Preoperative MRI evaluation of lesion–nipple distance in breast cancer patients: thresholds for predicting occult nipple–areola complex involvement

Positive Nipple Margins in Nipple-Sparing Mastectomy: Management of Nipples Containing Cancer or Atypia

BACKGROUND

Nipple-sparing mastectomy (NSM) is an oncologically safe approach for breast cancer treatment and prevention; however, there are little long-term data to guide management for patients whose nipple margins contain tumor or atypia.

METHODS

NSM patients with tumor or atypia in their nipple margin were identified from a prospectively maintained, single-institution database of consecutive NSMs. Patient and tumor characteristics, treatment, recurrence, and survival data were assessed.

RESULTS

A total of 3158 NSMs were performed from June 2007 to August 2019. Nipple margins contained tumor in 117 (3.7%) NSMs and atypia only in 164 (5.2%) NSMs. Among 117 nipple margins that contained tumor, 34 (29%) margins contained invasive cancer, 80 (68%) contained ductal carcinoma in situ only, and 3 (3%) contained lymphatic vessel invasion only. Management included nipple-only excision in 67 (57%) breasts, nipple-areola complex excision in 35 (30%) breasts, and no excision in 15 (13%) breasts. Only 23 (24%) excised nipples contained residual tumor. At 67 months median follow-up, there were 2 (1.8%) recurrences in areolar or peri-areolar skin, both in patients with nipple-only excision. Among 164 nipple margins containing only atypia, 154 (94%) nipples were retained. At 60 months median follow-up, no patient with atypia alone had a nipple or areola recurrence.

CONCLUSIONS

Nipple excision is effective management for nipple margins containing tumor. No intervention is required for nipple margins containing only atypia. Our results support broad eligibility for NSM with careful nipple margin assessment.

Multimodality Imaging of Benign and Malignant Diseases of the Nipple-Areolar Complex

The nipple-areolar complex (NAC), a unique anatomic structure of the breast, encompasses the terminal intramammary ducts and skin appendages. Several benign and malignant diseases can arise within the NAC. As several conditions have overlapping symptoms and imaging findings, understanding the distinctive nipple anatomy, as well as the clinical and imaging features of each NAC disease process, is essential. A multimodality imaging approach is optimal in the presence or absence of clinical symptoms. The authors review the ductal anatomy and anomalies, including congenital abnormalities and nipple retraction. They then discuss the causes of nipple discharge and highlight best practices for the imaging workup of pathologic nipple discharge, a common condition that can pose a diagnostic challenge and may be the presenting symptom of breast cancer. The imaging modalities used to evaluate and differentiate benign conditions (eg, dermatologic conditions, epidermal inclusion cyst, mammary ductal ectasia, periductal mastitis, and nonpuerperal abscess), benign tumors (eg, papilloma, nipple adenoma, and syringomatous tumor of the nipple), and malignant conditions (eg, breast cancer and Paget disease of the breast) are reviewed. Breast MRI is the current preferred imaging modality used to evaluate for NAC involvement by breast cancer and select suitable candidates for nipple-sparing mastectomy. Different biopsy techniques (US -guided biopsy and stereotactic biopsy) for sampling NAC masses and calcifications are described. This multimodality imaging approach ensures an accurate diagnosis, enabling optimal clinical management and patient outcomes. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

A Nomogram Based on Conventional and Contrast-Enhanced Ultrasound for Pre-operative Prediction of Nipple-Areola Complex Involvement in Breast Cancer: A Prospective Study

OBJECTIVE

Accurately predicting nipple-areola complex (NAC) involvement in breast cancer is essential for identifying eligible patients for a nipple-sparing mastectomy. This study was aimed at developing a pre-operative nomogram for NAC involvement in breast cancer using conventional ultrasound (US) and contrast-enhanced ultrasound (CEUS).

METHODS

All patients with primary breast cancer confirmed by pre-operative biopsy underwent US and CEUS examinations. Post-operative pathology was used as the gold standard in assessing NAC involvement. Lasso regression was used to select the predictors most associated with NAC involvement. A nomogram was constructed to calculate the diagnostic efficacy. The data were internally verified with 500 bootstrapped replications, and a calibration curve was generated to validate the predictive capability.

RESULTS

Seventy-six patients with primary breast cancer were included in this study, which included 16 patients (21.1%) with NAC involvement and 60 patients (78.9%) without NAC involvement. Among the 23 features of US and CEUS, Lasso regression selected one US feature and two CEUS features, namely, ductal echo extending from the lesion, ductal enhancement extending to the nipple and focal nipple enhancement. A nomogram was constructed, and the results revealed that the area under the curve, sensitivity, specificity and accuracy were 0.891, 81.3%, 86.7% and 85.5%, respectively. The calibration curve exhibited good consistency between the predicted probability and the actual probability.

CONCLUSION

The nomogram developed based on US and CEUS had good performance in predicting NAC involvement in breast cancer before surgery, which may facilitate the selection of suitable patients for NAC preservation with greater oncological safety.

Diagnostic Accuracy of Magnetic Resonance Imaging Features and Tumor-to-Nipple Distance for the Nipple-Areolar Complex Involvement of Breast Cancer: A Systematic Review and Meta-Analysis

OBJECTIVE

This systematic review and meta-analysis evaluated the accuracy of preoperative breast magnetic resonance imaging (MRI) features and tumor-to-nipple distance (TND) for diagnosing occult nipple-areolar complex (NAC) involvement in breast cancer.

MATERIALS AND METHODS

The MEDLINE, Embase, and Cochrane databases were searched for articles published until March 20, 2022, excluding studies of patients with clinically evident NAC involvement or those treated with neoadjuvant chemotherapy. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Two reviewers independently evaluated studies that reported the diagnostic performance of MRI imaging features such as continuity to the NAC, unilateral NAC enhancement, non-mass enhancement (NME) type, mass size (> 20 mm), and TND. Summary estimates of the sensitivity and specificity curves and the summary receiver operating characteristic (SROC) curve of the MRI features for NAC involvement were calculated using random-effects models. We also calculated the TND cutoffs required to achieve predetermined specificity values.

RESULTS

Fifteen studies (n = 4002 breast lesions) were analyzed. The pooled sensitivity and specificity (with 95% confidence intervals) for NAC involvement diagnosis were 71% (58-81) and 94% (91-96), respectively, for continuity to the NAC; 58% (45-70) and 97% (95-99), respectively, for unilateral NAC enhancement; 55% (46-64) and 83% (75-88), respectively, for NME type; and 88% (68-96) and 58% (40-75), respectively, for mass size (> 20 mm). TND had an area under the SROC curve of 0.799 for NAC involvement. A TND of 11.5 mm achieved a predetermined specificity of 85% with a sensitivity of 64%, and a TND of 12.3 mm yielded a predetermined specificity of 83% with a sensitivity of 65%.

CONCLUSION

Continuity to the NAC and unilateral NAC enhancement may help predict occult NAC involvement in breast cancer. To achieve the desired diagnostic performance with TND, a suitable cutoff value should be considered.

Preoperative Breast Magnetic Resonance Imaging: An Ontario Health (Cancer Care Ontario) Clinical Practice Guideline

BACKGROUND

The use of preoperative breast magnetic resonance imaging (MRI) after the diagnosis of breast cancer by mammography and/or ultrasound is inconsistent.

METHODS

After conducting a systematic review and meta-analysis comparing preoperative breast MRI versus no MRI, we reconvened to prepare a clinical practice guideline on this topic.

RESULTS

Based on the evidence that MRI improved recurrence, decreased the rates of reoperations (re-excisions or conversion mastectomy), and increased detection of synchronous contralateral breast cancer, we recommend that preoperative breast MRI should be considered on a case-by-case basis in patients diagnosed with breast cancer for whom additional information about disease extent could influence treatment. Based on stronger evidence, preoperative breast MRI is recommended in patients diagnosed with invasive lobular carcinoma for whom additional information about disease extent could influence treatment. For both recommendations, the decision to proceed with MRI would be conditional on shared decision-making between care providers and the patient, taking into account the benefits and risks of MRI as well as patient preferences. Based on the opinion of the Working Group, preoperative breast MRI is also recommended in the following more specific situations: (a) to aid in surgical planning of breast conserving surgery in patients with suspected or known multicentric or multifocal disease; (b) to identify additional lesions in patients with dense breasts; (c) to determine the presence of pectoralis major muscle/chest wall invasion in patients with posteriorly located tumours or when invasion of the pectoralis major muscle or chest wall is suspected; (d) to aid in surgical planning for skin/nipple-sparing mastectomies, autologous reconstruction, oncoplastic surgery, and breast conserving surgery with suspected nipple/areolar involvement; and (e) in patients with familial/hereditary breast cancer but who have not had recent breast MRI as part of screening or diagnosis.

How to accurately preoperative screen nipple-sparing mastectomy candidate-a nomogram for predicting nipple-areola complex involvement risk in breast cancer patients

BACKGROUND

Nipple-sparing mastectomy (NSM) offers superior cosmetic outcomes and has been gaining wide acceptance. It has always been difficult to objectively quantify the risk of nipple-areola complex involvement (NACi). The goal was to develop a prediction model for clinical application.

METHODS

Patients who had a total mastectomy (TM) between January 2016 and January 2020 at a single institute formed the development cohort (n = 578) and those who had NSM + immediate breast reconstruction (IBR) between January 2020 and January 2021 formed the validation cohort (n = 112). The prediction model was developed using univariate and multivariate logistic regression studies. Based on NACi risk variables identified in the development cohort, a nomogram was created and evaluated in the validation cohort. Meanwhile, stratified analysis was performed based on the model's risk levels and was combined with intraoperative frozen pathology (IFP) to optimize the model.

RESULTS

Tumor central location, clinical tumor size (CTS) > 4.0 cm, tumor-nipple distance (TND) ≤ 1.0 cm, clinical nodal status positive (cN +), and KI-67 ≥ 20% were revealed to be good predictive indicators for NACi. A nomogram based on these major clinicopathologic variables was employed to quantify preoperative NACi risk. The accuracy was verified internally and externally. The diagnostic accuracy of IFP was 92.9%, sensitivity was 64.3%, and specificity was 96.9% in the validation group. Stratified analysis was then performed based on model risk. The diagnostic accuracy rates of IFP and NACiPM in low-risk, intermediate-risk, and high-risk respectively were 96.0%, 93.3%, 83.9%, 61.3%, 66.7%, and 83.3%.

CONCLUSION

We created a visual nomogram to predict NACi risk in breast cancer patients. The NACiPM can be used to distinguish the low, intermediate, and high risk of NAC before surgery. Combined with IFP, we can develop a decision-making system for the implementation of NSM.

The Usefulness of Magnetic Resonance Imaging (MRI) for the Detection of Local Recurrence after Mastectomy with Reconstructive Surgery in Breast Cancer Patients

The purpose of this study is to investigate the usefulness of magnetic resonance imaging (MRI) for the detection of local recurrence after nipple-sparing mastectomy (NSM) or skin-sparing mastectomy (SSM) with immediate reconstructive surgery for breast cancer. Two hundred and eighty-six NSM or SSM procedures and immediate reconstruction cases between August 2015 and February 2020 were reviewed. The detectability rates of for local recurrence using MRI and ultrasound were assessed, and the characteristics of recurrent and primary cancers were evaluated. The patients with multifocal or multicentric primary cancer and a dense parenchymal pattern showed a higher recurrence rate (p < 0.001). A total of 22 cases showed recurrence, and due to multifocal recurrence, a total of 27 recurrent lesions were identified in the reconstructed breast, of which 12 were symptomatic and 15 were asymptomatic (p < 0.001). With the exception of skin recurrence (n = 6), MRI showed a significantly higher detectability rate (95.2%, 20 of 21) than ultrasound (38.1%, 8 of 21) for the recurrence of cancer in the reconstructed breast (p < 0.001), especially for small-sized (<1 cm) asymptomatic lesions. In addition, the mean recurrence interval of MRI-detected asymptomatic lesions was 21.7 months (SD ± 17.7), which was significantly longer than that of symptomatic recurrence. In conclusion, postoperative MRI can be useful for identifying small-sized (<1 cm) asymptomatic recurrence lesions in reconstructed breast tissue after NSM or SSM, which can be implemented within two years of surgery.

Prediction of nipple-areolar complex involvement by breast cancer: role of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI)

Background

Skin-sparing and nipple-sparing mastectomies were considered as alternative techniques for modified radical mastectomy. In patients who are candidates for nipple-sparing mastectomy, preoperative assessment of the nipple-areolar complex (NAC) is essential for adequate surgical planning. Breast MRI is highly sensitive for cancer detection and has an important role in disease staging. The aim of this study was to estimate the role of DCE-MRI in predicting malignant NAC invasion by underlying breast cancer and assess the best predictors on MRI that can suspect malignant NAC invasion.

Results

Out of the 125 patients with breast cancer, 33 patients (26.4%) showed malignant NAC invasion. On basis of multivariate analysis, abnormal nipple enhancement, tumor nipple enhancement, tumor nipple distance ≤ 2 cm, and abnormal and asymmetric nipple morphology were all significant predictors of malignant NAC invasion (P < 0.001) with abnormal unilateral nipple enhancement as the most important independent MRI predictor of malignant NAC invasion (odds ratio = 61.07, 95% CI 12.81–291.22, P < 0.001). When combining more than positive suspicious MRI features, DCE-MRI had 66.6% sensitivity, 76% specificity, 50% PPV, 86.4% NPV, and 73.6% accuracy in prediction of malignant NAC invasion.

Conclusion

DCE-MRI could predict malignant NAC invasion with abnormal unilateral nipple enhancement as the most important independent MRI predictor.

A Retrospective Study of Latissimus Dorsi Flap in Immediate Breast Reconstruction

Background

There are many different methods used for immediate breast reconstruction, but the advantages and disadvantages between distinct methods are not reported and compared directly.

Methods

We collected the data of patients who underwent breast reconstruction from 2010 to 2015 and classified a total of 103 patients into three groups: i) skin- or nipple-sparing mastectomy with implant and partial latissimus dorsi flap (MIPLD); ii) skin- or nipple-sparing mastectomy with the whole latissimus dorsi flap (MWLD); and iii) breast-conserving surgery and partial latissimus dorsi flap (BCSPLD). The outcome, safety, and cosmetic outcome of the latissimus dorsi muscle flap with or without implant were reported and compared.

Results

The procedures were successful in all cases. None of the patients had severe complications. The 5-year distant metastasis-free survival is 94.2%. All the patients exhibited good arm and back function. Based on the evaluation of the BREAST-Q score, the cosmetic outcome of Satisfaction with Breasts was excellent or good in 97.8% of the cases.

Conclusions

MIPLD, MWLD, and BCSPLD stand for three distinct methods for immediate breast reconstruction with good outcome and aesthetic effect. They were safe, were easy to perform, and provided quick recovery and good quality of life. Therefore, these three breast reconstructive methods are worthy of widespread use in clinical practice and provide different ways to reconstruct the breast according to the patients’ conditions and preferences.

Tumor-Nipple Distance of ≥ 1 cm Predicts Negative Nipple Pathology After Neoadjuvant Chemotherapy

BACKGROUND

As neoadjuvant chemotherapy (NAC) for breast cancer has become more widely used, so has nipple-sparing mastectomy. A common criterion for eligibility is a 1 cm tumor-to-nipple distance (TND), but its suitability after NAC is unclear. In this study, we examined factors predictive of negative nipple pathologic status (NS-) in women undergoing total mastectomy after NAC.

METHODS

Women with invasive breast cancer treated with NAC and total mastectomy from August 2014 to April 2018 at our institution were retrospectively identified. Following review of pre- and post-NAC magnetic resonance imaging (MRI) and mammograms, the association of clinicopathologic and imaging variables with NS- was examined and the accuracy of 1 cm TND on imaging for predicting NS- was determined.

RESULTS

Among 175 women undergoing 179 mastectomies, 74% of tumors were cT1-T2 and 67% were cN+ on pre-NAC staging; 10% (18/179) had invasive or in situ carcinoma in the nipple on final pathology. On multivariable analysis, after adjusting for age, grade, and tumor stage, three factors, namely number of positive nodes, pre-NAC nipple-areolar complex retraction, and decreasing TND, were significant predictors of nipple involvement (p < 0.05). The likelihood of NS- was higher with increasing TND on pre- and post-NAC imaging (p < 0.05). TND ≥ 1 cm predicted NS- in 97% and 95% of breasts on pre- and post-NAC imaging, respectively.

CONCLUSIONS

Increasing TND was associated with a higher likelihood of NS-. A TND ≥ 1 cm on pre- or post-NAC imaging is highly predictive of NS- and could be used to determine eligibility for nipple-sparing mastectomy after NAC.

Distance Between the Tumour and Nipple as a Predictor of Axillary Lymph Node Involvement in Breast Cancer

Purpose

The possibility of axillary node metastasis via the lymphatics might be related to a cancer’s location within the breast. Previous studies of this topic had small sample sizes, inaccuracies because of subjective differences, and the inability to depict the entire three-dimensional structure of the breast. Here, we aimed to improve upon these existing drawbacks by retrospectively analysing whether tumour location (quadrants) and tumour–nipple distance can predict axillary node positivity.

Patients and Methods

We identified 961 patients with invasive breast cancer between January 2000 and April 2016. The tumour–nipple distance was objectively measured intraoperatively and clinicopathological information was extracted from hospital database. The distance was measured radially from the nipple to the epicentre rather than the edge of tumour to obviate confounders resulting from tumour size variations.

Results

A total of 847 breast cancers (839 patients) met the eligibility criteria and were included in the statistical analysis. The tumour–nipple distance was smaller in node-positive patients (n = 307; 2.76 ± 2.07 cm) than in node-negative patients (n = 297; 3.41 ± 2.18 cm) (p < 0.001). Tumour–nipple distance was an independent predictor of axillary involvement on logistic regression analysis. However, no statistically significant relationship was detected between node positivity and breast quadrant tumour location.

Conclusion

Tumour–nipple distance can be used to predict axillary lymph node metastasis and assist in surgical decision-making and therapy planning. However, exploratory studies are required to increase our understanding of the mechanism.

MIP image derived from abbreviated breast MRI: potential to reduce unnecessary sub-nipple biopsies during nipple-sparing mastectomy for breast cancer

OBJECTIVE

To determine the value of a maximum-intensity projection (MIP) image derived from abbreviated breast MRI for excluding occult nipple-areolar complex (NAC) involvement in patients with breast cancer.

METHODS

This prospective study included breast cancer patients with clinically normal NACs between April 2016 and May 2019. Abbreviated breast MRI was performed, and an MIP image was generated for each patient. MIP images were examined for the following features: asymmetric nipple enhancement, tumor-nipple distance (TND), tumor diameter, lesion type, location, and multifocality. Independent predictive MIP features for occult NAC involvement were identified by univariable and multivariable logistic regression analyses. Models based on independent predictive MIP features were developed, and their diagnostic performances were evaluated using ROC analysis. The utility of an MIP image for excluding occult NAC involvement was assessed by considering NPVs across patient subgroups.

RESULTS

Eight hundred forty-three patients (67 NAC-positive and 776 NAC-negative) were enrolled. On MIP images, asymmetric nipple enhancement (odds ratio, 6.098; p < 0.001) and TND (odds ratio, 0.564; p = 0.003) were independent predictors of occult NAC involvement. A parallel test model of "asymmetric nipple enhancement or TND ≤ 15 mm" yielded the highest AUC value (0.838) among prediction models. The NPV of MIP images for excluding occult NAC involvement was 99.5%, which was applicable across various patient subgroups.

CONCLUSIONS

A single MIP image derived from abbreviated breast MRI has utility for excluding occult NAC involvement in breast cancer patients and reducing the number of unnecessary sub-nipple biopsies in nipple-sparing mastectomy.

KEY POINTS

• On MIP images derived from abbreviated breast MRI, asymmetric nipple enhancement and tumor-nipple distance were independent predictors for occult nipple involvement in patients with breast cancer. • Negative findings on MIP image can help select patients at minimal risk of occult nipple involvement, for whom unnecessary intraoperative sub-nipple biopsies in nipple-sparing mastectomy can be omitted.

A novel MRI-based predictive index can identify patients suitable for preservation of the nipple-areola complex in breast reconstructive surgery

INTRODUCTION

Accurately predicting nipple-areola complex (NAC) involvement in breast cancer is necessary for identifying patients who may be candidates for a nipple-sparing mastectomy. Although multiple risk factors are indicated in the guidelines, it is difficult to predict NAC involvement (NAC-i) preoperatively even if these factors are evaluated individually. This study aimed to develop a more accurate and practical preoperative NAC-i prediction model using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

All tumors in 252 patients were evaluated using postcontrast T1-weighted subtraction on MRI.

RESULTS

The receiver operating characteristic curves identified cut-off values for tumor size and tumor-to-nipple distance (TND) as 4 cm and 1.2 cm, respectively. Multivariate analysis demonstrated that TND (p < 0.001), ductal enhancement extending to the nipple (DEEN) (p < 0.001), and nipple enhancement (NE) (p = 0.005) were independent clinical risk factors for pathological NAC-i. A formula was constructed using odds ratios for these three independent preoperative risk factors in multivariate analysis: the MRI-based NAC-i predictive index (mNACPI) = TND × 4 + DEEN × 3 + NE × 1. A total score of ≤4 points was defined as low risk and ≥5 points as high risk. NAC-i rates were 2.4% in the low-risk group and 89.4% in the high-risk group; a significant correlation was observed between the risk group and permanent pathological NAC-i (p < 0.001). Assuming that the NAC was preserved in low-risk patients and resected in high-risk patients, NAC-i was verified using the mNACPI.

CONCLUSION

mNACPI may contribute greatly to the improvement of selecting suitable patients for NAC preservation in breast reconstructive surgery while maintaining oncological safety.

Nipple-sparing mastectomy for early breast cancer: the importance of intraoperative evaluation of retroareolar margins and intra-nipple duct removal

Background

Nipple-sparing mastectomy (NSM) is increasingly performed for breast cancer (BC) treatment. To ensure local control with this procedure, it is important to obtain clear surgical margins. Here, we aimed to estimate the confidence in intraoperative evaluation of the retroareolar margin (IERM) and the necessity of removing the intra-nipple ducts.

Methods

In this retrospective cohort study, we evaluated 224 BC (infiltrating carcinoma 178, ductal carcinoma in situ 46) patients, who underwent NSM. IERM was determined via cytology and frozen sections. Following gland removal, the intra-nipple ducts were excised and embedded in paraffin for analysis. The retroareolar tissue was also paraffin-embedded and reanalyzed for definitive evaluation of retroareolar margins (DERM). The IERM predictive capacity in relation to DERM and the frequency of intra-nipple duct involvement were estimated.

Results

IERM classified the sub-nipple areolar complex area as cancer-free in 219 cases (97.8%). The condition of clear retroareolar margin was confirmed by DERM in 216 cases (98.6%). The IERM accuracy was estimated as 98.6%. Ductal carcinoma in situ was detected in intra-nipple ducts using paraffin sections in 1.8% of the cases, despite clear IERM (4/219).

Conclusions

In conclusion, IERM affords high accuracy and its results are suitable to manage the nipple-areolar complex. Nevertheless, some patients may retain residual disease in the intra-nipple ducts; thus, these ducts should ideally be removed during NSM.

Role of diffusion-weighted imaging in prediction of nipple-areolar complex invasion by breast cancer

THE AIM OF THIS WORK

The aim of this work was to estimate the role of diffusion-weighted imaging (DWI) in predicting malignant invasion of the nipple-areolar complex (NAC) by underlying breast cancer.

MATERIAL AND METHODS

This prospective study included 70 female patients with breast cancer with a mean age of 45.8 years (range: 28-68). DWI of the breast was done for all patients. Apparent diffusion coefficient (ADC) maps were automatically constructed. The mean ADC values of NAC were independently measured by two observers who are experts in breast imaging and correlated with the results of histopathological examinations.

RESULTS

Both observers found a significantly lower ADC value of malignant NAC invasion (n = 18) when compared with free NAC (n = 52), with mean ADC value for malignant NAC invasion was 0.86 ± 0.35 × 10^-3 mm²/s and 0.84 ± 0.08 × 10^-3 mm²/s for observer one and two respectively versus mean ADC value of 1.34 ± 0.25 × 10^-3 mm²/s and 1.4 ± 0.26 × 10^-3 mm²/s for free NAC by observer one and two respectively (P-value =0.001). Observer one found that a cutoff ADC value of 1.05 × 0^-3 mm²/s can predict malignant NAC invasion with 0.975 AUC, 92.8% accuracy, 94.4% sensitivity, and 92.3% specificity. Observer two found that a cutoff ADC value of 0.95 × 10^-3 mm²/s can predict malignant NAC invasion with 0.992 AUC, 95.7% accuracy, 88.9% sensitivity, and 98.1% specificity.

CONCLUSION

DWI can predict malignant NAC invasion in patients with breast cancer.

Oncologic Outcomes of Nipple-Sparing Mastectomy with Immediate Breast Reconstruction in Patients with Tumor-Nipple Distance Less than 2.0 cm

Purpose

Although the indications for nipple-sparing mastectomy (NSM) are expanding, there remains a debate regarding the oncologic outcomes of patients treated with this method, especially those with a short tumor–nipple distance (STND). The aim of this study was to compare the long-term oncologic outcomes between patients with a long tumor–nipple distance (LTND) (≥ 2.0 cm) and those with STND (< 2.0 cm).

Methods

This was a retrospective study in which 266 patients who underwent NSM with immediate breast reconstruction between January 2008 and December 2014 at a single institution were enrolled. Of these patients, 21 were excluded because of loss to follow-up; thus, 245 patients were finally analyzed. All patients underwent preoperative breast magnetic resonance imaging and intraoperative frozen biopsy.

Results

The mean age of the patients was 42.4 years. STND was identified in 128 patients, and LTND in 117 patients. The mean follow-up period was 60.5 months. There were no significant differences between the 2 groups with respect to lymphovascular invasion, nuclear grade, nodal status, and subtype (p = 0.339, 0.372, 0.955, and 0.338, respectively). The STND group had significantly smaller tumors than the LTND group (p = 0.005). The median TND in the STND and LTND groups was 0.7 cm and 3.0 cm, respectively. Locoregional recurrence was reported in 4 patients in the STND group (3.1%) and 6 (5.1%) in the LTND group. A total of 3 patients died (1.2%; 2 in the STND group and one in the LTND group). There was no significant difference between the 2 groups with respect to disease-free survival or local recurrence-free survival (p = 0.334 and p = 0.477, respectively).

Conclusion

The long-term oncologic outcomes of patients treated with NSM did not significantly differ according to TND when the intraoperative frozen biopsy was negative for tumor cells.

Use of preoperative mammography, ultrasonography, and MRI to predict nipple areolar complex involvement in breast cancer

OBJECTIVE

To identify the predictive factors of cancer invading into the nipple.

METHODS

Patients with breast cancer undergoing mastectomy between May 2009 and March 2019 were reviewed retrospectively. Of these, those with breast cancer within 2 cm of the nipple areolar complex on ultrasonography were included in this study. Clinicopathological data of the primary tumor and imaging findings from mammography, ultrasonography, and MRI were compared between cases with and without nipple involvement by cancer.

RESULTS

In total, 156 of the 821 patients identified were included in the analysis. Of them, 29 had nipple involvement by cancer. Univariate analysis revealed that the following imaging results were significantly associated with nipple involvement: perineural invasion, lymphovascular invasion, lymph node metastasis; relation type between the tumor and the nipple on ultrasonography; periareolar skin thickening on mammography; and short tumor-nipple distance, continuous enhancement between the nipple and tumor, skin enhancement, and nipple enhancement on MRI. However, on multivariate logistic regression analysis, only invasion type of tumor on ultrasonography and nipple enhancement and short tumor-nipple distance on MRI were significantly correlated with nipple involvement by cancer.

CONCLUSION

Imaging findings on preoperative mammography, ultrasonography and MRI are effective predictors for nipple involvement by cancer.

ADVANCES IN KNOWLEDGE

Preoperative mammography, ultrasonography, and MRI help predict nipple involvement by breast cancer.