Nipple-Sparing Mastectomy – Extended Indications and Limitations

Abstract

Key WordsMastectomy · Nipple areola complex · Skin-sparing mastectomy · Breast neoplasm surgery Summary 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. Because NSM 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. In breast cancer patients with invasive carcinomas, the incidence of occult NAC involvement ranges from 0% [15] to 58% [16] which is probably due to differences in both histological methods and tumor criteria (table 1). Several studies have suggested that the risk of NAC involvement could be assessed by certain criteria. In a retrospective study on 397 breast cancer patients, tumor location, number of positive axillary lymph nodes, and lymphatic vascular invasion were identified as conclusive risk factors for NAC involvement. In this study, overall NAC involvement was determined in 58 (14.6%) patients by histopathological examination. NAC involvement was found in 50% of patients with 2 or 3 risk factors. Importantly, incidence of NAC involvement dropped to 8.1% in patients with only 1 risk factor [17].Most reports have consistently identified tumor location and tumor distance from the nipple as reliable predictors for neoplastic NAC involvement. Simmons et al. [18] found an overall frequency of 10.6% of NAC involvement in mastectomy patients. Prevalence increased if tumors were centrally located (27.3%) but decreased to 6.4% in patients with tumors located in the lower inner/lower outer, upper inner/ upper outer quadrants. In a retrospective analysis on 302 women who had undergone mastectomies because of invasive breast cancer or DICS, NAC involvement was found in 10% of cases and was negatively correlated with tumor distance from the nipple. The authors concluded that if tumor distance from the nipple is less than 4.96 cm as determined by mammography, NAC involvement can be predicted with a sensitivity

Comparison of oncological safety between nipple sparing mastectomy and total mastectomy using propensity score matching

“…Varying widely in sample size, inclusion criteria and follow-up duration, prospective and retrospective studies have found local recurrence rates of 0-24% after NSM. [13][14][15][16][17][18][19][20][21][22][23][24][25] Although Benediktsson and Perbeck reported a relatively high local recurrence rate of 24%, the NAC recurrence rate was 4%. 15 Comparison of NSM, SSM and modified mastectomy revealed local recurrence rates of 10.4%, 11.5% and 11.7% respectively.…”

Nipple-sparing mastectomy in breast cancer patients: The role of adjuvant radiotherapy (Review)

“…In addition, there are two critical points to consider: 21 of the identified studies included high-risk patients with ≥T3 tumors and/or lymph node involvement of ≥4 positive lymph nodes, and did not comment on adjuvant RT (5,20,21,27,33,38,40,47). For advanced TN stages, several recent national guidelines have recommended external beam RT to the whole thoracic wall, with or without irradiation of the lymphatic drainage system (44)(45)(46).…”

“…A study by Gerber et al (3) was the first to describe nipple-sparing mastectomy (NSM), which additionally saved the NAC, aiming to improve the esthetics and psychological results. The indications of NSM have been extended from a prophylactic scenario and small tumors distant from the NAC to larger and multi-centric tumors (4,5). There are several studies and reviews on NSM (1,2,5-10), a number of which focus on oncological safety (3,(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24), cosmetic outcome (24)(25)(26)(27)(28)(29) and surgical techniques (24)(25)(26)(27)(28)(29)(30)(31)(32).…”