Nipple preservation during mastectomy

Intraoperative frozen section of subareolar tissue in nipple-sparing mastectomy: Towards a less is more approach

BACKGROUND

Nipple preservation contributes to aesthetic outcome and quality of life in women undergoing Skin-Sparing Mastectomy (SSM) with immediate breast reconstruction for the treatment of breast cancer. Intraoperative Frozen Section (IFS) has been advocated to facilitate conversion from Nipple-Sparing Mastectomy (NSM) to SSM in cases with positive subareolar margins. This study investigated the application of IFS at our comprehensive cancer centre.

METHODS

In this single-centre retrospective study, for all patients who underwent therapeutic NSM with IFS from 2000 to 2021 pathological reports, patient- and tumour characteristics were retrieved.

RESULTS

In total 640 women were included in whom 662 intended NSMs with IFS had been performed. Sensitivity and specificity of frozen section compared with definitive histopathology were 75.2% and 98.5% respectively. In six women with a false positive result, the nipple had been removed. In 16 out of 32 women with a false negative result, the nipple was excised in a second procedure. In total 115 nipples were resected. In 40% of these nipples, no residual disease was detected.

DISCUSSION

IFS is a moderately sensitive and highly specific diagnostic tool to detect positive subareolar margins. An alternative approach is to omit frozen section but take intraoperative biopsies of the sub areolar margin, which are postoperatively analysed with definitive formalin-fixed paraffin-embedded histopathology. This allows for shared decision making regarding nipple excision in cases where minimal disease is found in subareolar tissue or cases with an indication for post-mastectomy radiotherapy.

An Algorithm for Selecting Buoy Skin Paddle Design for Flap Monitoring in Total Autologous Breast Reconstruction After Nipple-Sparing Mastectomy

Introduction Monitoring buried flaps in reconstructive breast surgery is challenging, and the ideal technique is controversial. Established options include leaving an exterior ("buoy" or "sentinel") skin paddle versus invasive implantable devices to avoid removing the paddle later. Technical modifications and an algorithm for strategic skin paddle positioning to circumvent this while avoiding complex monitoring equipment are proposed. Patients and methods Patients in whom buoy skin paddles were utilized for breast flap monitoring by a single surgeon were reviewed. Indications, demographic details, precise monitoring paddle location, and flap outcomes were evaluated. An algorithm and classification system were then formulated. Results Thirteen buoy skin paddles were utilized in seven patients (mean age: 43.5 years; range: 31-65) to monitor reconstructive flaps performed for risk-reducing mastectomies (four patients and seven breasts), therapeutic mastectomy (one breast), and revision surgery (three patients and five breasts). The flaps comprised seven deep inferior epigastric artery perforators (DIEPs), four superficial inferior epigastric arteries (SIEAs), and two pedicled latissimus dorsi (LDs) (mean free flap weight: 809 g; average mastectomy weight (n = 10 breasts): 467 g; range: 248-864). The skin paddles were located horizontally along the inframammary crease or vertically inferior to the nipple-areola or both. All flap transfers were successful with no re-explorations. All patients declined the monitoring paddle excision, and none have requested breast mound revision for poor cosmesis or contour deformities. Conclusion Vertical and horizontal skin paddles proved reliable for buried flap monitoring without recourse to invasive and expensive equipment. When designed appropriately, they do not require revision surgery. An algorithmic classification of skin paddle location to enable this is proposed.

Satisfaction with Long-Term Aesthetic and 10 Years Oncologic Outcome following Risk-Reducing Mastectomy and Implant-Based Breast Reconstruction with or without Nipple Preservation

Incidence of bilateral risk-reducing mastectomies (RRMs) is increasing. The aim of this study was to compare satisfaction, aesthetic and oncological outcomes in women undergoing RRM with implant-based reconstruction comparing nipple-sparing mastectomy (NSM) with skin-sparing mastectomy (SSM) (sacrificing the nipple +/− nipple reconstruction). Women who had undergone bilateral RRM between 1997 and 2016 were invited. Aesthetic outcome and nipple symmetry were evaluated using standardized anthropometric measurements. The oncological outcome was assessed at last documented follow up. Ninety-three women (186 breasts) participated, 60 (64.5%) had NSM, 33 (35.5%) SSM. Median time between surgery and participation was 98.4 months (IQR: 61.7−133.9). Of the women, 23/33 (69.7%) who had SSM underwent nipple reconstruction. Nipple projection was shorter in the reconstructed SSM group than the maintained NSM group (p < 0.001). There was no significant difference in overall symmetry (p = 0.670), satisfaction regarding nipple preservation (p = 0.257) or overall nipple satisfaction (p = 0.074). There were no diagnoses of breast cancer at a median follow up of 129 months (IQR: 65−160.6). Women who undergo nipple-sparing RRM maintain long-term nipple symmetry. Nipple projection was less maintained after nipple reconstruction. Although satisfaction with the nipples was higher in the NSM group, this did not reach statistical significance. No breast cancers developed after RRM with long-term follow up.

Subareolar Tissue Biopsy Predicts Occult Nipple Involvement in Nipple-Sparing Mastectomies

OBJECTIVES

Subareolar tissue is examined during nipple-sparing mastectomy (NSM) to minimize the risk of occult malignancy within the preserved nipple. A positive subareolar tissue biopsy typically warrants subsequent nipple excision. We study the factors associated with a positive subareolar tissue biopsy, the rate of residual malignancy in subsequent nipple excisions, and the value of subareolar tissue biopsy intraoperative frozen section (IOF).

METHODS

We identified 1,026 consecutive NSMs with separately submitted subareolar tissue biopsies over a 5.5-year period. Clinicopathologic data were reviewed. We examined concordance rates between subareolar tissue biopsy and subsequent nipple excisions as well as IOF diagnosis and permanent control diagnosis.

RESULTS

Among cases of therapeutic NSM, the rate of a positive subareolar tissue biopsy was 7.2%. Multifocal/multicentric disease (P = .0005), presence of lymphovascular invasion (P = .033), and nodal involvement (P = .006) were significantly associated with a positive subareolar tissue biopsy. Thirty-nine of 41 cases with positive subareolar biopsies underwent subsequent nipple excision, with 20 (51%) showing residual carcinoma. Among all IOF samples, 9 (3.3%) showed a discrepancy between the IOF and permanent diagnoses, mostly because of false-negatives.

CONCLUSIONS

A positive subareolar tissue biopsy predicts residual carcinoma in the excised nipples in 51% of cases. IOF is accurate and reliable.

Assessment of the Grisotti oncoplastic procedure for the management of central breast tumors

INTRODUCTION

The Grisotti technique consists to excise central breast tumor with nipple areolar and mobilize a dermo-glandular flap which is de-epithelized in order to reshape the breast and recreate an areola. The objective was to assess oncological results, postoperative side-effects, and patient and surgeon satisfaction rates resulting from this technique.

MATERIALS AND METHODS

From September 2016 to December 2019, 38 patients have been treated with a central breast tumor using the Grisotti technique.

RESULTS

The mean age was 61.6 ± 11. The median body mass index was 27 kg/m² [20-42]. Thirty one patients benefited from a sentinel lymph node dissection. Preoperative histology found a majority of invasive ductal carcinomas (IDC) (71%). There were no intraoperative complications, and the average operating time was 90 min [60-200]. Postoperative histology found IDC associated with ductal carcinoma in situ in 28 patients. The surgical margins were invaded in two patients (reoperated by mastectomy after adjuvant treatment) and invasion of a margin of less than 1 mm in another six patients (supplemented by re-excision). The main postoperative complications were an abscess of the operating site and a partial necrosis of the neo-areola. The appearance of the breasts after radiotherapy gives a high satisfaction rate, both for patients and for surgeons.

CONCLUSION

The Grisotti technique is an easily reproducible procedure without major complications. It makes it possible to perform a carcinological satisfactory central lumpectomy, correction of the central glandular defect, and reconstruction of a new areola.

Nipple Preservation in Breast Cancer Associated with Nipple Discharge

BACKGROUND

Breast carcinoma presented with nipple discharge is a rare condition. There is theoretical concern about preserving nipple in these patients since the risk of nipple-areolar complex involvement may be greater, but not many studies in the literature have addressed on this issue. The aim of the current study was to determine the incidence and outcome of nipple preservation in breast cancer associated with nipple discharge.

METHODS

Medical records of patients who were diagnosed to have breast carcinoma and presented with nipple discharge from May 2009 to October 2014 were retrospectively reviewed.

RESULTS

Sixty patients presented with nipple discharge were diagnosed with breast cancer, which represent 3.8 % of all patients who underwent breast cancer surgery in our unit during the study period. Forty-six patients (76.7 %) had nipple discharge as their only symptom, while the rest also presented with breast mass clinically or radiologically. All patients had mammogram and ultrasound performed, and 53.3 and 63.3 % respectively showed suspicious findings. Forty-one out of 46 (89.1 %) nipple discharge cytology were inadequate or benign. Thirty-two microdochectomy were performed. Routine frozen section was utilized intra-operatively to ensure clear margins. The most common histology was ductal carcinoma in situ (DCIS) (n = 29, 48.3 %), followed by DCIS with invasive ductal carcinoma (n = 23, 38.3 %). Regarding treatment, 26 patients (43.3 %) had nipple preserved, including 21 breast conservative surgery and five nipple-sparing mastectomies. Overall, no local or systemic recurrence was observed at a median follow-up of 27 months. Ten out of 34 (29.4 %) mastectomy specimens showed NAC involvement on pathology. By comparing patients with NAC preserved to patients with NAC removed, no significant preoperative predictors were identified.

CONCLUSION

Breast carcinoma patients who present with nipple discharge usually have early-stage cancer. Presence of nipple discharge is not equivalent to NAC involvement. Nipple preservation can be oncologically safe if negative margins are ascertained.

Fibroadenoma progress to ductal carcinoma in situ, infiltrating ductal carcinoma and lymph node metastasis? Report an unusual case

Fibroadenoma of the breast is the most common benign neoplasm in young women who present with a palpable, movable mass. Malignancy inside fibroadenomas is rare, with reported rates ranging from 0.002% to 0.125%. Carcinoma in situ inside a fibroadenoma is usually found incidentally when tumours are excised. Whether fibroadenoma is a risk factor for breast cancer remains controversial. Due to the rarity of carcinomas inside fibroadenomas, medical institutes have little experience with this phenomenon. We report an unusual case in which progression occurred from benign fibroadenoma to ductal carcinoma in situ, infiltrating ductal carcinoma and lymph node metastasis. A nipple-areolar complex-preserving mastectomy with immediate breast reconstruction with a gel implant and contralateral augmentation was performed. No local recurrence or metastasis was found during 5 years of follow-up.

Evaluation of Local Oncologic Safety in Nipple-Areola Complex-sparing Mastectomy After Primary Chemotherapy: A Propensity Score-matched Study

BACKGROUND

Nipple-areola complex-sparing mastectomy (NSM), extending the concept of skin-sparing mastectomy, allows for the provision of a better cosmetic result. Large operable T2-T3 breast cancer might theoretically appear suitable for this surgical option as an alternative to conventional mastectomy or breast-conserving surgery, when a good response to primary chemotherapy has been achieved.

PATIENTS AND METHODS

From January 2009 to May 2013, 422 patients with invasive breast cancer were progressively accrued to NSM. Of the 422 patients, 361 underwent NSM as first-line treatment (NSM group), and 61 underwent surgery after primary chemotherapy (NSM-PC group). A total of 151 breast cancer patients, who had undergone PC and conventional total mastectomy (TM-PC group) from 2004 to 2009 were evaluated as comparative group with respect to the NSM-PC group. Using propensity score matching, local disease-free survival (LDFS) was evaluated comparatively.

RESULTS

The rate of nipple-areola involvement in the NSM and NSM-PC groups was 13.3% and 9.8%, respectively (P = .539). The nipple-areola involvement in the NSM and NSM-PC groups was significantly associated with the tumor size (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.13-1.95; P = .004), plurifocal or pluricentric tumor (OR, 3.18; 95% CI, 1.72-5.89; P < .001), and the presence of an intraductal component (OR, 2.38; 95% CI, 1.22-4.64; P = .011). The LDFS in the NSM-PC and TM-PC matched cohorts did not show a significant difference, with a 4-year LDFS of 0.89 (95% CI, 0.77-0.95) and 0.93 (95% CI, 0.83-0.97), respectively (hazard ratio [HR], 1.31; 95% CI, 0.40-4.35; P = .655). The NSM-PC cohort was also compared with the NSM cohort in terms of LDFS using 2 different matching criteria, with the tumor size before and after neoadjuvant chemotherapy as the balancing covariate. In the first of the 2 comparisons, the hazards of local relapse were comparable between the 2 matched groups (HR, 1.23; 95% CI, 0.37-4.04; P = .739). In the second comparison, the NSM-PC patients showed a significant greater hazard of local relapse than did the NSM patients (HR, 3.60; 95% CI, 1.10-11.80; P = .035).

CONCLUSION

NSM might be a valuable option for large breast cancer treated by primary chemotherapy. The rate of local relapse seemed to be related to the disease stage, and no significant association with the type of surgery was detected.

Society of Surgical Oncology Breast Disease Working Group Statement on Prophylactic (Risk-Reducing) Mastectomy

Over the past several years, there has been an increasing rate of bilateral prophylactic mastectomy (BPM) and contralateral prophylactic mastectomy (CPM) surgeries. Since publication of the 2007 SSO position statement on the use of risk-reducing mastectomy, there have been significant advances in the understanding of breast cancer biology and treatment. The purpose of this manuscript is to review the current literature as a resource to facilitate a shared and informed decision-making process regarding the use of risk-reducing mastectomy.

Patient satisfaction with nipple-sparing mastectomy: A prospective study of patient reported outcomes using the BREAST-Q

BACKGROUND AND OBJECTIVES

The authors sought to study patient-reported outcomes following nipple-sparing mastectomy (NSM).

METHODS

From 2008 to 2011, the BREAST-Q was administered to women undergoing NSM surgery for cancer treatment or risk-reduction prior to surgery and at 2 years after completion of reconstruction. The change in score over time and the impact of surgical indication, complication occurrence, and laterality on scores were analyzed.

RESULTS

The BREAST-Q was prospectively administered to 39 women undergoing NSM for cancer treatment (n = 17) or risk-reduction (RR) (n = 22). At 2 years after operation, median overall satisfaction with breasts was 75 (IQR = 67,100). There were significant postoperative increases in scores for overall satisfaction with breasts (+8, P = 0.021) and psychosocial well-being (+14, P = 0.003). Postoperatively, RR patients had significantly higher scores for psychosocial wellness, physical impact (chest), and overall satisfaction with outcome compared to cancer treatment patients (P < 0.05). Also, increase from preoperative to postoperative psychosocial wellness was higher in the RR compared to cancer treatment patients (+17 vs. +1, P = 0.043). Complication occurrence did not significantly impact postoperative scores.

CONCLUSIONS

Following NSM for cancer treatment or RR, patients demonstrated high levels of satisfaction and quality of life as measured by BREAST-Q. Satisfaction level increased 2 years following operation. J. Surg. Oncol. 2016;114:416-422. © 2016 Wiley Periodicals, Inc.

Oncoplastic breast conserving surgery: Volume replacement vs. volume displacement

Oncoplastic breast conserving surgery (BCS) has emerged as a third option between conventional BCS and mastectomy. Oncoplastic BCS includes two fundamentally different approaches: volume replacement and volume displacement. The former involves partial mastectomy and immediate reconstruction of the breast with the transposition of autologous tissue from elsewhere, while the latter involves partial mastectomy and using the remaining breast tissue to fill the defect resulting from extirpation of the tumor. There are several benefits associated with oncoplastic BCS. First, it allows partial mastectomy without cosmetic penalties, and can achieve better cosmetic outcomes than total mastectomy with immediate breast reconstruction. Second, it avoids the need for total mastectomy in an increasing number of patients without compromising local control. Third, partial breast reconstruction is less extensive and has fewer complications than conventional procedures. Partial mastectomy and partial breast reconstruction can be carried out either simultaneously as a one-stage procedure, or using a two-stage approach. Although patients prefer a one-stage procedure, it requires intraoperative confirmation of complete tumor excision using frozen-section analysis. Moreover, oncoplastic BCS requires combined skills, knowledge, and understanding of both oncological and plastic surgeries, which may be optimally achieved by an oncoplastic surgeon.

Nipple areola complex sparing mastectomy

Breast conservative therapy (BCT) is established as a safe option for most women with early breast cancer (BC). The best conservative mastectomy that can be performed, when mastectomy is unavoidable, is nipple-areola-complex sparing mastectomy (NSM), which allows the complete glandular dissection preserving the skin envelope and the nipple areola complex. In the treatment of BC, the cosmetic outcomes have become fundamental goals, as well as oncologic control. NSM is nowadays considered an alternative technique to improve the overall quality of life for women allowing excellent cosmetic results because it provides a natural appearing breast. The breast surgeon must pay attention to details and skin incision must be planned to minimize vascular impairment to the skin and the nipple. Preservation of the blood supply to the nipple is one of the most important concern during NSM because nipple or areolar necrosis is a well-described complication of this surgery. Another issue associated with the nipple preservation and the surgical technique is oncological safety related to nipple-areola-complex (NAC) involvement in patients with invasive BC. The authors present their experience on 252 NSM performed in the Breast Surgery Unit in Forlì. Careful selection of patients for this surgical procedure is imperative and many patients are not ideal candidates for this procedure because of concerns about nipple-areolar viability as women with significant large/ptotic breast, pre-existing breast scars and history of active cigarette smoking. To extend the benefits of nipple preservation to patients who are perceived to be at higher risk for nipple necrosis the authors describe technical modifications of NSM to allow nipple preservation and obtain good cosmetic outcomes.

What is the evidence behind conservative mastectomies?

INTRODUCTION

Besides the diffusion of breast reconstructive techniques, several "conservative" approaches in mastectomy have been developed, in order to perform an immediate reconstruction with better aesthetic results: the skin-sparing mastectomy (SSM), the nipple-areola complex (NAC)-sparing mastectomy (NSM) and the skin-reducing mastectomy (SRM). During the last decade, SSMs and NSMs have gained widespread acceptance and are currently considered standard treatment for early breast cancer. We would like to investigate the evidence behind this radical shift towards conservative mastectomies, where there has been a renewed interest worldwide.

METHODS

We reviewed English literature by consulting the following databases: Medline, Embase, Cochrane Register of Controlled Trials, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal and Clinicaltrials.gov. The objective is to include any randomized controlled trial (RCT) comparing a "conservative mastectomy" technique to breast conservative surgery or modified radical mastectomy (MRM) for the treatment of early-stage breast cancer. In the absence of randomized trials, we took into account prospective cohorts and retrospective series for a narrative description of available evidence.

RESULTS

Our review included 58 studies [19 prospective cohorts (34%) and 39 retrospective series (66%)] considering NSM and immediate reconstruction and ten studies [1 prospective cohort (10%) and 9 (90%) retrospective series] considering SSM and immediate reconstruction. In the NSM group, 29 studies reported data about complication rates and 42 studies presented data on NAC partial or complete necrosis. In the NSM group 45 studies and all the studies in the SSM group presented data on local and NAC recurrence.

CONCLUSIONS

In order to achieve higher levels of evidence, RCTs comparing conservative mastectomies to traditional mastectomy and breast conservative surgery would be desirable. However we can conclude that conservative mastectomies offer the psychological advantages of good cosmetics and maintenance of woman body image without compromising the oncological safety of mastectomy.

Nipple-sparing Mastectomy and Sub-areolar Biopsy: To Freeze or not to Freeze? Evaluating the Role of Sub-areolar Intraoperative Frozen Section

Use of nipple-sparing mastectomy (NSM) for risk-reduction and therapeutic breast cancer resection is growing. The role for intraoperative frozen section of the nipple-areolar complex remains controversial. Records of patients undergoing NSM at our institution from 2006 to 2013 were reviewed. Records from 501 nipple-sparing mastectomies were reviewed (216 therapeutic, 285 prophylactic). Of the 480 breasts with sub-areolar biopsies, 307 had intraoperative frozen sections and 173 were evaluated with permanent paraffin section only. Among the 307 intraoperative frozen sections, 12 biopsies were positive on permanent paraffin section (3.9% or 12/307). Of the 12 positive permanent biopsies, five were false negative and the remaining seven concordant intraoperatively. Sensitivity and specificity of sub-areolar frozen section were 0.58 and 1, respectively. Positive sub-areolar biopsies consisted primarily of ductal carcinoma in situ (62% or 13/21). The nipples or nipple-areolar complex were resected in a separate procedure following mastectomy (10/21), intraoperatively following frozen section results (7/21) or during second-stage breast reconstruction (3/21; 1 additional scheduled). Only 30% (6/20) of resected specimens had abnormal residual pathology. Intraoperative frozen section is highly specific and moderately sensitive for the detection of positive sub-areolar biopsies in NSM. Its use can help guide intraoperative reconstructive planning. The presence of positive sub-areolar biopsies in both contralateral and high-risk prophylactic mastectomy specimens emphasizes the need to perform sub-areolar biopsies in all nipple-sparing mastectomies.

Cost Analysis of Intraoperative Subareolar Frozen Section During Nipple-Sparing Mastectomy

BACKGROUND

Permanent paraffin subareolar biopsy during nipple-sparing mastectomy (NSM) tests for occult cancer at the nipple-areolar complex. Intraoperative subareolar frozen section can provide earlier detection intraoperatively. Cost analysis for intraoperative subareolar frozen section has never been performed.

METHODS

NSM cases from 2006-2013 were reviewed. Patient records including financial charges were analyzed.

RESULTS

Of 480 subareolar biopsies for NSM from 2006-2013, 21 were abnormal (4.4 %). A total of 307 of the subareolar biopsies included intraoperative frozen section. Of the 307, 12 (3.9 %) were abnormal with 7 of 12 detected on intraoperative frozen section. The median baseline charge for an intraoperative subareolar frozen section was $309 for an estimated total cost of $94,863 in 307 breasts. The median baseline charge for interval operative resection of a nipple-areolar complex following an abnormal subareolar pathology result was $11,021. Intraoperative subareolar biopsy avoided an estimated six return trips to the operating room for savings of $66,126. At our institution, routine use of intraoperative frozen section resulted in an additional $28,737 in healthcare charges or $95 per breast.

CONCLUSIONS

We present the first cost analysis to evaluate intraoperative subareolar frozen section in NSM. This practice obviated an estimated six return trips to the operating room. With our institutional frequency of abnormal subareolar pathology, intraoperative frozen sections resulted in a marginal increased charge per mastectomy.

Predictive factors of nipple involvement in breast cancer: a systematic review and meta-analysis

Nipple-sparing mastectomy (NSM) provides a cosmetic and psychological benefit for patients, but concerns on nipple involvement (NI) of tumor continue to persist. Several studies have reported factors for predicting NI, but the results were inconsistent and uncomprehensive, making patient selection difficult. The aim of the systematic review was to pool the published data to further discern factors associated with NI. A literature review was conducted of PubMed database, following the PRISMA guidelines. Relative risks (RRs) and 95 % confidence intervals (CIs) were calculated using random-effect or fix-effect model. Publication bias and Chi-square test were also calculated. From 1978 to 2014, 27 clinical studies with 7971 patients met the inclusion criteria. Predictive factors suggest higher rates of NI including the following: tumor-to-nipple distance (TND) ≤ 2.5 cm (3.65, 1.42-9.33); positive lymph node status (2.09, 1.71-2.57); stage III or IV disease (2.41, 1.93-3.00); tumor size > 5 cm (2.42, 1.95-3.02); estrogen receptor (ER)-negative status (1.19, 1.01-1.40); progesterone receptor (PR)-negative status (1.52, 1.25-1.84); HER-positive status (1.76, 1.46-2.12); patients with ductal carcinoma in situ (DCIS) compared with invasive ductal carcinoma (1.55, 1.16-2.08). Due to the statistical heterogeneity detected with certain parameters, further investigations to confirm their association with NI will be needed. Patients with one or more risk factors such as centrally located tumors; higher tumor stage; large tumors; ER-negative/PR-negative/HER-positive status and associated DCIS have higher risk of NI. Taking these factors into consideration comprehensively may help with decision-making process for NSM.

Skin sparing mastectomy with preservation of nipple areola complex and immediate breast reconstruction in patients with breast cancer: a single centre prospective study

Background. Skin and nipple areola sparing mastectomy (NASM) has recently gained popularity as the management of breast cancer. This study aims to evaluate the aesthetic outcome, patient satisfaction, and oncological safety of NASM. Methods. The study prospectively analyzes the results of NASM and immediate breast reconstruction in 34 women with breast cancer. The criteria for inclusion were core biopsy-proven, peripherally located breast cancer of any tumor size and with any “N” status, with documented negative intraoperative frozen section biopsy of retroareolar tissue, and distance from the nipple to tumor margin >2 cm on mammography. Results. The median age of the patients was 45 years. The majority had either stage II or stage III breast cancer. The median mammographic distance of tumor from nipple areola complex (NAC) was 3.8 cm. The overall operative morbidity was minimal. The NAC could be preserved in all the patients. There was no local recurrence of tumor at median follow-up of 28.5 months. The aesthetic outcomes were satisfactory. Conclusion. NASM and immediate breast reconstruction can be successfully achieved with minimal morbidity and very low risk of local recurrence in appropriately selected breast cancer patients, with acceptable aesthetic results and good patient satisfaction.

[The role of nipple-sparing mastectomy in breast cancer: a comprehensive review of the literature]

BACKGROUND

The role of nipple-sparing mastectomy (NSM) for breast cancer is controversial as there is concern regarding its oncological safety and complication rate. We carried out a review of the literature to quantify the incidence of occult nipple malignancy in breast cancer, identify the factors influencing occult nipple malignancy, quantify locoregional recurrence rates and quantify NSM complication rates.

METHODS

A search of the literature was performed using PubMed. Keywords used were "mastectomy", "nipple involvement", "nipple-sparing mastectomy", "skin-sparing mastectomy" "occult nipple malignancy" "occult nipple disease" "breast cancer recurrence". Articles were analyzed regarding incidence of occult nipple malignancy, potential factors influencing the incidence of occult malignancy and recurrence/complications following NSM. The incidence of occult nipple disease was compared between groups using Chi(2) or Fisher's exact tests for categorical variables and Student's t-tests for continuous variables. P values were considered significant<0.05. We identified nearly 30 studies compiling nearly 10 000 cases examining the rate of occult nipple malignancy and 23 studies compiling 2300 cases providing information on the rate of local recurrence after NSM.

RESULTS

The overall rate of occult nipple malignancy was 11.5 %. Primary tumour characteristics influencing occult nipple malignancy were tumour-nipple distance<2cm, grade, lymph node metastasis, lymphovascular invasion, HER2 positive, ER/PR negative, tumour size>5cm, retro-areolar/central location and multicentric tumours. The overall nipple recurrence rate following NSM was 0.9 %, skin flap recurrence rate was 4.2 %. Full and partial thickness nipple necrosis rates were 2.9 % and 6.3 % respectively.

CONCLUSION

NSM for primary breast cancer is appropriate in carefully selected patients. All patients should have retro-areolar sampling. There is strong evidence to suggest that suitable cases are well circumscribed single or multifocal lesions that have a TND>2cm. Tumours should be graded 1-2 and not have LVI, axillary node metastasis or HER2 positivity.

One-stage nipple and breast reconstruction following areola-sparing mastectomy

BACKGROUND

Skin-sparing mastectomy with immediate breast reconstruction is increasingly becoming a proven surgical option for early-stage breast cancer patients. Areola-sparing mastectomy (ASM) has also recently become a popular procedure. The purpose of this article is to investigate the reconstructive and aesthetic issues experienced with one-stage nipple and breast reconstruction using ASM.

METHODS

Among the patients who underwent mastectomy between March 2008 and March 2010, 5 women with a low probability of nipple-areolar complex malignant involvement underwent ASM and immediate breast reconstruction with simultaneous nipple reconstruction using the modified C-V flap. The cosmetic outcomes of this series were reviewed by plastic surgeons and patient self-assessment and satisfaction were assessed via telephone interview.

RESULTS

During the average 11-month follow-up period, there were no cases of cancer recurrence, the aesthetic outcomes were graded as excellent to very good, and all of the patients were satisfied. Two patients developed a gutter-like depression around the reconstructed nipple, and one patient developed skin erosion in a small area of the areola, which healed with conservative dressing. The other complications, such as necrosis of the skin flap or areola, seroma, hematoma, or fat necrosis did not occur.

CONCLUSIONS

Since one-stage nipple and breast reconstruction following ASM is an oncologically safe, cost-effective, and aesthetically satisfactory procedure, it is a good surgical option for early breast cancer patients.

The role of nipple-sparing mastectomy in breast cancer: a comprehensive review of the literature

BACKGROUND

The role of nipple-sparing mastectomy for breast cancer is controversial, as there is concern regarding its oncologic safety and complication rate. The authors reviewed the literature to quantify the incidence of occult nipple malignancy in breast cancer, identify the factors influencing occult nipple malignancy, quantify locoregional recurrence rates, and quantify nipple-sparing mastectomy complication rates.

METHODS

A search of the literature was performed using PubMed. Key words used were "mastectomy," "nipple involvement," "nipple-sparing mastectomy," "skin-sparing mastectomy," "occult nipple malignancy," "occult nipple disease," and "breast cancer recurrence." Articles were analyzed regarding incidence of occult nipple malignancy, potential factors influencing the incidence of occult malignancy, and recurrence/complications following nipple-sparing mastectomy. The incidence of occult nipple disease was compared between groups using chi-square or Fisher's exact tests for categorical variables and t tests for continuous variables. Values of p < 0.05 were considered significant.

RESULTS

The overall rate of occult nipple malignancy was 11.5 percent. Primary tumor characteristics influencing occult nipple malignancy were tumor-nipple distance less than 2 cm, grade, lymph node metastasis, lymphovascular invasion, human epidermal growth factor receptor-2-positive, estrogen receptor/progesterone receptor-negative, tumor size greater than 5 cm, retroareolar/central location, and multicentric tumors. The overall nipple recurrence rate considered significant was 0.9 percent, and the skin flap recurrence rate was 4.2 percent. Full- and partial-thickness nipple necrosis rates were 2.9 and 6.3 percent, respectively.

CONCLUSIONS

Nipple-sparing mastectomy for primary breast cancer is appropriate in carefully selected patients. All patients should have retroareolar sampling. There is strong evidence to suggest that suitable cases are well circumscribed single or multifocal lesions that have a tumor-to-nipple distance greater than 2 cm. Tumors should be grade 1 to 2 and not have lymphovascular invasion, axillary node metastasis, or human epidermal growth factor receptor-2 positivity.

The effect of incision choice on outcomes of nipple-sparing mastectomy reconstruction

INTRODUCTION

The indications for nipple-sparing mastectomy (NSM) are broadening as more breast surgeons appreciate the utility of preserving the nipple-areolar complex. A number of incision locations are available to the mastectomy surgeon, including inframammary, lateral and periareolar approaches. The present study investigated the effect of these three incisions on reconstructive outcomes; specifically, nipple necrosis.

METHODS

A single-centre, retrospective review of 37 breast NSM reconstructions treated with immediate tissue expander reconstruction with acellular dermis between 2007 and 2008 was performed. The primary outcome was the incidence of nipple necrosis associated with periareolar, lateral and inframammary incisions. Secondary outcomes were the effects of radiation, chemotherapy and breast size on nipple necrosis.

RESULTS

Thirty-seven breast procedures performed on 20 patients were included in the present study. Periareolar incisions were used in 21 cases, lateral incisions in 14 and inframammary incisions in two. The periareolar incision was associated with a significantly higher incidence of nipple necrosis compared with lateral or inframammary incisions (38.1% versus 6.3%, P=0.028). Patients receiving breast radiation (45.5% versus 15.4%, P=0.066) and those with larger breast size (540.4 g versus 425.7 g, P=0.130) also demonstrated a modest trend toward an increased rate of nipple necrosis.

CONCLUSION

The periareolar incision results in a higher rate of nipple necrosis following NSM and immediate tissue expander breast reconstruction. Using the lateral or inframammary incision reduces the incidence of nipple necrosis and may help improve overall reconstructive and cosmetic outcomes.

A comparison of clinical and pathologic assessments for the prediction of occult nipple involvement in nipple-sparing mastectomies

BACKGROUND

Nipple-sparing mastectomy (NSM) for both risk reduction and cancer is increasing. In the cancer setting, most studies suggest the use of both clinical and intraoperative biopsy criteria in patient selection. This study examines the use of both biopsy and clinical criteria in women undergoing total nipple-removing mastectomy.

METHODS

The study consisted of 58 patients undergoing total mastectomy without nipple sparing. Biopsies of the subareola tissue (SA), proximal nipple (NC) contents and radial sections of the residual nipple (NR) were examined microscopically. Tumor size and distance from the nipple were also noted.

RESULTS

Using clinical criteria alone, the false negative rate was 53.8% and a false positive rate of 44.4%. When adding subareola and nipple core biopsies to clinical criteria the false negative rate fell to 7.7% but the false positive rate remained at 44.4%. When using only SA and NC biopsies to predict occult nipple involvement, the false negative rate was 11.8%. In 4 cases the NC was positive while the SA was negative for cancer and in 6 cases the SA was positive and NC negative. In 2 cases both the NC and SA biopsies were negative while the NR was positive.

CONCLUSIONS

This study supports a more limited role in the use of clinical criteria for evaluating patients for NSM. This maximizes the number of patients who are candidates for NSM with minimal risk of nipple involvement. It was also noted that intraoperative biopsies are not totally reliable in predicting occult nipple involvement.

Nipple-sparing mastectomy: technical aspects and aesthetic outcomes

INTRODUCTION

Nipple-sparing mastectomy (NSM) is increasingly used to improve the results of immediate breast reconstruction. Technical aspects and aesthetic outcomes of this procedure are examined.

METHODS

A study of a prospective institutional database of all cases of NSM between 2009 and 2010 was performed. Aesthetic outcomes (symmetry, inframammary fold, volume, contour, and nipple) are compared with patients undergoing skin-sparing mastectomy and immediate breast reconstruction by grading postoperative photographs. Technical refinements in incision types and nipple positioning are described.

RESULTS

Twenty-six patients underwent 40 NSMs during the study period. Partial nipple necrosis occurred in 15 breasts (37.5%); of them, 14 healed uneventfully with local wound care, and 1 patient required delayed nipple reconstruction. Nipple necrosis by incision type was radial/circumareolar in 6 of 8 (75%) patients; radial, 3 of 9 (33.3%); inframammary fold, 6 of 22 (27.3%); and vertical, 0 of 1 (0%). The nipple aesthetic outcome was significantly better for NSM compared with nipple reconstruction after skin-sparing mastectomy (P = 0.01).

CONCLUSIONS

The incidence of partial nipple necrosis was high and was related to circumareolar incisions. Most cases of nipple necrosis are superficial and heal uneventfully. Preservation of the nipple improves the aesthetic outcome of immediate breast reconstruction.

Nipple- or skin-sparing mastectomy and immediate breast reconstruction by the "moving window" operation

BACKGROUND

Endoscope-assisted skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM) has been developed to minimize the skin incision and to improve the cosmetic outcome of reconstructed breast for patients with breast cancer. However, this procedure can be performed without using endoscopic instruments.

METHODS

We have performed SSM or NSM via a small periareolar incision with axillary incision using wound retractors without disposable endoscopic instruments. After the entire breast tissue was removed, immediate breast reconstruction (IBR) using tissue expanders was performed through the axillary incision.

RESULTS

Twelve patients (13 cases: 1 patient had synchronous bilateral primary cancer) underwent NSM, and 8 had SSM because of involvement of the nipple-areola complex. IBR was performed with tissue expanders in 18 patients, while 2 patients refused to have IBR because of small breast size. When 3 patients with synchronous or metachronous bilateral breast cancer were excluded, the average length of surgery was 267 min in 15 patients who underwent SSM or NSM followed by IBR with implants, while it was only 120 min in 2 patients who underwent NSM alone. Average blood loss was 135 mL (range 40-350 mL).

CONCLUSION

We have described a novel technique using the wound retractor for SSM or NSM followed by IBR in treating breast cancer patients. This technique can minimize skin incisions without using disposable endoscopic instruments and improve the cosmetic outcome of the reconstructed breast.

Prophylactic and therapeutic mastectomy in BRCA mutation carriers: can the nipple be preserved?

BACKGROUND

Use of nipple-sparing mastectomy (NSM) is increasing. We sought to look at the role of NSM in BRCA mutation carriers.

METHODS

Tissue from women with a BRCA1 or BRCA2 mutation who underwent mastectomy between March 1987 and June 2009 at a single institution was reviewed. The entire nipple-areolar complex (NAC) was excised and histologically evaluated. The presence of terminal duct lobular units (TDLUs) and premalignant or malignant lesions in the NAC was noted.

RESULTS

Sixty-two NACs from 33 women (25 BRCA1, 8 BRCA2) were studied. TDLUs were present in 15 (24%) NAC specimens. No evidence of atypical hyperplasia, carcinoma in situ, or invasive carcinoma was found in any of the 33 prophylactic mastectomy specimens. Among the 29 breasts with cancer and available tissue, 2 (7%) had malignant findings and 1 (3%) had atypia in the NAC. One woman who underwent bilateral mastectomy for bilateral invasive carcinoma had one nipple with tumor within lymphatics, and her contralateral nipple had atypical lobular hyperplasia. A second woman had ductal carcinoma in situ involving a single major lactiferous duct.

CONCLUSIONS

The probability of nipple involvement by premalignant or malignant lesions in the NAC of BRCA mutation carriers is low at time of prophylactic mastectomy, but higher (10%) in women undergoing therapeutic mastectomy. NSM may be appropriate and oncologically safe for selected women with BRCA mutations. However, 24% of NACs contained TDLUs, with only 8% found in the nipple papilla; the significance of this for long-term risk is unknown.

[Retroareolar breast cancer: oncoplastic resection technique with central quadrantectomy and reconstruction with Grisotti's inferior dermo-glandular flap]

Centrally located breast cancers account for 5-20% of all breast cancer cases. Historically, patients with central breast cancers were not offered breast conservation surgery but conventional mastectomy only. The relatively frequent nipple-areola-complex involvement and consequent nipple-areolar resections with an adequate safety margin around the tumor usually result in an unacceptable cosmetic result. However, breast conservation surgery can be offered to these patients applyingoncoplastic surgical techniques. In this study, central quadrantectomy and breast reconstruction with Grisotti's dermo-glandular flap is evaluated.

Oncologic safety of nipple skin-sparing or total skin-sparing mastectomies with immediate reconstruction

BACKGROUND

Success with skin-sparing mastectomy (SSM) has led to the reconsideration of the necessity to remove the skin overlying the nipple-areola complex. The aim of our study was to compare complications and local recurrence in patients undergoing SSM and total skin-sparing mastectomy (TSSM) with immediate reconstruction.

METHODS

This IRB-approved retrospective study involved patients who underwent mastectomy with reconstruction (1998 to 2010). Patient demographics, tumor characteristics, type of surgery, cosmesis, postoperative complications, and recurrence were analyzed.

RESULTS

The 293 patients in our study group had a total of 508 procedures: 281 TSSMs and 227 SSMs, distributed among 215 patients with bilateral procedures and 78 with unilateral operations. Mean age was 51.2 ± 10.9 years for TSSM and 53.1 ± 11.5 years for SSM. The average tumor size was 1.9 ± 1.6 cm for TSSM versus 2.1 ± 1.7 cm for the SSM group. The overall complication rate (TSSM 7.1% [20 of 281] and SSM 6.2% [14 of 227], p = 0.67) and local-regional recurrence rate (TSSM 6% [7 of 152] and SSM 5.0% [7 of 141], p = 0.89) were comparable. The TSSM rating was significantly higher (score 9.2 ± 1.1) than the SSM group (score 8.3 ± 1.9, p = 0.04).

CONCLUSION

TSSM appears to be oncologically safe with superior cosmesis, affords one-step immediate reconstruction, and can be offered to patients with stages I and II breast cancer and those who have been down-staged with neoadjuvant chemotherapy.

Extended indications for nipple-sparing mastectomy

Ablative breast cancer surgery still includes the routine excision of the nipple-areola complex (NAC). Nipple-sparing mastectomy (NSM) removes the breast tissue leaving no or little retroareolar ductal tissue but preserves the entire skin of the breast and the NAC. There is some consensus that NSM might be an oncologically safe option for patients with small and peripherally located tumors and probably for high-risk patients with prophylactic mastectomy. Several studies demonstrated that NSM may be feasible even in patients with large centrally located tumors or multicentric invasive carcinoma. So far, no generally applicable indications for NSM have been defined because long-term data are still limited. However, from our review of the literature obtained from a MEDLINE search (2003-2009) we conclude that the range of indications for NSM needs not to be limited to small peripheral tumors or to prophylactic treatment.

Early results of an endoscopic nipple-sparing mastectomy for breast cancer

BACKGROUND.: Endoscopic mastectomy has been reportedly associated with smaller scars and greater patient satisfaction; however, few reports on this topic have been made. The purpose of this retrospective study was to examine the early results of endoscopic nipple-sparing mastectomy (ENSM) and to investigate the safety of this procedure. METHODS.: Between January 2002 and December 2005, a total of 87 patients with breast cancer but without skin and nipple involvement, including two cases of bilateral breast cancer, underwent E-NSM. In case of bloody nipple discharge and suspicious extension near the nipple as assessed by magnetic resonance imaging, the major ducts within the nipple were cored (nipple coring). In other cases, nipple coring was not performed. RESULTS.: Of the 89 breasts in 87 patients, 42 had tumors of >2 cm and 80 were diagnosed as having invasive carcinoma. Lymph node involvement was observed in 36 procedures. The overall rate of nipple necrosis was 18% (16 of 89). The rate of nipple necrosis among the procedures with nipple coring was statistically higher than that among those without nipple coring (7 of 17, 41%, vs. 9 of 72, 13%) (P = .01). Nipple involvement was observed in 2.2% (2 of 89). After a median follow-up period of 52 months, distant metastasis was observed in nine cases; no local recurrences occurred in this series. CONCLUSIONS.: E-NSM is an oncologically safe procedure and an acceptable method in selected patients requiring a mastectomy. The higher rate of nipple necrosis may have been the result of a technical problem, indicating the need for continued improvement in nipple coring procedures.

Advances in nipple-sparing mastectomy: oncological safety and incision selection

BACKGROUND

With the evolution of breast reconstruction and oncoplastic techniques, more aesthetic mastectomies are being offered to patients. Nipple-sparing mastectomy (NSM) has been controversial, but an expanding body of published experience has allowed this concept to gain momentum.

OBJECTIVES

The authors review their experience with NSM.

METHODS

From 2007 to 2009, 112 consecutive patients (204 breasts) who were candidates for NSM presented to one of two private plastic surgery practices. All patients underwent preoperative magnetic resonance imaging to assess the size of the tumor, its distance from the nipple, and any additional disease within the ipsilateral/contralateral breast or axillae. Exclusion criteria included tumors larger than 3 cm, clinical invasion of the nipple-areolar complex, tumors within 2 cm of the nipple, evidence of multicentric disease, a positive intraoperative retroareolar frozen section, or nodal disease (excluding isolated immunohistochemistry positivity). Fourteen patients were excluded from the study for one of these reasons, leaving a total of 98 patients (186 breasts) who underwent NSM.

RESULTS

Risk-reducing mastectomies were performed on 45 patients. Therapeutic mastectomies were performed for Stage 0 cancer (ductal carcinoma in situ) in 26 patients, for Stage 1A in 24 patients, and for Stage 1B in three patients. Disease-free survival was calculated from the date of surgery to any local, regional, or distant relapse (whichever occurred first). As of the writing of this article, follow-up ranged from nine months to three years, and there has been no local or regional recurrence in any patient.

CONCLUSIONS

NSM is evolving and should be considered a good treatment option in carefully-selected patients. These findings add to the growing body of evidence showing that, with proper patient selection and operative technique, NSM is a safe and effective intervention for patients requiring therapeutic or prophylactic mastectomy.

Areola and nipple-areola-sparing mastectomy for breast cancer treatment and risk reduction: report of an initial experience in a community hospital setting

Background

The use of areola-sparing (AS) or nipple-areola-sparing (NAS) mastectomy for the treatment or risk reduction of breast cancer has been the subject of increasing dialogue in the surgical literature over the past decade. We report the initial experience of a large community hospital with AS and NAS mastectomies for both breast cancer treatment and risk reduction.

Methods

A retrospective chart review was performed of patients undergoing either AS or NAS mastectomies from November 2004 through September 2009. Data collected included patient sex, age, family history, cancer type and stage, operative surgical details, complications, adjuvant therapies, and follow-up.

Results

Forty-three patients underwent 60 AS and NAS mastectomies. Forty-two patients were female and one was male. The average age was 48.7 years (range, 28–76 years). Forty mastectomies were for breast cancer treatment, and 20 were prophylactic mastectomies. The types of cancers treated were as follows: invasive ductal (n = 19), invasive lobular (n = 5), ductal carcinoma-in situ (n = 15), and malignant phyllodes (n = 1). Forty-seven mastectomies (78.3%) were performed by inframammary incisions. All patients underwent immediate reconstruction with either tissue expanders or permanent implants. There was a 5.0% incidence of full-thickness skin, areola, or nipple tissue loss. The average follow-up of the series was 18.5 months (range, 6–62 months). One patient developed Paget’s disease of the areola 34 months after an AS mastectomy (recurrence rate, 2.3%). There were no other instances of local recurrence.

Conclusions

AS and NAS mastectomies can be safely performed in the community hospital setting with low complication rates and good short-term results.

Nipple-Sparing Mastectomy - Extended Indications and Limitations

If mastectomy is indicated for removal of breast cancer, the nipple areola complex (NAC) is routinely excised during surgery followed by nipple reconstruction. Despite advances in reconstruction techniques, removal of the NAC often results in a sense of mutilation. However, recent studies regarding the tumorigenic involvement of the NAC have provided some evidence that in carefully selected patients the NAC could be preserved. Nipplesparing mastectomy (NSM) preserves the breast skin envelope and the NAC, and has therefore emerged as an alternative to conventional radical mastectomies. BecauseNSM leaves no or sparse retroareolar ductal tissue, NSM is increasingly considered as oncologically safe both in patients with small and peripherally located tumors and in women with high breast cancer risk, who opt for prophylactic mastectomy. Moreover, NSM has been applied in patients with large and centrally located or multicentric invasive carcinomas but oncologic safety as well as postoperative complications such as NAC necrosis are still controversial. Since long-term data are limited, there is no general recommendation for NSM indications. To evaluate if indications for NSM may be rather enlarged under certain conditions, we performed a MEDLINE search for studies published between 2003 and 2009.

Nipple-sparing mastectomy

Background

Although effective local control is the primary goal of surgery for breast cancer, the long-term aesthetic outcome is also important. Nipple-sparing mastectomy aims to address this, but there is no consensus on its clinical application. Evidence relating to oncological safety, surgical technique and early data on aesthetic outcome was reviewed.

Methods

The review was based on a PubMed search using the terms ‘nipple-sparing’ or ‘subcutaneous mastectomy’ and ‘breast cancer’.

Results

Large pathological studies report occult nipple involvement with cancer in 5·6–31 per cent, reflecting variation in inclusion criteria. Recent clinical series with careful patient selection report local recurrence in less than 5 per cent of patients. The incidence of cancer in the retained nipple after risk-reducing mastectomy is less than 1 per cent. Nipple necrosis rates range up to 8 and 16 per cent for total and partial necrosis respectively. Variations in outcome result from differences in extent of resection, placement of incisions and type of breast reconstruction.

Conclusion

Nipple-sparing mastectomy is an acceptable technique for women undergoing risk-reducing mastectomy. In the therapeutic setting, it may be offered to patients with smaller tumours far from the nipple and favourable pathological features. Women should be counselled about nipple necrosis and the potential for local recurrence.

Nipple-sparing mastectomy and immediate tissue expander/implant breast reconstruction

BACKGROUND

The nipple is an uncommon site for breast cancer development, but the nipple-areola complex is routinely excised in breast cancer treatment. The authors evaluated the risks and benefits of nipple- or areola-sparing mastectomy with breast reconstruction.

METHODS

The authors analyzed data on 115 consecutive nipple- or areola-sparing mastectomies with immediate tissue expander breast reconstruction performed in 66 patients from 1998 to 2008 at a single tertiary-care cancer center. Nipple-sparing mastectomies were performed for prophylaxis (n = 75) or treatment of disease (n = 40).

RESULTS

Mean patient age was 45 years (range, 24 to 61 years) and mean follow-up time was 22 months (range, 2 weeks to 91 months). There were 115 nipple- or areola-sparing mastectomies (48 bilateral and 19 unilateral), including 111 nipple-sparing and four areola-sparing mastectomies. On pathologic review, 20 breasts had ductal carcinoma in situ, 20 breasts had invasive cancer, 11 breasts had lobular carcinoma in situ, one breast had phyllodes tumor, one breast had mucinous carcinoma, and 62 breasts were cancer-free. Incision placement was periareolar and radial (n = 61), inframammary (n = 25), omega type (n = 14), customized to include a previous scar (n = 10), or transareolar (n = 5). Of all 115 nipple- or areola-sparing mastectomies, six nipples were lost because of occult disease (5.2 percent), and four nipples were lost because of wound-healing problems (3.5 percent).

CONCLUSIONS

In the authors' series of nipple- and areola-sparing mastectomies performed for risk reduction or breast cancer, there was a low incidence of occult disease (5.2 percent). Nipple- and areola-sparing mastectomy may be feasible in selected patients and should be the subject of additional investigation.

Clinical and morphological factors predictive of occult involvement of the nipple-areola complex in mastectomy specimens

OBJECTIVE

To evaluate characteristics predictive of nipple-areola complex (NAC) involvement by the breast tumor.

STUDY DESIGN

Cases of infiltrative ductal carcinoma (stages I, IIA and IIB) treated by mastectomy in which the distance between the tumor and the NAC was >or=2 cm were included. NAC involvement was evaluated using serial histological sections. The distance between the tumor and the NAC was measured on mammograms. Other parameters taken into consideration were: tumor size, histological and nuclear grades, vascular invasion, and the presence of an in situ component. For comparisons between categorical variables, the chi-square test or Fisher's exact test were used. Student's t-test was used for numerical variables with normal distribution and the Mann-Whitney U-test was applied when distribution was not normal.

RESULTS

Fifty patients were included. NAC was affected in 12 and unaffected in 38. There was no statistically significant difference in mean age between the unaffected and affected groups (58.9+/-13.5 years versus 55.8+/-12.5 years, p=0.477); however, 13.2% and 58.3% (p=0.046) in the NAC-unaffected and NAC-affected groups, respectively, were <50 years of age. Distance <or=3 cm between the tumor and the NAC on mammograms was found in 60.5% of the NAC-unaffected group and in 100% of the NAC-affected group (p=0.007). With respect to the in situ component, there was a difference between the NAC-unaffected and NAC-affected groups regarding micropapillary pattern (13.2% versus 50.0%; p=0.014) and extensive in situ component (13.2% versus 41.7%; p=0.046). No statistically significant difference was found for any of the other parameters analyzed.

CONCLUSIONS

A distance between the tumor and the NAC <or=3 cm, age <50 years, and ductal carcinoma in situ with micropapillary pattern or with an extensive in situ component were factors significantly associated with a higher likelihood of NAC involvement.

Subcutaneous mastectomy with conservation of the nipple-areola skin: broadening the indications

BACKGROUND

Numerous authors take multiple predictive factors into account to decide whether or not the nipple-areola complex (NAC) can be conserved during mastectomy. These factors include the tumor-nipple distance, tumor size, axillary lymph node status, and lymphovascular invasion. Thus only a very limited percentage of patients can keep their NAC. If the breast gland tissue and all milk ducts can be separated completely from the nipple-areola skin (NA-skin) during subcutaneous mastectomy (SCM), conservation of the NA-skin is feasible even in the case of large, central, and retroareolar tumors.

PATIENTS AND METHODS

From July 2003 to May 2006, we performed 109 SCMs on 96 patients. Total mastectomy was indicated in 94 of these breasts, in 16 because of extensive ductal carcinoma in situ, and 78 breasts with invasive carcinoma required additional axillary dissection resulting in indication for modified radical mastectomy. At least 33 of the breasts had malignancy underneath the skin within the areolar margin (centrally located tumors). After dissection of all the breast tissue, the skin envelope with the areola is turned inside out and all milk ducts and any tissue beneath the areola are precisely dissected under the surgeon's visual control. Frozen sections and HE histopathologic examination of this retroareolar tissue next to the skin are requested to decide whether the NA-skin can be preserved or not. This study was registered on the www.clinicaltrials.com website and has the following identification number ID: NCT00641628.

RESULTS

We found it necessary to dissect the NA-skin in 13 of 109 breasts (12%), altering the procedure to a skin sparing mastectomy. Necrosis of the NA-skin requiring surgical intervention occurred in only 1 of the conserved 96 breasts. After follow-up of 20 to 54 months (median: 34 months), no recurrence within the nipple-areola region was observed. One local recurrence on the chest wall and 1 axillary recurrence were detected. Of 96 patients, 2 developed distant metastases. One death was recorded. Occasionally, partial necrosis of the nipple occurred, with residual depigmentation of the skin but a good or excellent cosmetic result was maintained in most cases.

CONCLUSION

SCM with NAC-skin conservation may be performed according to total mastectomy indications if an intraoperative frozen section (and the corresponding HE histopathology) of the tissue next to the nipple-areola skin is free of tumor. The remaining contraindications for SCM are: extensive tumor involvement of the skin, inflammatory breast cancer, and a clinically suspicious nipple.