Breast Disease

Paget’s disease of the breast is rare. The National Cancer Database (NCDB) is one of the largest tumor databases in the United States.

We queried the NCDB to identify male and female patients with Paget’s disease of the breast who were treated from January 1, 2004, through December 31, 2015. No age limitations were applied. Descriptive statistical analysis and survival analysis were performed.

We analyzed the demographic, disease, and treatment characteristics of 7,191 patients with Paget’s disease of the breast. The median (range) age was 64 (20–90) years. Only 2.1% of patients were men, and 85.4% were white. The most common treatment was complete mastectomy (65.3%), followed by partial mastectomy (30.3%). Tumor destruction was performed in 0.1% of patients, and 4.3% of patients did not undergo any surgery. We examined survival in the subset of 6,864 patients who were treated surgically with complete mastectomy or partial mastectomy. The 5-year survival rate after surgery was 82.5% (95% CI, 81.1%–83.9%). Factors associated with shorter survival were older age, black race/ethnicity, higher tumor grade, regional lymph node metastasis, higher cancer stage, metastatic cancer, and larger tumor size.

Paget’s disease of the breast usually affects patients older than 60 years, and the most common treatment is complete mastectomy. The 5-year overall survival rate of patients with Paget’s disease of the breast is greater than 80% but is lower among older and black people.

Traditionally lumpectomy as a part of breast-conserving surgery (BCS) is performed by palpation-guided method leading to positive margins and large excision volumes. There is no evidence suggesting that wide margin excisions decrease intra-breast tumour recurrence. Various perioperative techniques are used for margin assessment. We aimed to compare three commonly used techniques, i.e., ultrasound-guided surgery, palpation-guided surgery and cavity shaving for attaining negative margins and estimating the extent of healthy breast tissue resection.

A prospective comparative study was performed on 90 patients who underwent breast conservation surgery for early breast cancer between August 2018 and June 2019. Tumour excision with a minimum of 1 cm margin was done either using ultrasound, palpation or cavity shaving. Histopathological evaluation was done to assess the margin status and excess amount of resected normal breast tissue. Calculated resection ratio (CRR) defining the excess amount of the resected breast tissue was achieved by dividing the total resection volume (TRV) by optimal resection volume (ORV). The time taken for excision was also recorded.

Histopathology of all 90 patients (30 in each group) revealed a negative resection margin in 93.3% of 30 patients in palpation-guided surgery group and 100% in both ultrasound-guided surgery and cavity shaving groups. Two patients (6.7%) from the cavity shaving group had positive margins on initial lumpectomy but shave margins were negative. TRV was significantly less in the ultrasound-guided surgery group compared to the palpation-guided surgery group and cavity shaving group (76.9 cm³, 94.7 cm³ and 126.3 cm³ respectively; p < 0.0051). CRR was 1.2 in ultrasound group compared to 1.9 in palpation group and 2.1 in cavity shave group which was also statistically significant (p < 0.0001).

Excision time was significantly less (p < 0.001) in palpation-guided surgery group (13.8 min) compared to cavity shaving group (15.1 min) and ultrasound-guided group (19.4 min).

Ultrasound-guided surgery is more accurate in attaining negative margins with the removal of least amount of healthy breast tissue compared to palpation-guided surgery and cavity shaving.

The importance of cancer stem cells (CSCs) in initiation and progression of breast cancer has been well established. This population of cells is characterized by high expression of CD44 and low expression of CD24.

However, the relative abundance of CD24 and CD44 transcripts in breast cancer tissues and adjacent non-cancerous tissues (ANCTs) has not been quantified yet.

In the present investigation, we assessed expression of CD24 and CD44 at transcript level in breast cancer tissues and ANCTs in association with clinical determinants of patients’ outcome and parameters that predict response to therapeutic options.

There was no significant difference in expression of CD24 and CD44 in breast cancer tissues compared with ANCTs (Expression ratios: 1.03 and 0.84, P values: 0.92 and 0.61, respectively). However, CD44 expression was associated with tumor size in a way this gene was up-regulated in all of small sized (≤2 cm) tumors compared with the corresponding ANCTs (P value = 0.04). Besides, CD44 expression was significantly higher in tumors with extracapsular nodal extension compared with those without extension (P = 0.04). Expression of CD24 was higher in grade 3 tumors compared with grade 2 tumors (P = 0.04).

Expression levels of CD24 and CD44 were correlated with each other in ANCTs but not in tumoral tissues. The current study shows another aspect of CSC markers in the development of breast cancer.