Breast—Paget’s Disease
Concept
Malignant cells that have migrated from underlying DCIS or invasive cancer. Paget’s cells are identified in the epider- mis. May regress with topical steroids, so don’t prescribe them. Bilateral eczematous changes to the nipple areolar complex (NAC) are likely benign.
Way Question May be Asked?
“43 y/o female presents to your office with a 4 week history of itching to her left nipple. Examination reveals a red- dened eczematous L NAC and a 1.5 cm mass in the upper outer quadrant approximately 4 cm from the NAC margin.
What would you do?” May or may not be associated mass, but always do PE/mammogram/U/S.
How to Answer?
History
Establish risk factors for breast cancer (menarche, breast-feeding, family history, number of children, previous breast cancer, etc.)
Physical Exam
Try to palpate a mass Check both breasts!
Examine for cervical/axillary adenopathy
How to Answer?
Need to order bilateral mammograms Now, a couple of situations possible:
(1) No palpable mass, no lesions on
mammography →wedge resection of NAC, check
pathology, if Paget’s cells identified, proceed to simple mastectomy (if CA in mastectomy specimen →don’t forget ALND!)
(2) Palpable mass or lesion on mammogram → wedge resection of NAC and excisional biopsy of mass, if Paget’s cells identified and mass is invasive cancer, then MRM
(3) Palpable mass or lesion on mammogram → wedge resection of NAC and excisional biopsy of mass, if Paget’s cells identified and mass is DCIS, then sim- ple mastectomy
Don’t forget radiation/chemotherapy/hormonal ther- apy when appropriate for DCIS or underlying inva- sive cancer
Common Curveballs
There will be a palpable mass
There will be a mammographically detected lesion There will be lesion in opposite breast
Pt will have recurrence after mastectomy to chest wall or incision site (changing scenario)
Strikeouts
Forgetting to order mammograms
Forgetting post-op chemo/XRT treatment when appropriate
Forgetting ALND if invasive cancer identified
Forgetting to obtain usual history/physical exam (estab- lish risk factors, checking masses in both breasts) Forgetting to examine both breasts/axillae
Treating nipple with steroids (Paget’s can remit on steroids)
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