Cancer in nipple of breast
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Cancer in the Nipple of the Breast: A Comprehensive Overview
Prevalence and Detection of Nipple Involvement in Breast Cancer
Nipple involvement in breast cancer is more common than often realized. Studies have shown that malignant changes in the nipple occur frequently, with one study reporting tumor presence in 58% of examined nipples from mastectomy cases. Another study found nipple involvement in 38% of breast cancer patients, highlighting the need for thorough examination of the nipple during diagnosis and treatment planning.
Types of Nipple Involvement
Non-Invasive and Invasive Carcinomas
Nipple involvement can be both non-invasive and invasive. Non-invasive tumors, such as ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS), are often found in the nipple. Invasive carcinomas, although less common, also occur and can present as larger masses or skin changes . In one study, 30.2% of mastectomy specimens showed carcinomatous changes in the nipple, with an equal distribution between invasive and non-invasive types.
Paget's Disease of the Nipple
Paget's disease is a rare form of breast cancer that affects the nipple-areolar complex. It often presents with symptoms like itching and eczematous changes, which can progress to ulceration and destruction of the nipple and areola in advanced stages. Paget's cells are thought to originate from ductal cancer cells that migrate to the nipple epidermis.
Clinical and Imaging Features
Symptoms and Presentation
Patients with nipple-involved breast cancer often present with symptoms such as nipple thickening, exudative crusts, or palpable masses. These symptoms can be subtle, making early detection challenging. In some cases, skin changes from DCIS involving the nipple skin (Paget disease) are observed, with small foci of invasion into the dermis.
Imaging and Diagnostic Challenges
Mammography and other imaging studies frequently fail to detect nipple-involved cancers, necessitating a high index of suspicion and thorough clinical examination. Histological examination of multiple transverse sections of the nipple is crucial for accurate diagnosis, as a single sagittal section may miss eccentrically located tumors.
Implications for Treatment and Surgery
Nipple-Sparing Mastectomy
The oncological safety of nipple-sparing mastectomy (NSM) is still debated. Studies suggest that NSM may be suitable for selected cases with a low probability of nipple involvement. A retroareolar en-face margin can be used to test for occult involvement in patients undergoing NSM. However, thorough direct sampling is essential to predict the presence of non-invasive carcinomatous involvement.
Conservative Therapeutic Programs
The high incidence of nipple involvement necessitates careful consideration in planning conservative therapeutic programs. The presence of multicentric and multifocal carcinomas further complicates treatment decisions, as these factors correlate with nipple involvement.
Conclusion
Nipple involvement in breast cancer is a significant and often under-recognized issue. Both non-invasive and invasive carcinomas can affect the nipple, with Paget's disease being a notable subtype. Clinical symptoms are often subtle, and imaging may not always detect these cancers, underscoring the importance of thorough histological examination. Treatment strategies, including nipple-sparing mastectomy, must consider the high prevalence of nipple involvement to ensure comprehensive cancer management.
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