Nipple Sparing Mastectomy
7/24/2010 (10:11:04am)Tags: mastectomy reconstruction nippleComments: (0)
It seems obvious that one of the more difficult parts of breast reconstruction is creating a new and natural-looking nipple and arerola. Women sometimes wonder about the possibility of a mastectomy that spares the nipple. Here is a brief interview, from MedScape, with Dr. Lisa Newman from the University of Michigan Medical Center about this surgery:
Nipple-Sparing Mastectomy With Breast Reconstruction
Lisa A. Newman, MD, MPH
Posted: 06/25/2010
Question
My patient is a 35-year-old woman with a clinical stage I left breast cancer. She has a strong family history of breast cancer and is considering bilateral prophylactic mastectomy with immediate reconstruction. She has asked about nipple-sparing mastectomy. Is this a safe approach, either for the therapeutic or the prophylactic mastectomy?
Response from Lisa A. Newman, MD, MPH
Professor of Surgery; Director, Breast Care Center, University of Michigan, Ann Arbor
Reports of nipple-sparing mastectomy are appearing more frequently in the published medical literature, with most groups suggesting that the procedure is not only technically feasible, but also oncologically safe. However, it must be strongly emphasized that the conventional mastectomy, which entails sacrifice of the nipple-areolar skin, is still widely considered to be the gold standard procedure for patients requiring mastectomy for either cancer treatment or risk reduction. Studies of nipple-sparing mastectomy have been retrospective in nature with variable selection criteria,
including mixed samples of patients undergoing the procedure for prophylaxis or treatment; the patient follow-up intervals have been relatively brief.
Nonetheless, the preliminary data in regard to outcomes following nipple-sparing mastectomy are promising, suggesting that it is a technique worthy of further study and should be rigorously evaluated in the context of a prospective clinical trial. Historically, the largest series of bilateral prophylactic mastectomy, such as the Mayo Clinic database,[1] featured cases performed by plastic surgeons as subcutaneous (nipple-sparing) mastectomy. In the now-landmark study of approximately 1000 selected high-risk women undergoing prophylactic mastectomy in this setting, Hartmann and colleagues[1] found that prophylactic mastectomy reduces breast cancer risk by 90%, and of the 7 prophylactic failures, only 2 were cases of breast cancer occurring in the retained nipple-areolar skin. These results have prompted others to explore nipple-sparing mastectomy for breast cancer as an extension of the skin-sparing mastectomy concept. The skin-sparing mastectomy includes a periareolar incision but sacrifices the nipple-areolar skin, and is now routinely
coupled with immediate breast reconstruction, with well-documented acceptably low local recurrence rates that are comparable to those reported after conventional mastectomy.[2,3] Pathologic analyses of the nipple-areolar skin from mastectomy specimens reveal occult cancer in this tissue in 6%-58% of cases,[4,5] with risk for occult nipple-areolar
involvement highest with central tumors. This has prompted some investigators to offer nipple-sparing mastectomy to patients with peripherally located disease. Simmons and coworkers[6] found that most cases of occult nipple-areolar
involvement were related to disease within the nipple, and this group has reported excellent local control with areolar- sparing mastectomy in 17 cases, but with follow-up limited to only 2 years.[7
Several single-institution groups have reported their outcomes with nipple-sparing mastectomy, with wide variation in local recurrence rates ranging from 0% to 28%, and with median follow-up intervals often shorter than 2 years.[8-10] In contrast, rare reports of larger sample sizes with longer follow-up have also demonstrated low local recurrence
rates.[11,12]
Of note, at least 1 group from Italy has reported on routine use of intraoperative radiation to the retained nipple-areolar skin.[13] The consistent observation that failures only rarely involve the preserved nipple-areolar complex has nonetheless prompted concerns that the limited exposure from a nipple-sparing mastectomy might actually compromise the adequacy of the mastectomy, leaving more at-risk breast tissue in the remote portions of the breast/chest wall.
Nipple-sparing mastectomy would be the preferred procedure for cases of small unicentric breast tumors located more than 2 cm peripheral to the areolar edge, as well as for cases in which the intraoperative frozen section analysis revealed no evidence of occult nipple-areolar involvement.
Patients considering this procedure should be informed that the nipple-areolar skin will need to be sacrificed if any disease proximal to the area is identified pathologically, and that if preserved, the nipple-areolar skin may be insensate or develop necrotic wound complications. Of importance, patients must also be informed about and understand the lack of high-quality prospective data in regard to the oncologic safety of this procedure.
Supported by an independent educational grant from Susan G. Komen for the Cure.
