乳腺导管扩张症

目的　探讨乳腺导管扩张症的诊断和治疗。方法　对７６ 例乳腺导管扩张症的临床资料进行回顾性分析。结果　该病主要临床表现为乳房肿块（３１ 例,４０．７８ ％ ） ,脓肿（２４ 例,３１．５８ ％ ） ,乳头内陷（５２ 例,６８．４２ ％ ） ,乳头溢液（２１ 例,２７．６３ ％ ） ,乳瘘（２１ 例,２７．６３ ％ ） 。术前误诊率５５．２６ ％ （４２／７６） ,其中２０ 例（２６．３２ ％ ） 误诊为乳癌。本组均经手术治疗,治愈率为９２．１１ ％ （７０／７６） 。结论　乳腺导管扩张症易误诊,术中病理检查是确诊的可靠方法;彻底切除或切开病变的乳管是手术成功的关键。     

Does Nipple Discharge Color Predict (pre‐) Malignant Breast Pathology?

Unilateral single‐duct nipple discharge is associated with an increased risk for underlying breast malignancy. There is no consensus whether color of nipple discharge independently indicates the risk of malignancy. We sought to assess the relationship between the color of discharge and the risk of malignancy. Patients with unilateral single‐duct nipple discharge without abnormalities on clinical and radiologic examination were included. Prior to diagnostic microdochectomy nipple discharge characteristics were registered. Multiple logistic regressions were performed to assess the relationship between color of nipple discharge and malignancy, corrected for age. During a mean follow‐up period of 7.1 years we determined complication rate and false‐negative rate of microdochectomy. A total of 184 patients were included (median age 53 years, range 19–84). Histologic examination revealed (in situ or invasive) breast carcinoma in 10.9% (20) of patients and high‐risk lesions in 11.4% (21). Malignancy or high‐risk lesions were found in 25% (OR: 1.37; 95% CI: 0.62–3.00) of patients with bloody discharge. Risk of underlying malignancy increased in patients >60 years (OR: 2.35; 95% CI: 1.14–4.83). Complication rate of microdochectomy was 2.7%. Single‐duct, unilateral nipple discharge is a sign of underlying malignancy in a substantial proportion of cases. The majority of patients with unilateral single‐duct nipple discharge, diagnosed with breast cancer, present with bloody discharge. However, the association between bloody nipple discharge and malignancy is not strong enough to distinguish high‐risk patients. Therefore, invasive diagnostic procedures like microdochectomy should be offered to all patients with unilateral uniductal nipple discharge to search for underlying malignancy.     

Periareolar abscess in the nonlactating breast

Periareolar abscesses in nonlactating women are usually accompanied by a sinus tract that communicates with the nipple. This abnormal tract represents the source of the initial invasive infection and, if left unattended, may be the nidus for recurrence. The medical records of 32 patients with periareolar abscess treated at Temple University Hospital from January 1970 through January 1980 were reviewed. Follow-up data were obtained recently for 21 patients, including 1 patient with bilateral disease. Several patients also had an inverted nipple. Nineteen patients denied recurrence after our initial treatment and two required a secondary procedure for cure. Only one patient was dissatisfied with the postoperative appearance of the surgical site. None required partial or simple mastectomy for cure, as reported elsewhere. Excision of the sinus tract and, when present, correction of the inverted nipple as herein described are necessary to prevent reinfection. Simple abscess excision or incision and drainage is usually inadequate therapy.     

Mammotome微创旋切系统治疗乳腺脓肿：附53例报告

目的探讨Mammotome微创旋切系统治疗乳腺脓肿的可行性及其临床应用价值。方法2004年1月—2007年1月在超声引导下应用Mammotome微创旋切系统治疗乳腺脓肿53例。乳房上取适当隐蔽小切口;超声引导Mammotome微创旋切系统抽吸脓汁,切除脓肿壁,留置引流管冲洗;乳头内陷行二期矫形术。结果53例乳腺脓肿均得到临床治愈。穿刺切口0.3 cm;平均手术时间47.3mim。手术损伤小,病程短,乳腺外形满意。常规病理检查符合临床诊断。Ⅰ期愈合48例,5例乳头部分表层结痂,经保守治疗于2周后痊愈。随访1~22个月,临床及B超复查均未发现复发。结论Mammotome微创旋切系统治疗乳腺脓肿特点明显,手术安全、可靠,乳房无瘢痕、不变形,为二期乳头矫形提供条件,具有较好的美容效果。     

Predictors of outcomes in managing breast abscesses—A large retrospective single‐center analysis

We have retrospectively examined a wide range of clinical characteristics, sonographic features, microbiology, and antibiotic regimens in patients with breast abscesses to seek predictive features related to outcome. Because consensus for optimal treatment of breast abscesses has moved toward minimally invasive management using single or repeated needle aspiration (ASP) coupled with adjuvant antibiotics, we assessed whether any factors correlate with the need for repeat procedures by analyzing the number of ASPs and/or surgical incision and drainage (I&D) per abscess. We examined 127 abscesses in 114 patients from a single urban public hospital, and among clinical characteristics, we found that only smoking history (P = .021) and the presence of nipple rings (P = .005) were associated with greater likelihood of necessitating repeat for abscess resolution procedures. Neither diabetes, lactational status, and HIV nor ultrasound features imaging of an abscess including size >3 cm, multiloculation, rind thickness, or central vs peripheral location were correlated with the need for a repeat procedure. Likewise, no specific micro‐organisms predicted a greater likelihood of requiring repeat procedures, and no specific initial antibiotic regimen (gram‐positive and/or gram‐negative or multiresistance coverage) impacted clinical outcomes. Our data indicate that no specific imaging abscess characteristics, type of micro‐organism, or initial choice of antibiotics affect outcomes, and therefore, these features should not preclude attempts at conventional therapy by repeated aspiration and antibiotic treatment. While a smoking history and presence of a nipple ring may increase the risk of a prolonged course, the decision to change antibiotics or repeat aspiration should rely instead on clinical evaluation and judgment by experienced physicians.     

Clinical abnormalities of the nipple-areola complex: The role of imaging

Clinical examination of the nipple is part of normal breast screening procedures. Abnormal processes of benign or malignant nature may be reflected by erythema, erosion, swelling or acquired inversion. In patients presenting with a persistent unilateral nipple lesion, it is advisable to collect a sample to exclude Paget's disease of the nipple, a rare form of ductal carcinoma in situ (DCIS). Imaging should be performed to detect breast cancer, which is found in more than 80% of cases, and determine its possible multifocal nature. Breast MRI is indicated if breast-conserving surgery is planned. The main differential diagnoses are erosive adenomatosis and eczema of the nipple. Acquired inverted nipple is generally of inflammatory origin. It is usually diagnosed by conventional breast examination but breast MRI can be helpful when in doubt about possible underlying neoplasia.     

Surgical drainage of lactational breast abscess with ultrasound‐guided Encor vacuum‐assisted breast biopsy system

Lactational breast abscess is a serious complication of mastitis and commonly diagnosed in breast‐feeding women. The traditional drainage of breast abscess was often performed with incisive technique which may result in prolonged healing time, regular dressings, dressing pain, interfering with breastfeeding and unsatisfactory cosmetic outcome. As minimal invasive alternatives to incisive drainage, needle aspiration or percutaneous catheter placement cannot completely replace incisive drainage for the inability to treat large, multiloculated or chronic abscess. Vacuum‐assisted breast biopsy system (VABB) has been successfully applied in the treatment of benign breast diseases with satisfactory cosmetic outcomes. Among VABB devices, EnCor system has some distinctive features that make it an appropriate candidate for the treatment of lactational breast abscesses. In this study, for the first time, we investigated the feasibility, efficacy, and cosmetic results of surgical drainage of lactational breast abscess with US‐guided Encor VABB system. Our data suggests this procedure could serve as a promising alternative for women with lactational breast abscess who require incisive intervention with high cure rate, relatively short healing time, low recurrence rate, few complications, satisfactory cosmetics outcome and without interfering with breastfeeding.     

Office-based breast ductoscopy for diagnosis

OBJECTIVE: Ductoscopy is an evolving technology that has been used primarily and historically in conjunction with open surgical procedures. New technical improvements allow intraductal biopsy and therefore its application in the clinical setting for diagnostic evaluations of the breast. This study looks at the initial use of intraductal biopsy in a variety of settings from an academic university practice to a private single-surgeon office. METHODS: This is a multicenter retrospective series of 88 patients undergoing ductoscopy of > or =1 duct for the diagnostic workup of common breast problems. The procedures were done with the patient under local anesthesia, and intraductal biopsy specimens were taken and analyzed as breast cytology samples. RESULTS: Of the 88 patients undergoing office ductoscopy, nipple discharge was the most common indication (n = 83 patients; 94% to 66% spontaneous and 34% elicited). Fifty-five percent were high risk for breast cancer by history. The majority of patients had normal previous mammograms: 48 Breast Imaging-Reporting and Data System (BIRADS) 1, 24 BIRADS 2, and 7 BIRADS 3 to 5. The most common finding was papilloma present in 29 (32%) patients by endoscopy. Only 31% of patients had a history of brown or bloody nipple discharge. A wide variety of other endoscopic abnormalities were seen and biopsied. The average number of biopsies per patient was 2 with 18 (20.5%) having severe or malignant atypia. Further follow-up and management of these more concerning abnormalities is currently ongoing. CONCLUSIONS: These results indicate that office ductoscopy with biopsy is both feasible and does identify suspicious or malignant atypia in patients with expressed or spontaneous nipple fluid.     

Parameters that predict nipple involvement in breast cancer

BACKGROUND: Breast conservation therapy has been shown to produce survival rates equivalent to those seen with modified radical mastectomy. Synchronous occult neoplastic involvement of the nipple may lead to incomplete excision of the tumor in patients undergoing breast conservation therapy, possibly leading to recurrence. STUDY DESIGN: The charts of 803 breast cancer patients treated between 1990 and 1995 at two teaching hospitals were retrospectively reviewed. The patients were divided into three groups: nipple-positive for malignancy (n = 54), nipple-negative for malignancy (n = 404), and nipple-not-removed (n = 345). Ten different clinical and tumor parameters including age, race, primary tumor location, histologic grade, primary tumor size, nodal involvement, TNM stage, estrogen receptor status, DNA ploidy, and S-phase were examined for the ability to predict cancerous nipple involvement. RESULTS: Overall, the rate of nipple positivity was 12%. In univariate analysis pathologic stage, tumor size, lymph node status, histologic grade, and tumor location were significant predictors of positive nipple involvement. Patients with tumors that were stage III or higher were nearly ten times (odds ratio [OR] = 9.8, 95% confidence interval [CI] = 5.5 to 17.7) more likely to have nipple involvement than patients with early-stage tumors. Patients with a tumor size of 4 cm or greater were nearly eight times (OR = 7.8, 95% CI = 4.2 to 14.5) more likely to have nipple involvement than patients with tumor size less than 4 cm. Patients with positive lymph nodes were five times (OR = 5.0, 95% CI = 2.7 to 9.1) more likely to have nipple involvement than patients with negative lymph nodes. Patients with tumors in a central location or that overlapped quadrants were nearly four times (OR = 3.8, 95% CI = 2.2 to 6.8) more likely to have nipple involvement than patients with tumors in other locations. Patients with grade 3 or undifferentiated tumors were three times (OR = 3.0, 95% CI = 1.4 to 6.4) more likely to have nipple involvement than patients with lower grade tumors. In multivariable analysis, stage > or = 3 (OR = 9.2, 95% CI = 4.2 to 20.3) central/ overlap location (OR = 4.1, 95% CI = 2.0 to 8.7) and grade 3 or undifferentiated (OR = 3.1, 95% CI = 1.3 to 7.5) were the only variables that remained significant predictors of nipple involvement. CONCLUSIONS: The decision to perform breast conservation surgical procedures with nipple preservation can be difficult, particularly in patients with larger, more centrally located tumors. The multivariable model developed in this study may be useful in predicting the risk of cancerous nipple involvement and selecting appropriate breast conservation patients for nipple preservation.     

The effect of incision choice on outcomes of nipple-sparing mastectomy reconstruction

INTRODUCTION

The indications for nipple-sparing mastectomy (NSM) are broadening as more breast surgeons appreciate the utility of preserving the nipple-areolar complex. A number of incision locations are available to the mastectomy surgeon, including inframammary, lateral and periareolar approaches. The present study investigated the effect of these three incisions on reconstructive outcomes; specifically, nipple necrosis.

METHODS

A single-centre, retrospective review of 37 breast NSM reconstructions treated with immediate tissue expander reconstruction with acellular dermis between 2007 and 2008 was performed. The primary outcome was the incidence of nipple necrosis associated with periareolar, lateral and inframammary incisions. Secondary outcomes were the effects of radiation, chemotherapy and breast size on nipple necrosis.

RESULTS

Thirty-seven breast procedures performed on 20 patients were included in the present study. Periareolar incisions were used in 21 cases, lateral incisions in 14 and inframammary incisions in two. The periareolar incision was associated with a significantly higher incidence of nipple necrosis compared with lateral or inframammary incisions (38.1% versus 6.3%, P=0.028). Patients receiving breast radiation (45.5% versus 15.4%, P=0.066) and those with larger breast size (540.4 g versus 425.7 g, P=0.130) also demonstrated a modest trend toward an increased rate of nipple necrosis.

CONCLUSION

The periareolar incision results in a higher rate of nipple necrosis following NSM and immediate tissue expander breast reconstruction. Using the lateral or inframammary incision reduces the incidence of nipple necrosis and may help improve overall reconstructive and cosmetic outcomes.     

Treatment of recurrent subareolar abscess

Recurrent subareolar abscess is an infrequent but troublesome disease of the breast among young women. Recent experience with 5 patients indicated that successful treatment of recurrent subareolar abscess requires excision of the diseased ducts and necrotic cavity, including the inverted section of the nipple. The operative procedure described herein allows us to radically manage recurrent subareolar abscess and at the same time leave a nipple with a good cosmetic appearance.     

The use of a combined technique in reduction mammaplasty (inferior pyramidal and superior glandular techniques)

The management of mammary hypertrophy is a developing process. The common surgical options for reduction mammaplasty include amputation with free nipple graft as well as the bipedicled, inferior pedicle and vertical pedicle techniques. All techniques are used widely. Disadvantages of these procedures include nipple areola necrosis, insensitivity, hypopigmentation, and poor breast projection. Even with the standard modifications of the original techniques, the resultant breast and nipple may be wide and flat. The purpose of this study was to assess whether combined inferior pyramidal pedicle and superior glandular pedicle reduction mammaplasty can optimize nipple and breast projection. Attention will focus on the viability and sensation of the nipple areola complex. Nine patients with mammary hypertrophy were studied. The change in nipple position ranged from 7 to 13 cm. The amount of tissue removed from each breast ranged from 500 to 1150 g. Nipple/areola sensation was retained in all cases with the exception of one breast. Nipple/areola necrosis or hypopigmentation were not observed. Optimal central breast projection was maintained in all patients, and postoperative evaluation was carried out at 12 and 22 months. The patient satisfaction was very high.     

单孔充气法腔镜乳房皮下腺体切除术联合一期假体植入乳房重建术临床分析

目的探讨单孔充气法腔镜乳房皮下腺体切除术联合一期假体植入乳房重建术在早期乳腺癌治疗中的临床应用价值。方法回顾性分析2014年2月至2019年7月于首都医科大学附属北京友谊医院接受单孔充气法腔镜乳房皮下腺体切除术联合假体植入乳房重建手术的34例早期乳腺癌患者的临床病理学资料。患者均为女性,年龄46(11)岁[M(QR)](范围:26~64岁)。对手术根治性、术后美容效果进行评估,并采用乳腺患者报告结局量表评价患者的生活质量和满意度。结果 34例患者手术均顺利完成,手术时间(313.4±11.7)min(范围:200~485 min),术中出血量(33.8±3.3)ml(范围:10~100 ml)。5例患者术后发生乳头乳晕缺血坏死,其中1例因乳头乳晕坏死导致假体外露最终手术取出假体;无包膜挛缩、术后出血等并发症。术后随访时间为35(17)个月(范围:12~77个月),1例发生局部复发伴远处转移,1例发生远处转移。患者术后乳房满意度、社会心理状态、胸壁状态、性健康程度评分分别为(78.3±2.6)分(范围:55~100分)、(89.1±2.3)分(范围:82~100分)、(91.47±1.33)分(范围:43~100分)、(78.5±2.7)分(范围:39~100分)。结论单孔充气法腔镜乳房皮下腺体切除术联合一期假体植入乳房重建术可获得较好的根治效果和美容效果,患者术后生活质量和满意度较高。     

Simultaneous Breast Augmentation and Lift

Often, both augmentation and mastopexy are necessary to solve the problems of breast ptosis with hypoplasia. These two procedures can be done simultaneously with no increased risks. Patients who have any degree of ptosis may benefit from some lifting of the nipple areola complex if the nipple is not in the central portion of the general contour of the breast mound when seen in the upright position. A simple crescent or eccentric excision in the upper quadrant may be sufficient to lift the nipple–areola complex 1–2 cm. If the nipple needs to be moved more than a couple of centimeters, or if the distance between the nipple and the inframammary crease is already excessive, an inframammary skin excision and redraping will be necessary. We have been using these combined techniques for 20 years with universal patient satisfaction.     

真空辅助微创活检治疗慢性乳腺炎的临床研究

目的探讨真空辅助微创活检加置管冲洗引流治疗慢性乳腺炎的操作技巧和临床优势。方法2010年6月～2012年5月,超声引导下应用真空辅助微创活检系统加旋切刀对肿块型与脓肿型慢性乳腺炎局部病灶进行切除,残腔冲洗及置管引流,观察其治愈率、治愈时间和复发率。结果32例一期治愈率96．9％（31／32）,仅I例在手术后5天换药仍可见脓液溢出,为术后引流不畅,扩大引流口后22天痊愈。随访时间2—24个月,中位数10个月,局部复发率3．1％（1／32）。结论应用真空辅助微创活检系统可在超声引导下对慢性乳腺炎局部病灶进行大范围甚至完全切除,辅以置管冲洗引流,可很快获得良好的治疗效果。     

A new method for using a silicone rod for permanent nipple projection after breast reconstruction procedures

Nipple-areola complex (NAC) is a unique part of the human body. Not only is it a functional structure, but it plays an aesthetic role as well. It offers the final touch to the convex shape of the breast. Its lack frequently leads to depression in patients. This paper describes the method used by the authors for reconstructing nipple mound projection in patients following an autologous breast reconstruction procedure.To reconstruct the nipple mound an adapted local C-V flap technique described by Losken was used, with a silicone rod to support the nipple. The new method is based on simple preparation of flaps, fixing the silicone rod at the nipple bottom and below the top, it is quick and efficient in terms of time and materials used.The procedure was conducted in 30 patients: 10 cases following LDf reconstruction and Becker prosthesis or expander prosthesis, 20 cases following body tissue reconstruction with TRAM flap (Transverse Rectus Abdominis Musculocutaneous flap). All the patients who had undergone the LDf procedure developed flap necrosis followed by rod removal. In the patients who had undergone TRAM flap reconstruction no necrosis or wound split was observed, healing progressed without complications. In this group durable nipple projection was achieved. The new method for reconstructing nipple projection may be applied both in simultaneous and staged procedures, only in patients who have undergone autologous breast reconstruction procedure.     

Defining a Place for Nipple Sparing Mastectomy in Modern Breast Care: An Evidence Based Review

Abstract: Breast cancer is a diverse disease that requires a fully integrated multidisciplinary approach. Breast surgery has undergone a revolutionary change leading us from the conventional radical mastectomy of the Halstedian era to the current motion of nipple sparing mastectomy (NSM). Despite the lack of randomized controlled trials, the technique of NSM continues to gain popularity as a prophylactic procedure in high risk patients. The current indications for NSM, if any, in the treatment of early invasive breast cancer remains uncertain and requires rigorous scientific scrutiny. This article aims to critically review the indications and limitations of NSM, discuss evidence based intra‐operative protocols and to discuss ways in which radiation therapy may be incorporated in treatment planning following NSM. A comprehensive search of the scientific literature was carried out using PubMed to access all publications related to nipple sparing mastectomy. The search focused specifically on technique, current management, safety, and complications of these procedures. Keywords searched included “Nipple sparing mastectomy,”“breast conserving surgery,”“Nipple areola complex preservation” and “skin sparing mastectomy.” NSM offers an opportunity to preserve native breast envelope without mutilation of nipple‐areola complex (NAC), and avoids multiple surgical procedures required for reconstruction. NSM may be a reasonable alternative for prophylactic and select breast cancer patients without NAC involvement; however, oncological safety of NSM has not yet been fully demonstrated. Best available evidence suggests that patients should be selected based on study of breast duct anatomy by breast Magnetic Resonance Imaging, mammographic distance between tumor and nipple and obligatory intra‐operative frozen section from retro‐areolar tissue. Additional factors such as tumor size, axillary lymph node status, lymphovascular invasion and degree of intraductal component are also being used to either include or exclude NSM candidates based on institutional protocols. Heterogeneity of patients selected for NSM is great and the lack of standardization of preoperative investigations, intra‐operative technique and pathologic sampling of retro‐areola tissues mandates a multi‐institutional prospective study to define and validate a role for NSM in invasive breast cancer and DCIS. Nipple necrosis or sloughing is an important problem after NSM which can be greatly reduced using alternative skin incisions. Even if the nipple survives, an insensate nipple and lack of sexual function is common and requires preoperative counseling and discussion. Finally the relation and timing of intra‐operative versus adjuvant breast radiation and tailoring of dosage and delivery methods has not been fully explored. Although NSM reduces the psychological trauma associated with nipple loss, the oncologic safety as well as functional and aesthetic outcomes needs additional investigation.     

Clinical impact of oncoplastic surgery in a specialist breast practice

Background: Oncoplastic breast surgery is an integral and fundamental component of the clinical management of breast cancer. The aim of this study was to determine the proportion of oncoplastic and reconstructive breast cancer procedures undertaken within a specialist breast practice. Methods: An audit of breast‐related cancer procedures was undertaken for patients with early breast cancer between 1 January 2001 and 31 December 2005, treated at the Royal Adelaide Hospital and in private practice. The proportion of oncoplastic and breast reconstructive procedures was calculated to determine the clinical effects on a specialist breast‐surgical practice. Results: Breast cancer resection procedures accounted for 1514 of 2113 of operations (72%). Most of these (897 of 1514, 59.2%) were wide local excision or re‐excision procedures. Total breast reconstruction operations (i.e. autogenous tissue flaps, tissue expander/implant reconstructions) accounted for 251 procedures. Of these, 67 (26.7%) were carried out at the time of simple mastectomy. Contralateral breast procedures (i.e. reduction mammaplasty, mastopexy and augmentation) accounted for 138 procedures and nipple–areola reconstruction/tattoo accounted for 153 procedures. Oncoplastic procedures, such as skin‐sparing mastectomy, latissimus dorsi miniflap and therapeutic mammaplasty accounted for 57 of 599 procedures (9.5%). Breast reconstruction and oncoplastic operations accounted for 599 of 2113 procedures (28%). Conclusion: Specialist breast surgeons trained in breast reconstruction and oncoplastic techniques can expect a substantial proportion of their breast practice to include such operative procedures (28% in this series). Subspecialist training in breast surgery should incorporate experience in breast reconstructive and aesthetic surgery for trainees who wish to practise as specialist breast surgeons in the future.     

An Analysis of Complication Risk Factors in 641 Nipple Reconstructions

Nipple‐areola reconstruction represents the completion of the breast restorative process and is associated with significant positive psychological implications. While factors such as medical comorbidities, smoking status, and radiation therapy have been shown to be associated with an increase in complications following breast reconstruction, their impact on nipple reconstruction remains largely unaddressed in the literature. An IRB‐approved, retrospective review of 472 patients who underwent nipple reconstruction at Wake Forest University over a 15‐year period was completed. Demographic and surgical characteristics were assessed including age, body mass index, medical comorbidities, smoking status, need for radiation, breast reconstruction type, and nipple flap used. Four hundred and seventy‐two patients with 641 nipple reconstructions were included with an average follow‐up of 56.5 months. Radiation prior to nipple reconstruction was required in 146 breasts (22.8%). Overall, postoperative nipple projection problems occurred in 7.6% of reconstructions with a 4.1% rate of other complications, including nipple necrosis, tip loss, wound infection and wound breakdown. Implant‐based reconstruction and radiation were associated with significantly more nipple projection problems (p = 0.009 and 0.05, respectively). Higher rates of complications and nipple projection problems were seen with skate flap reconstruction compared to a star flap (p = 0.046 and 0.001, respectively). Implant‐based breast reconstruction and radiotherapy are associated with higher rates of nipple reconstruction problems. Identification of patient and surgical variables associated with increased risk of poor outcomes preoperatively could help in patient counseling and selection of the most appropriate method of breast and nipple reconstruction.     

Paget's disease of the breast

Twenty patients with histologically proven Paget's disease of the breast are reviewed. They represent an incidence of 1.06% of all breast carcinomas seen over a 12-year period in the Bloemfontein academic hospitals. All cases had ductal carcinoma. Clinically, 20% presented with a mass only, 20% with nipple disease only and 60% with both lesions. More patients with a mass compared with patients with only nipple disease had positive axillary lymph nodes--68.7% v. 25%. Cumulative 5-year survival rates showed a 100% survival rate for patients with only nipple disease, and an 83% survival rate for stage I and II disease. All the patients with stage III and IV disease died within the 4-year follow-up period. Nipple (skin) involvement per se did not worsen the prognosis of patients presenting with both a mass and nipple disease. The main predictors of prognosis were tumour size and lymph node involvement. It is suggested that patients presenting with nipple involvement only and/or small T1 lesions close to the nipple could be treated with wide local excision and axillary dissection in discontinuity followed by radiotherapy to the rest of the breast.