Prediction of nipple and areola involvement in breast cancer

Nipple sparing mastectomy with nipple areola intraoperative radiotherapy: one thousand and one cases of a five years experience at the European institute of oncology of Milan (EIO)

In order to reduce mutilation, nipple-areola complex (NAC) conservation can be proposed for the treatment of breast cancer when mastectomy is indicated. To reduce the risk of retro areolar recurrence, a novel radiosurgical treatment combining subcutaneous mastectomy with intraoperative radiotherapy (ELIOT) is proposed. One thousand and one nipple sparing mastectomies (NSM) were performed from March 2002 to November 2007 at the European institute of oncology (EIO), for invasive carcinoma in 82% of the patients and in situ carcinoma in 18%. Clinical complications, aesthetic results, oncological and psychological results were recorded. A comparison was performed between the 800 patients who received ELIOT and the 201 who underwent delayed one-shot radiotherapy on the days following the operation. The median follow up time was 20 months (range 1-69) for a follow up performed in 83% of the patients. The NAC necrosed totally in 35 cases (3.5%) and partially in 55 (5.5%) and was removed in 50 (5%). Twenty infections (2%) were observed and 43 (4.3%) prostheses removed. The median rate of the patients for global cosmetic result on a scale ranging from 0 (worst) to 10 (excellent) was 8. Evaluation by the surgeon in charge of the follow-up gave a similar result. Only 15% of the patients reported a partial sensitivity of the NAC. Of the fourteen (1.4%) local recurrences, ten occurred close to the tumour site, all far from the NAC corresponding to the field of radiation. No recurrences were observed in the NAC. In a group of patients characterized by a very close free margin under the areola, no local recurrence was observed. Overall, 36 cases of metastases and 4 deaths were observed. No significant outcome difference was observed between the 800 patients receiving intraoperative radiotherapy (ELIOT) and the 201 patients receiving delayed irradiation.

Preservation of nipple-areola complex in breast cancer – a clinicopathological assessment

BACKGROUND

Skin-sparing mastectomy (SSM) with immediate breast reconstruction (IBR), which traditionally includes the nipple-areola complex (NAC), is the modern way of improving the cosmetic and aesthetic outcome of advanced breast cancer surgery. However, with nipple and areola lacking, it fails to simulate the original breast. This study is directed at exploring the possibility of NAC preservation in selected mastectomy patients.

METHODS

A retrospective analysis of the breast specimens of 219 consecutive mastectomy patients was performed after categorising the tumour characteristics on the basis of their TNM staging. The relationship of malignant involvement of the NAC with positive regional lymph nodes (pN), tumour size (T), site, stage and skin involvement by the breast tumour was noted and analysed. Chi-square analysis was performed for different characteristics vis-à-vis NAC involvement. Two-sided lists, wherever possible, had been performed at the 5% level of significance and P values were evaluated.

RESULTS

The total frequency of malignant involvement of NAC was 44 (20%) out of 219. The frequency of NAC involvement in stage I and II tumours was found to be 9.38% compared to stage III tumours where it was 30%. The NAC was involved in 4 (2.5%) of 160 patients with peripheral tumours compared with 40 (68%) of 59 patients with tumours located centrally. Only 2 (1.5%) of 130 peripheral tumours bigger than 5 cm had malignant NAC involvement while the number in their central counterparts was much bigger (59%). Not a single breast cancer patient with skin involvement in the peripheral quadrants had any nipple-areola involvement.

CONCLUSIONS

NAC can be preserved in patients having stage I, II and III diseases with peripheral tumours less than 5 cm in size, irrespective of the nodal status and skin involvement.

Nipple-sparing mastectomy: risk of nipple-areolar recurrences in a series of 579 cases

BACKGROUND

When the conservative treatment is not recommended, Nipple Sparing Mastectomy (NSM) is proposed more and more frequently for the surgical treatment of breast cancer. The risk of local recurrence behind the nipple areolar complex (NAC) is the main limiting factor of the NSM procedure. To minimize such risk, we proposed in 2002 a intraoperative radiotherapy of the preserved NAC.

PATIENTS AND METHODS

From March 2002 to November 2006, 579 cases (in 570 patients) of NSM were performed for carcinoma. The median follow up time was 19 months (Range: 1-60). The subcutaneous mastectomy was performed through an incision removing a portion of the skin overlying the tumour. An extemporaneous histological examination was performed on the retroareolar glandular tissue. If the histology was positive the patient was not considered eligible. Then an intraoperative radiotherapy with electrons (ELIOT) of 16 Gy in one shot was delivered on the NAC area. An immediate breast reconstruction was done using implants in most cases and in several cases a musculocutaneous flaps, usually in large breast. The number of local recurrences was recorded and the correlation between their occurrence and the clinical and histological criteria were analysed using the Gray test statistical method in a competing framework.

RESULTS

In 516 cases the negative retroareolar frozen section biopsy was confirmed by the final histology, while in 63 cases, the final histology showed foci of carcinoma. Seven out of these 63 cases underwent a secondary NAC removal. In the 56 cases which preserved areolas we did not observe any local recurrence after 19 months follow up. The probability of retro areola positive histology increases with the tumour size. and was not related to the nodal status. The rate of local relapses was 0.9% per year. We didn't find any significant difference in the local relapse rate according to different patient's and tumour's features. Most relapses were located close to the tumour bed but never in the NAC area.

CONCLUSION

Our study confirms that the local recurrence rate in the NSM completed with local radiotherapy on the NAC is not higher than the usual rate observed in the literature and the preservation of the NAC does not increase the risk. The absence of local recurrence in the region where a portion of glandular tissue has been purposely preserved is a good argument in favour of ELIOT.

Mammographic distance as a predictor of nipple-areola complex involvement in breast cancer

BACKGROUND

Although involvement of the nipple-areola complex (NAC) occurs in a minority of patients with breast cancer, standard skin-sparing mastectomy requires its removal. To assist in patient selection for NAC preservation we evaluated NAC involvement and correlated this with preoperatively available clinical data.

METHODS

Patients with invasive breast cancer or ductal carcinoma in situ undergoing mastectomy from 1998 to 2005 were reviewed retrospectively. The NAC had been evaluated with multiple thin sections. Pathologic data including NAC involvement were analyzed. The mammographic tumor distance from the nipple was measured in 2 standard views.

RESULTS

There were 302 patients enrolled, of which 10% were noted to have NAC involvement. This correlated negatively with tumor distance from the nipple (P < .05). A logistic regression equation was derived from the data, with NAC involvement as the dependent variable and distance from the nipple as the independent variable. The equation predicted involvement of the NAC when the distance was less than 4.96 cm with a sensitivity of 82% and a negative predictive value of 97%.

CONCLUSIONS

A majority of patients are candidates for NAC preservation. The mammographic distance between the tumor and the nipple is independently predictive of NAC involvement and is useful as an equation variable.

Oncological safety and patient satisfaction with skin-sparing mastectomy and immediate breast reconstruction

INTRODUCTION

The management of early breast cancer with skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) is not based on evidence from randomised controlled trials. The purpose of this study is to evaluate the oncological safety, post-operative morbidity and patients' satisfaction with SSM and IBR using the latissimus dorsi (LD) myocutaneous flap and/or breast prosthesis.

METHODS

Eighty-three consecutive women underwent 93 SSMs with IBR (10 bilateral), using the LD flap plus implant (n=55) or implant alone (n=38), indications included early breast cancer and prophylaxis due to BRCA-1 gene mutation. Nipple reconstruction was performed in 38 patients, using the trefoil local flap technique, nipple sharing or Monocryl mesh. Twenty-three underwent contra-lateral surgery in order to optimise symmetry, including 15 augmentations and eight mastopexy/reduction mammoplasties. Patient satisfaction with the outcome of surgery was assessed on a linear visual analogue scale ranging from 0 (not satisfied) to 10 (most satisfied).

RESULTS

There was no local recurrence (LR) after a median follow-up of 34 months (range=3-79 months). Overall survival was 98.8%, three patients developed distant disease and one patient died of metastatic breast cancer. No case of partial or total LD flap loss was observed. Morbidities included infection, requiring implant removal in two patients and one patient developed marginal ischaemia of the skin envelope. Significant capsule formation, requiring capsulotomy, was observed in 87% of patients who had either PMR or prior RT compared with 13% for those who did not have RT. Sixty-one (73.5%) of 83 patients completed the questionnaire with a median and mean satisfaction scores of 10.0 and 9.3, respectively (range=6-10).

CONCLUSION

SSM with IBR is associated with low morbidity, high levels of patient satisfaction and is oncologically adequate for T(is), T1 and T2 tumours without extensive skin involvement.

Central quadrantectomy with resection of the nipple-areola complex compared with mastectomy in patients with retroareolar breast cancer

Appropriate surgery in women with retroareolar breast cancer should allow resection of the cancer with wide free margins and an acceptable cosmetic result. The aim of this study was to compare breast conservation surgery (BCS) to mastectomy for treatment of retroareolar breast cancer. In a prospective nonrandomized study, 69 women with retroareolar breast cancers underwent either central quadrantectomy (n=33) with complete removal of the nipple-areola complex or mastectomy (n=36). Two of 33 (6%) patients scheduled for BCS had a secondary mastectomy and immediate reconstruction due to involved margins. After a median follow-up of 42 month (range 17-99 months) in the BCS group and 43 months (range 16-118 months) in the mastectomy group local and regional recurrences as well as systemic disease were comparable between both groups. The postoperative cosmetic result after BCS as evaluated by the patients was rated as excellent in 80% and good in 20% with no poor result. BCS followed by radiation therapy is a feasible alternative to mastectomy in patients with retroareolar breast cancer.

Oncological and aesthetic considerations of skin-sparing mastectomy

AIM

To review the oncological safety and aesthetic value of skin-sparing mastectomy (SSM) for invasive breast cancer (IBC) and ductal carcinoma in-situ (DCIS). Controversies including the impact of radiotherapy (RT) on immediate breast reconstruction (IBR), preservation of the nipple-areola complex (NAC) and the role of endoscopic mastectomy are also considered.

METHODS

Literature review facilitated by Medline and PubMed databases.

RESULTS

SSM is an oncologically safe technique in selected cases, including IBC <5 cm, multi-centric tumours, DCIS and prophylactic risk-reduction surgery. The high risk of local recurrence (LR) excludes inflammatory breast cancers and tumours with extensive involvement of the skin. SSM can facilitate IBR and is associated with an excellent aesthetic result. Prior breast irradiation or the need for post-mastectomy radiotherapy (PMR) do not preclude SSM, however the cosmetic outcome may be affected. Nipple/areola preservation is possible for remote tumours, employing a frozen section protocol for the retro-areolar tissue. There is limited data available for endoscopic mastectomy and superiority over conventional SSM has not been established.

CONCLUSION

In appropriately selected cases SSM is oncologically adequate. There are several patient centred advantages over conventional mastectomy, including aesthetic outcome and the avoidance of multiple staged procedures. Despite widespread uptake into surgical practice, validation of these techniques from randomised controlled trials is lacking.

Nipple sparing mastectomy: an innovative skin incision for an alternative approach

Choice of the most appropriate surgical treatment for breast cancer patients can also be a technical issue. Cosmetic results after conservative surgery can be poor in certain instances and, at the same time, total mastectomy can appear as an over-treatment. For some selected patients, the "nipple sparing mastectomy" (NSM) is an alternative surgical treatment and more and more papers on this technique are appearing in the literature. One hundred and two NSMs have been performed in our department between June 2003 and October 2006, initially via periareolar skin incision, now through a skin incision on the lateral aspect of the breast to reduce the necrotic risk for the nipple. The lateral skin incision saves the integrity of skin blood supply, allows for a complete breast gland removal and saves the integrity of the body image of women who show no scars when seen upfront.

Nipple-sparing mastectomy for breast cancer and risk reduction: oncologic or technical problem?

BACKGROUND

We evaluated the risks and benefits of nipple-sparing mastectomy in a multiinstitutional experience in the settings of risk-reducing surgery and breast cancer treatment.

STUDY DESIGN

We analyzed data on 123 patients who had undergone nipple-sparing mastectomy with breast reconstruction for prophylaxis (n=55), treatment of breast cancer (n=41), or both (n=27) at four large centers.

RESULTS

Median patient age was 45 years (range 22 to 70 years). There were 192 procedures (69 bilateral, 54 unilateral). Forty-four patients had invasive cancer; 20 had ductal carcinoma in situ (DCIS); 4 had phyllodes tumor. In all of these patients, the nipple tissue was cancer free on pathologic review. Median followup was 24.6 months (range 2.0 to 570.4 months). Local recurrence developed in two patients: one had DCIS in the upper-outer quadrant, with 71.8 months of followup; the other's cancer was invasive, in the upper-outer quadrant, with 6 months of followup. Distant metastasis developed in a third patient, who died 50 months after the procedure. Breast cancer developed in two patients after prophylactic mastectomy: one in the upper-outer quadrant at 61.8 months; one in the axillary tail at 24.4 months. No patients had recurrences in the nipple-areolar complex. Necrosis of the nipple was reported in 22 of 192 patients (11%) and it was judged minimal (less than one-third total skin of nipple) in 13 of 22 patients (59%). Overall cosmesis was judged by the patient and surgeon as good to excellent in the majority of patients. Level of satisfaction with cosmetic results was similar between prophylactic and treatment patients.

CONCLUSIONS

The risk of local relapse was very low in our series of nipple-sparing mastectomies performed for DCIS or invasive cancer. Nipple-sparing mastectomy in the risk-reducing and breast cancer-treatment settings may be feasible in selected patients and should be the subject of additional prospective clinical trials.

Oncological considerations of skin-sparing mastectomy

Aim

To review evidence concerning the oncological safety of performing skin-sparing mastectomy (SSM) for invasive breast cancer and ductal carcinoma in situ (DCIS). Furthermore, the evidence concerning RT in relation to SSM and the possibility of nipple preservation was considered.

Methods

Literature review facilitated by Medline and PubMed databases.

Findings

Despite the lack of randomised controlled trials, SSM has become an accepted procedure in women undergoing mastectomy and immediate reconstruction for early breast cancer. Compared to non-skin-sparing mastectomy (NSSM), SSM seems to be oncologically safe in patients undergoing mastectomy for invasive tumours smaller than 5 cm, multicentric tumours, DCIS or risk-reduction. However, the technique should be avoided in patients with inflammatory breast cancer or in those with extensive tumour involvement of the skin in view of the high risk of local recurrence. SSM with nipple areola complex (NAC) preservation appears to be oncologically safe, provided the tumour is not close to the nipple and a frozen section protocol for the retro-areolar tissue is followed. Although radiotherapy (RT) does not represent a contraindication to SSM, the latter should be used with caution if postoperative RT is likely, since it detracts from the final cosmetic outcome.

Breast Reconstruction following Subcutaneous Mastectomy for Cancer: A Critical Appraisal of the Nipple-Areola Complex

BACKGROUND

Subcutaneous mastectomy for women with advanced breast cancer has been historically controversial because of the increased risk for tumor recurrence. Despite this, some women remain interested in this method of treatment as a means of preserving the appearance of the breast and nipple-areola complex. Several studies have evaluated the feasibility of subcutaneous mastectomy; however, there has been no study that has critically analyzed the aesthetic outcome of the nipple-areola complex following this approach.

METHODS

Over a 14-month interval, 12 women had subcutaneous mastectomy with preservation of the nipple-areola complex. The reconstruction was unilateral in 10 women and bilateral in two women, totaling 14 breasts. The mastectomy was for cancer in 11 and for prophylaxis in three breasts. Outcomes were assessed based on the sensation, appearance, and secondary procedures of the nipple-areola complex, and tumor recurrence and patient satisfaction.

RESULTS

Of the five parameters, sensation was present in six breasts (42.9 percent), delayed healing was noted in four breasts (28.6 percent), symmetry with the contralateral breast was achieved in five of 10 women (50 percent) following unilateral reconstruction, tumor recurrence was noted in three of 11 breasts (27.3 percent), and secondary procedures related to the nipple-areola complex were necessary in five of the 14 breasts (35.7 percent). Outcome was graded as excellent in three, good in eight, and poor in three breasts.

CONCLUSION

This study has demonstrated that aesthetic outcome of the nipple-areola complex is variable following subcutaneous mastectomy and immediate breast reconstruction. However, patient satisfaction was graded as good to excellent in 11 of 14 breasts (78.6 percent). Subcutaneous mastectomy with flap reconstruction results in fewer secondary procedures and improved aesthetic outcome when compared with implant reconstruction.

Nipple-areola complex preservation: predictive factors of neoplastic nipple-areola complex invasion

Recently, skin-sparing mastectomy (SSM) with nipple-areola complex (NAC) preservation has been promoted as an oncologically safe procedure in practice for selected patients. The criteria of selection have not been yet defined precisely. The focus of this study was to investigate predictive factors of NAC-base neoplastic involvement to define the indications for NAC preservation. A prospective clinical study was conducted of 108 randomly selected female patients with invasive breast cancer. Analyzed markers of NAC involvement were tumor-nipple distance (TND), tumor size, localization, histologic type, grade, lymphovascular invasion (LVI), site, and axillary lymph-node status. The definitive histologic findings of the NAC base were compared with analyzed markers and the frozen section results. NAC base was positive in 23.15% patients at definitive histology with false-negative results in 4.63% patients at intraoperative frozen section. Significant differences were found in TND, tumor size, axillary lymph-node status, and LVI. There were no significant differences in tumor grade and site and not enough cases for statistical evaluation in histologic type and localization. Clinical indications for NAC preservation, according to this study, include tumors < or =2.5 cm, TND >4 cm, negative axillary lymph node status, and no LVI. Considering the possibility of pre- or intraoperative measurement, tumor size, and TND evaluation will result in the lowest possible mistakes in NAC preservation. Frozen section analyses of the NAC base, because of the "false-negative" possibility, could be deemed as a relative prognostic factor until definitive histologic findings. The presence of an extensive intraductal component (EIC) in the "borderline" cases of these criteria could be an additional argument for NAC removal.

When mastectomy becomes inevitable: The nipple-sparing approach

The preservation of the nipple areola complex (NAC) could improve the quality of life in cases of mastectomy. A novel radiosurgical treatment combining subcutaneous mastectomy with intraoperative radiotherapy is proposed. Three hundred nipple-sparing mastectomies (NSM) were performed. Invasive (58%) and in situ (42%) carcinomas were included. Clinical complications, aesthetic results, oncological and psychological results were recorded. The NAC necrosed totally in 10 cases and partially in 29 and it was removed in 12. Nine infections (3%) were observed and 10 prostheses removed. Good results were rated by 82.3% of the patients and by 84.8% of the surgeons. In 7.5% a radiodystrophy was observed. The sensitivity of the NAC recovered partially in 48%. Two local recurrences occurred outside the radiated field. Overall, we observed three metastases and no deaths. Sixty-eight of the patients were satisfied with their reconstructed breast and 85.5% were satisfied having preserved the NAC.

Breast-conserving surgery with resection of the nipple-areola complex for subareolar breast carcinoma

INTRODUCTION

Breast-conserving therapy for centrally located tumours has in the past been viewed with reservation, but is now an accepted treatment. There is little published evidence, however, to show that it is safe and cosmetically acceptable.

METHODS

In a prospective investigation carried out between 1996 and 2002, 44 women had surgery for 45 breast carcinomas with suspected nipple involvement. The breast was conserved and the nipple-areola complex removed. Secondary mastectomy was performed in three women because the tumour was found to reach the resection margin. Forty-one women underwent further observation. The mean tumour size at the time of operation was 18 (range 4-50) mm. Six women received preoperative chemotherapy.

RESULTS

Histologically, there were seven preinvasive and 35 invasive cancers. No local failure had occurred at a median follow-up of 51 months. Six women developed distant metastasis, of whom five died. The mean score for cosmetic results (evaluated on a scale of 1-5 where a score of 1 was excellent) was 1.5 for patients and 1.7 for physicians.

CONCLUSION

Breast-conserving therapy is a safe and cosmetically acceptable alternative to mastectomy for subareolar breast cancer.

Nipple-sparing mastectomy in association with intra operative radiotherapy (ELIOT): A new type of mastectomy for breast cancer treatment

BACKGROUND

Breast-conserving surgery has become the standard approach for about 80% of patients treated for primary breast cancer in most centres. However, mastectomy is still required in case of multicentric and/or large tumours or where recurrences occur after conservative treatment. When a total mastectomy is performed, the removal of the nipple areola complex (NAC) is a strongly debated issue. In fact, although removal of the NAC greatly increases the patient's sensation of mutilation, and the risk of tumor involvement of the areola is reported as a very variable percentage, NAC excision still remains the standard treatment.

PATIENTS AND METHODS

From March 2002 to September 2003, 106 nipple sparing mastectomies (NSM) were peformed in 102 patients, 63% of whom had invasive carcinoma and 37% of whom had in situ carcinoma. Four patients underwent bilateral surgery. In all cases, a large or multicentric tumour and/or diffuse microcalcifications, clinically distant from the NAC, were present. During surgery, the tissue under the areola was routinely sampled to exclude the presence of tumor. If disease-free at the frozen sections, the NAC was spared and a NSM was performed. Additionally, a total dose of 16 Gy of radiotherapy (ELIOT) was delivered intraoperatively in the region of the NAC. All the patients underwent an immediate plastic breast reconstruction.

RESULTS

In eleven patients (10.4%), the breast tissue under the areola resulted infiltrated at the definitive histological examination: in 10 cases a single or multiple foci of in situ carcinoma and in one case an invasive component were present. Eleven patients (10.4%) developed a superficial skin areolar slough followed by spontaneous healing, and 5 patients (4.7%) lost their NAC due to total necrosis. Among these, one patient had a poor cosmetic result on the NAC with asymmetrical location and required further surgical removal and reconstruction with tattoo and local flap in a better position. When rating the results from 0 (bad) to 10 (excellent), on average, the colour of the areola was rated 9/10, the sensitivity of nipple 3/10, the overall aesthetic result was rated 8/10 by both the surgeon and the patients. Early radiodystrophy (pigmentation) was observed in eight cases (7.5%). After an average follow up of 13 months, one local recurrence, located under the clavicula, far from the NAC, was observed. The preliminary results of the psychological study show a very high satisfaction with the preservation of the nipple (97.6 %), with younger women expressing a higher satisfaction than older counterparts.

CONCLUSIONS

In selected cases, NSM with ELIOT of NAC has so far permitted good local control of the disease and satisfactory cosmetic results. Wider surgical experience is required to minimise the risk of leaving tumor cells in the region of the spared NAC and a longer follow up is necessary to evaluate the long term tumor recurrence rate at the NAC.

Skin-sparing mastectomy and immediate breast reconstruction: incidence of recurrence in patients with invasive breast cancer

The aim of this study was to investigate whether skin-sparing mastectomy (SSM), which is gaining increasing importance and gives well-accepted cosmetic results, provides adequate treatment of the patients' oncologic disease. From 1995 to 2003, 60 patients diagnosed with invasive breast cancer were treated with SSM and complete axillary dissection. All patients underwent immediate breast reconstruction after primary surgery. Patients were treated either with a latissimus dorsi flap or with a transversus rectus abdominis myocutaneous flap. Depending on the intraoperative analysis of frozen sections, 14 patients were treated with preservation of the nipple-areola complex. During a median follow-up of 52 months (4-92 months), four local recurrences (6.6%) occurred. One patient was also found to have contralateral breast carcinoma. Three patients developed distant metastases, and two patients died of their disease a mean of 18 months after primary therapy. Factors associated with local recurrence were tumor size, poor tumor differentiation, and positive node involvement. SSM followed by immediate breast reconstruction is an alternative to modified radical mastectomy in a subset of patients with invasive breast cancer. The risk of local recurrence is low and is associated with such factors as tumor stage, poor tumor differentiation, and node-positive disease. This procedure does not increase the risk of distant metastases, which is comparable to that after other surgical approaches.

Omega (??) and Inverted Omega Incision

In the history of breast surgery, we have seen a lot of changes in orientation, position, and localization of breast incisions. Most of the biopsy incisions have been made with no consideration of future mastectomy or reconstruction because a wide ellipse of skin removed during the mastectomy included the biopsy site. The primary surgical treatment was in the competence of the oncologic or general surgeon. Reconstruction was not an integral part of breast carcinoma therapy and was considered as a secondary, unimportant treatment to be preformed by a plastic surgeon at a later date if desired by the patient. Wide acceptance of conservative breast operations, skin-sparing mastectomy, and reconstruction as an integral part of breast cancer therapy necessitates new consideration about the initial incisions used for breast biopsy. We consider the omega incision not only as a type of incision but also as a concept that can be used for all breast surgery, including biopsy, lumpectomy, skin-sparing mastectomy, and reconstruction.

Skin-sparing mastectomy

BACKGROUND

Skin-sparing mastectomy represents a new surgical approach that allows a mastectomy while preserving the natural skin envelope of the breast. It facilitates immediate breast reconstruction using an implant or myocutaneous flap, resulting in excellent cosmesis.

DATA SOURCES

A PubMed database literature search was performed.

CONCLUSIONS

Skin-sparing mastectomy is an oncologically safe technique in selected cases; T1/T2, multicentric tumors, ductal carcinoma in situ, and prophylactic mastectomies are particularly suited to this technique. Further research is required to confirm oncologic safety in T3 tumors. In selected cases, the nipple-areola complex can be preserved. A modification of skin-sparing mastectomy includes the removal of the nipple while preserving the areola. The balance of evidence suggests that skin-sparing mastectomy does not increase the risk of locoregional recurrence. Furthermore, it does not delay adjuvant therapies. Contraindications to skin-sparing mastectomy approaches include inflammatory breast cancer and extensive skin involvement by tumor. Preoperative and postoperative radiotherapy are not a contraindication to skin-sparing mastectomy.

Skin-Sparing and Nipple-Sparing Mastectomy: Preoperative, Intraoperative, and Postoperative Considerations

The last several decades have witnessed significant advances in the surgical management of breast cancer. Although many have embraced breast conservation as the procedure of choice, some patients will still opt for mastectomy for a variety of reasons. Recently, the concept of skin sparing mastectomy and immediate breast reconstruction has emerged as an option that provides excellent cosmetic results while being oncologically safe. However, this surgical approach must be considered within a multidisciplinary context, and there are a number of perioperative issues that need to be considered. In addition, newer techniques, which spare the nipple and/or areola, warrant further examination.

Skin-sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction is an oncologically safe procedure

OBJECTIVE

Is skin-sparing mastectomy (SSM) with conservation of the Nipple-Areola Complex (NAC) and immediate autologous reconstruction as safe in oncologic terms as SSM with resection of the NAC as modified radical mastectomy (MRM)?

SUMMARY BACKGROUND DATA

The originally described technique of SSM included the removal of gland, NAC, and biopsy scar. However, the risk of tumor involvement of NAC in patients with breast cancer has been overestimated.

PATIENTS AND METHODS

Between 1994 and 2000, 286 selected patients with an indication for MRM and tumor margins of greater than 2 cm from the nipple were presented with the alternative of a SSM. Regular follow-up data were evaluable of 112 patients with SSM and 134 patients with MRM. Immediate reconstruction was achieved by latissimus dorsi flap or TRAM flap. The mean follow-up time was 59 (18 to 92) months.

RESULTS

Patients with SSM were significantly younger than those with MRM but were comparable regarding clinical data, tumor parameters, adjuvant treatment, and overall complications. After intraoperative frozen sections of the NAC-ground, the NAC could be conserved in 61 (54.5%) but was resected in 51 (45.5%) of the 112 patients with SSM. The aesthetic results after SSM were evaluated as excellent or good in 91.1% (102/112) patients and were significantly better after preservation of the NAC (P = 0.001). Six (5.4%) recurrences occurred in 112 patients with SSM compared with 11 (8.2%) cases after MRM. Only 1 recurrence in a conserved nipple was treated by wide excision of nipple with conservation of the areola. This patient is still free of disease after 52 months.

CONCLUSION

In patients who are candidates for a mastectomy and tumors distant from the nipple, SSM with intraoperative frozen section of the NAC ground offers the opportunity of NAC conservation without increasing the risk of local recurrences.

Endoscopic muscular latissimus dorsi flap harvesting for immediate breast reconstruction after skin sparing mastectomy

AIM

Immediate breast reconstruction after mastectomy using the latissimus dorsi musculo-cutaneous flap is well recognized. It allows for satisfactory aesthetic results. To minimize scanning in skin sparing mastectomy patients, we used a surgical technique consisting of an endoscopic harvesting of the latissimus dorsi pure muscular flap with a virtual cavity created by CO(2) gas distention.

METHOD

Between 9 April 2001 and 30 September 2001, 8 patients underwent latissimus dorsi endoscopic harvesting for an immediate breast reconstruction after skin sparing mastectomy.

RESULT

The mean operating endoscopic time was 112 minutes. No open surgical conversion was necessary. The mean lymphatic drainage was 2720 ml with removal of the drainage on post operative day 15.

CONCLUSION

The endoscopic harvesting of the latissimus dorsi muscular flap, using a mixed technique of dissection guided by the lighted cleaver forceps and a closed technique by CO(2) insufflation using an endoscope is feasible, reproducible and has acceptable morbidity. This technique brings encouraging aesthetic results after skin sparing mastectomy.

Complete one-stage, immediate breast reconstruction with prosthetic material in patients with large or ptotic breasts

Immediate prosthetic breast reconstruction is a relatively simple, quick procedure with no donor site morbidity. This report discusses immediate one-stage breast reconstruction using prostheses in 18 patients (19 breasts) who also required a contralateral reduction or mastopexy. In all cases, an inverted-T pattern was applied to both breasts. The mean age of the patients was 49 years (range, 32 to 62 years), and the mean size of the gel implant used was 330 ml (range, 120 to 550 ml); the implant was inserted in a total submuscular pocket in seven patients and subcutaneously in 11 patients. In two patients with multiple risk factors, the prosthesis extruded, and one patient required removal for a periprosthetic infection. In 10 patients with early stage disease (T1 or T2) with tumors more than 5 cm from the nipple-areola complex, the original areola (n = 3) or nipple-areola complex (n = 7) was retained as a full-thickness skin graft. The breast shape after submuscular prosthesis insertion is different than that of the contralateral breast after a mastopexy or reduction, and nipple-areola complex symmetry was difficult to obtain; thus, this technique was abandoned in favor of the subcutaneous position (using a modified Wise keyhole pattern with a de-epithelialized portion, which still allows two-layer closure). In the subgroup of patients with large breasts or marked ptosis, a single-stage breast reconstruction procedure can be performed with symmetrical incisions. The subcutaneous position allows for symmetrical shape and nipple-areola complex symmetry to be obtained. When the tumors are small and situated in the periphery of the breast, the nipple-areola complex may be retained as a full-thickness graft.

Analysis of nipple/areolar involvement with mastectomy: can the areola be preserved?

BACKGROUND

Skin-sparing mastectomy (SSM), which involves the resection of the nipple/areolar complex with the breast parenchyma, improves the aesthetic outcome for breast cancer patients. Most patients undergoing SSM desire reconstruction of the nipple/areolar complex for symmetry. These data explore the possibility of preserving the areola in selected mastectomy patients.

METHODS

A retrospective analysis of 217 mastectomy patients was conducted to determine the frequency of malignant nipple and/or areola involvement. The association between nipple and/or areola involvement and prognostic factors, including tumor size, stage, nuclear grade, axillary nodal status, and tumor location, was evaluated.

RESULTS

The overall frequency of malignant nipple involvement was 23 of 217 (10.6%). In a subgroup of patients with tumors <2 cm, peripheral tumors, and with two positive nodes or less, the incidence of nipple involvement was 6.7%. When the nipple and areolar involvement were analyzed separately, only 2 of 217 patients had involvement of the areola (0.9%). All patients with areolar involvement had stage 3 breast cancer and were located centrally in the breast.

CONCLUSIONS

We conclude from these data that nipple preservation is not a reasonable option for mastectomy patients. However, preservation of the areola with mastectomy in selected patients warrants further study.

Recurrence rates in patients with central or retroareolar breast cancers treated with mastectomy or lumpectomy

BACKGROUND

Although breast conservation with lumpectomy and radiation treatment has become a commonly used treatment for breast cancer, there are little data to support the use of lumpectomy for central and retroareolar breast cancers. In this study, we investigate the local and distant recurrence rates of patients with central or retroareolar breast cancers treated with lumpectomy compared with mastectomy.

METHODS

This study provides a retrospective analysis of 99 patients, from 1981 to 2000, with central or retroareolar breast cancers treated with mastectomy or lumpectomy to determine the frequency of local and distant recurrence. The mastectomy and lumpectomy patients were compared with respect to recurrence and other prognostic factors including: tumor location, tumor size, axillary nodal status, and final surgical margins.

RESULTS

The overall frequency of local recurrence was 5 of 99 (5.0%) in the entire group, 3 of 67 (4.5%) and 2 of 32 (6.3%) of patients who underwent mastectomy and lumpectomy, respectively (P >0.99). Overall, 3 patients experienced a distant recurrence as a first event, with 2 patients (3.0%) in the mastectomy group and 1 patient (3.1%) in the lumpectomy group (P >0.99). The type of surgical management was not statistically significant related to either local or distant disease recurrence, with median time to local recurrence of 3.0 years for the mastectomy patients and 5.0 years for lumpectomy patients. Of the patients with central tumors who underwent mastectomy 2 of 42 (4.8%) developed local recurrences compared with those who had a lumpectomy, 1 of 21 (4.8%). Similarly for retroareolar tumors, the local recurrence rate was 1 of 25 (4.0%) for patients undergoing mastectomy and 1 of 11 (9.1%) for those undergoing lumpectomy (P >0.99).

CONCLUSIONS

In this study there was no significant difference in local or distant failure rates of those patients with central or retroareolar tumors treated with mastectomy versus lumpectomy. We conclude lumpectomy to be a reasonable treatment option for selected patients with central or retroareolar breast cancers.

Single-stage, autologous breast restoration

The skin-sparing mastectomy, when performed with immediate reconstruction, is a major advance in breast reconstruction. Traditionally, reconstruction of the nipple-areola complex is performed as a subsequent procedure. In this study, 17 patients (mean age, 43 years; range, 35 to 53 years) underwent one-stage breast and nipple-areola reconstruction over a 21-month period. In all cases of breast reconstruction, a buried transverse rectus abdominis musculocutaneous (TRAM) flap was used, and all patients had a simultaneous nipple-areola complex reconstruction performed. Nine patients had a Wise keyhole pattern used and contralateral reduction performed. Four patients retained all their breast skin, and a TRAM skin island was used in another four. It has recently been shown that patients with early-stage breast cancer and peripherally sited tumors have a very low risk of nipple-areola involvement. In 10 patients with early disease and peripheral tumors, the areola was retained (as a thin full-thickness graft), but more recently, in three patients with early-stage disease, the entire nipple-areola complex was used as a thin full-thickness graft. The thin full-thickness skin graft is removed from the breast in an apple-coring fashion, so that most of the ducts are retained as part of the mastectomy specimen. (There was histological confirmation of absence of tumor in the nipples of these patients.)One-stage autologous reconstruction should be considered for all patients undergoing immediate breast reconstruction. In patients with early-stage disease and peripheral tumors, the nipple-areola complex may be retained through the use of a thin full-thickness graft that is applied to a deepithelialized CV flap on the TRAM flap. This allows the best method of nipple-areola complex reconstruction: by retaining the original breast envelope, the color match and texture in the reconstruction are ideal. Patient satisfaction in this study was high. Necrosis of the mastectomy flaps impaired the cosmetic results in some patients. A large multicenter study is required to confirm the effectiveness of this procedure.

Nipple-sparing mastectomy in breast cancer: a viable option?

BACKGROUND

In women with breast cancer for whom breast-conserving therapy (BCT) is not the best option, a nipple and areola complex-(NAC) sparing mastectomy with immediate reconstruction has been proposed as a good and safe alternative to conventional, more radical mastectomy. Surgeons hesitate to perform this operation for fear of recurrence of tumour in the NAC due to undetected nipple involvement (NI) of the tumour. In order to determine whether a NAC-sparing mastectomy is a viable option, the frequency and predictive factors of NI by the tumour were studied in the literature.

METHODS

A literature survey was performed by searching the Medline database. Other references were derived from the material perused.

RESULTS AND CONCLUSIONS

NI is found in up to 58% of mastectomy specimens and correlates with tumour size, tumour-areola or tumour-nipple distance, positive lymph nodes and clinical suspicion. Best candidates for NAC-sparing mastectomy are patients with a small tumour (T1) at a large distance (>4-5 cm) from the nipple. However, in these patients BCT has excellent results with low complications and recurrence rates. Considering the incidence of NI in larger tumours (T2 average 33%, T3 average >50%) a NAC-sparing mastectomy may carry an unacceptable high risk for local relapse and should therefore not be advocated.