examined whether outcome following BCT could be affected by tumor location within the breast. The study found that nei- ther disease-free survival nor overall survival were increased in those patients with central cancers. Paget disease has historically been treated with mastectomy but was seen in 5 of the subjects in the present study un- dergoing NAC resection. A multi-institution review

4was recently published in which all patients had histological confirmation of Paget disease and were treated with BCT, including adjuvant radiotherapy. Only 4 (11%) of 36 patients had an inbreastrecurrenceat113monthsofmedianfollow-up,indicatingthatmostpatientswithPagetdiseasecanbemanagedsuccessfully with BCT, which commonly requires excision of the NAC. Such studies should serve to increase the acceptance of this procedure as an appropriate alternative to mastectomy in the setting of Paget disease. Although only 7 patients in the current study responded to the postoperative satisfaction survey, the results were nevertheless heartening. All respondents answered that they would choose the same procedure again and were very satisfied with their appearance in clothing. Patient selection remains an important consideration for NAC resection, as for all candidates considered for BCT. In patients with smaller breasts, excision of the NAC may result in a significant deformity. In such cases, a skin-sparing mastectomy with reconstruction may yield a superior cosmetic result, although this must obviously be balanced against the increased potential for perioperative morbidity. For patients with larger breasts, particularly those with ptosis, we have found that a contralateral mastopexy is an excellent option to consider as part of surgical treatment planning. Finally, 5 of 10 patients in the study with known invasive cancer underwent axillary dissection, with the remainder treated by axillary radiation. This may reflect the interval in which patients were treated (1989-1999), a time when there was a notable shift in the management of the axilla for breast cancer. Patients known to have invasive cancer prior to NAC resection would be excellent candidates for sentinel lymphadenectomy with subareolar injection of technetium, lymphazurin, or both. Although this study is limited by its size and potential ascertainment bias, the overall findings are encouraging. Given the alternative of mastectomy and possible reconstruction, this procedure presents a very attractive option to many women with central lesions interested in BCT.