeply located invasive cancer lesion as well as nipple lesion. Especially, the delayed phase of Tc-MIBI scan demonstrated the tumor site more accurately. In conclusion, 99mTc-MIBI scan could be a useful adjunct to clinical decision making in the management of Paget's disease of the breast.

99m Tc MIBI prone scintimammography in breast Paget's disease: a case report

A 99m Tc MIBI prone scintimammography (PSM) was performed in a case of underlying Paget's disease of the breast. 99m Tc MIBI PSM showed a diffuse scintigraphic image like a spread of uptake from the deeply located zones of the breast toward epidermis. In vivo, 99m Tc MIBI PSM represents the spread of neoplastic Paget's cells probably attracted by chemotactic factors released by keratinocytes. This spread in Paget's disease is correlated to neu oncogene overexpression which increases the metastatic activity as a consequence of motility enhancement and growth stimulation effect. These scintigraphic images suggest that 99m Tc MIBI PSM could be relevant in management of Paget's disease of the breast.

F-18-FDG uptake in tuberculosis

Two patients are described who showed abnormal fluorine-18 fluorodeoxyglucose (F-18 FDG) uptake that was due to benign disease, specifically tuberculous lymphadenitis and pneumonitis. The first patient had ulceration and oozing of the left nipple that was related to Paget's disease. An F-18 FDG PET, whole-body scan, which was performed for staging, showed no breast uptake. However, there was intense multifocal uptake in mediastinal, supraclavicular, and para-aortic areas that was confirmed radiologically to represent widespread lymphadenopathy. Pathologic examination of a mediastinal lymph node showed active tuberculosis. The second patient showed intense focal F-18 FDG uptake in mediastinal and supraclavicular areas and para-aortic lymphadenopathy due to non-Hodgkin's lymphoma. In addition, there was abnormal F-18 FDG lung uptake that revealed the presence of acid-fast bacilli on bronchial lavage. Intense focal F-18 FDG uptake in widespread lymphadenopathy or in the lung could be caused by infectious diseases such as tuberculosis. This possibility should be considered when whole-body scans of patients with cancer are interpreted, especially in those with a high incidence of infectious disease.

Paget disease of the breast: a pictorial essay

Paget disease of the breast accounts for approximately 2%-3% of breast cancers. It is characterized by infiltration of the nipple epidermis by adenocarcinoma cells, which cause an eczematous eruption on the nipple and areola. The clinical features are highly suggestive of the disease; awareness of these on the part of the clinician should lead to more prompt diagnosis and earlier initiation of appropriate treatment. Mammograms, although not always positive, should be obtained in all cases suggestive of Paget disease to search for the underlying tumor and direct further treatment. Findings that may be seen at mammography include skin thickening, nipple retraction, subareolar or more diffuse malignant microcalcifications, and a discrete mass or masses. However, a negative mammogram should not alter the course of treatment. Conversely, identification of subareolar mammographic findings should alert the clinician to search for physical signs in the nipple and areolar region suggestive of Paget disease.

Breast MR and the appearance of the normal and abnormal nipple

AIM

To identify the magnetic resonance (MR) morphological and enhancement characteristics of the normal and diseased nipple.

MATERIALS AND METHODS

The MR appearances of the nipple in 35 patients with known primary breast cancer who went on to mastectomy was reviewed by two radiologists (blinded to the clinical, mammographic and histopathological information) and correlated with histology. The appearance of the contra-lateral nipple in 31 patients was reviewed and compared with that of the affected side. MR was performed at 1.0T using a receive-only double breast coil in 33 patients and a single breast coil in two patients. Three dimensional (3-D) T1-weighted gradient-echo images were made before and immediately after a fast hand injection of gadolinium-DTPA (0.1 mmol/kg).

RESULTS

Twenty-six breasts had histopathologically normal nipples and retroareolar tissue, four had evidence of tumour within the nipple and four had retroareolar tumour but with nipple sparing. Fifteen normal nipples were everted and 11 were inverted (flat). All showed superficial linear dermal enhancement above a non-enhancing zone in the nipple areolar complex. Linear or patchy enhancement deep to the non-enhancing zone was seen in four breasts and linear enhancement through the non-enhancing zone was seen in two. The nipple in all four breasts with tumour involvement showed increased thickening/bulkiness and enhancement of the nipple-areolar complex and retroareolar tissue. The four breasts with retroareolar tumour and nipple sparing showed increased thickening and enhancement of the retroareolar tissue only. There was one false positive result on breast MR for retroareolar tumour involvement. In this case the abnormally enhancing retroareolar tissue adjacent to the focal mass was shown to be an area of sclerosing adenosis on histology. The 31 contra-lateral nipples had the characteristic 'normal' appearance and when compared with its normal ipsilateral nipple showed marked symmetry. When compared with its abnormal ipsilateral nipple showed marked asymmetry.

CONCLUSION

MR of the breast can show nipple involvement even when clinically unsuspected. This is important for treatment planning of breast cancer, in particular nipple preserving surgery.

Underlying pathology in mammary Paget's disease

BACKGROUND

Management of patients with mammary Paget's disease is controversial; recent recommendations range from primary radiotherapy to modified radical mastectomy. This review correlates associated breast findings with disease stage and outcome to help guide evaluation and treatment.

METHODS

Retrospective review of clinical, mammographic and pathologic data from 38 women with mammary Paget's disease treated between 1979 and 1995 was performed. Mastectomies were performed on all but two patients with the entire breast and lymph nodes evaluated for histopathologic evidence of carcinoma.

RESULTS

Underlying carcinoma (ductal carcinoma in situ and/or invasive ductal cancer) was found in most patients (92%) even when no palpable mass was evident (85%); this carcinoma is often multifocal (73%). Mammography fails to identify the underlying disease in many patients with no palpable mass and multifocal underlying disease (64%). Patients with Paget's disease and a palpable mass have a much greater incidence of invasive cancer, multifocal lesions, and positive lymph nodes, and have worse survival.

CONCLUSIONS

Although some patients with Paget's disease might be well treated by breast conservation therapy, many patients have underlying multifocal carcinoma (including invasive cancer), which can be inapparent by examination and mammography. Selecting candidates with disease amenable to complete excision without mastectomy is problematic.

Is ipsilateral mammography worthwhile in Paget's disease of the breast?

AIMS

To identify the clinical value of pre-operative ipsilateral mammography in patients with Paget's disease of the breast.

METHOD

The mammograms and histological data of 27 patients with Paget's disease and 60 patients with symptomatic DCIS without Paget's disease were reviewed and compared.

RESULTS

Forty-four percent of patients with Paget's disease had normal mammograms. Mammography did not discriminate between DCIS and invasive disease, and could not predict DCIS sub-type. DCIS was large cell in 80% of patients with Paget's disease. Given that large cell DCIS in non Paget's patients is normally visible mammographically, the large proportion of Paget's patients with normal mammography is difficult to explain, but could be due to the small size of the lesions. Comparison of the Paget's and non-Paget's groups showed that large cell solid disease was more common, small cell cribriform less common and normal mammography more common in the Paget's group. Given that mastectomy is the treatment of choice, the only clinical value of ipsilateral mammography in our unit would be to allow image guided core biopsy of any detected mammographic abnormalities to determine the presence of invasive disease prior to surgery, thus indicating the need for node sampling pre-operatively rather than as a delayed procedure. This study also confirms that mammography is of little help in deciding if breast conserving surgery is appropriate for individual cases of Paget's disease of the nipple due to the insensitivity of mammography in showing the site of disease.

Paget's disease of the breast: what the radiologist may expect to find

Paget's disease of the nipple is characterized by the presence of Paget's cells in the epidermis of the nipple or areola. Two case reports of Paget's disease are described and used to highlight unusual features of the disease. The literature on the radiographic and pathologic findings of this disease is reviewed.

[Diagnosis of the breast tumor entity with "vocal fremitus" in ultrasound diagnosis]

In the published study a totally new method for the diagnosis of malign and benign tumors of the female breast is presented. During sonographic examinations with the maximum entropy method we found out, purely by chance, that artifacts produced by vibrations of the thorax can be used to differentiate malignant from benign lesions. These artifacts in form of small colour pixels can be provoked by the vocal fremitus of the internal medicine or by humming a deep sound. In case of malignancy, the colour artifacts are visible inside of the tumor, in benign lesions, however, only in the surrounding tissue. On the preoperative day, 95 patients were examined with the method described above. In 91% of the cases the diagnosis of the dignity corresponded with the histological results. Seven times a benign lesion was classified as a malignant tumor and twice malignancy was not correctly diagnosed. Our explanation of these phenomena is the following: Benign lesions of the female breast show a displacing growth and a definable boundary. Thus the vibrations are damped and not conducted into the tumor. In contrast, malignant lesions grow invasively into the surrounding tissue. Consequently, the vibrations can be conducted into the center of the tumor by this dissemination.

Mammographic appearances in Paget's disease of the breast

The mammographic appearances in 17 patients with Paget's disease of the breast were retrospectively reviewed. Appearances were normal in only five cases. Microcalcification was present in 10 including one where it encircled the nipple. A radiologically-visible tumour was seen in nine breasts with carcinoma being diagnosed in a further three by the pattern of calcification alone. Multifocal tumours were present in four breasts but no lymphadenopathy or contralateral tumours were seen. Despite high quality radiography a tumour was only detected in 71% of cases of Paget's disease and radiographers should be trained to recognize the condition clinically. Patients without a visible tumour may be suitable for radiotherapy.

Paget disease of the nipple: radiologic-pathologic correlation

PURPOSE

To correlate the range of clinical presentations with mammographic and histologic findings in patients with Paget disease of the nipple.

MATERIALS AND METHODS

The clinical, pathologic, and mammographic records of 58 patients who had biopsy-proved Paget disease of the nipple were retrospectively reviewed. The results of two previous studies were also included.

RESULTS

Among 34 patients who had typical findings of Paget disease, the mammograms of 17 (50%) showed normal findings, those of 10 (29%) showed nipple, areolar, or subareolar abnormalities, and those of seven (21%) showed evidence of masses or calcifications. Of the mammograms of 24 women with Paget disease but without clinical findings, 19 (79%) showed evidence of suspicious masses or calcifications, four (17%) showed nipple or areolar abnormalities, and one was negative.

CONCLUSION

Nonspecific findings of nipple-areolar complex thickening should be correlated with findings at breast physical examination to confirm or exclude Paget disease.

Paget's disease of the nipple without clinically and radiologically detectable breast tumor. Histochemical and immunohistochemical study of 44 cases

Paget's disease of the nipple is a rare lesion nearly always associated with an underlying breast cancer, clinically impalpable and radiologically undetectable in about 40% of the patients. Fourty-four cases (28 mastectomies and 16 biopsies of the nipple) of Paget's disease of the nipple without clinically and radiologically detectable breast tumor were retrospectively studied by means of histochemistry and immunohistochemistry. Histochemical study showed that Paget cells were PAS positive and diastase resistant, and alcian blue positive at pH 2.5 in 32% and 18%, respectively. Immunohistochemical study showed that Paget cells were EMA and c-erbB-2 positive in 100% and 84%, respectively. Four of the six EMA positive and c-erbB-2 negative cases of Paget's disease of the nipple in which the underlying tumor could be pathologically analyzed were associated with ductal carcinoma in situ of cribriform or mixed types. These findings are helpful for differentiating Paget's disease from other lesions of the nipple, namely Bowen's disease and eczema which do not react with both antibodies, and from nipple adenoma which exhibits a positive staining with anti-EMA antibody and no reactivity with anti-c-erbB-2 antibody.

Mammography in the symptomatic woman

This is a statistical analysis of the use of mammography in the symptomatic patient. Eighty-eight percent of women older than 50 years who had a palpable cancer of the breast had a positive mammogram; only 57% of women younger than 51 years of age had a positive mammogram. When the cancer presented as nipple discharge or Paget's disease without a mass, mammography was of no help in determining the need for surgery. One synchronous cancer per 100 patients, in the contralateral breast, was detected by mammography only. Eleven percent of the patients, who had a previous cancer of the breast and were followed for a maximum 11 years, developed cancer of the contralateral breast; 50% of the metachronous cancers were found by mammography only. In 1000 symptomatic patients without an indication for biopsy on physical examination, five cancers were found on mammography. Mammography uncommonly demonstrates unsuspected cancer in the symptomatic patient. Its greatest value is in finding metachronous cancers.

The diagnostic value of xero-mammography in clinically occult breast carcinoma

Seventy-four clinically occult breast carcinomas were detected in 7535 patients who were examined clinically and by xeromammography. The criteria by which a diagnosis of clinically occult breast carcinoma was established are described in detail. The most frequent finding of a clinically occult breast carcinoma in the xeromammogram was an irregular mass density 1 cm in diameter or less with microcalcifications. Axillary lymph node metastases were present in 29.7% of the total group of patients, which is much fewer than what might have been expected if the carcinomas had been discovered by palpation during the clinical examination or by the patient herself. This means a better prognosis and a lower death rate from breast carcinoma. Screening xeromammography is encouraged for all women after the age of 40, especially for those who belong to the high-risk group, even though they are quite asymptomatic, as there is hope of detecting cancers before they become palpable.

Diagnostic error in breast disease

Fifty-six breast biopsies, incorrectly assessed by preoperative clinical or mammographic examination, were reviewed to define the characteristics in the tumor or patient that caused the clinician and mammographer to be diagnostically inaccurate. The most important patient characteristic associated with error was the use of hormones. Failure to recognize that oral contraceptive use significantly reduces the incidience of benign breast disease contributed to the frequent misdiagnosis of lesions in those patients. Twelve of 16 masses in oral contraceptive users were malignant. In seven, their resemblance to cysts or fibroadenomas resulted in treatment delay of two weeks or 18 months. Because benign disease is uncommon in women who have used contraceptives two or more years, all new lesions in those women should be studied by biopsy promptly. Neither clinical nor mammographic evaluation of lesions in postmenopausal women who used estrogens was accurate. Twelve postmenopausal patients with carcinoma had used estrogens. Three of these lesions were considered benign clinically and four, by mammogram. In one, treatment was delayed four years. In women over 50 not using hormones, clinical diagnosis of malignancy was accurate. Ten carcinomas in those women were missed by mammogram. Eight had negative nodes; thus a negative mamogram when the clinical diagnosis is correct may be an effective guide in predicting the status of axillary nodes. Paget's disease was not recognized clinically in two of eight patients with that disease, and an additional two were not recognized on mammography. The initial examiner did not identify three of six inflammatory carcinomas. Ten percent of benign lesions were intraductal hyperplasia or papillomatosis with atypia and were the benign lesions most often misdiagnosed clinically and by mammogram. No microscopic lesions were noted on mammography without an associated palpable mass. Twenty-five per cent of the lesions in women aged 40-49 were incorrectly assessed by mammography or clinical examination. Four (15%) of the 27 carcinomas in this age group were not recognized by either modality. Mammography helped delineate the characteristics of masses in premenopausal women. With recognition that any mass that appears in a woman using oral contraceptives must be studied by biopsy, combined clinical and mammographic study in primenopausal women should minimize diagnostic error. Unfortunately, neither clinical nor mammographic evaluation of the women with irregular periods approaching menopause or within three years past menopause is accurate. It is in that age group that new diagnostic modalities are needed and when reported their efficacy in that age group should be stressed.