Nipple-sparing mastectomy: critical assessment of 51 procedures and implications for selection criteria.
ABSTRACT 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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ABSTRACT: The side effects of mastectomy can be significant. Breast reconstruction may alleviate some distress; however, there are currently no provincial recommendations regarding the integration of reconstruction with breast cancer therapy. The purpose of the present article is to provide evidence-based strategies for the management of patients who are candidates for reconstruction. A systematic review of meta-analyses, guidelines, clinical trials and comparative studies published between 1980 and 2013 was conducted using the PubMed and EMBASE databases. Reference lists of publications were manually searched for additional literature. The National Guidelines Clearinghouse and SAGE directory, as well as guideline developers' websites, were also searched. Recommendations were developed based on the available evidence. Reconstruction consultation should be made available for patients undergoing mastectomy. Tumour characteristics, cancer therapy, patient comorbidities, body habitus and smoking history may affect reconstruction outcomes. Although immediate reconstruction should be considered whenever possible, delayed reconstruction is acceptable when immediate is not available or appropriate. The integration of reconstruction and postmastectomy radiotherapy should be addressed in a multidisciplinary setting. The decision as to which type of procedure to perform (autologous or alloplastic with or without acellular dermal matrices) should be left to the discretion of the surgeons and the patient after providing counselling. Skin-sparing mastectomy is safe and appropriate. Nipple-sparing is generally not recommended for patients with malignancy, but could be considered for carefully selected patients. Immediate reconstruction requires resources to coordinate operating room time between the general and plastic surgeons, to provide supplies including acellular dermal matrices, and to develop the infrastructure needed to facilitate multidisciplinary discussions.The Canadian journal of plastic surgery, Journal canadien de chirurgie plastique 06/2014; 22(2):103-11. · 0.27 Impact Factor
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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 · 3.94 Impact Factor
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ABSTRACT: Prophylactic skin-sparing mastectomy (SSM) is associated with major breast cancer risk reduction in high-risk patients. In prophylactic nipple-sparing mastectomy (NSM) it is unknown how many terminal duct lobular units (TDLUs) remain behind the nipple-areola complex (NAC) additionally to those behind the skin flap. Therefore, safety of NSM can be doubted. We compared amounts of TDLUs behind the NAC as compared with the skin. In prophylactic SSM and conventional therapeutic mastectomy patients, the NAC and an adjacent skin island (SI) were resected as if it were an NSM. NAC and SI were serially sectioned perpendicularly to the skin and analyzed for the amount of TDLUs present. Slides of NAC and SI were scanned, and slide surface areas (cm) were measured. TDLUs/cm in NAC versus SI specimen, representing TDLU density, were analyzed pairwise. In total, 105 NACs and SIs of 90 women were analyzed. Sixty-four NACs (61%) versus 25 SIs (24%) contained ≥1 TDLUs. Median TDLU density was higher in NAC specimens (0.2 TDLUs/cm) as compared with SI specimens (0.0 TDLUs/cm; P<0.01). Independent risk factors for the presence of TDLUs in the NAC specimen were younger age and parity (vs. nulliparity). The finding of higher TDLU density behind the NAC as compared with the skin flap suggests that sparing the NAC in prophylactic NSM in high-risk patients possibly may increase postoperative breast cancer risk as compared with prophylactic SSM. Studies with long-term follow-up after NSM are warranted to estimate the level of residual risk.The American journal of surgical pathology 04/2014; 38(5). DOI:10.1097/PAS.0000000000000180 · 4.59 Impact Factor