Predictors of nipple-areolar complex involvement by breast carcinoma: histopathologic analysis of 787 consecutive therapeutic mastectomy specimens

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 clinical factors for preoperative prediction of nipple involvement in breast cancer

Background

At present, the indication for nipple-sparing mastectomy (NSM) remains inconclusive, and occult nipple involvement (NI) is one of the most important problems when carrying out NSM. Therefore, we aimed to identify the predictive factors of NI, to provide a tool for selecting suitable candidates for NSM.

Methods

In this retrospective study, a total of 250 breast cancer patients who received mastectomy were recruited, and the association between NI and tumor clinicopathologic characteristics was investigated. Nipple signs, tumor size measured by ultrasound (US), and tumor location were developed as a nomogram to predict NI.

Results

Among the 250 patients, 34 (12.6%) had NI, and 216 (86.4%) did not. In the training group, NI was associated with nipple signs, tumor size, tumor–nipple distance (TND), tumor location, lymph node metastasis, and HER2 overexpression. Both in the training and in the validation groups, NI showed a significant association with nipple signs, tumor size measured by ultrasound, and tumor location. Based on these three clinical factors, the preoperative model nomogram was proved to have high efficiency in predicting NI, possessing a sensitivity of 80.0% and a specificity of 86.7% in the validation group.

Conclusions

We proposed a predictive model nomogram utilizing preoperative tumor characteristics, including nipple signs, tumor size measured by ultrasound, and tumor location. This predictive model could help in the planning of nipple-sparing mastectomy.

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.

Diagnostic Accuracy of Nonmass Enhancement at Breast MRI in Predicting Tumor Involvement of the Nipple: A Prospective Study in a Single Institution

Background Although nonmass enhancement (NME) extension to the nipple at preoperative MRI frequently leads to sacrifice of the nipple-areolar complex (NAC), its correlation with pathologically confirmed NAC involvement is unclear. Purpose To evaluate the diagnostic accuracy of using NME extension to the subareolar region at breast MRI to predict pathologic nipple involvement and the eligibility for nipple-sparing mastectomy. Materials and Methods From November 2017 to November 2019, the authors prospectively enrolled participants with breast cancer and NME within 2 cm of the nipple at breast MRI who underwent surgery that included removal of the NAC. The authors evaluated NME extensions that were ipsilateral and contiguous with the biopsy-proven tumor lesions on images acquired during the early contrast phases. Pathologic nipple involvement and the distance from the nipple to the nearest cancer cell were evaluated by using serial vertical sectioning of the area extending from the entire NAC to the tumor. The primary end point was the positive predictive value (PPV) of NME, which was calculated as follows: (number with pathologic nipple invasion and NME extension to the nipple at breast MRI/number with NME extension to the nipple at breast MRI) × 100. Results Of 64 women (mean age, 52 years ± 9.8 [standard deviation]), 49 (77%) had NME extension to the nipple at breast MRI. The PPV of NME extension to the nipple was 86% (42 of 49 women; 95% CI: 73, 94). Among the 15 participants without NME extension to the nipple, only one (7%) had pathologic nipple involvement. The diagnostic accuracy of using NME extension to the nipple was 88% (56 of 64 women; 95% CI: 77, 95). The radiologic distance correlated well with the pathologic distance (Spearman correlation coefficient = 0.71, P = .003). Conclusion Nonmass enhancement extension to the nipple base at preoperative MRI has a high positive predictive value for identifying tumor involvement of the nipple, a contraindication to nipple-sparing mastectomy. © RSNA, 2021 Online supplemental material is available for this article.

Magnetic resonance imaging in the evaluation of pathologic nipple discharge: indications and imaging findings

Pathologic nipple discharge (PND) is typically unilateral, spontaneous, involves a single duct, and is serous or bloody in appearance. In patients with PND, breast MRI can be helpful as an additional diagnostic tool when conventional imaging with mammogram and ultrasound are negative. MRI is able to detect the etiology of nipple discharge in 56-61% of cases when initial imaging with mammogram and ultrasound are negative. Advantages to using MRI in evaluation of PND include good visualization of the retroareolar breast and better evaluation of posterior lesions which may not be well evaluated on mammograms and galactograms. It is also less invasive compared to central duct excision. Papillomas and nipple adenomas are benign breast masses that can cause PND and are well visualized on MRI. Ductal ectasia, and infectious etiologies such as mastitis, abscess, and fistulas are additional benign causes of PND that are well evaluated with MRI. MRI is also excellent for evaluation of malignant causes of PND including Paget's disease, ductal carcinoma in-situ and invasive carcinoma. MRI's high negative predictive value of 87-98.2% is helpful in excluding malignant etiologies of PND.

The nipple-areolar complex: comprehensive imaging review

The nipple-areolar complex can be affected by a variety of benign and malignant entities that can present with non-specific symptoms. Benign pathologies commonly affecting the nipple-areolar complex include nipple calcifications, nipple adenoma, abscess of Montgomery tubercles, ductal ectasia, periductal mastitis, and papilloma. Malignant pathologies that affect the nipple-areolar complex include Paget's disease of the breast, ductal carcinoma in-situ, and invasive ductal carcinoma. Clinical history and examination, imaging, and tissue sampling when appropriate are co-dependent factors that guide the assessment of nipple-areolar pathologies. This article provides a review of the normal anatomy, common anatomical variants, benign and malignant pathologies, and imaging techniques to guide the diagnostic assessment of the nipple-areolar complex.

Oncological Outcomes of Total Skin-Sparing Mastectomy for Invasive Lobular Carcinoma of the Breast: A 20-Year Institutional Experience

BACKGROUND

Although rates of total skin-sparing (nipple-sparing) mastectomies are increasing, the oncologic safety of this procedure has not been evaluated in invasive lobular carcinoma (ILC). ILC is the second most common type of breast cancer, and its diffuse growth pattern and high positive margin rates potentially increase the risk of poor outcomes from less extensive surgical resection.

METHODS

We compared time to local recurrence and positive margin rates in a cohort of 300 patients with ILC undergoing either total skin-sparing mastectomy (TSSM), skin-sparing mastectomy, or simple mastectomy between the years 2000-2020. Data were obtained from a prospectively maintained institutional database and were analyzed by using univariate statistics, the log-rank test, and multivariate Cox proportional hazards models.

RESULTS

Of 300 cases, mastectomy type was TSSM in 119 (39.7%), skin-sparing mastectomy in 52 (17.3%), and simple mastectomy in 129 (43%). The rate of TSSM increased significantly with time (p < 0.001) and was associated with younger age at diagnosis (p = 0.0007). There was no difference in time to local recurrence on univariate and multivariate analysis, nor difference in positive margin rates by mastectomy type. Factors significantly associated with shorter local recurrence-free survival were higher tumor stage and tumor grade.

CONCLUSIONS

TSSM can be safely offered to patients with ILC, despite the diffuse growth pattern seen in this tumor type.

Tumor-to-Nipple Distance in Selecting Patients for Nipple-sparing Mastectomy

Nipple-sparing mastectomy (NSM) is a valid option for carefully selected cases. Oncologic guidelines have not been established, but proximity of the tumor to the nipple, tumor size, lymph node involvement, and neoadjuvant chemotherapy have been suggested as contraindications to nipple preservation. This study describes our experience with NSM in relation to these factors, in particular distance of tumor from the nipple, to help establish evidence-based guidelines for 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.

Breast cancer involvement of the nipple-areola complex and implications for nipple-sparing mastectomies: a retrospective observational study in 137 patients

Introduction

Nipple-sparing mastectomy (NSM) has gained much attention by enhancing the aesthetic outcome in breast carcinoma patients. The aim of this study was to assess the prevalence of malignant affection of the nipple-areola complex (NAC) in breast carcinoma patients and its correlation with prognostic factors for breast cancer.

Patients and methods

This study included 137 female patients diagnosed with breast carcinoma at different disease stages who were admitted to our surgical oncology unit at Suez Canal University Hospital from June 15, 2014 to January 25, 2017. We excluded patients with evidence of nipple involvement as ulceration or patients with previous breast surgery with periareolar incisions. This study was designed to test the hypothesis that the NAC can be spared in certain selected patients. All studied participants provided a full history and underwent general and local clinical examinations, pre-operative laboratory tests, and radiological and pathological evaluations.

Results

The mean age of the study population was 47.39 ± 8.01 years. Among the patients, the NAC was affected in 12 (11.40%) patients. Patients with NAC involvement showed a significantly larger tumor size of more than 4 cm and a shorter tumor-nipple distance of less than 2 cm (p = 0.000). Lymph node metastasis was associated with NAC involvement (p = 0.001), with increased risk when more than 10 lymph nodes were involved (p = 0.007). Lymphovascular invasion was a significant predictor of NAC involvement (p = 0.014). Multifocal as well as multicentric tumors were significantly associated with NAC involvement (p = 0.016 and 0.003, respectively). NAC involvement was more likely in Estrogen receptor (ER) and Progesterone receptor (PR) patients than in ER+ and PR+ patients (p = 0.000), while Human epidermal receptor (HER+) patients were more likely to have NAC involvement than HER patients (p = 0.000). Additionally, stage ΙΙΙ cancer was significantly associated with NAC involvement (p = 0.041), and histological grade III disease carried a greater risk than grade I disease of NAC involvement (p = 0.008).

Conclusion

The incidence of NAC affection among breast carcinoma patients who underwent mastectomy and axillary clearance was associated with important parameters, such as tumor size, areola edge-tumor distance, lymph node affection, hormonal receptor status and lymphovascular invasion. Accordingly, NAC-preserving surgeries could be tailored to patients with favourable tumor characteristics.

Clinical value of delayed 18F-FDG PET/CT for predicting nipple-areolar complex involvement in breast cancer: A comparison with clinical symptoms and breast MRI

Objective

We aimed to evaluate the predictive value of delayed ¹⁸F-FDG PET/CT for identifying malignancies involved in the nipple-areolar complex (NAC) in comparison with clinical symptoms and breast MRI.

Methods

We enrolled 90 patients who underwent preoperative delayed ¹⁸F-FDG PET/CT and MRI between October 2015 and May 2017. We calculated the NAC-Standardized uptake value ratio (SUVR) using the following formula: maximum SUV (SUV_max) of the NAC in the malignant breast /SUV_max of the NAC in the contralateral normal breast on early (NAC-SUVR_early) and delayed (NAC-SUVR_delay) phase images. MRI was used to measure the distance between the tumor and NAC and to analyze NAC enhancement patterns. Univariate and multivariate analyses were performed to identify significant predictive factors for NAC involvement.

Results

Seventeen patients were confirmed to have pathologic NAC involvement. NAC symptoms (p = 0.009), tumor multiplicity (p = 0.006), NAC-SUVR_delay (> 1.23, p = 0.007), and MRI-based tumor-to-NAC distance (≤ 22.0 mm, p = 0.003) were independent predictive factors for NAC involvement. Ten of 76 patients with no clinical NAC symptoms had NAC malignancy. Tumor multiplicity (p = 0.009), tumor-to-NAC distance (≤ 20.0 mm, p = 0.014)), and NAC-SUVR_delay (> 1.23, p = 0.018) had independent predictive value for NAC involvement.

Conclusions

Delayed ¹⁸F-FDG PET/CT is a useful modality for predicting NAC involvement in breast cancer patients whether or not NAC symptoms are present.

Nipple Areola Complex Involvement in Invasive Carcinoma Breast

A variety of factors including tumor biology and distance of the tumor from the nipple have been associated with nipple areola complex involvement in patients with breast cancer. Preoperative understanding regarding these factors can help in modifying the surgical options including preservation of nipple areola complex (NAC) and breast conservation. Nipple sparing surgery (breast conservation surgery/skin sparing mastectomy with immediate reconstruction) for breast cancer has gained widespread interest with the aim of achieving oncologically safe and cosmetically acceptable outcome. To study the proportion of cases with nipple areola complex involvement in invasive carcinoma breast and to describe the variables predictive of nipple areola complex involvement in patients undergoing excision of tumor along with NAC for invasive carcinoma breast. A cross-sectional study was conducted among 136 patients who underwent mastectomy in Regional Cancer Center, Thiruvananthapuram. Tumor nipple distance was assessed preoperatively using mammogram and postoperatively by histopathological examination. Nipple involvement was seen only among 4.4%. Preoperative assessment of tumor to nipple distance, tumor size, location, and stage of the disease agrees with the histopathological examination. Only a small proportion of breast cancer has NAC involvement and preoperative assessment could help the surgeon in deciding on the feasibility of NAC preservation.

The impact of malignant nipple discharge cytology (NDc) in surgical management of breast cancer patients

Background

The role of nipple discharge cytology (NDc) in the surgical management of breast cancer patients is unclear. We aimed: (i) to evaluate the effect of malignant NDc on the surgical approach to the nipple-areola complex, and (ii) to verify the association between malignant NDc and nipple malignancy.

Methods

We retrospectively analyzed a case series of 139 patients with NDc who underwent breast surgery. The clinical and histological findings, types of surgery with emphasis on nipple-areola complex amputation, immunohistochemical phenotypes of the carcinomas and measurements of the tumor-nipple distance were recorded. Additionally, in patients who showed HER2-positive lesions on definitive surgery, we evaluated the HER2 immunocytochemistry of the NDc smears.

Results

Thirty-two malignant and 107 benign/borderline NDc diagnoses were identified. All 32 malignant-NDc cases were histologically confirmed as malignant. Thirty borderline/benign-NDc cases were histologically diagnosed as malignant (sensitivity 58%). The majority of the patients with malignant NDc were treated with nipple-areola complex amputations in both the mastectomy and conservative surgery groups (P<0.001, χ²51.77). Nipple involvement was strongly associated with HER2-positive ductal carcinoma in-situ (P<0.001, χ²11.98). HER2 immunocytochemistry on the NDc revealed a 100% correlation with the immunocytochemistry performed on the surgical tissues.

Conclusions

Malignant NDc influenced surgical management. The association of malignant NDc with nipple involvement is highly related to ductal carcinoma in-situ with HER2 overexpression. In case of HER2 positive NDc, nipple-areola complex involvement is more likely than in HER2 negative cases.

Skin-Reducing Mastectomy in Immediate Reconstruction: How to Limit Complications and Failures

BACKGROUND

In hypertrophic and/or very ptotic breasts, skin-reducing mastectomy (SRM) is challenging and the risk of complications is high. Few publications have reported the use of an autologous latissimus dorsi flap (ALDF) in this indication. Most studies opt for implant reconstructions, with a high failure rate.

OBJECTIVES

We aimed to identify and present the technical refinements that reduce the risk of reconstruction failure in patients with hypertrophic and/or ptotic breasts with breast cancer or at risk of breast cancer after SRM with immediate breast reconstruction (IBR) utilizing an ALDF.

METHODS

Our retrospective study, covering a period of 18 years, included a series of 60 patients with hypertrophic and/or ptotic breasts who underwent 67 SRM and IBR procedures utilizing an ALDF. The complications were recorded and the risk factors analyzed.

RESULTS

Sixty-seven SRMs were reviewed. Forty-nine procedures were performed with an inverted-T scar technique and 18 with a vertical scar technique. The nipple-areola complex (NAC) was preserved in 10 cases. There were eight (11.9%) cases of minor mastectomy flap necrosis after skin-reducing reconstructions, 16 (23.8%) wound dehiscences, no infections, no breast seromas, and no reconstruction failures. Smoking increased the risk of minor mastectomy flap necrosis (P = 0.048) and wound dehiscence (P = 0.002). Previous radiotherapy was associated with minor mastectomy flap necrosis (P = 0.001).

CONCLUSIONS

The use of an ALDF together with technical refinements that preserve the vascular supply of the skin envelope leads to successful IBR with consistently good aesthetic results. Above all, it avoids failure of the reconstruction in very large or ptotic breasts.

LEVEL OF EVIDENCE 4

Nipple-sparing mastectomies: Clinical outcomes from a single academic institution

Nipple-sparing mastectomies (NSMs) are increasingly used in the surgical treatment of patients with breast cancer and for prevention of breast cancer. The present study was performed to review the outcomes of patients undergoing NSMs at a single large university setting. A retrospective chart review was performed on all patients undergoing NSMs from 2008-2014. Charts were reviewed for demographic data and patient characteristics. Tumor and breast size, cancer recurrence and complications were also evaluated. Descriptive statistics were utilized to summarize the findings. From 2008-2014, 110 patients underwent 197 NSMs. The mean patient age was 44.4 years (range, 20-77). The average body mass index was 24 (range, 18-47). Breast weight was available for 106 specimens, with a mean weight of 475.5 g (range, 124.1-1,625.0 g). Seventy-three NSMs were performed for cancer and 124 were performed prophylactically. The mean tumor width was 1.38 cm (range, 0-6.0 cm), with an average nipple to tumor distance of 5.87 cm (range, 2.93-10.0 cm). Three (4%) patients required removal of the nipple areolar complex (NAC) due to pathological extension of the tumor. A total of 34 (17.2%) complications occurred, including infections, hematomas and nipple necrosis, with 9 requiring removal of the NAC and 13 requiring removal of the tissue expander or implant. Smokers had a 36.0% (9/25) complication rate, compared with 14.5% (25/172) of nonsmokers (P<0.05). During follow-up, one recurrence was noted, located on the chest wall. There were no recurrences in the NAC group. Therefore, NSMs may safely be performed without compromising oncologic outcomes or increasing complication rates in properly selected patients.

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.

Trends and variation in the use of nipple-sparing mastectomy for breast cancer in the United States

PURPOSE

For many women, nipple-sparing mastectomy (NSM) provides aesthetic and quality-of-life outcomes superior to skin-sparing mastectomy. Accumulating data suggest that NSM provides similar oncologic outcomes in select breast cancer patients. This study sought to determine national trends in NSM use.

METHODS

Using the National Cancer Data Base, 6254 women with breast cancer who underwent NSM between 2010 and 2013 were identified. NSM rates were determined relative to the number of patients who received a mastectomy with reconstruction (n = 114,849). Associations between patient, tumor, and facility characteristics and NSM were assessed using logistic regression.

RESULTS

The rate of NSM increased from 2.9 to 8.0 % between 2010 and 2013. NSM was most commonly performed in academic (adjusted odds ratio [OR] 1.43, p < 0.001) and high-volume (OR 1.59, p < 0.001) breast centers. There was up to a 5.8-fold variation in its delivery between geographic census regions (p < 0.001). Of 1231 hospitals, only 491 (39.9 %) reported performing at least one NSM during the study period. Half of all NSMs were performed by the top 6 % (n = 30) of NSM-performing centers. NSM was associated with small tumor size (p < 0.001), lower tumor grades (p < 0.05), and negative nodal status (p < 0.001). However, half of NSM patients had at least one tumor characteristic that diverged from current (2016) NCCN recommendations for the procedure.

CONCLUSIONS

The use of therapeutic NSM is increasing dramatically in the United States, despite recommendations that the procedure be used with caution. As NSM becomes increasingly common, efforts are needed to monitor its long-term oncologic outcomes and to ensure equitable access to it.

Nipple-sparing mastectomy: A contemporary perspective

Increasing numbers of women are undergoing nipple-sparing mastectomy, and evidence to support its use for cancer treatment and prophylaxis is expanding. An understanding of technical aspects and pitfalls of the procedure is paramount to ensure that the best results are attained. J. Surg. Oncol. 2016;113:883-890. © 2016 Wiley Periodicals, Inc.

Nipple Pathology in Total Skin-Sparing Mastectomy: Implications for Immediate Reconstruction

PURPOSE

The management of occult tumor involvement of the nipple during total skin-sparing mastectomy (TSSM) and immediate reconstruction is not well addressed in the literature. We reviewed our experience with positive nipple core biopsies, comparing outcomes of different management options.

METHODS

Mastectomy and implant/expander reconstructions over a 5-year period were reviewed. Patient characteristics, type of mastectomy, and complications were analyzed. Patients were grouped by type of mastectomy/immediate reconstruction and delayed reconstruction to compare outcomes. Positive intraoperative core nipple biopsy cases formed a subset of the TSSM group.

RESULTS

Forty-four of 240 (18%) cases were TSSMs performed through inferolateral incisions. All were reconstructed immediately, 24 with tissue expanders and 20 with implants. Major complications (necrosis, infection, seroma) were significantly lower than for skin-sparing mastectomies, but higher than delayed reconstruction. One case of full thickness nipple necrosis occurred. Seven of the TSSM group had positive core nipple biopsies (16%). Three of these patients underwent nipple excision and tissue expander placement at the initial surgery, of which 2 developed subsequent mastectomy skin flap necrosis requiring explantation. A third patient underwent staged nipple excision without complication. The remaining 3 patients underwent delayed nipple resection at the time of tissue expander replacement without complication. Pathology in the nipple core was invasive ductal carcinoma and ductal carcinoma in situ. No TSSM patients have developed local recurrence at follow-up.

CONCLUSIONS

Concurrent excision of the nipple and an inferolateral incision increase the incidence of skin flap necrosis. Delaying nipple excision may prove to be a safer option.

Nipple-sparing Mastectomy in Breast Cancer: From an Oncologic Safety Perspective

Objective:

To evaluate the oncologic safety of nipple-sparing mastectomy (NSM) for breast cancer patients based on current literature.

Data Sources:

A comprehensive literature search of Medline, Embase databases was conducted for studies published through March 2014.

Study Selection:

Our search criteria included English-language studies that focused on NSM at nipple-areola complex (NAC) involvement, patient selection, and recurrence. Prophylaxis NSM, case series or reports that based on very small population were excluded. In the end, 42 studies concerning NSM and oncological safety were included into the review.

Results:

NSM is a surgical procedure that allows the preservation of the skin and NAC in breast cancer patients or in patients with prophylactic mastectomy. However, the oncologic safety and patient selection criteria associated with NSM are still under debate. The incidence of NAC involvement of breast cancer in recent studies ranges from 9.5% to 24.6%, which can be decreased through careful patient selection. Tumour-nipple distance, tumour size, lymph node involvement and molecular characteristics can be evaluated preoperatively by clinical examinations, imaging studies and biopsies to predict the risk of NAC involvement. Currently, there is no available standard protocol for surgical approaches to NSM or pathological examination of NSM specimens. The local recurrence (ranges from 0% to 24%) of NSM is not significantly higher than that of traditional mastectomy in selected patients based on long-term follow-up. The role of radiotherapy in NSM is still controversial and is not universally accepted.

Conclusions:

NSM appears to be oncologically safe following careful patient selection and assessment of margins.

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.

Clinical abnormalities of the nipple-areola complex: The role of imaging

Clinical examination of the nipple is part of normal breast screening procedures. Abnormal processes of benign or malignant nature may be reflected by erythema, erosion, swelling or acquired inversion. In patients presenting with a persistent unilateral nipple lesion, it is advisable to collect a sample to exclude Paget's disease of the nipple, a rare form of ductal carcinoma in situ (DCIS). Imaging should be performed to detect breast cancer, which is found in more than 80% of cases, and determine its possible multifocal nature. Breast MRI is indicated if breast-conserving surgery is planned. The main differential diagnoses are erosive adenomatosis and eczema of the nipple. Acquired inverted nipple is generally of inflammatory origin. It is usually diagnosed by conventional breast examination but breast MRI can be helpful when in doubt about possible underlying neoplasia.

Neoadjuvant chemotherapy is not a contraindication for nipple sparing mastectomy

BACKGROUND

Nipple-sparing mastectomy (NSM) has been recently implemented to improve cosmetic outcome after mastectomy, but it is rarely considered today after neoadjuvant chemotherapy (NCH).

PATIENTS AND METHODS

Among 275 NSMs performed from January 2007 to January 2015, 186 cases, with a minimum follow-up of 12 months, were carried out for invasive or intraductal carcinoma. Patients were considered for NSM if there were no clinical and radiological evidence of invasion or close proximity (<1 cm) to the nipple-areola complex (NAC). We compared patients operated with NSM after NCH (Group I N = 51) with those who underwent primary surgery (Group II, N = 135).

RESULTS

At a median follow-up of 35 months, 166/186 patients were alive and disease-free (89.7%). Three local relapses (1.6%) were observed, all in the skin flap outside the NAC in Group I: (6%; p < 0.01). No NAC recurrences have been recorded, in either group. Nipple loss due to full thickness necrosis or resection for insufficient margins was recorded in 31 cases (17%); 12 in Group I (24%) and 19 in Group II (14%) (P = 0.1). This event decreased by half in the second part of the study (21/93 vs 10/93) (P = 0.03).

CONCLUSIONS

NSM after NCH is not associated with a statistically significant difference in terms of post-operative complications, total nipple loss for necrosis or margins, and results improve with experience. The loco-regional relapse rate was higher after NCH, yet it was consistent with traditional mastectomy in the high-risk setting. There is no need to avoid NSM after NCH for locally advanced cancers, if the retro-areolar margins of resection are clear at the time of surgery.

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.

Immediate nipple-areola-sparing mastectomy reconstruction: An update on oncological and reconstruction techniques

Nipple-sparing mastectomy (NSM) is a safe technique in patients who are candidates for conservation breast surgery. However, there is worry concerning its oncological safety and surgical outcome in terms of postoperative complications. The authors reviewed the literature to evaluate the oncological safety, patient selection, surgical techniques, and also to identify the factors influencing postoperative outcome and complication rates. Patient selection and safety related to NSM are based on oncological and anatomical parameters. Among the main criteria, the oncological aspects include the clinical stage of breast cancer, tumor characteristics and location including small, peripherally located tumors, without multicentricity, or for prophylactic mastectomy. Surgical success depends on coordinated planning with the oncological surgeon and careful preoperative and intraoperative management. In general, the NSM reconstruction is related to autologous and alloplastic techniques and sometimes include contra-lateral breast surgery. Choice of reconstructive technique following NSM requires accurate consideration of various patient related factors, including: breast volume, degree of ptosis, areola size, clinical factors, and surgeon’s experience. In addition, tumor related factors include dimension, location and proximity to the nipple-areola complex. Regardless of the fact that there is no unanimity concerning the appropriate technique, the criteria are determined by the surgeon’s experience and the anatomical aspects of the breast. The positive aspects of the technique utilized should include low interference with the oncological treatment, reproducibility, and long-term results. Selected patients can have safe outcomes and therefore this may be a feasible option for early breast cancer management. However, available data demonstrates that NSM can be safely performed for breast cancer treatment in selected cases. Additional studies and longer follow-up are necessary to define consistent selection criteria for NSM.

[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.

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.