Applicability of the nipple-areola complex-sparing mastectomy - A prediction model using mammography to estimate risk of nipple-areola complex involvement in breast cancer patients

Rhode Island Hospital, Providence, Rhode Island, United States
Annals of Plastic Surgery (Impact Factor: 1.49). 06/2006; 56(5):498-504; discussion 504. DOI: 10.1097/
Source: PubMed


The purpose of this study was to develop a prediction model that can be used to identify breast cancer patients at lowest risk for neoplastic nipple-areola complex (NAC) involvement to offer total NAC-sparing mastectomy with immediate reconstruction. Medical records, pathology slides, and mammograms were reviewed for all breast cancer patients treated with total mastectomy at Rhode Island Hospital between 2000 and 2004. The distance between the nipple and the closest tumor margin was measured using mammography. NAC involvement was identified in 42% of the 31 study patients. Mammographic distance, pathologic stage, and tumor size were identified as independent predictors of malignant NAC involvement by multivariate analysis (rho < 0.05). Based on these predictors, a linear discriminant score, the NAC Involvement Score (NACIS), was computed to distinguish between the presence and absence of NAC involvement. For individual patients, positive NACIS values (> or = -0.3665) were associated with NAC involvement with a sensitivity of 92%, specificity of 77%, and negative predictive value of 93%. These preliminary findings indicate that the NACIS formula may be a useful clinical tool for selecting low-risk patients for total NAC-sparing mastectomy with immediate reconstruction.

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    • "The rates of tumour NAC involvement in the literature are inconsistent [14] [15] [16] [17] [18] [19] [20] [21] likely due to different pathological protocols for NAC evaluation and variable accuracy of clinical and pathological data collection. For example, a recent systematic review of the literature showed that only 6.4% of the nipple cores of 2477 NAC sparing mastectomies were involved with tumour [13]. "
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    ABSTRACT: Nipple-areola sparing mastectomy (NSM) with immediate implant reconstruction is an option for patients with non-locally advanced breast cancer. The prediction of occult tumour involvement of the nipple-areola complex (NAC) may help select candidates to NSM. We prospectively recorded clinical and pathological data, magnetic resonance imaging (MRI) results and intraoperative pathological assessments of the subareolar (SD) and proximal nipple ducts (ND) of 112 consecutive breast cancer patients scheduled for NSM. All parameters were correlated with final pathological NAC assessment by univariate and multivariate analysis. Thirty-one patients (27.7%) had tumour involvement of the NAC. At univariate analysis, age (p=0.001), post-menopausal status (0.003), tumour central location (p=0.03), tumour-NAC distance measured by MRI (p=0.000) and intraoperative pathologic assessment (SD+ND) (p=0.000) were significantly correlated with NAC involvement. At multivariate analysis, only MRI tumour-NAC distance (p=0.008) and menopausal status (p=0.039) among all preoperative variables retained statistical significance. The sensitivity and specificity of MRI tumour-NAC distance were 32.2% and 88.6% and those of intraoperative pathologic assessment were 46.7% and 100%, respectively. Sensitivity, specificity and accuracy of the double assessment (MRI plus intraoperative pathology) were 50.0%, 96.2% and 84.1%, respectively. Intraoperative pathologic assessment and tumour-NAC distance measured by MRI are the most important predictors of occult NAC involvement in breast cancer patients. A negative pathological assessment and a tumour-NAC distance⩾5mm allow optimal discrimination between NAC positive and NAC negative cases and may serve as a guide for the optimal planning of oncological and reconstructive surgery. Copyright © 2015 Elsevier Ltd. All rights reserved.
    No preview · Article · Jul 2015 · European journal of cancer (Oxford, England: 1990)
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    • "e presence of the nipples seems fundamental to marking the identity of the breast. Based on the psychological impact of nipple-areola complex (NAC) removal in classical mastectomy techniques, several authors have evaluated the risk of nipple areola involvement and investigated the possibility of nipple areola preservation, but the risk of cancer recurrence in the breast tissue preserved beneath the NAC for the blood supply is considered a major reason to avoid NAC conservation during the mastectomy [5]. e authors combined the SSM technique with the preservation of a small part of the areola with immediate nipple and breast reconstruction. "
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    ABSTRACT: . Most women with breast cancer today can be managed with breast conservation; however, some women still require mastectomy for treatment of their disease. Skin-sparing mastectomy (SSM) with immediate reconstruction has emerged as a favorable option for many of these patients. The authors combined the SSM technique with the preservation of a small part of the areola with immediate nipple together with with breast reconstruction. Methods . In an 8-year-period 155 female patients (age: 20–52 years old; mean age: 37.5 years) with extensive ductal intraepithelial neoplasia (DIN) or invasive breast cancer were treated with areola skin sparing mastectomy with immediate nipple and breast reconstruction. Patients were followed up prospectively by the breast surgeon, the plastic surgeon, and the oncologist for complications and recurrence. Results . After treatment, only 2 cases (1.29%) had a local recurrence. 8 out of 155 (5.5%) patients developed early complications (infections, seroma, haematoma), and 5 out of 155 patients (3.22%) developed delayed complications (implant rotation, aestethic deterioration) in the post operative time period. The final aesthetic outcome was judged as positive in 150 out of 155 patients (96.78%). Conclusion . In our experience, immediate nipple reconstruction after skin-sparing mastectomy is a technically feasible procedure which can give excellent cosmetic results.
    Full-text · Article · Jan 2013
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    • "We previously proposed that immunopathologic patterns strongly associated with mammary Paget disease depend upon the underlying tumor type (ER negative, PR negative, and HER2-positive for DCIS and HER2-positive for IDC).24 Schecter et al. proposed a predictive model for NAC involvement with 92% sensitivity and 77% specificity based on mammographic distance between tumor and nipple, tumor size, and pathologic staging in a small study of 31 cases.33 Rusby et al. have reported a similar predictive model on the basis of a study of 130 patients.34 "
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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.
    Full-text · Article · Oct 2011 · Annals of Surgical Oncology
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