Eczema-like carcinoma of the breast, also known as Paget’s disease of the breast, is a specific type of breast cancer with a low incidence and low malignancy. This disease is easily confused with true nipple eczema in its early stages, which delays diagnosis and treatment.
What are the early signs?
The early manifestations of eczema-like carcinoma of the breast are mainly red, itchy, slightly painful, and sometimes slightly exuding skin in the nipple areola area, which may be followed by thickening, exudation, crusting, flaking, or skin erosion or ulceration.
The above symptoms may heal temporarily after treatment by a dermatologist, but can recur many times. Therefore, when a woman has recurrent eczema-like changes in the skin of the nipple areola area, a visit to a breast specialist is recommended to rule out the possibility of eczema-like carcinoma of the breast. If the skin lesions in the nipple areola area do not heal well after more than 2 weeks of treatment, a visit to a breast specialist is recommended.
How is it diagnosed?
Physicians diagnose eczematous carcinoma of the breast based primarily on the above presentation and pathology, and finding Paget’s cells on pathology will confirm the diagnosis. Common pathologic diagnoses include cytology and surgical excision of the entire skin layer of the lesion for histopathologic examination.
- Cytological examination is a noninvasive diagnostic method. Usually, after removing the scab from the lesion in the nipple-areola area and removing the secretions, a glass slide is pressed onto the wound to obtain cells (blotting method), and if there is a spill, the spill is also taken and applied to the peeled slide for examination. Multiple cytologic examinations help increase the accuracy of the diagnosis, but a negative result does not completely rule out breast cancer.
- Histopathology is an invasive test that involves surgically removing a small piece of skin from the lesion for a full pathologic examination and is currently the most reliable way to make a definitive diagnosis. The skin wound will heal in about 1 week. A positive histopathological examination confirms the diagnosis, and repeated negative results basically rule out the disease.
Because eczematous carcinoma of the breast is often associated with intraductal or invasive ductal carcinoma of the breast, doctors also usually recommend imaging such as breast ultrasound or x-ray to detect lesions within the breast. For those with combined nipple discharge, the diseased duct and corresponding glandular tissue will be removed if necessary, and the diagnosis will be confirmed by pathological examination.
How is staging determined?
How is staging determined?
How is staging determined?
An important feature of eczema-like carcinoma of the breast is the presence of other types of carcinoma in addition to tumor cells in the epidermis of the nipple areola in about 80% to 90% of patients. Therefore, in addition to managing lesions in the nipple areola, the concomitant carcinoma should also be managed.
Before treatment, the physician will first define the stage of eczema-like carcinoma of the breast, which is usually one of the following 3 conditions:
Simple eczema-like carcinoma of the breast, without other cancers, without axillary lymph nodes and distant metastases, is an early stage cancer;
Eczematous carcinoma of the breast with intraductal carcinoma, without axillary lymph nodes and distant metastases, is also early-stage cancer;
Eczematous carcinoma of the breast with invasive breast cancer should be staged with reference to invasive carcinoma.
As seen, the staging of eczema-like carcinoma of the breast is mainly related to the associated carcinoma.
How is it treated?
Treatment of eczematous carcinoma of the breast should be aggressive, and physicians will be particularly concerned about the accompanying cancer.
Surgery is a very important treatment for eczematous carcinoma of the breast and is considered first unless there is an absolute contraindication. The type of surgery is associated with the presence of other breast cancers.
- In cases of simple eczematous carcinoma of the breast or in the absence of axillary lymph node metastasis on preoperative examination, total excision of the affected breast + biopsy of the sentinel lymph node is usually considered, and axillary debulking may be omitted if there is no metastasis in the sentinel lymph node. The same approach applies when combined with intraductal carcinoma.
- If eczematous breast cancer is combined with invasive breast cancer, it is treated as invasive breast cancer, and the decision to biopsy the sentinel lymph node and to perform axillary lymph node dissection is based on preoperative evaluation and postoperative pathology.
Breast-conserving surgery is also an option for eczema-like carcinoma of the breast.
- If no mass is found on examination and no abnormal changes are detected on imaging, the surgeon will consider excision of the nipple areola and its deeper breast. Preoperative axillary lymph node examination without metastasis can be performed without axillary sentinel lymph node biopsy.
- Even with concomitant cancer, breast conservation is considered, provided that the criteria for breast conservation are met and the margins are negative, and the surgeon will decide to do an axillary sentinel lymph node biopsy or axillary lymph node dissection, depending on the situation.
In summary, mastectomy + axillary staging (sentinel lymph node biopsy or axillary lymph node dissection) is the appropriate option for all eczematous carcinomas of the breast, and for those who need breast conservation and are eligible for breast conservation, but the surgeon will determine whether axillary lymph node management is needed based on the preoperative evaluation. In postoperative treatment, the surgeon will decide whether to give endocrine therapy, chemotherapy, radiotherapy, or targeted therapy based on the concomitant breast cancer, but radiotherapy must be done after breast-conserving surgery (unless radiotherapy is contraindicated).
How does the treatment work?
The outcome after treatment for simple eczematous carcinoma of the breast is usually very good, but the presence of an associated cancer leads to a worse outcome, especially if it is an invasive cancer. Concomitant cancer determines the staging, treatment, and outcome of eczematous carcinoma of the breast. Therefore, preoperative evaluation and detailed postoperative pathologic examination are critical.