Nipple-Sparing Mastectomy: Critical Assessment of 51 Procedures and Implications for Selection Criteria

Department of Surgery, Division of Surgical Oncology, Johns Hopkins University, Baltimore, MD 21287, USA.
Annals of Surgical Oncology (Impact Factor: 3.93). 11/2008; 15(12):3396-401. DOI: 10.1245/s10434-008-0102-0
Source: PubMed


Retrospective studies have shown that occult nipple-areolar complex (NAC) involvement in breast cancer is low, occurring in 6-10% of women undergoing skin-sparing mastectomy (SSM). The cosmetic result and high patient satisfaction of nipple-sparing mastectomy (NSM) has prompted further evaluation of the oncologic safety of this procedure.
We conducted a retrospective chart review of 36 self-selected patients who underwent 51 NSM procedures between 2002 and 2007. Criterion for patient selection was no clinical evidence of nipple-areolar tumor involvement. All patients had the base of the NAC evaluated for occult tumor by permanent histologic section assessment. We also evaluated tumor size, location, axillary node status, recurrence rate, and cosmetic result.
Malignant NAC involvement was found in 2 of 34 NSM (5.9%) completed for cancer which prompted subsequent removal of the NAC. Of the 51 NSM, 17 were for prophylaxis, 10 for ductal carcinoma in situ (DCIS), and 24 for invasive cancer. The average tumor size was 2.8 cm for invasive cancer and 2.5 cm for DCIS. Nine patients had positive axillary nodes. Overall, 94% of the tumors were located peripherally in the breast. After mean follow-up of 18 months, only two patients (5.9%) had local recurrence.
Using careful patient selection and careful pathological evaluation of the subareolar breast tissue at surgery, NSM can be an oncologically safe procedure in patients where this is important to their quality of life. A prospective study based on focused selection criteria and long-term follow-up is currently in progress.

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    • "Currently, SSM is being used in most centers, including ours, which allows the removal of all breast tissue and the NAC, but preserves most of the native skin enveloping the breast.4 Because NAC involvement is present in only a small percentage of breast cancers, some believe that NSM, which preserves the NAC and may provide better cosmeses and functional results, may be an appropriate alternative for many patients undergoing mastectomy with immediate reconstruction.5–7,27–29 Because most of the NAC involvement occurs within the nipple and not the areola, Simmons et al. suggested areolar-sparing mastectomy with removal of nipple while preserving the areola as an alternative to NSM.21 "
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    ABSTRACT: Breast-conserving therapy (BCT) is an accepted therapeutic option for most breast cancer patients. However, mastectomy is still performed in 30-50% of patients undergoing surgeries. There is increasing interest in preservation of the nipple and/or areola in hopes of achieving improved cosmetic and functional outcomes; however, the oncologic safety of nipple-areolar complex (NAC) preservation is a major concern. We sought to identify the predictive factors for NAC involvement in breast cancer patients. We analyzed the rates and types of NAC involvement by breast carcinoma, and its association with other clinicopathologic features of the tumors in 787 consecutive therapeutic mastectomies performed at our institution between 1997 and 2009. Among these, 75 cases (9.5%) demonstrated NAC involvement. Only 21 (28%) of 75 of cases with NAC involvement could be identified grossly by inspection of the surgical specimen (seven of these had been clinically identified). NAC involvement was most significantly associated with tumors located in all four quadrants (P<0.0001), tumors>5 cm in size (P=0.0014 for invasive carcinoma and P=0.0032 for in-situ carcinoma), grade 3 tumors (P=0.0192), tumors with higher nuclear grades (P=0.0184), and tumors with HER2 overexpression (P=0.0137). On the basis of our findings, we have developed a mathematical model that is based on the extent and location of the tumor, HER2 expression, and nuclear grade that predicts the probability of NAC involvement by breast cancer. This model may aid in preoperative planning in selecting appropriate surgical procedures based on an individual patient's relative risk of NAC involvement.
    Annals of Surgical Oncology 10/2011; 19(4):1174-80. DOI:10.1245/s10434-011-2107-3 · 3.93 Impact Factor
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    • "A review article by Voltura et al. found local recurrence rates with NSM showed an equivalency to SSM.7 They thought that patients undergoing neoadjuvant chemotherapy were acceptable candidates for NSM. "
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    ABSTRACT: 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. 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. 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. AS and NAS mastectomies can be safely performed in the community hospital setting with low complication rates and good short-term results.
    Annals of Surgical Oncology 10/2010; 18(4):917-22. DOI:10.1245/s10434-010-1365-9 · 3.93 Impact Factor
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    • "Oncological concerns regarding the risk of occult NAC involvement have been assuaged to some extent by several recent studies [2,27-29]. Voltura et al [30] recently reported outcomes for 34 NSMs undertaken for cancer (24 BC and 10 DCIS). In each case histological analysis of the sub-areolar tissue was performed and only 2 cases (5.9%) required subsequent NAC removal. "
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    ABSTRACT: The management of early breast cancer (BC) with skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) is not based on level-1 evidence. In this study, the oncological outcome, post-operative morbidity and patients' satisfaction with SSM and IBR using the latissimus dorsi (LD) myocutaneous flap and/or breast prosthesis is evaluated. 137 SSMs with IBR (10 bilateral) were undertaken in 127 consecutive women, using the LD flap plus implant (n = 85), LD flap alone (n = 1) or implant alone (n = 51), for early BC (n = 130) or prophylaxis (n = 7). Nipple reconstruction was performed in 69 patients, using the trefoil local flap technique (n = 61), nipple sharing (n = 6), skin graft (n = 1) and Monocryl mesh (n = 1). Thirty patients underwent contra-lateral procedures to enhance symmetry, including 19 augmentations and 11 mastopexy/reduction mammoplasties. A linear visual analogue scale was used to assess patient satisfaction with surgical outcome, ranging from 0 (not satisfied) to 10 (most satisfied). After a median follow-up of 36 months (range = 6-101 months) there were no local recurrences. Overall breast cancer specific survival was 99.2%, 8 patients developed distant disease and 1 died of metastatic BC. There were no cases of partial or total LD flap loss. Morbidities included infection, requiring implant removal in 2 patients and 1 patient developed marginal ischaemia of the skin envelope. Chemotherapy was delayed in 1 patient due to infection. Significant capsule formation, requiring capsulotomy, was observed in 85% of patients who had either post-mastectomy radiotherapy (PMR) or prior radiotherapy (RT) compared with 13% for those who had not received RT. The outcome questionnaire was completed by 82 (64.6%) of 127 patients with a median satisfaction score of 9 (range = 5-10). SSM with IBR is associated with low morbidity, high levels of patient satisfaction and is oncologically safe for T(is), T1 and T2 tumours without extensive skin involvement.
    BMC Cancer 03/2010; 10(1):171. DOI:10.1186/1471-2407-10-171 · 3.36 Impact Factor
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