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: 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.
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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
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ABSTRACT: The guiding principles of nipple-sparing mastectomy (complete removal of the breast from its skin and reconstructing without changing the appearance of the breast) are based on patient safety followed by oncologic safety. Recent advances have also taken into account cosmetic outcome. The ultimate in cosmetic outcome after mastectomy with reconstruction includes preservation of the nipple-areola complex, called a nipple-sparing mastectomy. The evidence-based transition and transformation to nipple-sparing mastectomy from both an oncologic standpoint and a cosmetic perspective are outlined in this article.Surgical Oncology Clinics of North America 01/2014; DOI:10.1016/j.soc.2014.03.013 · 1.67 Impact Factor