VOLUME 4, NUMBER 5 ■ MAY 2006www.SupportiveOncology.net
J Support Oncol 2006;4:225–230 © 2006 Elsevier Inc. All rights reserved.
R E V I E W
Abstract There is renewed interest in the use of nipple-sparing mas-
tectomy (NSM), which combines skin-sparing mastectomy with preser-
vation of the nipple-areola complex. NSM may be an oncologically safe
treatment in a subgroup of patients who are candidates for breast-con-
serving surgery but still prefer to undergo mastectomy. A combination
of newer techniques and good coordination between plastic and on-
cologic surgeons can achieve excellent cosmetic results and a low inci-
dence of postoperative complications. However, major concerns about
NSM include the persistent risk for breast cancer development when
it is used for prophylaxis as well as the potential failure of local control
when it is used for treatment. The reported experience with these newer
techniques lacks the power to generate a consensus for its indications
because of limited reported series with small populations. Although the
current role of NSM seems to be more defined as a prophylactic proce-
dure in high-risk patients, prospective studies and reports are needed to
better define its indications.
tempts to preserve the NAC and excess skin dur-
ing mastectomy. Sparing the NAC was historically
reported by Freeman4,5 in the 1960s with subcuta-
neous mastectomy. He advocated the procedure
in the presence of benign breast lesions, but did
not address its role for prophylaxis in high-risk pa-
tients or cancer treatment.
Issues that arise when considering preservation
of the NAC are safety, cosmesis, and function.
The major concern about this procedure is the risk
of breast cancer development of residual major
ducts. The risk of cancer developing de novo in
preserved tissue should be distinguished from the
risk of cancer involving the nipple by direct exten-
sion. Involvement of the nipple by direct extension
is more common than are de novo lesions.
PAGET’S DISEASE OF THE NIPPLE
Paget’s disease represents a form of carcinoma
in situ that arises from a lactiferous sinus near
the nipple and grows up onto the surface of the
nipple epidermis. Its incidence ranges from 0.5%
Manuscript submitted December 23, 2005;
accepted January 16, 2006.
Correspondence to: Patrick I. Borgen, MD, Department of
Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York
Avenue, MRI-1034, New York, NY 10021; telephone: (212)
639-7754; fax: (646) 422-2922; e-mail: email@example.com
Dr. Garcia-Etienne is a
Fellow and Dr. Borgen
is Chief, Breast Service,
Department of Surgery,
Kettering Cancer Center,
New York, New York.
Update on the Indications for
Carlos A. Garcia-Etienne, MD, and Patrick I. Borgen, MD
cancer treatment is still evolving to include more
conservative and cosmetic approaches. Advances
in plastic surgery techniques have made immedi-
ate breast reconstruction available to the major-
ity of patients undergoing mastectomy. These
advances and increasing patient concerns about
cosmesis have led surgical oncologists and plastic
surgeons to explore approaches that combine on-
cologic safety and aesthetic results.
The need for removal of the nipple-areola
complex (NAC) as part of mastectomy is an area
of renewed interest. Nipple-sparing mastectomy
(NSM), which combines skin-sparing mastectomy
(SSM) with preservation of the NAC, is a con-
troversial procedure lacking general consensus.
Physicians involved in the management of breast
disease should be familiar with the possible indica-
tions for the use of this procedure.
he surgical management of breast cancer
has changed in the past 30 years from Hal-
sted’s radical mastectomy to breast-con-
serving surgery in the early 1990s. Breast
Before oncologic criteria for breast cancer
were established, many factors contributed to the
classic dogma that the NAC should be removed
along with the specimen during mastectomy for
any indication. Early descriptions of centripetal
lymphatic drainage toward the subareolar plexus
played a major role in this widespread concept,
despite later studies showing that the lymphatic
drainage is downward to the deep pectoral lym-
phatic plexus and the axilla.1–3
In the prereconstructive era, there were no at-
www.SupportiveOncology.netTHE JOURNAL OF SUPPORTIVE ONCOLOGY
6. Ashikari R, Park K, Huvos AG, Urban JA. Paget’s
disease of the breast. Cancer 1970;26:680–685.
7. Kister SJ, Haagensen CD. Paget’s disease of the
breast. Am J Surg 1970;119:606–609.
8. Freund H, Maydovnik M, Laufer N, Durst AL. Paget’s
disease of the breast. J Surg Oncol 1977;9:93–98.
9. Berg JW, Hutter RV. Breast cancer. Cancer
10. Lagios MD, Westdahl PR, Margolin FR, Rose MR.
Duct carcinoma in situ: relationship of extent of non-
invasive disease to the frequency of occult invasion,
multicentricity, lymph node metastases, and short-
term treatment failures. Cancer 1982;50:1309–1314.
11. Cense HA, Rutgers EJ, Lopes Cardozo M,
Van Lanschot JJ. Nipple-sparing mastectomy in
breast cancer: a viable option? Eur J Surg Oncol
12. Smith J, Payne WS, Carney JA. Involvement of
the nipple and areola in carcinoma of the breast. Surg
Gynecol Obstet 1976;143:546–548.
13. Parry RG, Cochran TC Jr, Wolfort FG. When is
there nipple involvement in carcinoma of the breast?
Plast Reconstr Surg 1977;59:535–537.
14. Andersen JA, Pallesen RM. Spread to the nipple
and areola in carcinoma of the breast. Ann Surg
15. Lagios MD, Gates EA, Westdahl PR, Richards
V, Alpert BS. A guide to the frequency of nipple
involvement in breast cancer: a study of 149 con-
secutive mastectomies using a serial subgross
and correlated radiographic technique. Am J Surg
16. Wertheim U, Ozzello L. Neoplastic involvement
of nipple and skin flap in carcinoma of the breast. Am
J Surg Pathol 1980;4:543–549.
17. Quinn RH, Barlow JF. Involvement of the nipple
and areola by carcinoma of the breast. Arch Surg
18. Morimoto T, Komaki K, Inui K, et al. Involvement
of the nipple and areola in early breast cancer. Cancer
19. Luttges J, Kalbfleisch H, Prinz P. Nipple involve-
ment and multicentricity in breast cancer: a study
on whole organ sections. J Cancer Res Clin Oncol
20. Santini D, Taffurelli M, Gelli MC, et al. Neoplastic
involvement of nipple-areolar complex in invasive
breast cancer. Am J Surg 1989;158:399–403.
21. Menon RS, van Geel AN. Cancer of the breast
with nipple involvement. Br J Cancer 1989;59:81–84.
22. Verma GR, Kumar A, Joshi K. Nipple involve-
ment in peripheral breast carcinoma: a prospective
study. Indian J Cancer 1997;34:1–5.
23. Vyas JJ, Chinoy RF, Vaidya JS. Prediction of
nipple and areola involvement in breast cancer. Eur J
Surg Oncol 1998;24:15–16.
24. Laronga C, Kemp B, Johnston D, Robb GL,
Singletary SE. The incidence of occult nipple-areola
complex involvement in breast cancer patients re-
ceiving a skin-sparing mastectomy. Ann Surg Oncol
25. Simmons RM, Brennan M, Christos P, King V,
Osborne M. Analysis of nipple/areolar involvement
with mastectomy: can the areola be preserved? Ann
Surg Oncol 2002;9:165–168.
26. Hartmann LC, Schaid DJ, Woods JE, et al.
Efficacy of bilateral prophylactic mastectomy in
women with a family history of breast cancer. N Engl
J Med 1999;340:77–84.
27. Hartmann LC, Sellers TA, Schaid DJ, et al.
Efficacy of bilateral prophylactic mastectomy in
BRCA1 and BRCA2 gene mutation carriers. J Natl
Cancer Inst 2001;93:1633–1637.
28. Petit JY, Veronesi U, Orecchia R, et al. The nipple-
sparing mastectomy: early results of a feasibility study
of a new application of perioperative radiotherapy
(ELIOT) in the treatment of breast cancer when mas-
tectomy is indicated. Tumori 2003;89:288–291.
29. Gerber B, Krause A, Reimer T, et al. Skin-
sparing mastectomy with conservation of the
nipple-areola complex and autologous reconstruc-
tion is an oncologically safe procedure. Ann Surg
30. Crowe JP Jr, Kim JA, Yetman R, Banbury J,
Patrick RJ, Baynes D. Nipple-sparing mastectomy:
technique and results of 54 procedures. Arch Surg
31. Goldman LD, Goldwyn RM. Some anatomical
considerations of subcutaneous mastectomy. Plast
Reconstr Surg 1973;51:501–505.
32. King T, Borgen P. Atlas of Procedures in Breast
Cancer Surgery. 1st ed. Oxon, United Kingdom: Taylor
& Francis Group; 2005:103–115.
Update on the Indications for Nipple-Sparing Mastectomy