Prediction of nipple and areola involvement in breast cancer

Intraoperative frozen section of subareolar tissue in nipple-sparing mastectomy: Towards a less is more approach

BACKGROUND

Nipple preservation contributes to aesthetic outcome and quality of life in women undergoing Skin-Sparing Mastectomy (SSM) with immediate breast reconstruction for the treatment of breast cancer. Intraoperative Frozen Section (IFS) has been advocated to facilitate conversion from Nipple-Sparing Mastectomy (NSM) to SSM in cases with positive subareolar margins. This study investigated the application of IFS at our comprehensive cancer centre.

METHODS

In this single-centre retrospective study, for all patients who underwent therapeutic NSM with IFS from 2000 to 2021 pathological reports, patient- and tumour characteristics were retrieved.

RESULTS

In total 640 women were included in whom 662 intended NSMs with IFS had been performed. Sensitivity and specificity of frozen section compared with definitive histopathology were 75.2% and 98.5% respectively. In six women with a false positive result, the nipple had been removed. In 16 out of 32 women with a false negative result, the nipple was excised in a second procedure. In total 115 nipples were resected. In 40% of these nipples, no residual disease was detected.

DISCUSSION

IFS is a moderately sensitive and highly specific diagnostic tool to detect positive subareolar margins. An alternative approach is to omit frozen section but take intraoperative biopsies of the sub areolar margin, which are postoperatively analysed with definitive formalin-fixed paraffin-embedded histopathology. This allows for shared decision making regarding nipple excision in cases where minimal disease is found in subareolar tissue or cases with an indication for post-mastectomy radiotherapy.

Intraoperative Examination of Retro-Areolar Margin is not Routinely Necessary During Nipple-Sparing Mastectomy for Cancer

BACKGROUND

Intraoperative examination of retro-areolar margin (IERM) often is used during nipple-sparing mastectomy (NSM) for cancer, but there is no robust data regarding its real advantage.

METHODS

Consecutive patients undergoing NSM for cancer with omission of IERM according to institutional protocols from 2016 to 2021 were retrospectively analyzed. The decision to maintain or remove the Nipple-Areola Complex (NAC) after definitive pathology was taken at the multidisciplinary meeting.

RESULTS

Among 162 women operated in the study period, the presence of neoplastic cells within 2 mm from the inked retroareolar margin (RAM) was detected at permanent pathology in 17 cases (10.5%). Nipple-Areola-Complex (NAC) was removed postoperatively in five patients (3%) for margins <1 mm, the other 12 were observed, whereas postoperative NAC necrosis required surgical removal in additional five cases (3%). The NAC was thus preserved in 152 of 162 patients (94%). At multivariate analysis, RAM ≤2 mm was associated with radiological tumor-to-nipple distance less than or equal to 1 cm (p = 0.04) and Ki67 label index ≥ 20 (p = 0.04), whereas multifocality/multicentricity showed a trend towards significance (p = 0.07). At a median follow-up of 46 months, five locoregional relapses occurred (3%), only one of them involving the NAC (0, 6%). Locoregional relapse and overall survival for patients with RAM > or < 2 mm were not different.

CONCLUSIONS

IERM is not routinely necessary during NSM for cancer, because its omission is associated with a very low return to the operating room, it is oncologically safe, and associated pitfalls are avoided. Further studies are necessary to confirm these findings.

Patient satisfaction after nipple-sparing mastectomy with intraoperative radiotherapy and breast reconstruction for breast cancer

INTRODUCTION

The use of nipple-sparing mastectomy (NSM) combined with breast reconstruction is increasing in breast cancer surgeries despite its controversial safety profile. To reduce the recurrence rate of tumors in the nipple-areola complex (NAC), we used intraoperative radiotherapy (IORT). The purpose of this study was to explore patients' feedback on this novel treatment strategy.

PATIENTS AND METHODS

From January 2014 to May 2018, eligible patients with breast cancer were enrolled in this study and separated into 2 groups. Patients in the NSM group underwent IORT to the NAC flap, and patients in the skin-sparing mastectomy (SSM) group underwent SSM and breast reconstruction. The postoperative satisfaction was collected and assessed using the Breast-Q reconstruction questionnaire and a standardized questionnaire; this was compared between the 2 groups.

RESULTS

There were 46 patients (52 NSMs) in the NSM group and 20 patients (22 SSMs) in the SSM group. The breast-Q scores were higher in the NSM group than the SSM group, with trends for a 'higher satisfaction with breasts' (67.39 ± 20.59 vs. 55.00 ± 19.33; p = 0.026) and 'higher sexual well-being' (61.74 ± 22.24 vs. 49.50 ± 20.12; p = 0.039). All the patients recognized the importance of nipple preservation. Thirty-seven women (80.40%) were satisfied or very satisfied with the appearance and shape of the NAC in the NSM group, while 38/46 women (82.60%) were very unsatisfied or unsatisfied with the sensitivity of the nipples.

CONCLUSIONS

The Breast-Q scores showed great satisfaction with breasts and sexual well-being in the NSM group. However, more effort should be made in improving postoperative NAC sensitivity.

A nomogram based on clinical factors for preoperative prediction of nipple involvement in breast cancer

Background

At present, the indication for nipple-sparing mastectomy (NSM) remains inconclusive, and occult nipple involvement (NI) is one of the most important problems when carrying out NSM. Therefore, we aimed to identify the predictive factors of NI, to provide a tool for selecting suitable candidates for NSM.

Methods

In this retrospective study, a total of 250 breast cancer patients who received mastectomy were recruited, and the association between NI and tumor clinicopathologic characteristics was investigated. Nipple signs, tumor size measured by ultrasound (US), and tumor location were developed as a nomogram to predict NI.

Results

Among the 250 patients, 34 (12.6%) had NI, and 216 (86.4%) did not. In the training group, NI was associated with nipple signs, tumor size, tumor–nipple distance (TND), tumor location, lymph node metastasis, and HER2 overexpression. Both in the training and in the validation groups, NI showed a significant association with nipple signs, tumor size measured by ultrasound, and tumor location. Based on these three clinical factors, the preoperative model nomogram was proved to have high efficiency in predicting NI, possessing a sensitivity of 80.0% and a specificity of 86.7% in the validation group.

Conclusions

We proposed a predictive model nomogram utilizing preoperative tumor characteristics, including nipple signs, tumor size measured by ultrasound, and tumor location. This predictive model could help in the planning of nipple-sparing mastectomy.

Practical consensus recommendations regarding the management of sentinel lymph node issues in early breast cancer

Axillary lymph node involvement is a very important poor prognostic factor in the clinical staging and management of breast cancer patients. Traditionally, axillary lymph node dissection (ALND) has been used for determining the status of the axillary lymph nodes. More recently the sentinel lymph node biopsy (SLNB) procedure has gained wider acceptance as the standard of care, having the advantage of being less invasivewhile providing good accuracy. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations in regards with the use of the two different procedures and other issues in patients with early breast cancer for the benefit of community oncologists.

Collaboration between breast and reconstructive surgery in optimizing outcomes for women with breast cancer

Performing successful breast reconstruction after mastectomy requires communication and collaboration between the breast and reconstruction surgery teams. This allows for oncologic safety while providing esthetic and functional reconstruction. In this article, we discuss the numerous techniques we have adopted successfully into our breast reconstructive practice that were possible due to this collaboration including prophylactic lymphaticovenous bypass (LVB), tumor ultrasound-guided incision (TUGI), esthetic closure in patients not eligible or desiring reconstruction, nerve identification at time of mastectomy to allow for sensate reconstruction, and the prevention of chronic pain and strategic oncoplasty.

Increase in Utilization of Nipple-Sparing Mastectomy for Breast Cancer: Indications, Complications, and Oncologic Outcomes

BACKGROUND

Nipple-sparing mastectomy (NSM) is increasingly performed for invasive breast cancer. Growing evidence supporting the oncologic safety of NSM has led to its widespread use and broadened indications. In this study, we examine the indications, complications, and long-term outcomes of therapeutic NSM.

METHODS

From 2003 to 2016, women undergoing NSM for invasive cancer or ductal carcinoma in situ (DCIS) were identified from a prospectively maintained database. Patient and disease characteristics were compared by procedure year, while complications were compared by procedure year using generalized mixed-effects models accounting for a random surgeon effect. Overall survival and time to recurrence were examined.

RESULTS

Of the 467 therapeutic NSMs, 337 (72%) were invasive cancer, 126 (27%) were DCIS, and 4 (1%) were phyllodes tumors. Median age was 45 years (range 24-75) and median follow-up among survivors was 39.4 months. Three hundred and fifty-seven (76.4%) cases were performed in 2011 or after. When comparing NSMs performed before and after 2011, there was a significant increase in NSMs performed for invasive tumors (58% vs. 77%; p < 0.001). There was no difference in family history, genetic mutations, smoking status, neoadjuvant chemotherapy, prior radiation, nodal involvement, or tumor subtype. Twenty-one (4.5%) nipple excisions were performed, of which 14 were performed for cancer at the nipple margin. Forty-four breasts (9.4%) had complications that required re-operation. Fifteen patients had locoregional recurrence or distant metastasis.

CONCLUSIONS

NSM use for invasive carcinoma has doubled at our institution since 2011, while postoperative complications and recurrence rates remain low. Our experience supports the selective use of NSM in the malignant setting with careful patient selection.

Oncologic outcomes and radiation safety of nipple-sparing mastectomy with intraoperative radiotherapy for breast cancer

BACKGROUND

Nipple-sparing mastectomy combined with breast reconstruction helps to optimize the contour of the breast after mastectomy. However, the indications for nipple-sparing mastectomy are still controversial. Local radiation to the nipple-areola complex may play some roles in improving the oncological safety of this procedure.

METHODS

From January 2014 to December 2017, 41 consecutive patients who underwent nipple-sparing mastectomy combined with Intrabeam intraoperative radiotherapy to the nipple-areola complex flap and breast reconstruction were enrolled in this prospective study. The prescribed radiation dose at the surface of the spherical applicator was 16 Gy.

RESULTS

In eight cases, carcinomas were in the central portion of the breast. Partial necrosis of the nipple-areola complex occurred in three cases. Over 90% of patients reported "no or poor sensation" of the nipple-areola complex postoperatively. With a median follow-up time of 26 months, no recurrences or metastases were identified; however, breast-cancer mortality occurred in one patient. Pathologic evaluation of paraffin-embedded sections showed ductal carcinoma in situ in the remaining tissues deep to the nipple-areola complex flap in two patients. Although no further treatment was administered to the nipple-areola complexes postoperatively, no recurrences or metastases were identified 20 months and 24 months later, respectively. Optical microscopy and transmission electron microscopy revealed changes in some normal tissues immediately after Intrabeam intraoperative radiotherapy. Karyopyknosis were observed in gland tissues, and the collagenous fibers became sparse and arranged chaotically. As assessed by thermoluminescence, radiation doses at different sites in the nipple-areola complex flap varied considerably and were about 10 Gy at the areola surface. No Intrabeam intraoperative radiotherapy-related acute or chronic radiation injuries of the lung, heart or bone marrow were identified.

CONCLUSIONS

Our findings indicate that Intrabeam intraoperative radiotherapy during nipple-sparing mastectomy combined with breast reconstruction is safe and feasible.

TRIAL REGISTRATION

The current study was approved by the Ethics Committee of the First Affiliated Hospital of Guangzhou Medical University (registering order 201750). All participants gave their written informed consent.

Breast cancer involvement of the nipple-areola complex and implications for nipple-sparing mastectomies: a retrospective observational study in 137 patients

Introduction

Nipple-sparing mastectomy (NSM) has gained much attention by enhancing the aesthetic outcome in breast carcinoma patients. The aim of this study was to assess the prevalence of malignant affection of the nipple-areola complex (NAC) in breast carcinoma patients and its correlation with prognostic factors for breast cancer.

Patients and methods

This study included 137 female patients diagnosed with breast carcinoma at different disease stages who were admitted to our surgical oncology unit at Suez Canal University Hospital from June 15, 2014 to January 25, 2017. We excluded patients with evidence of nipple involvement as ulceration or patients with previous breast surgery with periareolar incisions. This study was designed to test the hypothesis that the NAC can be spared in certain selected patients. All studied participants provided a full history and underwent general and local clinical examinations, pre-operative laboratory tests, and radiological and pathological evaluations.

Results

The mean age of the study population was 47.39 ± 8.01 years. Among the patients, the NAC was affected in 12 (11.40%) patients. Patients with NAC involvement showed a significantly larger tumor size of more than 4 cm and a shorter tumor-nipple distance of less than 2 cm (p = 0.000). Lymph node metastasis was associated with NAC involvement (p = 0.001), with increased risk when more than 10 lymph nodes were involved (p = 0.007). Lymphovascular invasion was a significant predictor of NAC involvement (p = 0.014). Multifocal as well as multicentric tumors were significantly associated with NAC involvement (p = 0.016 and 0.003, respectively). NAC involvement was more likely in Estrogen receptor (ER) and Progesterone receptor (PR) patients than in ER+ and PR+ patients (p = 0.000), while Human epidermal receptor (HER+) patients were more likely to have NAC involvement than HER patients (p = 0.000). Additionally, stage ΙΙΙ cancer was significantly associated with NAC involvement (p = 0.041), and histological grade III disease carried a greater risk than grade I disease of NAC involvement (p = 0.008).

Conclusion

The incidence of NAC affection among breast carcinoma patients who underwent mastectomy and axillary clearance was associated with important parameters, such as tumor size, areola edge-tumor distance, lymph node affection, hormonal receptor status and lymphovascular invasion. Accordingly, NAC-preserving surgeries could be tailored to patients with favourable tumor characteristics.

Expression of the RAC1, RHOA and CXCR4 proteins and their interaction as risk factors for infiltration to the nipple areola complex in operable breast carcinoma

BACKGROUND

Nipple areola complex (NAC) infiltration in operable breast carcinoma (OBC) is associated with local recurrence. NAC infiltration in OBC suggests that RAC1, RHOA and CXCR4 proteins are risk factors for migration and infiltration of OBC to NAC. This study aims to analyze the expression and interactions of these proteins as risk factors for NAC infiltration in OBC.

MATERIALS AND METHODS

This is an analytic observational cross-sectional study coupled with a categorical comparative study in each 40 subjects of OBC with and without NAC infiltration. The immunohistochemistry performed with a cut-off point based on the result of a receiver operating characteristics (ROC).

RESULTS

RAC1, p < 0.001 with POR 5.76, 95% CI: 2.06-16.08; RHOA, p < 0.001 with POR 7.00, 95% CI: 2.28-21.53; and CXCR4, p = 0.001 with POR 6.33, 95% CI 2.06-19.49. There was an interaction between RAC1 and RHOA (p < 0.001 with POR 17.14, 95% CI: 3.07-125.66); between RAC1 and CXCR4 (p < 0.001 with POR 30.93, 95% CI 3.62-686.89); between RHOA and CXCR4 (p < 0.001 with POR 10.21, 95% CI 2.19-54.17); and between the RAC1, RHOA and CXCR4 proteins (p < 0.001 with POR = 23.69, 95% CI 2.51-544.86).

CONCLUSION

We conclude that the expression of the RAC1, RHOA, and CXCR4 proteins and their interactions play a role as risk factors of NAC infiltration.

Nipple Areola Complex Involvement in Invasive Carcinoma Breast

A variety of factors including tumor biology and distance of the tumor from the nipple have been associated with nipple areola complex involvement in patients with breast cancer. Preoperative understanding regarding these factors can help in modifying the surgical options including preservation of nipple areola complex (NAC) and breast conservation. Nipple sparing surgery (breast conservation surgery/skin sparing mastectomy with immediate reconstruction) for breast cancer has gained widespread interest with the aim of achieving oncologically safe and cosmetically acceptable outcome. To study the proportion of cases with nipple areola complex involvement in invasive carcinoma breast and to describe the variables predictive of nipple areola complex involvement in patients undergoing excision of tumor along with NAC for invasive carcinoma breast. A cross-sectional study was conducted among 136 patients who underwent mastectomy in Regional Cancer Center, Thiruvananthapuram. Tumor nipple distance was assessed preoperatively using mammogram and postoperatively by histopathological examination. Nipple involvement was seen only among 4.4%. Preoperative assessment of tumor to nipple distance, tumor size, location, and stage of the disease agrees with the histopathological examination. Only a small proportion of breast cancer has NAC involvement and preoperative assessment could help the surgeon in deciding on the feasibility of NAC preservation.

Nipple-Areola Complex Sensation after Nipple-sparing Mastectomy

Background:

Nipple-sparing mastectomy (NSM) has been proven to be oncologically safe for treating breast cancer. This procedure had been developed to optimize the esthetic outcome and reduce feeling mutilation after mastectomy. Risks of necrotic complications and diminishing nipple-areola complex (NAC) sensation are common complications affecting the patient’s satisfaction after the surgery. The evaluation of NAC sensation should be also investigated.

Methods:

We prospectively analyzed 55 NSMs that were performed on 52 patients for both therapeutic and prophylactic indications in Ramathibodi Hospital from May 2007 to September 2015. Patients’ demographics, operative details, oncologic outcome, and postoperative complications, focusing on NAC sensation and necrotic complications, were analyzed.

Results:

Forty-seven NSMs (87%) were performed for therapeutic indications, and another 7 NSMs (13%) were risk-reducing operations. Of the 43 patients performing NSM for breast cancer treatment, 33 patients (77%) had invasive cancer and 11 patients (23%) had ductal carcinoma in situ. One subareola base tissue was found an occult cancer, and the NAC was then removed. There were 3 locoregional recurrences after a median follow-up time of 24 months (range, 2–104 months). The NAC sensation was evaluated in a total of 35 patients. Twenty-five patients (46%) underwent serial evaluation after 6 months of operation, and 10 patients were evaluated at more than 1 year after operation. In the first 6 months, 11 patients (44%) showed partial sensation recovery, and 3 more patients had partial recovery after 1-year follow-up. Only 1 patient (2%) had complete sensation recovery in all area of the NAC. In late evaluation group, 7 out of 10 patients had partial recovery. Most pain sensation remained in the lower aspect of the areola away from surgical incision.

Conclusions:

NSM is technically feasible in selected patients with low rates of NAC removal. Some patients can preserve the NAC sensation. Long-term outcome should receive follow-up.

Nipple- and areola-sparing mastectomy for the treatment of breast cancer

BACKGROUND

The efficacy and safety of nipple-sparing mastectomy and areola-sparing mastectomy for the treatment of breast cancer are still questionable. It is estimated that the local recurrence rates following nipple-sparing mastectomy are very similar to breast-conserving surgery followed by radiotherapy.

OBJECTIVES

To assess the efficacy and safety of nipple-sparing mastectomy and areola-sparing mastectomy for the treatment of ductal carcinoma in situ and invasive breast cancer in women.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialized Register, the Cochrane Center Register of Controlled Trials (CENTRAL), MEDLINE (via PubMed), Embase (via OVID) and LILACS (via Biblioteca Virtual em Saúde [BVS]) using the search terms "nipple sparing mastectomy" and "areola-sparing mastectomy". Also, we searched the World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov. All searches were conducted on 30th September 2014 and we did not apply any language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) however if there were no RCTs, we expanded our criteria to include non-randomised comparative studies (cohort and case-control studies). Studies evaluated nipple-sparing and areola-sparing mastectomy compared to modified radical mastectomy or skin-sparing mastectomy for the treatment of ductal carcinoma in situ or invasive breast cancer.

DATA COLLECTION AND ANALYSIS

Two review authors (BS and RR) performed data extraction and resolved disagreements. We performed descriptive analyses and meta-analyses of the data using Review Manager software. We used Cochrane's risk of bias tool to assess studies, and adapted it for non-randomised studies, and we evaluated the quality of the evidence using GRADE criteria.

MAIN RESULTS

We included 11 cohort studies, evaluating a total of 6502 participants undergoing 7018 procedures: 2529 underwent a nipple-sparing mastectomy (NSM), 818 underwent skin-sparing mastectomy (SSM) and 3671 underwent traditional mastectomy, also known as modified radical mastectomy (MRM). No participants underwent areola-sparing mastectomy. There was a high risk of confounding for all reported outcomes. For overall survival, the hazard ratio (HR) for NSM compared to SSM was 0.70 (95% CI 0.28 to 1.73; 2 studies; 781 participants) and the HR for NSM compared to MRM was 0.72 (95% CI 0.46 to 1.13; 2 studies, 1202 participants). Local recurrence was evaluated in two studies, the HR for NSM compared to MRM was 0.28 (95% CI 0.12 to 0.68; 2 studies, 1303 participants). The overall risk of complications was different in NSM when compared to other types of mastectomy in general (RR 0.10, 95% CI 0.01 to 0.82, 2 studies, P = 0.03; 1067 participants). With respect to skin necrosis, there was no evidence of a difference with NSM compared to other types of mastectomy, but the confidence interval was wide (RR 4.22, 95% CI 0.59 to 30.03, P = 0.15; 4 studies, 1948 participants). We observed no difference among the three types of mastectomy with respect to the risk of local infection (RR 0.95, 95% CI 0.44 to 2.09, P = 0.91, 2 studies; 496 participants). Meta-analysis was not possible when assessing cosmetic outcomes and quality of life, but in general the NSM studies reported a favourable aesthetic result and a gain in quality of life compared with the other types of mastectomy. The quality of evidence was considered very low for all outcomes due to the high risk of selection bias and wide confidence intervals.

AUTHORS' CONCLUSIONS

The findings from these observational studies of very low-quality evidence were inconclusive for all outcomes due to the high risk of selection bias.

Trends and variation in the use of nipple-sparing mastectomy for breast cancer in the United States

PURPOSE

For many women, nipple-sparing mastectomy (NSM) provides aesthetic and quality-of-life outcomes superior to skin-sparing mastectomy. Accumulating data suggest that NSM provides similar oncologic outcomes in select breast cancer patients. This study sought to determine national trends in NSM use.

METHODS

Using the National Cancer Data Base, 6254 women with breast cancer who underwent NSM between 2010 and 2013 were identified. NSM rates were determined relative to the number of patients who received a mastectomy with reconstruction (n = 114,849). Associations between patient, tumor, and facility characteristics and NSM were assessed using logistic regression.

RESULTS

The rate of NSM increased from 2.9 to 8.0 % between 2010 and 2013. NSM was most commonly performed in academic (adjusted odds ratio [OR] 1.43, p < 0.001) and high-volume (OR 1.59, p < 0.001) breast centers. There was up to a 5.8-fold variation in its delivery between geographic census regions (p < 0.001). Of 1231 hospitals, only 491 (39.9 %) reported performing at least one NSM during the study period. Half of all NSMs were performed by the top 6 % (n = 30) of NSM-performing centers. NSM was associated with small tumor size (p < 0.001), lower tumor grades (p < 0.05), and negative nodal status (p < 0.001). However, half of NSM patients had at least one tumor characteristic that diverged from current (2016) NCCN recommendations for the procedure.

CONCLUSIONS

The use of therapeutic NSM is increasing dramatically in the United States, despite recommendations that the procedure be used with caution. As NSM becomes increasingly common, efforts are needed to monitor its long-term oncologic outcomes and to ensure equitable access to it.

Immediate nipple reconstruction with a C-V flap and areolar reconstruction with an autograft of the ipsilateral areola

BACKGROUND

The authors report a new nipple-areolar complex (NAC) reconstruction technique using an autograft of the ipsilateral areola for breast cancer with nipple invasion.

METHODS

A total of 43 patients with breast cancer involving nipple invasion underwent oncoplastic surgery with NAC reconstruction. The nipple was reconstructed with a C-V flap, and the areola was autografted onto the new areola bed after the ipsilateral areola was confirmed to be tumour-free. The cosmetic results were self-evaluated by the patients after chemotherapy or radiotherapy according to a 4-point scoring system.

RESULTS

Overall satisfaction with the cosmetic result was assessed as follows: excellent (n = 14), good (n = 19), fair (n = 7) or poor (n = 3). Oncological evaluation revealed no cases of local recurrence and five cases of distant metastasis.

CONCLUSION

The immediate NAC reconstruction technique involving a C-V flap and autografting of the ipsilateral areola is a feasible method for obtaining realistic areolar reconstruction.

Nipple-sparing mastectomy: A contemporary perspective

Increasing numbers of women are undergoing nipple-sparing mastectomy, and evidence to support its use for cancer treatment and prophylaxis is expanding. An understanding of technical aspects and pitfalls of the procedure is paramount to ensure that the best results are attained. J. Surg. Oncol. 2016;113:883-890. © 2016 Wiley Periodicals, Inc.

What is the evidence behind conservative mastectomies?

INTRODUCTION

Besides the diffusion of breast reconstructive techniques, several "conservative" approaches in mastectomy have been developed, in order to perform an immediate reconstruction with better aesthetic results: the skin-sparing mastectomy (SSM), the nipple-areola complex (NAC)-sparing mastectomy (NSM) and the skin-reducing mastectomy (SRM). During the last decade, SSMs and NSMs have gained widespread acceptance and are currently considered standard treatment for early breast cancer. We would like to investigate the evidence behind this radical shift towards conservative mastectomies, where there has been a renewed interest worldwide.

METHODS

We reviewed English literature by consulting the following databases: Medline, Embase, Cochrane Register of Controlled Trials, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal and Clinicaltrials.gov. The objective is to include any randomized controlled trial (RCT) comparing a "conservative mastectomy" technique to breast conservative surgery or modified radical mastectomy (MRM) for the treatment of early-stage breast cancer. In the absence of randomized trials, we took into account prospective cohorts and retrospective series for a narrative description of available evidence.

RESULTS

Our review included 58 studies [19 prospective cohorts (34%) and 39 retrospective series (66%)] considering NSM and immediate reconstruction and ten studies [1 prospective cohort (10%) and 9 (90%) retrospective series] considering SSM and immediate reconstruction. In the NSM group, 29 studies reported data about complication rates and 42 studies presented data on NAC partial or complete necrosis. In the NSM group 45 studies and all the studies in the SSM group presented data on local and NAC recurrence.

CONCLUSIONS

In order to achieve higher levels of evidence, RCTs comparing conservative mastectomies to traditional mastectomy and breast conservative surgery would be desirable. However we can conclude that conservative mastectomies offer the psychological advantages of good cosmetics and maintenance of woman body image without compromising the oncological safety of mastectomy.

Nipple-sparing Mastectomy and Sub-areolar Biopsy: To Freeze or not to Freeze? Evaluating the Role of Sub-areolar Intraoperative Frozen Section

Use of nipple-sparing mastectomy (NSM) for risk-reduction and therapeutic breast cancer resection is growing. The role for intraoperative frozen section of the nipple-areolar complex remains controversial. Records of patients undergoing NSM at our institution from 2006 to 2013 were reviewed. Records from 501 nipple-sparing mastectomies were reviewed (216 therapeutic, 285 prophylactic). Of the 480 breasts with sub-areolar biopsies, 307 had intraoperative frozen sections and 173 were evaluated with permanent paraffin section only. Among the 307 intraoperative frozen sections, 12 biopsies were positive on permanent paraffin section (3.9% or 12/307). Of the 12 positive permanent biopsies, five were false negative and the remaining seven concordant intraoperatively. Sensitivity and specificity of sub-areolar frozen section were 0.58 and 1, respectively. Positive sub-areolar biopsies consisted primarily of ductal carcinoma in situ (62% or 13/21). The nipples or nipple-areolar complex were resected in a separate procedure following mastectomy (10/21), intraoperatively following frozen section results (7/21) or during second-stage breast reconstruction (3/21; 1 additional scheduled). Only 30% (6/20) of resected specimens had abnormal residual pathology. Intraoperative frozen section is highly specific and moderately sensitive for the detection of positive sub-areolar biopsies in NSM. Its use can help guide intraoperative reconstructive planning. The presence of positive sub-areolar biopsies in both contralateral and high-risk prophylactic mastectomy specimens emphasizes the need to perform sub-areolar biopsies in all nipple-sparing mastectomies.

Cost Analysis of Intraoperative Subareolar Frozen Section During Nipple-Sparing Mastectomy

BACKGROUND

Permanent paraffin subareolar biopsy during nipple-sparing mastectomy (NSM) tests for occult cancer at the nipple-areolar complex. Intraoperative subareolar frozen section can provide earlier detection intraoperatively. Cost analysis for intraoperative subareolar frozen section has never been performed.

METHODS

NSM cases from 2006-2013 were reviewed. Patient records including financial charges were analyzed.

RESULTS

Of 480 subareolar biopsies for NSM from 2006-2013, 21 were abnormal (4.4 %). A total of 307 of the subareolar biopsies included intraoperative frozen section. Of the 307, 12 (3.9 %) were abnormal with 7 of 12 detected on intraoperative frozen section. The median baseline charge for an intraoperative subareolar frozen section was $309 for an estimated total cost of $94,863 in 307 breasts. The median baseline charge for interval operative resection of a nipple-areolar complex following an abnormal subareolar pathology result was $11,021. Intraoperative subareolar biopsy avoided an estimated six return trips to the operating room for savings of $66,126. At our institution, routine use of intraoperative frozen section resulted in an additional $28,737 in healthcare charges or $95 per breast.

CONCLUSIONS

We present the first cost analysis to evaluate intraoperative subareolar frozen section in NSM. This practice obviated an estimated six return trips to the operating room. With our institutional frequency of abnormal subareolar pathology, intraoperative frozen sections resulted in a marginal increased charge per mastectomy.

Predictive factors of nipple involvement in breast cancer: a systematic review and meta-analysis

Nipple-sparing mastectomy (NSM) provides a cosmetic and psychological benefit for patients, but concerns on nipple involvement (NI) of tumor continue to persist. Several studies have reported factors for predicting NI, but the results were inconsistent and uncomprehensive, making patient selection difficult. The aim of the systematic review was to pool the published data to further discern factors associated with NI. A literature review was conducted of PubMed database, following the PRISMA guidelines. Relative risks (RRs) and 95 % confidence intervals (CIs) were calculated using random-effect or fix-effect model. Publication bias and Chi-square test were also calculated. From 1978 to 2014, 27 clinical studies with 7971 patients met the inclusion criteria. Predictive factors suggest higher rates of NI including the following: tumor-to-nipple distance (TND) ≤ 2.5 cm (3.65, 1.42-9.33); positive lymph node status (2.09, 1.71-2.57); stage III or IV disease (2.41, 1.93-3.00); tumor size > 5 cm (2.42, 1.95-3.02); estrogen receptor (ER)-negative status (1.19, 1.01-1.40); progesterone receptor (PR)-negative status (1.52, 1.25-1.84); HER-positive status (1.76, 1.46-2.12); patients with ductal carcinoma in situ (DCIS) compared with invasive ductal carcinoma (1.55, 1.16-2.08). Due to the statistical heterogeneity detected with certain parameters, further investigations to confirm their association with NI will be needed. Patients with one or more risk factors such as centrally located tumors; higher tumor stage; large tumors; ER-negative/PR-negative/HER-positive status and associated DCIS have higher risk of NI. Taking these factors into consideration comprehensively may help with decision-making process for NSM.

Magnetic resonance imaging and clinicopathological factors for the detection of occult nipple involvement in breast cancer patients

Purpose

Nipple sparing mastectomy provides good cosmetic results and low local recurrence rates for breast cancer patients. However, there is a potential risk of leaving an occult tumor within the nipple, which could lead to cancer relapse and poor prognosis for the patient. The objective of this study was to investigate the occult nipple involvement rate in mastectomy specimens, and to identify preoperative magnetic resonance imaging (MRI) findings and the clinicopathological characteristics of the primary tumor that may correlate with nipple invasion.

Methods

Four hundred sixty-six consecutive mastectomy samples with grossly unremarkable nipples were evaluated. Demographic and clinicopathological data were collected. Nipple involvement was evaluated using serial histological sections. The tumor size and tumor-nipple distance were measured using preoperative MRI images.

Results

Thirty-six of the 466 therapeutic mastectomy specimens (7.7%) were found to have occult nipple involvement. In univariate analysis, tumor size, tumor-nipple distance, lymph node status, p53 mutation, and lymphovascular invasion (LVI) were found to influence the likelihood of nipple involvement. Multivariate logistic regression analysis, adjusted by lymph node status, p53 mutation, and LVI, showed that tumor size and tumor-nipple distance were predictive factors indicating nipple involvement. With regard to tumor location, only tumors in the central area of the breast showed a significant association with nipple involvement.

Conclusion

In this study, a statistically significant association was found between occult nipple involvement and tumor size, tumor-nipple distance, axillary lymph node status, LVI, and p53 mutation. A cutoff point of 2.2 cm for tumor size and 2 cm for tumor-nipple distance could be used as parameters to predict occult nipple involvement.

[The role of nipple-sparing mastectomy in breast cancer: a comprehensive review of the literature]

BACKGROUND

The role of nipple-sparing mastectomy (NSM) for breast cancer is controversial as there is concern regarding its oncological safety and complication rate. We carried out a review of the literature to quantify the incidence of occult nipple malignancy in breast cancer, identify the factors influencing occult nipple malignancy, quantify locoregional recurrence rates and quantify NSM complication rates.

METHODS

A search of the literature was performed using PubMed. Keywords used were "mastectomy", "nipple involvement", "nipple-sparing mastectomy", "skin-sparing mastectomy" "occult nipple malignancy" "occult nipple disease" "breast cancer recurrence". Articles were analyzed regarding incidence of occult nipple malignancy, potential factors influencing the incidence of occult malignancy and recurrence/complications following NSM. The incidence of occult nipple disease was compared between groups using Chi(2) or Fisher's exact tests for categorical variables and Student's t-tests for continuous variables. P values were considered significant<0.05. We identified nearly 30 studies compiling nearly 10 000 cases examining the rate of occult nipple malignancy and 23 studies compiling 2300 cases providing information on the rate of local recurrence after NSM.

RESULTS

The overall rate of occult nipple malignancy was 11.5 %. Primary tumour characteristics influencing occult nipple malignancy were tumour-nipple distance<2cm, grade, lymph node metastasis, lymphovascular invasion, HER2 positive, ER/PR negative, tumour size>5cm, retro-areolar/central location and multicentric tumours. The overall nipple recurrence rate following NSM was 0.9 %, skin flap recurrence rate was 4.2 %. Full and partial thickness nipple necrosis rates were 2.9 % and 6.3 % respectively.

CONCLUSION

NSM for primary breast cancer is appropriate in carefully selected patients. All patients should have retro-areolar sampling. There is strong evidence to suggest that suitable cases are well circumscribed single or multifocal lesions that have a TND>2cm. Tumours should be graded 1-2 and not have LVI, axillary node metastasis or HER2 positivity.

A novel approach of INTRABEAM intraoperative radiotherapy for nipple-sparing mastectomy with breast reconstruction

BACKGROUND

Despite the advancement and increasing use of breast-conserving surgery, mastectomies, including nipple-sparing mastectomy (NSM), are still carried out in a portion of breast cancer patients. However, the role of NSM is still controversial, mainly because of concern about the oncologic safety of the nipple-areola complex (NAC). INTRABEAM (Carl Zeiss, Oberkochen, Germany) is the most widely used mobile intraoperative radiotherapy (IORT) device to date. This pilot study aims to broaden the application of the INTRABEAM system for breast cancer, investigating the feasibility of INTRABEAM IORT in NSM with breast reconstruction.

PATIENTS AND METHODS

From December 2012 to June 2013, 7 female patients with breast cancer were enrolled in the study. NSM with or without axillary dissection was performed first. After confirming negative retroareolar frozen section results and no poor local bleeding in the NAC, INTRABEAM IORT was carried out with a single dose of 16 Gy, followed by breast reconstruction. The complications and short-term outcomes were assessed.

RESULTS

The median radiation time was 13 minutes 14 seconds in the 7 cases. One patient complained of mild pain in the radiation field on the skin in the first 2 weeks. All 7 patients were followed for a median of 7 months. No acute radiation injury with symptoms (heart, lung, or hematologic system), NAC necrosis, local recurrence, or metastasis was observed. Although every patient had reduction in NAC sensitivity, the contours of the breasts (including the NAC) were satisfactory.

CONCLUSIONS

INTRABEAM IORT may be a feasible and convenient approach for NSM with breast reconstruction in patients with breast cancer.

The role of nipple-sparing mastectomy in breast cancer: a comprehensive review of the literature

BACKGROUND

The role of nipple-sparing mastectomy for breast cancer is controversial, as there is concern regarding its oncologic safety and complication rate. The authors reviewed the literature to quantify the incidence of occult nipple malignancy in breast cancer, identify the factors influencing occult nipple malignancy, quantify locoregional recurrence rates, and quantify nipple-sparing mastectomy complication rates.

METHODS

A search of the literature was performed using PubMed. Key words used were "mastectomy," "nipple involvement," "nipple-sparing mastectomy," "skin-sparing mastectomy," "occult nipple malignancy," "occult nipple disease," and "breast cancer recurrence." Articles were analyzed regarding incidence of occult nipple malignancy, potential factors influencing the incidence of occult malignancy, and recurrence/complications following nipple-sparing mastectomy. The incidence of occult nipple disease was compared between groups using chi-square or Fisher's exact tests for categorical variables and t tests for continuous variables. Values of p < 0.05 were considered significant.

RESULTS

The overall rate of occult nipple malignancy was 11.5 percent. Primary tumor characteristics influencing occult nipple malignancy were tumor-nipple distance less than 2 cm, grade, lymph node metastasis, lymphovascular invasion, human epidermal growth factor receptor-2-positive, estrogen receptor/progesterone receptor-negative, tumor size greater than 5 cm, retroareolar/central location, and multicentric tumors. The overall nipple recurrence rate considered significant was 0.9 percent, and the skin flap recurrence rate was 4.2 percent. Full- and partial-thickness nipple necrosis rates were 2.9 and 6.3 percent, respectively.

CONCLUSIONS

Nipple-sparing mastectomy for primary breast cancer is appropriate in carefully selected patients. All patients should have retroareolar sampling. There is strong evidence to suggest that suitable cases are well circumscribed single or multifocal lesions that have a tumor-to-nipple distance greater than 2 cm. Tumors should be grade 1 to 2 and not have lymphovascular invasion, axillary node metastasis, or human epidermal growth factor receptor-2 positivity.

Simultaneous mastopexy in patients undergoing prophylactic nipple-sparing mastectomies and immediate reconstruction

BACKGROUND

In some patients, a satisfactory aesthetic result of reconstruction following a nipple-sparing mastectomy (NSM) is limited by breast ptosis that goes uncorrected in the early phase of reconstruction. Most plastic surgeons remain hesitant to perform a mastopexy at the time of NSM due to concerns with nipple and/or skin flap loss.

METHODS

From 1990 to 1995, 33 female patients underwent NSM with simultaneous mastopexy and immediate implant-based reconstruction by a single surgeon at our institution. On chart review, the following data were extracted: age, co-morbidity, indication, breast size, initial/final implant volumes, type of implant, mastopexy technique, mastectomy flap/nipple necrosis, other complications, revision surgery and follow-up. An unpaired, two-tailed t-test was performed where indicated. P-value<0.05 was considered significant.

RESULTS

Wound complications occurred in 18.2% patients (10.9% breasts) without delaying tissue expansion. As many as 3% patients developed unilateral, isolated partial ischaemia of the mastectomy flap and 8% patients developed unilateral, superficial areolar loss. All resolved with conservative treatment. Only one patient developed bilateral total nipple loss. There was no correlation between preoperative breast size and postoperative complications. None of the patients developed breast cancer. Average follow-up was 11.6 years.

CONCLUSION

With proper technique, simultaneous mastopexy is a safe procedure in highly selected patients undergoing NSM with reconstruction.

Surgical management of the breast: breast conservation therapy and mastectomy

The twentieth century has witnessed dramatic changes in the surgical management of breast cancer. Herein we focus on the evolution of breast conservation surgery and current surgical trends of lumpectomy, mastectomy and contralateral prophylactic mastectomy. Margin analysis, specimen localization and processing, and the benefits of magnetic resonance imaging remain controversial. Neoadjuvant chemotherapy can offer prognostic information and aid in surgical planning while radiation therapy continues to reduce the risk of local recurrence after breast conserving surgery. Despite these advances, mastectomy remains a popular choice for many women and the use of nipple sparing procedures is increasing. Overall the low rates of local recurrence are attributed to the combination of surgery and targeted adjuvant and radiation therapies.

Nipple-sparing mastectomy in modern breast practice

Breast cancer management has evolved from the conventional radical Halsted to a fully integrated multidisciplinary approach. Nipple sparing mastectomy (NSM) is an innovative technique that preserves native breast envelope without mutilation of nipple-areola complex (NAC), thus providing a reasonable alternative for early cancers without NAC involvement and prophylactic high risk patients and avoids multiple surgical procedures required for reconstruction. This article aims to critically review indications, intra-operative protocols, radiotherapy planning and limitations of NSM. Patient selection should be based on study of breast duct anatomy by Magnetic Resonance Imaging, mammographic tumor-nipple distance and obligatory intra-operative frozen section from retro-areolar tissue. Tumor size, axillary lymph node status, lymphovascular invasion and/or degree of intraductal component are factors used to include NSM candidates based on institutional practice. Given the heterogeneity of patients and lack of standardization of preoperative investigations, surgical technique and pathologic sampling of retro-areola tissue so far, mandates a multi-institutional prospective study to define and validate a role for NSM in invasive breast cancer and DCIS. Nipple necrosis is an important NSM complication which can be greatly reduced using alternative skin incisions. Even if the nipple survives, an insensate nipple and lack of sexual function is common and requires preoperative counseling and discussion. Finally the relation and timing of intra-operative versus adjuvant breast radiation and tailoring of dosage and delivery methods has not been fully explored. Although NSM reduces psychological trauma associated with nipple loss, the oncologic safety as well as functional and aesthetic outcomes needs additional investigation.

Risk factors associated with recurrence after nipple-sparing mastectomy for invasive and intraepithelial neoplasia

BACKGROUND

To identify risk factors of recurrence in a large series of patients with breast cancer who underwent a nipple-sparing mastectomy (NSM).

PATIENTS AND METHODS

Breast-related recurrences and local recurrences (LR) in the breast and the nipple areola complex (NAC) were studied. Cumulative incidences of events were estimated through competing risk analysis. Multivariate Cox regression models were also applied.

RESULTS

We identified 934 consecutive NSM patients during 2002-2007. Median follow-up was 50 months. In 772 invasive carcinoma patients, the rate of LR in the breast and in the NAC was 3.6% and 0.8%, respectively. In the 162 patients with intraepithelial neoplasia, the rate of LR in the breast and in the NAC was 4.9% and 2.9%, respectively. The significant risk factors of LR in the breast for the group A were grade, overexpression/amplification of HER2/neu and breast cancer molecular subtype Luminal B. In group B, the risk factors of LR in the breast and in the NAC were age (<45 years), absence of estrogen receptors, grade, HER2/neu overexpression and high Ki-67.

CONCLUSIONS

The LR rate after NSM in our series was low. Biological features of disease and young age should be taken into account when considering NSM in breast cancer patients.

Predictors of nipple-areolar complex involvement by breast carcinoma: histopathologic analysis of 787 consecutive therapeutic mastectomy specimens

Background

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.

Methods

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.

Results

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).

Conclusions

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.

Prophylactic and therapeutic mastectomy in BRCA mutation carriers: can the nipple be preserved?

BACKGROUND

Use of nipple-sparing mastectomy (NSM) is increasing. We sought to look at the role of NSM in BRCA mutation carriers.

METHODS

Tissue from women with a BRCA1 or BRCA2 mutation who underwent mastectomy between March 1987 and June 2009 at a single institution was reviewed. The entire nipple-areolar complex (NAC) was excised and histologically evaluated. The presence of terminal duct lobular units (TDLUs) and premalignant or malignant lesions in the NAC was noted.

RESULTS

Sixty-two NACs from 33 women (25 BRCA1, 8 BRCA2) were studied. TDLUs were present in 15 (24%) NAC specimens. No evidence of atypical hyperplasia, carcinoma in situ, or invasive carcinoma was found in any of the 33 prophylactic mastectomy specimens. Among the 29 breasts with cancer and available tissue, 2 (7%) had malignant findings and 1 (3%) had atypia in the NAC. One woman who underwent bilateral mastectomy for bilateral invasive carcinoma had one nipple with tumor within lymphatics, and her contralateral nipple had atypical lobular hyperplasia. A second woman had ductal carcinoma in situ involving a single major lactiferous duct.

CONCLUSIONS

The probability of nipple involvement by premalignant or malignant lesions in the NAC of BRCA mutation carriers is low at time of prophylactic mastectomy, but higher (10%) in women undergoing therapeutic mastectomy. NSM may be appropriate and oncologically safe for selected women with BRCA mutations. However, 24% of NACs contained TDLUs, with only 8% found in the nipple papilla; the significance of this for long-term risk is unknown.

Nipple-sparing mastectomy for breast cancer and risk-reducing surgery: the Memorial Sloan-Kettering Cancer Center experience

BACKGROUND

Nipple-sparing mastectomy (NSM) has been gathering increased recognition as an alternative to more traditional mastectomy approaches. Initially, questions concerning its oncologic safety limited the use of NSM. Nevertheless, mounting evidence supporting the practice of NSM for both prophylactic and oncologic purposes is leading to its more widespread use and broadened indications.

METHODS

Using a prospectively maintained database, we reviewed our experience of 353 NSM procedures performed in 200 patients over the past 10 years.

RESULTS

The indications for surgery were: 196 prophylactic risk-reduction (55.5%), 74 ductal carcinoma in situ (DCIS) (20.8%), 82 invasive cancer (23.2%), and 1 phyllodes tumor (0.5%). The nipple areolar complex (NAC) was entirely preserved in 341 mastectomies (96.7%). There were 11 patients (3.1%) who were found to have cancer at the nipple margin, warranting further excision. A total of 69 breasts (19.5%) had some degree of skin desquamation or necrosis, but only 12 (3.3%) required operative debridement, of which 3 breasts (1%) necessitated removal of a breast implant. Also, 6 patients (2%) were treated for infection. Of the 196 prophylactic NSMs, 11 specimens (5.6%) were found to harbor occult cancer (8 DCIS and 3 invasive cancers). One patient who underwent NSM for invasive ductal carcinoma in 2006 developed metastatic disease to her brain. No other recurrences are attributable to the 353 NSMs.

CONCLUSIONS

The trends demonstrate the increasing acceptance of NSM as a prophylactic procedure as well as for therapeutic purposes. Although NSM is not standard, our experience supports the selective use of NSM in both prophylactic and malignant settings.

Oncologic safety of nipple skin-sparing or total skin-sparing mastectomies with immediate reconstruction

BACKGROUND

Success with skin-sparing mastectomy (SSM) has led to the reconsideration of the necessity to remove the skin overlying the nipple-areola complex. The aim of our study was to compare complications and local recurrence in patients undergoing SSM and total skin-sparing mastectomy (TSSM) with immediate reconstruction.

METHODS

This IRB-approved retrospective study involved patients who underwent mastectomy with reconstruction (1998 to 2010). Patient demographics, tumor characteristics, type of surgery, cosmesis, postoperative complications, and recurrence were analyzed.

RESULTS

The 293 patients in our study group had a total of 508 procedures: 281 TSSMs and 227 SSMs, distributed among 215 patients with bilateral procedures and 78 with unilateral operations. Mean age was 51.2 ± 10.9 years for TSSM and 53.1 ± 11.5 years for SSM. The average tumor size was 1.9 ± 1.6 cm for TSSM versus 2.1 ± 1.7 cm for the SSM group. The overall complication rate (TSSM 7.1% [20 of 281] and SSM 6.2% [14 of 227], p = 0.67) and local-regional recurrence rate (TSSM 6% [7 of 152] and SSM 5.0% [7 of 141], p = 0.89) were comparable. The TSSM rating was significantly higher (score 9.2 ± 1.1) than the SSM group (score 8.3 ± 1.9, p = 0.04).

CONCLUSION

TSSM appears to be oncologically safe with superior cosmesis, affords one-step immediate reconstruction, and can be offered to patients with stages I and II breast cancer and those who have been down-staged with neoadjuvant chemotherapy.

Temporary banking of the nipple-areola complex in 97 skin-sparing mastectomies

BACKGROUND

Despite the improved appearance associated with skin-sparing mastectomy, removal of the nipple-areola complex has a negative impact on the patient. Still, nipple-areola complex-sparing mastectomy results in preservation of a substantial amount of mammary tissue at risk. This may be prevented by preservation of the nipple-areola complex as a graft that is temporarily banked (e.g., in the groin region).

METHODS

Ninety-seven nipple-areola complexes were banked as part of preventive (n = 62) or therapeutic (n = 35) skin-sparing mastectomies in 61 women with a median age of 41 years (range, 27 to 59 years) and a minimum follow-up of 2 years. The areola was harvested as a full-thickness skin graft with the nipple attached as a composite graft. In oncologic cases, the nipple-areola complexes were banked only after frozen section clearance.

RESULTS

Seventy-five nipple-areola complexes were replanted onto the reconstructed mammary mound after 10 months (range, 3 to 26 months). Repeated graft take was moderate to good in 73 of these 75 nipple-areola complexes. The projection of the nipple and pigmentation of the areola were moderate to good in 45 and 74 of the 75 repeatedly transplanted grafts, respectively.

CONCLUSIONS

In skin-sparing mastectomy, maximum oncologically safe conservation of autologous mammary structures can be realized by means of temporary banking of the nipple-areola complex. Even though such banking may not be successful in all women, it proved to be satisfactory in most.

Nipple Involvement in Breast Cancer: Retrospective Analysis of 2323 Consecutive Mastectomy Specimens

Breast cancer surgical options now include nipple-sparing mastectomy (NSM), but there has been much controversy regarding the oncologic safety of the preserved nipple. This study evaluates frequency and patterns of occult nipple involvement in a large contemporary cohort of patients, aiming to improve patient selection for NSM. A total of 2323 consecutive mastectomy specimens with grossly unremarkable nipples were evaluated by sagittal sections through the entire nipple and subareolar tissue. Sixteen different clinical and tumor parameters were examined to predict cancerous nipple involvement. Nipple involvement was noted in 331 of 2323 (14.2%) mastectomy specimens. Occult nipple involvement rate was 10.7% (248 cases). Occult nipple involvement usually occurs as ductal carcinoma in situ. In univariate analysis, patient age, tumor size, tumor-to-nipple distance, tumor central location, tumor type, lymph node status, lymphatic vascular invasion, histologic grade, estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2 (HER-2) amplification, and multicentric or multifocal tumor were associated with positive nipple involvement. By multivariate logistic regression analysis with the entire selection process, tumor size, tumor-to-nipple distance, central location, lymph node status, lymphatic vascular invasion, HER-2 amplification, and multicentric or multifocal tumor were shown to be associated with nipple involvement by carcinoma. Nearly 90% women undergoing mastectomy did not have occult nipple involvement. NSM may be a viable option in appropriate patient selection and setting. NAC preservation would be appropriate in HER-2 negative, axillary lymph node, and lymphatic vascular negative patients with small, solitary tumors located on the periphery of the breast.

Early results of an endoscopic nipple-sparing mastectomy for breast cancer

BACKGROUND.: Endoscopic mastectomy has been reportedly associated with smaller scars and greater patient satisfaction; however, few reports on this topic have been made. The purpose of this retrospective study was to examine the early results of endoscopic nipple-sparing mastectomy (ENSM) and to investigate the safety of this procedure. METHODS.: Between January 2002 and December 2005, a total of 87 patients with breast cancer but without skin and nipple involvement, including two cases of bilateral breast cancer, underwent E-NSM. In case of bloody nipple discharge and suspicious extension near the nipple as assessed by magnetic resonance imaging, the major ducts within the nipple were cored (nipple coring). In other cases, nipple coring was not performed. RESULTS.: Of the 89 breasts in 87 patients, 42 had tumors of >2 cm and 80 were diagnosed as having invasive carcinoma. Lymph node involvement was observed in 36 procedures. The overall rate of nipple necrosis was 18% (16 of 89). The rate of nipple necrosis among the procedures with nipple coring was statistically higher than that among those without nipple coring (7 of 17, 41%, vs. 9 of 72, 13%) (P = .01). Nipple involvement was observed in 2.2% (2 of 89). After a median follow-up period of 52 months, distant metastasis was observed in nine cases; no local recurrences occurred in this series. CONCLUSIONS.: E-NSM is an oncologically safe procedure and an acceptable method in selected patients requiring a mastectomy. The higher rate of nipple necrosis may have been the result of a technical problem, indicating the need for continued improvement in nipple coring procedures.

Immediate breast reconstruction with implants after skin-sparing mastectomy: a report of 96 cases

BACKGROUND

Skin-sparing mastectomy (SSM) with immediate breast reconstruction (IBR) has become increasingly popular as an effective treatment for patients with early-stage breast cancer requiring mastectomy. This study aimed to evaluate the clinical outcomes of IBR using permanent gel breast implants and Becker expandable breast implants after SSM.

METHODS

A review of 96 patients undergoing IBR with Beck expandable or permanent gel breast implants after SSM from July 2002 to December 2006 was performed. Of the 96 patients, 30 had IBR after SSM with conservation of the nipple-areola complex (NAC). The mean patient age was 42 years (range, 29-57 years). Aesthetic outcomes were assessed according to the breast volume, shape, and symmetry with the opposite breasts after a mean follow-up period of 44 months.

RESULTS

The aesthetic outcomes were graded as excellent for 29 patients, good for 47 patients, fair for 12 patients, and poor for 8 patients. The overall complication rate was 11.5% (11/96). The complications included prosthesis loss after skin flap necrosis subsequent to hematoma formation (n = 1), skin necrosis (n = 2), partial necrosis of preserved NAC (n = 1), capsular contracture (Baker 4, n = 2), wound infection not involving the prosthesis (n = 2), inversion of the injection port (n = 2), and seroma (n = 2).

CONCLUSION

This study demonstrates that prosthetic breast reconstruction is a safe, reliable method with minimal complications and good to excellent aesthetic results for the majority of patients with early-stage breast cancer. For selected patients, NAC-sparing mastectomy can be performed without increasing the risk of local recurrences. Success depends on patient selection, proper incision for SSM, total coverage of the prostheses with muscles, and careful intra- and postoperative management.

Nipple-Sparing Mastectomy - Extended Indications and Limitations

If mastectomy is indicated for removal of breast cancer, the nipple areola complex (NAC) is routinely excised during surgery followed by nipple reconstruction. Despite advances in reconstruction techniques, removal of the NAC often results in a sense of mutilation. However, recent studies regarding the tumorigenic involvement of the NAC have provided some evidence that in carefully selected patients the NAC could be preserved. Nipplesparing mastectomy (NSM) preserves the breast skin envelope and the NAC, and has therefore emerged as an alternative to conventional radical mastectomies. BecauseNSM leaves no or sparse retroareolar ductal tissue, NSM is increasingly considered as oncologically safe both in patients with small and peripherally located tumors and in women with high breast cancer risk, who opt for prophylactic mastectomy. Moreover, NSM has been applied in patients with large and centrally located or multicentric invasive carcinomas but oncologic safety as well as postoperative complications such as NAC necrosis are still controversial. Since long-term data are limited, there is no general recommendation for NSM indications. To evaluate if indications for NSM may be rather enlarged under certain conditions, we performed a MEDLINE search for studies published between 2003 and 2009.

Oncological outcome and patient satisfaction with skin-sparing mastectomy and immediate breast reconstruction: a prospective observational study

BACKGROUND

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.

METHODS

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).

RESULTS

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).

CONCLUSION

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.

Nipple-sparing mastectomy

Background

Although effective local control is the primary goal of surgery for breast cancer, the long-term aesthetic outcome is also important. Nipple-sparing mastectomy aims to address this, but there is no consensus on its clinical application. Evidence relating to oncological safety, surgical technique and early data on aesthetic outcome was reviewed.

Methods

The review was based on a PubMed search using the terms ‘nipple-sparing’ or ‘subcutaneous mastectomy’ and ‘breast cancer’.

Results

Large pathological studies report occult nipple involvement with cancer in 5·6–31 per cent, reflecting variation in inclusion criteria. Recent clinical series with careful patient selection report local recurrence in less than 5 per cent of patients. The incidence of cancer in the retained nipple after risk-reducing mastectomy is less than 1 per cent. Nipple necrosis rates range up to 8 and 16 per cent for total and partial necrosis respectively. Variations in outcome result from differences in extent of resection, placement of incisions and type of breast reconstruction.

Conclusion

Nipple-sparing mastectomy is an acceptable technique for women undergoing risk-reducing mastectomy. In the therapeutic setting, it may be offered to patients with smaller tumours far from the nipple and favourable pathological features. Women should be counselled about nipple necrosis and the potential for local recurrence.

Nipple-sparing mastectomy and immediate tissue expander/implant breast reconstruction

BACKGROUND

The nipple is an uncommon site for breast cancer development, but the nipple-areola complex is routinely excised in breast cancer treatment. The authors evaluated the risks and benefits of nipple- or areola-sparing mastectomy with breast reconstruction.

METHODS

The authors analyzed data on 115 consecutive nipple- or areola-sparing mastectomies with immediate tissue expander breast reconstruction performed in 66 patients from 1998 to 2008 at a single tertiary-care cancer center. Nipple-sparing mastectomies were performed for prophylaxis (n = 75) or treatment of disease (n = 40).

RESULTS

Mean patient age was 45 years (range, 24 to 61 years) and mean follow-up time was 22 months (range, 2 weeks to 91 months). There were 115 nipple- or areola-sparing mastectomies (48 bilateral and 19 unilateral), including 111 nipple-sparing and four areola-sparing mastectomies. On pathologic review, 20 breasts had ductal carcinoma in situ, 20 breasts had invasive cancer, 11 breasts had lobular carcinoma in situ, one breast had phyllodes tumor, one breast had mucinous carcinoma, and 62 breasts were cancer-free. Incision placement was periareolar and radial (n = 61), inframammary (n = 25), omega type (n = 14), customized to include a previous scar (n = 10), or transareolar (n = 5). Of all 115 nipple- or areola-sparing mastectomies, six nipples were lost because of occult disease (5.2 percent), and four nipples were lost because of wound-healing problems (3.5 percent).

CONCLUSIONS

In the authors' series of nipple- and areola-sparing mastectomies performed for risk reduction or breast cancer, there was a low incidence of occult disease (5.2 percent). Nipple- and areola-sparing mastectomy may be feasible in selected patients and should be the subject of additional investigation.

Clinical and morphological factors predictive of occult involvement of the nipple-areola complex in mastectomy specimens

OBJECTIVE

To evaluate characteristics predictive of nipple-areola complex (NAC) involvement by the breast tumor.

STUDY DESIGN

Cases of infiltrative ductal carcinoma (stages I, IIA and IIB) treated by mastectomy in which the distance between the tumor and the NAC was >or=2 cm were included. NAC involvement was evaluated using serial histological sections. The distance between the tumor and the NAC was measured on mammograms. Other parameters taken into consideration were: tumor size, histological and nuclear grades, vascular invasion, and the presence of an in situ component. For comparisons between categorical variables, the chi-square test or Fisher's exact test were used. Student's t-test was used for numerical variables with normal distribution and the Mann-Whitney U-test was applied when distribution was not normal.

RESULTS

Fifty patients were included. NAC was affected in 12 and unaffected in 38. There was no statistically significant difference in mean age between the unaffected and affected groups (58.9+/-13.5 years versus 55.8+/-12.5 years, p=0.477); however, 13.2% and 58.3% (p=0.046) in the NAC-unaffected and NAC-affected groups, respectively, were <50 years of age. Distance <or=3 cm between the tumor and the NAC on mammograms was found in 60.5% of the NAC-unaffected group and in 100% of the NAC-affected group (p=0.007). With respect to the in situ component, there was a difference between the NAC-unaffected and NAC-affected groups regarding micropapillary pattern (13.2% versus 50.0%; p=0.014) and extensive in situ component (13.2% versus 41.7%; p=0.046). No statistically significant difference was found for any of the other parameters analyzed.

CONCLUSIONS

A distance between the tumor and the NAC <or=3 cm, age <50 years, and ductal carcinoma in situ with micropapillary pattern or with an extensive in situ component were factors significantly associated with a higher likelihood of NAC involvement.

Skip Lesion of DIN (DCIS) in the Nipple in a Case of Breast Cancer

The authors present a case of breast cancer with a skip lesion of DIN 1 (ductal carcinoma in situ [DCIS] grade 1) in the nipple, leaving the base of the nipple free of disease. During the surgical procedure of nipple-sparing mastectomy (NSM) a frozen section evaluation of the base of the nipple and areola complex is often carried out to ascertain absence of any intraepithelial (in situ) or invasive neoplasms that could lead to nipple recurrences if left behind. This case illustrates a situation where a frozen section would have given a false-negative prediction of nipple involvement if the patient had been selected for NSM. This case illustrates the need to adhere to strict criteria for selecting patients eligible for NSM and to consider the use of additional preoperative and intraoperative measurements and methods to refine the selection of candidates for NSM and enhance the oncological safety of the procedure.