Her clinical picture seems suspicious enough for Paget's disease that I
would probably feel comfortable without an additional biopsy, but I agree
that the nipple could easily be biopsied to look for the presence of
Paget's cells.  Since diagnosis and treatment should be tailored to the
individual patient, and since she is interested in preserving that breast
for future breastfeeding if possible, IMO the nipple should be biopsied
for that reason alone.

If it is Paget's disease, my textbook (Greenfield) does state that under
some conditions (depending on tumor size, proximity to the nipple, etc.)
breast conserving therapy (BCT) can be performed.  However, this would
still necessitate removal of the nipple/areolar complex, so breastfeeding
from that side would not be possible.

You usually don't perform lymph node dissections for DCIS.  If there was
significant microinvasion, sentinel lymph node biopsy is considered
standard of care over axillary lymph node dissection (though still not
done universally.)  I'm not sure of the effects of the radioactive dye
given in a breastfeeding woman (not actually sure which one we give!) but
some well-respected and well-trained surgeons use the blue dye alone with
good effect -- the accuracy of identification is based on the use of
breast massage and the familiarity of the surgeon with the technique.  If
her sentinel node is cancer-free and her tumor was small OR her tumor was
noninvasive, then she should be able to get by without chemotherapy.

Shannon McElearney, MD
probable future breast surgeon, though currently with only a handful of
mastectomies to my name, so take with a grain of salt

On Wed, 23 Mar 2005 20:18:38 -0500, Catherine Watson Genna, IBCLC
<[log in to unmask]> wrote:

>A mom in my area has been diagnosed with DCIS (ductal carcinoma in situ)
>that may or may not be secondary to Paget's disease.  She is currently
>bf her 1 year old (and bf her 6 yo for 3 years).  For most of the past
>year she has had a raw peeling nipple, and pain in the breast.  She gave
>up bf on that breast at least 8 months ago, and consulted several
>doctors and was treated for infections and mastalgia.  Continued pain
>and a large lump brought her back to the doctor, and a fine needle
>aspiration was done of a 4-5cm tumor.  The FNA biopsy came back
>adenocarcinoma.  Next an incisional biopsy was done, and the results
>were DCIS, preinvasive, moderate grade.  The doctor who did the biopsies
>recommends a mastectomy, because she feels that the tumor started from
>Paget's disease of the nipple.  (Receptor tests and BRCA gene tests have
>not come back yet).
>
>No one seems interested in biopsying the nipple to see if the whole
>breast really does need to come off, or if lumpectomy and radiation
>would be enough.  She's also concerned about estrogen suppression
>therapy if the tumor turns out to be estrogen receptor positive, and
>would love to be able to continue breastfeeding.  Obviously her primary
>goal is to live to care for her small children, but she would like to
>preserve breastfeeding in the contralateral breast and be recovering
>from surgery for as little time as possible, hence the appeal of the
>more limited operation.
>
>Any words of wisdom, or experience with Paget's disease or DCIS in
>lactating women?
>Thanks.
>Catherine Watson Genna, IBCLC  NYC
>
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