Paget’s disease of the nipple in a population based cohort

Background Paget's disease of the nipple is a rare form of breast cancer characterised by the presence of intraepidermal tumour cells. It is often associated with ductal carcinoma in situ (DCIS) and/or invasive cancer in the breast parenchyma. We have studied the presentation and symptoms of Paget's disease, local control and breast cancer corrected survival following breast conserving surgery or mastectomy. Patients and methods The study is based on 223 women with histological verified Paget's disease of the nipple diagnosed between 1976 and 2001 at 13 Swedish hospitals. All women s charts were reviewed. All recurrences and deaths were registered. A comparison was made for differences in breast cancer-corrected survival (BCS) and disease-free survival (DFS) in univariate analyses. Results The median follow-up was 12 (4-28) years. In a vast majority (98%), the main presenting symptom was eczema or ulceration of the nipple. The diagnosis of an underlying breast malignancy was established in 79% of the women before surgery. A cone excision of the nipple-areola complex was performed in 43 women and 169 women had a mastectomy. Eleven elderly women were not operated. One hundred and seventeen women had a non-invasive Paget of which 40 had an underlying DCIS. Invasive cancer was seen in 68 women. In 38 cases the histopathological report did not state if the tumour was invasive or not. Thirty-three women died from breast cancer. In operated women BCS and DFS at 10 years were 87% and 82%, respectively. The 10-year BCS for non-operated patients (n = 11) was 34%. At 10 years, the cumulative local recurrence rate was 9%, 8% among women undergoing mastectomy and 16% among those treated with breast conserving surgery. In univariate analysis the type of surgery, cone excision or mastectomy, had no statistically significant impact on BCS or DFS. Risk factors for breast cancer death and recurrence were having an underlying invasive cancer compared with an in situ carcinoma and having a palpable tumour in the breast. Conclusion The main presenting symptoms were eczema or ulceration of the nipple. Patients with non invasive Pagets disease of the nipple had an excellent cancer outcome. Selected patients with Paget's disease of the nipple were treated with breast conserving surgery with survival rates similar to those achieved with mastectomy.     

Breast conserving treatment of Paget's disease

Between 1971 and 1984, 13 patients with histologically proven Paget's disease were treated conservatively with radiotherapy only. The disease was clinically confined to the nipple or surrounding skin, without signs of an underlying tumor. With a mean follow-up of 58.6 months (ranging between 15 and 118 months), and a median follow up of 52 months, no recurrences locally or at distance were seen. Therefore in these selected cases a mastectomy could be avoided. The results with this breast conserving management suggest a place for radiotherapy in the treatment of Paget's disease limited to the nipple.     

Paget's disease of the nipple as local recurrence after breast-conservation treatment for early-stage breast cancer

Breast conservation treatment (BCT) for early-stage breast cancer is associated with survival rates comparable with mastectomy but has the risk of ipsilateral breast tumor recurrence, including Paget's disease of the nipple. A small number of cases of Paget's disease presenting as local recurrence following BCT for breast cancer have been previously reported. Between 1977 and 2002, 2181 women with early-stage breast cancer were treated with BCT at the Hospital of the University of Pennsylvania. In this cohort, there were 183 local treatment failures, 4 of which were cases of Paget's disease (2.2%), which are reported herein. These local recurrences developed 1.8, 3.8, 7.3, and 9.7 years after diagnosis of the patients' primary tumors. Three of the 4 primary cancers were invasive ductal carcinomas, with an associated intraductal component, and 1 was ductal carcinoma in situ. All 4 patients were successfully given salvage therapy consisting of mastectomy with or without tamoxifen, with follow-up times of 20.9, 10.6, 3.1, and 3.8 years. Paget's disease as local recurrence after BCT is uncommon and can be treated with salvage therapy if detected early.     

Paget's disease of the nipple occurring after wide local excision and radiotherapy for carcinoma of the breast

Between 1979 and 1985, 356 cases of Stage I or II breast carcinomas have been treated at Westminster Hospital with breast conservation. Of these patients, 338 underwent local excision and radiotherapy and there have been 38 local recurrences. Three of these have been as Paget's disease of the nipple occurring 16, 8 and 5 months following radiotherapy. In each case the nipple appearances were attributed to postradiotherapy changes; the true diagnosis was not made for an average of 19 months. The increasing use of conservative breast management for early breast tumours permits the appearance of Paget's disease as a significant proportion of local recurrences. Previously this has been considered to be a rare event. We recommend that Paget's disease of the nipple should be suspected early following radiotherapy in the presence of any nipple changes.     

Extramammary Paget's disease of the perineal skin: role of radiotherapy.

We have reviewed our treatment results in 65 patients with extramammary Paget's disease arising in the vulva, perianal area, or scrotum. In 30 patients with primary disease, positive surgical margins were found in 53%, and there was an actuarial local recurrence rate of 40% within 5 years. The median follow-up period for primary extramammary Paget's disease patients treated with surgery alone was 198 months, and none died of this disease. Three patients treated with definitive radiotherapy were without recurrence at 12, 21, and 60 months after 56 Gy of supervoltage x-rays. In 22 patients with extramammary Paget's disease and associated adnexal or rectal adenocarcinoma, nine treated with surgery alone had a 75% local control rate. Three patients treated with surgery and adjuvant radiotherapy all had local control; of two patients treated with radiotherapy alone, one had persistent adenocarcinoma. The median survival for all patients with extramammary Paget's disease and adenocarcinoma was 22 months. We conclude that patients with extramammary Paget's disease have excellent survival but that local recurrence and morbidity from surgery, especially in the elderly, can be high. Radiotherapy greater than 50 Gy as primary treatment for extramammary Paget's disease in those medically unfit for surgery, or as an alternative to further surgery for recurrence after surgery and for anyone wishing to avoid mutilating surgery, is indicated. For those with adenocarcinoma and extramammary Paget's disease, the use of adjuvant postoperative radiotherapy in doses greater than 55 Gy is indicated because of the high risk of local recurrence after surgery alone.     

Ductal carcinoma in situ of the breast -- among factors predicting for recurrence, distance from the nipple is important.

AIMS: To assess local and systemic recurrence rates and factors predicting for recurrence in patients treated for ductal carcinoma of the breast (DCIS). METHODS: Patients with DCIS treated between January 1986 and January 1997 were identified. All pathology specimens were reviewed. DCIS type, lesion size, nuclear grade and margin clearance were assessed. Mammograms were reviewed and mammographic patterns, size, type of lesion and distance from the nipple were measured. Treatments and subsequent outcomes were established by case note review. Factors predicting for recurrence were analysed by both univariant and multivariant analysis. RESULTS: Of the 220 patients, 153 (70%) had breast-conserving surgery. Sixty-seven (30%) had a mastectomy. Ninety-seven patients had adjuvant therapy of which 22 had radiotherapy alone, 54 had tamoxifen alone and 21 had radiotherapy and tamoxifen. Following mastectomy, two patients developed axillary recurrences. Following breast-conserving surgery 20 (13%) patients developed local recurrences, of which one developed systemic disease and died from breast cancer. CONCLUSIONS: Mammographic nipple to lesion distance of <40 mm and high/intermediate nuclear grade were the only factors found to increase the likelihood of recurrence. Copyright Harcourt Publishers Limited.     

乳头Paget‘s病：附55例报告

Fifty-five female patients with Paget's disease of the nipple treated in our Hospital from 1958 to 1987 are reported. It comprised 1.1% of all the breast carcinomas. The lesions was on the left side in 27 and on the right side in 28. The average age was 48 years. The primary lesion was in breast ducts and then invaded the nipple, areola superficially and deeper breast tissue. Dermal manifestation of Paget's disease is easily confused with chronic dermopathy. In this series, four patients (7.2%) did not have the typical symptoms so pathologic or cytologic examination was relied upon for correct diagnosis. Thirty-one patients were treated by radical mastectomy giving a 3-year disease-free rate of 70.9%. It seems that radical mastectomy is more superior to the other surgical procedures. The 3-year recurrent rate was 38% for patients with Paget's disease of the nipple coexisting with breast carcinoma, but no recurrence was found in patients with simple Paget's disease of the nipple. The 3-year survival rate was 46.4% in patients with axillary lymph node metastasis, 85.2% in patients without, 54.3% in patients with palpable masses in the breast and 85.0% in patients without. Paget's disease of the nipple coexisting with breast carcinoma, axillary lymph node metastasis, palpable breast masses has poor prognosis.     

The place for conservative treatment in the management of Paget's disease of the nipple.

Four cases of Paget's disease confined to the nipple are presented. Three of them were treated conservatively by local radiotherapy and the fourth was treated by mastectomy. Histopathological examination of the breast in the last case failed to show any evidence of in situ or invasive carcinoma. The first three patients are well and without evidence of recurrence 3 to 5.5 years after treatment. Could conservative treatment in the form of local excision or radiotherapy offer an alternative to mastectomy? A discussion on the place of conservative treatment is presented.     

In situ carcinoma of the breast

The optimal management of ductal carcinoma in situ of the breast is controversial. With the introduction of the National Mammographic Breast Screening Programme the condition will be encountered more frequently. We have reviewed 76 patients from a 12-year period treated by one surgeon (R.W.B.) at the Nottingham City Hospital. Fifty-nine patients had either ductal carcinoma in situ or lobular carcinoma in situ; 17 patients had Paget's disease. The mean age at diagnosis was 54 years and the commonest mode of presentation was with a palpable breast lump. Pre-operative mammography was performed in 31 patients with ductal carcinoma in situ and 28 were reported as showing malignancy. Patients with a lesion in the breast parenchyma were treated either by mastectomy (simple, subcutaneous or 'wedge'--see text) or by lumpectomy and radiotherapy. Patients with Paget's disease were treated by simple mastectomy, wedge mastectomy or a cone excision of the nipple and underlying tissue. The mean follow-up period was 65 months. Patients treated by any of the procedures less than simple mastectomy had a significant chance of developing local recurrence. A detailed histological review was made and grade, microinvasion, calcification, necrosis and completeness of excision were assessed for each tumour. None of these factors was correlated with subsequent local recurrence.     

Conservative management of Paget disease of the breast with radiotherapy: 10- and 15-year results

BACKGROUND: At 5-year follow-up, patients with Paget disease of the breast who were treated with breast-conserving surgery (BCS) and radiotherapy (RT) had excellent results. The current report provides 10- and 15-year rates of tumor control in the breast, as well as disease-free and overall survival rates following BCS and RT in a cohort of patients with Paget disease presenting without a palpable mass or mammographic density. METHODS: Through a collaborative review of patients treated with BCS and RT from seven institutions, 38 cases of Paget disease of the breast presenting without a palpable mass or mammographic density were identified. All patients had pathologic confirmation of typical Paget cells at time of diagnosis. Thirty-six of 38 patients had a minimum follow-up greater than 12 months and constitute the study cohort. Ninety-four percent of patients underwent complete or partial excision of the nipple-areola complex and all patients received a median external beam irradiation dose of 50 Gy (range, 45-54 Gy) to the whole breast. Ninety-seven percent of patients also received a boost to the remaining nipple or tumor bed, a median total dose of 61.5 Gy (range, 50.4-70 Gy). RESULTS: With median follow-up of 113 months (range, 18-257 months), 4 of 36 patients (11%) developed a first recurrence of disease in the treated breast only. Two of the four recurrences in the breast were ductal carcinoma in situ (DCIS) only and two were invasive with DCIS. Two additional patients had a recurrence in the breast as a component of first failure. Actuarial local control rates for the breast as the only site of first recurrence were 91% at 5 years (95% confidence interval [CI], 80-100%) and 87% (95% CI, 75-99%) at both 10 and 15 years. Actuarial local control rates for breast recurrence, as a component of first failure, were 91% (95% CI, 80-100%), 83% (95% CI, 69-97%), and 76% (95% CI, 58-94%) at 5, 10, and 15 years, respectively. No clinical factors were identified as significant predictors for breast recurrence. Five-, 10- and 15-year actuarial rates for survival without disease of 97% (95% CI, 90-100%) and 5-, 10-, and 15-year actuarial rates of overall survival of 93% (95% CI, 84-100%) at 5 years and 90% (95% CI, 78-100%) at 10 and 15 years were reported. CONCLUSIONS: These data confirm excellent rates of local control, disease-free survival, and overall survival at 10 and 15 years following BCS and RT for Paget disease of the breast. This study continues to support the recommendation of local excision and definitive breast irradiation as an alternative to mastectomy in the treatment of patients with Paget disease presenting without a palpable mass or mammographic density.     

Paget's disease of the nipple: A ten year review including clinical,pathological, and immunohistochemical findings

Thirty-five women with biopsy-proven Paget's disease of the nipple were treated over a 10 year period at the Breast Cancer Unit, Guy's Hospital. Twenty-four (69%) patients had Paget's disease without a palpable mass in the breast; eleven (31%) presented with a palpable mass and Paget's disease of the nipple. Definitive treatment consisted of modified radical mastectomy in 32 patients, radiotherapy only in 2, and one patient had no definitive treatment.All 11 patients with Paget's disease and an associated lump proved to have invasive ductal carcinoma; five also had associated positive axillary nodes. Nine of the 23 patients with nipple changes only, treated by mastectomy, also had invasive carcinoma; three of these had positive axillary nodes. The remaining 14 patients with nipple changes only were found to have in situ ductal carcinoma, which was extensive in the majority of cases.In 13 cases, histological sections of the nipple were examined by immunohistochemical staining which showed that the Paget's cells expressed a keratin phenotype that was specifically characteristic of simple epithelial cells as seen in glandular epithelium. This was quite unrelated to the normal keratin phenotype of the surrounding skin keratinocytes.Clinical, pathological, and immunohistochemical data suggest a mammary origin of the abnormal cells in Paget's disease of the nipple. Mastectomy appears to be the treatment of choice.     

Pathogenesis and treatment of Paget's disease of the breast

Fifty cases of Paget's disease of the breast treated surgically at The Johns Hopkins Hospital during the past 30 years were studied. Nineteen patients had Paget's disease confined to the nipple and 31 had an associated palpable tumor. An underlying intraductal or infiltrating duct carcinoma of the breast was present in each case. In six cases, the underlying tumor was 2 cm or more from the nipple with no apparent anatomic connection to the Paget lesion, and one case was encountered in whom intradermal Paget's disease develop in the area of a congenitally absent nipple. These findings support the theory of an intradermal origin for the Paget cell. Survival rates of patients with Paget's disease and a palpable breast mass were similar to those of patients with infiltrating duct carcinoma, the presence of axillary node metastases being the most important prognostic factor. Actuarial five- and ten-year survival rates were 22% and 9.9% for patients with positive nodes. The modified radical mastectomy is recommended as primary therapy for this group of patients. In contrast, none of the patients with Paget's disease of the nipple and no evidence of a palpable breast mass developed recurrent carcinoma. A total mastectomy without an axillary node dissection is the treatment of choice in this type of patient.     

Treatment of intraductal carcinoma with limited surgery: long-term follow-up

Adequate therapy for ductal carcinoma in situ (DCIS) remains controversial. In spite of limited follow-up, recent studies advocate excision and postoperative radiotherapy as treatment. In an effort to provide long-term follow-up information, we evaluated retrospectively a group of 17 patients treated without mastectomy. Thirteen patients were treated with local excision, while four received excision and postoperative radiotherapy. Median follow-up is 100 months, with minimum follow-up 78 months. Five patients (29%) have recurred locally, at a median of 47 months following initial therapy. Three of the local recurrences were invasive carcinomas; two were DCIS. The patients recurring with invasive carcinoma progressed to disseminated disease and death, at a median of 131 months following their local recurrence. Of the eight patients followed for more than 9 years, four (50%) have recurred. Two patients have developed contralateral breast cancer, both treated by mastectomy. No recurrences have occurred in the group receiving radiotherapy. We conclude that long-term follow-up is required to accurately assess local recurrence rates in this disease, and that many recurrences will be invasive carcinomas. Since this lesion is virtually 100% curable by mastectomy, further analysis of long-term studies is warranted before recommending breast conservation to the majority of patients with DCIS.     

Local recurrence of breast cancer following surgery and radiotherapy: incidence and outcome

Local recurrence of cancer in the treated breast following breast-conserving surgery and radiotherapy occurs in a minority of patients, but can represent a significant clinical problem. The impact of local relapse on the subsequent course of the disease is disputed. The aim of this retrospective review was to identify the rate and prognostic factors for breast recurrence and to determine the subsequent outcome. The case notes of 2159 patients treated between 1989 and 1992 were reviewed. Actuarial local relapse rate was 6.3% at 5 years. Factors predictive for recurrence on multivariate analysis were age (P<0.001), status of excision margins (P=0.019), and pathological UICC stage (P=0.01). One hundred and sixty-one patients developed local recurrence in the treated breast of whom 101 were treated with further surgery. The 5-year cancer-specific survival of this group was comparable with that of the patients who remained free of breast relapse (82 vs. 88%) but subsequently fell to 61 vs. 80% at 8 years (P<0.001). Sixty patients were unable to have salvage surgery; their cancer-specific survival was much worse than that of patients with operable recurrences at 33% at 5 years and 13% at 8 years. Eighty-three patients (4% of the original 2159 patients) had uncontrolled local disease at time of death or last follow-up. The prognosis of patients who developed recurrence within 2 years of their initial treatment was inferior to those who developed recurrences after 4 years (cancer-specific survival 5 years post-recurrence 23 vs. 57% P=0.008). Systemic therapy should be considered for patients with early breast recurrence in view of their inferior survival.     

Non-infiltrating intraductal carcinoma of the breast (author's transl)]

Non-infiltrating intraductal carcinoma may be considered a type of "carcinoma in situ" of the breast. In a review of 47 cases diagnosed and treated at Gustave-Roussy Institute between 1956--1972, it appears that the early symptoms of this rare type of breast carcinoma (it occurs only in 2.4% of all breast cancers) were a bloody discharge (38%) or Paget's disease of the nipple (11%). The histological examination was of the utmost importance in these cases due to the diagnostic uncertainties between benign hyperplastic lesions and authentic carcinomas as well as between infiltrating carcinomas and strictly intraductal carcinomas. Frozen section was only accurate in 30% of cases. The high frequency of multicentric foci (76%) contrasted with the absence of lymph node involvment (none of the 23 cases in which at least one node was excised, showed lymph node metastases). Treatment was only of ablation of the whole mammary gland, except in 6 patients who had a tumorectomy, two of whom also received radiotherapy. Local recurrence occurred in 4 patients, 3 of whom had only tumorectomy. The contralateral breast was affected in 2 cases. No patient under follow-up died of cancer within 5 years. The peculiar and highly favorable course of non-infiltrating intraductal carcinoma calls for an adequate therapy which could later be followed by a plastic reconstructive surgery should the patient wish to have this procedure.     

Re-irradiation after salvage mastectomy for local recurrence after a conservative treatment: a retrospective analysis of twenty patients (Nancy: 1988-2001)]

PURPOSE: To retrospectively assess the efficacy of post-mastectomy re-irradiation for local relapse of breast cancer. PATIENTS AND METHODS: Twenty patients, initially treated by conservative surgery and radiotherapy (50 Gy in 25 fractions over 5 weeks) were treated from 1998 to 2001 for a local relapse by salvage mastectomy and re-irradiation (either electron or photon beams). Mean age was 53 years (31-71). Reasons for re-irradiation were that the local relapses were inflammatory (4 pts), multifocal (5 pts), cutaneous (5 pts), involved the nipple (3 pts) or because the surgical margins (either muscle or skin) were involved (3 pts). The median dose of re-irradiation was 45 Gy (33-65) in 15 fractions over 33 days. Mean follow-up was 48 months (5-97). RESULTS: Fifteen patients remained free of a second local recurrence and 10 were still alive, without metastasis. Neither the dose of re-irradiation nor the irradiated surfaces were prognostic factors of local control (P = 0.877 and P = 0.424). Five patients developed radiation-induced pneumonitis without functional respiratory impairment. The incidence of pneumonitis seemed to be related to the biological dose of re-irradiation (P = 0.037). Other late complications occurred such as pigmentation changes (12 pts), telangiectasia (8 pts), chondritis (2 pts), parietal fibrosis (7 pts), rib fractures (4 pts), severe pain (11 pts) and lymphedema (2 pts). The increase in biological equivalent dose was highly statistically linked with the occurrence of disabling pain (P = 0.0123). CONCLUSION: Parietal re-irradiation achieves good and lasting local control with an acceptable rate of acute complications but with a risk of disabling late sequelae such as severe pain.     

Locally advanced breast cancer: radiotherapy alone versus surgery and radiotherapy

From 1976 through 1984 46 patients with locally advanced breast cancer were treated by either radiotherapy alone or by combination of surgery and postoperative radiotherapy. Eleven of the 21 patients treated by radiotherapy alone had a local or regional recurrence, while no recurrences occurred in the combined treatment group. From this study it was concluded that "locally advanced" breast cancer is a heterogeneous disease and that further study concerning the role of surgery is justifiable for a selected subgroup of patients with non-inflammatory resectable tumours (meeting the criteria of "locally advanced" breast cancer).     

Breast cancer in very young women

Aims

The purpose was to analyse the characteristics, treatment, recurrences and survival of very young women with breast cancer.

Methods

212 female breast cancer patients ≤35 years old were treated during 1997-2007. The median follow-up time was 78 months.

Results

117 patients had lymph node metastases and 14 distant metastases at diagnosis. 81 (38%) tumours were hormone receptor negative and 130 (65%) grade 3. HER2 positivity was seen in 47 (34%) and triple negativity in 35 (26%) of the 137 tumours with known HER2 status. 140 women were treated with mastectomy and 68 with breast conserving surgery. 163 patients received postoperative radiotherapy, 175 adjuvant chemotherapy, 95 endocrine therapy and 18 trastuzumab. 63 patients experienced a recurrence, of which 20 had only a locoregional recurrence. 10 (15%) of the women with breast conserving surgery experienced ipsilateral breast tumour recurrence while ipsilateral thoracic wall recurrence was seen in 8 patients (6%) after mastectomy. Seven of these eight patients did not receive postmastectomy radiotherapy. DFI was shorter in patients with hormone receptor positive tumours. At the end of follow-up 44 women had died. The 5-year OS was 80%.

Conclusions

The 5-year OS for young women has become better but is still lower than for all breast cancer patients. DFI was shorter in patients with hormone receptor positive disease. Locoregional recurrences were seen more often after breast conserving surgery.     

Long-term follow-up of a randomised trial designed to determine the need for irradiation following conservative surgery for the treatment of invasive breast cancer.

Four hundred consecutive patients aged under 70 years diagnosed with a clinical T1 or T2 breast cancer were randomised to receive post-operative radiotherapy (n = 208) or not (n = 192), and monitored to record all local recurrences, distant recurrences and deaths for up to 20 years (median 13.7 years). All patients were treated by wide local excision and adjuvant therapy [estrogen receptor (ER) positive: tamoxifen; ER negative: CMF chemotherapy]. Kaplan-Meier and log-rank test methods were used to estimate and compare survival and recurrence. The 20-year Kaplan-Meier rates for local breast recurrence were 28.6% [95% confidence interval (CI) 19.6% to 37.6%] for radiotherapy and 49.8% (95% CI 40.8% to 58.9%). There was no significant difference between the two groups with regard to disease-free or overall survival. The hazard ratio for death among women who received radiation, as compared with those that did not, was 0.91 (95% CI 0.64-1.28; P = 0.59). Therefore, post-operative radiotherapy produced a clear-cut reduction in locoregional recurrence 0.45 (0.31-0.64; P = 0.0001), but did not influence the incidence of distant metastases or time of death. However, of the 119 patients who had a local recurrence, 51 (42.8%) had a distant recurrence, whereas of the 281 without local recurrence only 59 (21%) ever had a distant recurrence. A Cox's regression analysis with local recurrence as a time-dependent variable showed a risk ratio of 5.28 (P < 0.0001). This strong relationship is dependent on the intensity of post-treatment follow-up and investigation.     

Is radiotherapy needed after breast conservation for small invasive breast cancers?

AIMS: The purpose of this study was to determine the rate of local recurrence in patients with small invasive breast cancers (<1 cm) who had been treated with breast-conserving surgery either with (group 1) or without (group 2) adjuvant radiotherapy. METHODS: This is a retrospective study of 110 patients with an invasive breast cancer less than 1 cm in size, treated in our centre by breast-conserving surgery. Parameters examined included age at and mode of presentation, histopathological features, adjuvant therapy, length of follow-up and outcome in terms of local recurrence rate and death. RESULTS: In group 1 there were 59 women of median age 57 (38-80) years. The median tumour size was 9 (1-10) mm and median follow-up was 74 (15-110) months. There were no local recurrences. In group 2 the median age at presentation was 59 (48-81) years. The median tumour size was 7 (2-10) mm and median follow-up was 47 (14-93) months. There were three non-breast-cancer related deaths and three local recurrences (6%). CONCLUSIONS: A local recurrence rate of 6% at almost 4 years median follow-up suggests that it may be possible to avoid adjuvant radiotherapy in a subgroup of largely screen-detected, node-negative patients with invasive tumours less than 1 cm, in whom adequate local excision is performed. Further follow-up is required to substantiate this.