Nipple sparing mastectomy--- an option for breast cancer ?

06/08/2011

Yam Po Chu Patricia

Kwong Wah Hospital

Nipple Sparing Mastectomy

History

Advantages of nipple sparing mastectomy ( NSM )

Oncological safety

Surgical techniques

Clinical outcome

Conclusion

History

Freeman in 1962 :Subcutaneous mastectomy for benign breast lesions [1]

Skin sparing mastectomy proven to be safe

General belief of occult tumour in nipple –areola complex [2]

[1] Freeman BS. Subcutaneous mastectomy for benign breastlesions with immediate or delayed prosthetic replacement.Plast Reconstr Surg Transplant Bull 1962; 30: 676–682.[2] Singletary SE, Robb GL. Oncologic safety of skin-sparing mastectomy.Ann Surg Oncol 2003;10:95–7.

Why consider nipple sparing ?

Cosmesis, reduce sense of mutilation

- excellent or good in 91.1% patient

- body image and satisfaction

Sensation of nipple

Problems of reconstructed nipples :insensate and not erectile

loss of projection and fade over time

Jabor MA, Shayani P, Collins DR Jr, Karas T, Cohen BE.Nipple–areola reconstruction: satisfaction and clinicaldeterminants. Plast Reconstr Surg 2002; 110: 457–463.

The nipple is the focal point of the breast and its reconstruction is often cited by women as making their breast reconstruction complete

Wellisch DK, SchainWS, Noone RB, Little JWIII. Thepsychological contribution of nipple addition in breastreconstruction. Plast Reconstr Surg 1987; 80: 699–704.

High risk patients with bilateral prophylactic subcutaneous mastectomy :

1.2% had subsequent development of invasive carcinoma

0.2% occurred in the nipple areolar complex (NAC)

Similar incidence in total mastectomy

Oncological safety

Hartmann LC, Schaid DJ, Woods JE, et al. Efficacy of bilateralprophylactic mastectomy in women with a family history ofbreast cancer. N Engl J Med 1999;340:77–84.

Oncological safety

Invasive ductal carcinoma arising from the nipple is uncommon

5.6% - 31% NAC specimens contained occult tumour

Variables in patient selection, definition of nipple involvement and pathological techniques

Overall recurrence in the nipple <2%

Simmons RM, Brennan M, Christos P, King V, Osborne M. Analysis of nipple / areolar involvement with mastectomy : can the areola be preserved ? Ann Surg Oncol 2002;9:165-8.

Case Selection

Risk factors for nipple areola complex involvement

Nodal positivity

subareolar tumour location, distance from the areolar margin ( 2-4cm ) [1]

multicentricity–involvement

Nuclear grading [2]

[1] Vyas JJ, Chinoy RF, Vaidya JS. Prediction of nipple and areola involvement in breast cancer. Eur J Surg Oncol 1998;24:15–16.[2] Laronga C, Kemp B, Johnston D, Robb GL, Singletary SE. The incidence of occult nipple-areola complex involvement in breast cancer patients receiving a skin-sparing mastectomy. Ann Surg Oncol 1999;6:609–613.

Case SelectionT3 lesions involve the nipple-areola complex

> 50%

-ve axillary lymph node + peripheral tumours <2% missing an occult tumour with a NSM [1]

Extended indication : Rusby at el

Duct bundle could be completely excised in 96%

of cases if a peripheral rim of 2mm of nipple skin and subcutaneous tissue is left [2]

[1] FC, Smith BL. Nipple-sparing mastectomy: lessons from ex vivoprocedures. Breast J 2008;14:464–70.[2] Rusby JE, Kirstein LJ, Brachtel EF, Michaelson JS, KoernerFC, Smith BL. Nipple-sparing mastectomy: lessons from ex vivoprocedures. Breast J 2008;14:464–70.

Clinical data concerning the predictability of NAC involvement remain inconsistent

Frozen sections of the subareolar tissue -- crucial decision for NAC preservation- 54.5% negative for malignancy in a

series

Gerber B, Krause A, Reimer T, et al. Skin-sparing mastectomywith conservation of the nipple-areola complex and autologousreconstruction is an oncologically safe procedure. Ann Surg2003;238:120–7.

False negative rate 1- 4.6% when compared with definitive paraffin section [1] [2]

[1]Crowe JP, Patrick RJ, Yetman RJ, Djohan R. Nipple-sparingmastectomy update: one hundred forty-nine procedures andclinical outcomes. Arch Surg 2008; 143: 1106–1110.[2]47 Regolo L, Ballardini B, Gallarotti E, et alNipple sparing mastectomy: an innovative skin incision foran alternative approach. Breast 2008; 17: 8–11.

Case selection

Prophylactic mastectomy in high risk patientTumour < 4cm in sizeperipherally located ( > 2.5cm from nipple )Negative axillary lymph nodes

Surgical Techniques2-3mm thick nipple-areola flap with sparse or no ductal tissue presevation of the NAC and its blood supply

Transareolar, perinipple incision with lateral extensionTransareolar, transnipple incisionInferior-lateral mammary creaseNipple-sparing omega Envelope incision at the lateral border

A frozen section analyse the areola and immediate reconstruction

Stolier AJ, Grube BJ. Areola-sparing mastectomy : defining the risks. J Am Coll Surg 2005; 201:118-24.

Transareolar, perinipple incision with lateral extension

Transareolar, transnipple incision with medial and lateral extensions

Inferior-lateral mammary crease incision

Nipple-sparing omega (Mastopexy) Incision

Envelope incision at the lateral boder :- Allows excellent exposure of the axillary tail with good perfusion of nipple

Clinical outcomeNecrosis and partial loss of the NAC

6% - 9.8%

3.7% total necrosis of the NAC with subsequent removal

Petit JY, Veronesi U, Orecchia R, Rey P, Martella S, Didier F et al. 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). Breast Cancer Res Treat 2009; 117: 333–338.

This preserved areola underwent superficial necrosis, butthe pigment returned 4 months later

Risk factors for nipple necrosis Age > 45, smoker

Incisions > 30% of the areolar circumference

Reconstruction with tissue expander is preferrable to fixed-volume implant

Garwood ER, Moore D, Ewing C et al. Total skin-sparing mastectomy :

complications and local recurrence rates in 2 cohorts of patients.

Ann Surg 2009; 249:26-32.

Sensation in the preserved NAC 31% - 75%

Lateral incision is preferrable

Depigmentation 43%[1]Benediktsson KP, Perbeck L, Geigant E, Solders G. Touchsensibility in the breast after subcutaneous mastectomy andimmediate reconstruction with a prosthesis. Br J Plast Surg1997; 50: 443–449.[2]Yueh JH, Houlihan MJ, Slavin SA, et al. Nipple-sparing mastectomy: evaluation of patient satisfaction, aesthetic results, and sensation. Ann Plast Surg 2009; 62: 586–590.

Variants to improve outcome

Preserve a pad of breast tissue behind the nipple with Intraoperative electron-beam radiotherapy [1]

Areolar preserving with nipple removal

2/23 cases of NAC involvement had areolar involvement [2]

[1] Petit JY, Veronesi U, Orecchia R, et al. 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). Breast Cancer Res Treat 2009; 117: 333–338.[2] Simmons RM, Brennan M, Christos P , et al. Analysis of nipple/ areolar involvement with mastectomy : can the areola be preserved ? Nn Surg Oncol 2002; 9 :65-8.

Mastopexy performed 1 week before NSM ensured maximum perfusion of the nipple-areolar complex.

ConclusionNipple sparing mastectomy is oncologically safe in practiceNo definite concensus on clinical criteria for case selection : small tumours far from nipple and favourable pathological featuresNipple necrosis may occur, partial necrosis can usually be treated conservativelyNo prospective study – selection bias and publication bias, further prospective cohort studies required