A patient with Paget's disease of the nipple and no underlying mass on mammogram or MRI has a punch biopsy showing large pale Paget cells with prominent nucleoli within the epidermis, immunopositive for CK7 and HER2. What is the most appropriate surgical management?
- A Wide local excision of nipple-areola complex with clear margins ✓
- B Total (simple) mastectomy
- C Central lumpectomy with sentinel node biopsy
- D Nipple-sparing mastectomy
Explanation
Paget's disease confined to the nipple-areola complex without an underlying mass may be treated with central excision (wide local excision of the nipple-areola complex) with clear surgical margins, followed by whole-breast radiotherapy — analogous to breast-conserving therapy. Mastectomy is not always required. When no underlying mass is detected on MRI, breast conservation is oncologically acceptable. Sentinel node biopsy is performed as the nipple removal may compromise future lymphatic drainage. Option C combines the key surgical steps but 'central lumpectomy' is less precise than wide local excision of the NAC with SNB.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.