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

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.

Breaking the Binary: The Approach to Chest Masculinizing Gender-Affirming Surgery in Trangender Men.

BACKGROUND: The purpose of mastectomy for the transgender patient is to produce a masculine appearance of the chest. A number of algorithms have been proposed for selecting the surgical technique. A holistic and surgical approach to transgender men includes our experience-based classification system for selecting the correct surgical technique. OBJECTIVES: To present and discuss the Transgender Standard of Care and our personal experience. METHODS: Data were collected from the files of female-to-male transgender persons who underwent surgery during 2003-2019. Pictures of the patients were also analyzed. RESULTS: Until May 2021, 342 mastectomies were performed by the senior author on 171 patients. The 220 mastectomies performed on 110 patients until November 2019 were included in our cohort. Patient age was 13.5 to 50 years (mean 22.5 ± 6.1). The excision averaged 443 grams per breast (range 85-2550). A periareolar approach was performed in 14 (12.7%), omega-shaped resection (nipple-areola complex on scar) in 2 (1.8%), spindle-shaped mastectomy with a dermal nipple-areola complex flap approach in 38 (34.5%), and a complete mastectomy with a free nipple-areola complex graft in 56 (50.9%). Complications included two hypertrophic scars, six hematomas requiring revision surgery, three wound dehiscences, and three cases of partial nipple necrosis. CONCLUSIONS: A holistic approach to transgender healthcare is presented based on the World Professional Association for Transgender Health standard of care. Analysis of the data led to Wolf's classification for female-to-male transgender mastectomy based on skin excess and the distance between the original and the planned position of the nipple-areola complex.

Effect of LED therapy for the treatment nipple fissures: Study protocol for a randomized controlled trial.

INTRODUCTION: Poor positioning of the child in relation to the breast and improper suckling are the main causes of nipple fissure. Treatment options for nipple fissures include drug therapy with antifungal and antibiotics, topical applications of lanolin, glycerin gel, creams and lotions, the milk itself, hot compresses, and silicone nipple shields. Studies involving light-emitting diode (LED) therapy have demonstrated anti-inflammatory properties, the enhancement of the wound repair process, and the control of pain. As it does not cause discomfort, is relatively inexpensive and may impede the discontinuation of breastfeeding, phototherapy could be a viable option for the treatment of nipple fissures. AIM: The principal objective of the proposed study is to evaluate the effectiveness of LED therapy for the treatment of nipple fissures in postpartum mothers. MATERIALS AND METHODS: One hundred patients treated with a medical diagnosis of bilateral nipple trauma classified as nipple fissures or cracks will participate in the study, randomized into 2 groups: The control group will receive orientation regarding breast care and adequate breastfeeding techniques. The experimental group will receive the same orientation and phototherapy sessions using a device developed especially for the treatment of nipple trauma. Both groups will be followed up for 6 consecutive weeks.

Chemoprevention of Breast Cancer by Transdermal Delivery of α-Santalol through Breast Skin and Mammary Papilla (Nipple).

PURPOSE: Almost all breast cancers originate from epithelial cells lining the milk ducts in the breast. To this end, the study investigated the feasibility of localized transdermal delivery of α-santalol, a natural chemopreventive agent to the breast. METHODS: Different α-santalol formulations (cream, solution and microemulsion) were developed and the in vitro permeability was studied using excised animal (porcine and rat) and human breast skin/mammary papilla (nipple). The in vivo biodistribution and efficacy studies were conducted in female rats. A chemical carcinogenesis model of breast cancer was used for the efficacy studies. RESULTS: Phospholipid based α-santalol microemulsion showed the highest penetration through the nipple and breast skin. Delivery of α-santalol through the entire breast (breast skin and nipple) in vivo in rats resulted in significantly higher concentration in the mammary gland compared to transdermal delivery through the breast skin or nipple. There was no measurable α-santalol concentration in the blood. Transdermal delivery of α-santalol reduced the tumor incidence and tumor multiplicity. Furthermore, the tumor size was significantly reduced with α-santalol treatment. CONCLUSIONS: The findings from this study demonstrate the feasibility of localized transdermal delivery of α-santalol for chemoprevention of breast cancer.

Radiation delivery in patients undergoing therapeutic nipple-sparing mastectomy.

BACKGROUND: Although guidelines exist for radiation delivery in the setting of mastectomy or breast-conservation therapy, radiation delivery after nipple-sparing mastectomy (NSM) remains variable. Our goal is to determine whether patients who undergo therapeutic NSM are more likely to receive radiation than patients who undergo non-NSM and whether National Comprehensive Cancer Network (NCCN) guidelines for radiation after mastectomy are observed in NSM patients. METHODS: Female patients who underwent NSM or non-NSM for breast cancer from 2006 to 2010 were isolated from the Surveillance, Epidemiology, and End Results database. Univariate analysis stratified by tumor size and lymph node status, and multivariate analyses were used to compare odds of radiation in NSM and mastectomy patients. Adherence to NCCN guidelines based on tumor size and lymph node status was also investigated. RESULTS: A total of 112,817 patients were included: 470 (0.4 %) underwent NSM, and 112,347 (99.6 %) underwent non-NSM. NSM patients with 0 nodes/size ≤2 cm, 0 nodes/size 2-5 cm, and unexamined axilla/size ≤2 cm had higher odds of radiation when compared with size- and node-matched mastectomy patients. Multivariate logistic regression showed that NSM patients had higher odds of radiation (odds ratio 2.01, p < 0.001) than mastectomy patients. Radiation was given to 18 % of NSM patients who did not meet NCCN guidelines according to size or lymph node involvement, compared with 6 % of mastectomy patients. CONCLUSIONS: Patients who undergo therapeutic NSM are more likely to receive radiation compared with mastectomy patients. This may reflect a concern with leaving ductal tissue in the nipple-areolar complex.

[Effects of encircled needling plus electroacupuncture on hyperplastic mammary glands and serum sex hormones in the rat].

OBJECTIVE: To observe the effect of encircled needling plus electroacupuncture (EA) of the second pair of nipples on hyperplastic mammary glands, serum estradiol (E2), progesterone (P), prolactin (PRL) and testosterone (T) contents, estrogen receptor (ER) expression of the mammary glands in mammary hyperplasia rats. METHODS: Forty Wistar rats were equally randomized into normal control, model, acupuncture and medication groups. Mammary gland hyperplasia model was established by intramuscular injection of diethylstilbestrol (0.5 mg/kg, once daily for 25 days) and progesterone (4 mg/kg, once daily for 5 days). For rats of the acupuncture group, 4 filiform needles were inserted into the surrounding tissues of the second pair of breasts, respectively, followed by giving the animal with EA stimulation for 30 min. Another one acupuncture needle was inserted into "Danzhong" (CV 17) and retained for 30 min. For rats of the medication group, tamoxifen solution (1.8 mg/kg) was given by gavage. Both medication and EA intervention were given once daily for 30 days. The diameter and height of the second pair of nipples were measured before and on the 10th, 20th and 30th days of the treatment. Serum E2, P, PRL and T levels were assayed by radioimmunoassay, and the tissues of the second pair of nipples were stained with H. E. method. Estrogen receptor immunoactivity of the breast tissue was detected by immunohistochemistry. RESULTS: The diameter and height of the second pair of nipples, serum E2, PRL and T contents, and breast ER protein expression level were significantly higher in the model group than in the normal control group (P<0.05), while serum P content was remarkably lower in the model group than in the normal control group (P<0.05). In comparison with the model group, the diameter and height of the second pair of nipples, serum E2, PRL and T contents, and breast ER protein expression level were considerably lower in both acupuncture and medication groups (P<0.05), and serum P contents were significantly higher in the latter two groups (P<0.05). In addition, H.E. staining showed that the numbers of the lobule, alveolus and ducts of mammary glands were significantly increased, and the expansion of the acinar lumina and ducts was found in the model group. These pathological changes were relatively milder in both acupuncture and medication groups. CONCLUSION: Encircled needling plus EA stimulation of the surrounding tissues of the nipples can improve the hyperplasic nipples and pathological changes of the breast tissue in mammary gland hyperplasia rats, which is closely associated with its functions in lowering serum estradiol, prolactin, testosterone contents and estrogen receptor protein expression of the breast, and in increasing serum progesterone level.

[Cutaneous manifestations of male breast cancer]. / Manifestations cutanées du cancer du sein chez l'homme.

OBJECTIVE: The appearance of skin symptoms in male breast is the main reason for consultation in our context. The aim of this study is to describe the various cutaneous manifestations of male breast cancer through a series of cases collected in a dermatology department. METHODS: A retrospective study was conducted in the dermatology department at the CHU Ibn Rochd January 1988 to December 2009. All cases of male breast cancer initially diagnosed in dermatology were included. The various epidemiological, clinical, histological and therapeutic data were collected from medical records. RESULTS: Twenty cases were collected. The mean age was 61.25 years. Skin invasion by tumor was found in all patients, and it was the reason for consultation. It was a cutaneous involvement at the nipple and areola (17 cases) and at the periareolar skin (three cases). The clinical appearance of skin involvement was vegetative type in 12 cases, infiltrating with nipple retraction in five cases and nodule with skin change in three cases. The average period of consultation was 25 months. The axillary lymph nodes were noted in 11 patients and distant metastases in eight patients. The cutaneous metastases outside breast were noted in six patients. The histological types were: infiltrating ductal carcinoma in 15 cases (75%), papillary carcinoma in two cases (10%) and non-specific carcinoma in three cases (15%). The treatment was surgery in 14 patients and consisted of radical mastectomy with complete axillary nodal dissection according to Patey. Complementary therapies, chemotherapy or radiotherapy, were indicated in 14 patients. CONCLUSION: Our single-center study with dermatological recruitment illustrates the frequency and variety of skin disease in male breast cancer and demonstrates that they are still the main reason for consultation in our context. Better information for public and practitioners would allow earlier diagnosis and a more favourable prognosis.

An investigation of professional advice advocating therapeutic sun exposure.

OBJECTIVE: To determine the prevalence of inappropriate professional advice advocating therapeutic sun exposure in infancy and the post-partum period. METHODS: Self-administered postal questionnaires were completed by doctors (n=130; 71% response) and nurses (n=285; 58.6% response) responsible for the care of post-parturient women in eight hospitals in metropolitan and regional Queensland (1999/2000). RESULTS: Both groups reported several risky beliefs about the therapeutic benefits of sun exposure including using sunlight to treat: cracked nipples (41.1% nurses, 46.2% doctors); neonatal jaundice (49.5%, 34.9%); nappy rash (23.3%, 19.5%); and acne (12.3%, 20.2%). Approximately 10% of nurses and doctors recommended sunlight to treat sore/cracked nipples from breastfeeding, while 42% recommended sun exposure to treat neonatal jaundice. Relatively few doctors and nurses who recommended therapeutic sun exposure stipulated sunning through a window. Subtropical residence was a significant predictor of recommending sunlight to treat cracked nipples (p=0.002) and nappy rash (p=0.0005) among nursing staff. Midwives were more likely to recommend sunlight for neonatal jaundice than other nurses (p=0.004). Obstetricians (p=0.046), older doctors (p=0.049) and those who qualified earlier (p=0.031) were more likely to recommend sunlight to treat nappy rash. Paediatricians and neonatologists were less likely to recommend sunlight to treat neonatal jaundice than obstetricians and other doctors (p=0.009). CONCLUSIONS AND IMPLICATIONS: An education program is needed to change the practices of health professionals who recommend therapeutic sun exposure and should coincide with a health promotion campaign aimed at reducing the prevalence of related risky beliefs among parents.

Infant feeding and risk of mother-to-child transmission of HIV-1 in São Paulo State, Brazil. São Paulo Collaborative Study for Vertical Transmission of HIV-1.

Although vertical transmission of HIV-1 can occur through breast-feeding, little is known about the effect of colostrum, duration of breast-feeding, mixing feeding, and nipple pathology. We used retrospective cohort data to examine the association between breast-feeding-related factors and transmission of HIV-1 from mother to child in São Paulo State, Brazil. Information on maternal and postnatal factors was collected by medical record review and interview. Infection status was determined for 434 children by anti-HIV-1 tests performed beyond 18 months of age or diagnosis of AIDS at any age. Among 168 breast-fed children, the risk of transmission of HIV-1 was 21%, compared with 13% (p = .01) among 264 children artificially fed. Breast-feeding was independently and significantly associated with mother-to-child transmission of HIV-1 after controlling for stage of maternal HIV-1 disease (odds ratio [OR] = 2.2; 95% confidence interval [CI], 1.3-3.8). A trend was shown toward an increased risk of transmission with longer duration of breast-feeding, a history of bleeding nipples, and introduction of other liquid food before weaning, but these associations were not statistically significant. History of colostrum intake or cracked nipples without bleeding were not associated with transmission. Most of the women who breast-fed were unaware of their HIV-1 infection status at the time of delivery. Avoidance of mixed feeding and withholding of breast-feeding in the presence of bleeding nipples should be considered in further research as strategies to reduce postnatal transmission of HIV-1 in settings in which safe and sustainable alternatives for breast-feeding are not yet available.