05-02-2013, 10:13 AM
Breast Cancer
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INTRODUCTION
Breast cancer is the 2nd most prevalent carcinoma among Indian women 1st being carcinoma cervix. Even with this disease load, it is curable if it is treated in early stage. Hence diagnosis in early stage is of prime importance.
Paget’s disease of breast takes its name from the great English surgeon and pathologist Sir James Paget (1814-99). At St. Bartholomew's Hospital, London, Paget first reported the association between skin changes of the nipple and the development of breast cancer in 1874.
Paget’s disease of breast is an uncommon entity characterised by clinical findings such as nipple changes with or without an underlying palpable mass invariably associated with underlying malignancy. About 1-4% of female breast carcinoma cases are associated with Paget disease. Paget disease cases have almost 100% chance of underlying malignancy (Kao GF et al 1986). Mean age at the time of diagnosis of Paget disease of breast is 55 years (ranges from 53 to 59 years). The average age of diagnosis of patients with Paget disease of breast is 5-10 years older than individuals with breast carcinoma.
AIMS & OBJECTIVES
1. To study the frequency of Paget’s disease of breast among patients of carcinoma of breast presented to M.B.G.H, Udaipur.
2. To study clinical profile of patents of Paget’s disease of breast & comparison with non-Paget’s cases.
3. To study difference in outcome in terms of treatment and survival with that of non-Paget’s breast cancer.
REVIEW OF LITERATURE
John of Arderne (1307) recorded the several-year evolution of nipple ulceration in a male priest, with the subsequent development of a breast cancer. (Graham H. 1939). Velpeau (1840) described the visual surface lesion of Paget's disease of breast in two patients and is typically credited with the first clinical description of the condition.
Sir James Paget (1874) recorded the association of the clinical findings with an underlying breast cancer in 15 patients. Female breast cancer preceded by or associated with eczematoid changes of the nipple remains a classic of clinical observation. Paget's description of this lesion of the nipple which was inevitably followed by the "formation of scirrhous cancer in the mammary gland" has not been improved upon. In Paget's patients the eruption in the nipple preceded the development of cancer and he postulated that the underlying cancer was stimulated or induced by the eczematoid changes. (Ridenhour, C. E., 1969). Butlin (1880) and Cheatle (1923) also supported this study.
Menstrual status:
Martin VG et al. (1994) they found that it occurs most commonly in post-menopausal women, often during the sixth decade of life (mean age 57 years).They also observed Paget’s disease of breast in adolescents. According to Ascensao AC et al., (1985) Paget’s disease of breast occurs in elderly also.
In the Western countries, PD of breast is more common in older post-menopausal female. There are two patterns of PD of breast in physical examination, patients present with or without a palpable mass in the breast (Sakorafas et al. 2001).
Zheng et al (2012) in China found that Paget’s disease of breast was more common in premenopausal (63.2%) women with the mean age 48.1; the proportion of patients in postmenopausal status was 36.8%.
Duration of symptoms:
Helman et al. (1956), Maier and co-workers (1969) Prolonged symptoms are characteristic in Paget's disease. Almost 40% of patients had symptoms for a year or more. Delay in obtaining treatment has been reported by others. Interestingly, delay in instituting definitive therapy had no apparent deleterious effect on 5-year survival or on recurrence.
The diagnosis in patients with Paget's disease of the breast is often delayed for months because it is commonly treated initially as a benign dermatologic condition. (Kaelin CM et al. 2004).
Clinical presentation:
West and Nickel (1942) identified two clinical forms but divided their patients on the basis of complaints. Eight of 13 patients with "eczema" had underlying breast masses.
In a study done by Bhave S et al. (1992) at Tata Memorial Hospital Parel, Bombay, India found that on only few patients presented with a lump associated with underlying breast carcinoma either ductal carcinoma in situ or invasive ductal carcinoma. . The presence of an underlying breast carcinoma in Paget's disease of the breast suggests that radical mastectomy is the treatment of choice in this condition.
DISCUSSION
Paget's disease of the breast is a disorder of the nipple–areola complex, first described by Sir James Paget in 1874 as eczematous lesion of nipple associated with underlying breast carcinoma (Breslin TM et al. 2004), this is supported by Thin and in 1881 Thin observed that nipple lesion contained malignant cells which was related to underlying carcinoma suggest intraductal extension of Paget’s cells through lactiferous ducts that known today as Pagetoid spread. The most widely accepted hypothesis regarding the origin of Paget cells is the Epidermotropic theory, which maintains that Paget cells are derived from an underlying mammary adenocarcinoma. This is also supported by Muir (1939). According to him areolar and nipple changes occur as a result of direct extension of cells via the lactiferous ducts, from an underlying carcinoma.
Hormonal receptor status:
Receptor status in past two decades has gained increased popularity among mammologists throughout the globe as it opened a new arena for breast cancer specialists to treat breast cancer in novel way. In receptor positive patients clinical outcome was much better than receptor negative tumours and receptor status became important tool for management of breast cancer. The development of immune histochemistry assay for ER/PR hormone receptor and epidermal growth factor Her-2/neu led to a great deal as prognostic factor. ER/ PR positive patients had longer survival than ER/PR negative patients.
Smith KJ et al. (1997) and Yao DX et al. (2002) reported that immune histochemistry is useful not only in the diagnosis of the Paget's disease of breast but also in differentiating it from other entities and in attempting to clarify the cell of origin in Paget's disease of breast. Paget's cells show similar immune histochemical staining pattern as that of adenocarcinoma growing within the breast.
SUMMARY & CONCLUSION
1. A total 1068 primary breast cancer patients included in this study during 2002-2011, 30 patients diagnosed with Paget's disease of breast representing 2.81% (30/1068) of total primary breast cancer patients.
2. In Paget's disease of breast common age group affected is 51-60 years accounts 56.67% cases and in non- Paget's disease of breast 60.02% of patients are below 50 years (P=.003).
3. Although Paget's disease of breast are found to be more in post-menopausal women which is statistically found to be insignificant (P=.260).
4. In our study most common clinical presentation in Paget's disease of breast is eczematous lesion of nipple with lump (42.86%) and without lump (44.44%).
5. Paget's disease of breast commonly involve central portion of breast.