Local recurrence of mammary Paget’s disease after nipple-sparing mastectomy and implant breast reconstruction: a case report and literature review

Abstract

Objective To provide a rare case of local recurrent Paget’s disease after nipple-sparing mastectomy (NSM) with immediate breast reconstruction with 10 years of disease-free survival and to analyze the clinical and pathological characteristics. Background Mammary Paget’s disease can be considered a rare type of local recurrence after breast cancer treatment, both in cases of conservative surgery and NSM with immediate breast reconstruction (Lohsiriwat et al, Ann Surg Oncol 19:1850-1855, 2012). Recurrent patients who present with nipple-areolar Paget’s disease usually have unfavorable primary pathological characteristics and different latency periods. However, the recurrent status in patients with favorable primary pathological characteristics and the latency periods after NSM with immediate breast reconstruction are unclear. Methods First, we present a case of local recurrent Paget’s disease in a young patient diagnosed with invasive breast carcinoma at age 30 who underwent NSM with primary silicone reconstruction. Then, the keywords “Paget’s disease” and “nipple-sparing mastectomy” were selected. Articles including the local recurrence of Paget’s disease after NSM were collected from the PubMed, Springer, and OVID databases, and the acquired relevant data were analyzed. We did not restrict our search by study design or publication date. Results Five studies describing 31 cases of local recurrent Paget’s disease after NSM with implant breast reconstruction were included. The mean patient age reported was 45 years, and the average latency period from NSM to the local recurrence of Paget’s disease was 40.2 months. Recurrent tumor histological features were Paget’s disease with ductal carcinoma in situ (DCIS) in 16 patients (50%), Paget’s disease without DCIS in 13 patients (40.6%), and Paget’s disease with ductal intraepithelial neoplasia (DIN) in 3 patients (9.4%). The primary tumor histological feature was estrogen receptor (ER)(−)/progesterone receptor (PR)(−)/human epidermal growth factor receptor (HER-2)(+) in 21 patients (77.8%). Neither locoregional relapse nor metastatic events were found in these recurrent patients who accepted NAC excision after 4–5 years of follow-up. Our reported case showed that the patient experienced pregnancy and lactation after primary adjuvant chemotherapy and endocrine therapy. However, she developed an eczematoid lesion in the NAC 120 months after breast surgery. The histopathological examination was consistent with Paget’s disease of the breast. Complete NAC and breast silicone prosthesis removal were performed. The patient accepted no systematic or local therapy and is currently alive. It is noteworthy that the biological features of the primary tumor were ER(+), PR(+), and HER-2(−); however, the recurrent tumor changed to ER(−), PR(−), and HER-2(+). Conclusions The local recurrence of Paget’s disease after NSM is uncommon; it may develop at a very early age and have a very long time to recurrence, as in our patient, who presented with recurrence 10 years after primary surgery. Surgeons should be wary of local recurrence of the nipple-areola complex after NSM in patients with ER-negative and HER-2-positive primary tumors. However, patients with ER/PR-positive and HER-2-negative tumors should not be neglected; we reported a case of an ER/PR-positive and HER-2-negative primary tumor, and ER-positive recurrent cases have the longest latency period. The local recurrence rate of Paget’s disease after NSM is low, and the prognosis is good in recurrent patients who accept further extensive NAC excision. Further systematic treatment was not considered for this patient.

Dense Lichenoid Inflammation in Paget Disease: A Diagnostic Pitfall

“…Local recurrence of breast cancer in the form of Paget disease has been reported status post nipple-sparing mastectomy. 9,10 Herein, we describe a case of dense lichenoid inflammation obscuring a diagnosis of mammary Paget disease. Pseudolymphoma was the initial leading histopathologic diagnosis in this case.…”

“…Local recurrence of breast cancer in the form of Paget disease has been reported status post nipple-sparing mastectomy. 9,10…”

Mammary Paget’s Disease as a Sign of Local Recurrence Two Decades Following Breast Conservation and Adjuvant Therapy for Early Stage Breast Cancer

“…This case of MPD highlights a unique clinical sign for breast cancer diagnosis in the context of previously treated ipsilateral breast cancer after roughly two decades in remission. Two published case studies highlight MPD recurrence 10 years after treatment in women who underwent breast reconstruction and nipple-sparing mastectomy (NSM) [ 8 ]. Another is a report of MPD at a prior core needle biopsy site 1.5 years after the biopsy [ 9 ].…”

Oncoplastic surgery for Paget’s disease of the breast

“…Patients with PDB who undergo mastectomy typically do not undergo reconstruction. There are only a few articles in the literature reporting on patients with PDB who undergo mastectomy also undergo reconstruction, which can be performed with a prosthesis, as in skin-sparing mastectomy or skin-reducing mastectomy ( 19 , 40 , 41 ), a myocutaneous flap, such as the latissimus dorsi ( 37 ), or local flaps ( 15 ). In one study of 115 patients, 46 mastectomies (40%) were performed, of which 17 (36.9% of the mastectomies) were skin sparing/skin reducing mastectomies ( 19 ).…”