A Canadian study analyzes the radiological criteria to choose between mastectomy and conservative surgery in the breast page disease, a rare form representing 2 % of breast cancers.
The breast’s page disease represents approximately 2 % of breast cancers. This particular form characterized by an ulceration of the nipple is in two thirds of the cases associated with an underlying carcinoma on-site Or infiltrating, emphasizing the importance of interpreting preoperative imagery with finesse, which can be enriched with magnetic resonance imaging (MRI). Treatment, conventionally reduced to mastectomy (MT), can also be a conservative breast surgery (CCS), however sacrificing the nipple, by being distrusted with associated multifocal breast cancer. Canadian work wanted to determine the radiological criteria that would help to choose from these two therapeutic options.
A monocentric retrospective journal: 30 cases of Paget’s Disease
The authors took over the patients of patients processed in their Vancouver center (Canada) between 2009 and 2022, excluding recurrences of breast cancer and metastatic forms.
Mammography, ultrasound was systematic, a possible MRI request being left to the discretion of the surgeon. The diagnosis of Paget de breast disease, mentioned clinically, was confirmed by a cytopunction or biopsy in the nipple. The size of the suspicious lesion in preoperative imaging was compared with the size of the lesion on the Anatomo-Pathological piece, which made it possible to distinguish over-estimated or underestimated lesions (difference of at least 5mm), or concordant.
From 2009 to 2022, among 6,822 breast cancers, 30 cases of Paget disease (0.4 %) were diagnosed, including 21 treaties with mastectomy and 9 by conservative surgery.
A different clinical presentation
Patients who had benefited from conservative surgery presented themselves most often with isolated nipple changes, without flow or palpable mass, without lymph node involvement, with receptors for estrogens and positive but negative progesterone to Herceptin, and without tumor image. Of the 9 conservative surgeries, one had to be transformed secondarily into a mastectomy.
If the sample of the sentinel node was the rule during mastectomies, it was only practiced once during conservative surgeries.
No patient has received neoadjuvant chemotherapy. After surgery, 5 patients received adjuvant chemotherapy and 10 postoperative radiotherapy, including 5 of the 9 patients who had benefited from conservative surgery.
30 % concordance between positive pre-operative imaging and anatomo-pathological analysis
Of the 11 cases where mammography and ultrasound were negative, 5 patients were treated by MasterCtomie. The final diagnosis of these 5 patients was: a pure page disease, 1 cancer on-site3 infiltrating breast cancers. That for the 6 patients who benefited from conservative surgery was: a pure paget disease, 4 breast cancers on-siteinfiltrating cancer. The elements that had pushed to the indication of a mastectomy were: the desire of the patient, multifocal lesions, a too large tumor, a central seat in the breast, an axillary lymphadenopathy and a case of male sex.
Of these 11 cases, 5 gave rise to a pre-operative MRI, 4 of which revealed images of enhancement under areolar and were all operated in a conservative manner.
Among the 19 patients who had abnormal images on pre-operative ultrasound or mammography, imagery was only concordant with anatomopathology in 6 cases (31.6 %), with a majority underestimation of the lesion.
It is on the mammography of the lesions identified in T1 sequence on MRI that the concordance rate is the least bad (50 %); It is only 25 % with ultrasound on T1 and he is null in all cases on T2.
There was no local recurrence during an average follow -up of 3 years but a death by liver metastases after masterctomy in a patient in whom imagery (mammography and ultrasound) was normal and without palpable mass.
In conclusion, MRI can be useful in certain cases of preoperative radiological negativity and conservative surgery can be proposed when there are no disturbing clinical and radiological signs during the breast page disease.