Paget disease of the nipple: a multifocal manifestation of higher-risk disease.
BACKGROUND
The treatment of Paget disease by mastectomy has been challenged recently in favor of breast-conserving techniques. A large series of patients treated with mastectomy has been reviewed to assess the feasibility of less radical surgery.


METHODS
The cases of 70 women with a clinical diagnosis of Paget disease were reviewed. The type, grade, receptor and node status, and the mammographic and pathologic extent of the underlying breast malignancy were determined. The survival of patients with invasive disease was compared with matched controls without Paget disease.


RESULTS
The underlying malignancy was invasive in 58% of cases. Despite the fact that only one third of women presented with a palpable mass, the malignancy was frequently extensive, being confined to the retroareolar region in only 25% of cases. The true extent of the disease was underestimated by mammography in 43% of cases. Of the patients with ductal in situ carcinoma, 96.5% had high-grade carcinomas and 100% had invasive carcinomas of high cytonuclear grade. Overexpression of the c-erb-B2 oncogene was detectable in 83% of cases. Patients with Paget disease had a significantly worse survival than matched controls, but this difference was eliminated if they were also matched for c-erb-B2 status.


CONCLUSIONS
Paget disease is often associated with extensive underlying malignancy, which is difficult to assess accurately either clinically or mammographically. As a consequence, cone excision of the nipple would have resulted in incomplete excision in 75% of cases. The underlying disease is of high grade and is frequently c-erb-B2 positive with a resulting poor prognosis. Aggressive local and systemic treatment would seem to be merited.
Hedley Atkins Breast Unit, Guy's Hospital, London, United Kingdom.
Ashutosh S
AS
Kothari
Nicolas
N
Beechey-Newman
Hisham
H
Hamed
Ian S
IS
Fentiman
Corrado
C
D'Arrigo
Andrew M
AM
Hanby
Ken
K
Ryder
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery; D005260:Female; D006801:Humans; D008875:Middle Aged; D010144:Paget's Disease, Mammary / Q000401:mortality / Q000473:pathology* / Q000601:surgery; D011379:Prognosis; D015996:Survival Rate