Nipple-sparing Mastectomy Patients Research Articles

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

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. 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. 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. 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.

Duoderm®-Bra for Nipple-Sparing Mastectomy

Nipple-sparing mastectomy (NSM) with tissue expander reconstruction is a widely used technique that can produce aesthetically pleasing reconstruction results after mastectomy. Nipple position and healthy mastectomy flaps with good vascularity are important determinants of an adequate aesthetic final result. An initial high fill volume of the expander can produce a more natural breast mound appearance postoperatively. However, this can often lead to ischemia with loss of the nipple-areolar complex (NAC). Conversely, low intraoperative fill rates are conducive to enhanced tissue circulation and viability. But this may lead to poor skin envelope draping and nipple placement lower than desired. We have developed a new technique called "Duoderm®-bra" that brings together both mastectomy skin tissue health and aesthetic success with optimal nipple positioning. We hypothesized that with Duoderm®-bra, the NAC can be stabilized in the desired high position and ptosis can be reduced. We also hypothesized that by eliminating the need for acellular dermal matrix and intraoperative fill, "Duoderm®-bra" would decrease the rate of complications. The objective of this study was to evaluate the effects of using novel "Duoderm®-bra" technique in NSM. After an institutional review board approval, a retrospective chart review of 35 consecutive patients was done with 65 breasts undergoing NSM and tissue expander reconstruction by the same plastic surgeon. Patients in whom "Duoderm®-bra" was used were compared with patients without the "Duoderm®-bra." Patients with acellular dermal matrix were excluded. Age, ptosis grade, preoperative nipple to IMF ratio (R/L), tumor characteristics, mastectomy specimen weight (R/L), time from mastectomy to first fill, time from mastectomy to final fill, final fill volume (R/L), NAC and skin necrosis, and other complications requiring surgery were recorded. Postoperative photographs for NAC positioning (side view most projected point versus at a lower point) were assessed using a scoring system. Two groups were then compared. Complications were higher in the non-Duoderm® group compared with Duoderm®-bra (odds ratio, 4.5; 95% confidence interval [CI], 1.35-15.04; P = 0.021). Optimum nipple positioning was significantly higher with Duoderm®-bra compared with no Duoderm®-bra (odds ratio, 50.0; 95% CI, 10.9-230.1; P < 0.0001). There was no difference in timing from mastectomy to completion of expansion in the Duoderm® group compared with no Duoderm®-bra group (mean difference, -2.35; 95% CI, -10.37 to 5.68). Use of "Duoderm®-bra" without intraoperative tissue expansion in NSM is a new technique. This technique improves nipple position with less ptosis and greater elevation, decreases flap and NAC necrosis complications, and does not increase total reconstructive period in NSM patients.

Nipple-Sparing Mastectomy in Patients with Germline BRCA Mutations: Is it Safe?

Through most of recorded medical history, there has been debate about how much healthy tissue should be removed in order to effectively treat breast cancer. The prevailing opinion at the start of the twentieth century was “a lot.” The trend has been reversed in recent decades as advances in systemic treatments and radiation therapy have pushed local recurrence rates down even as breast surgery has become markedly less destructive. There is still debate, however, over the nipple-areolar complex in patients requiring mastectomy. A wealth of data has now accumulated demonstrating that occult nipple involvement with cancer is rare, and usually identifiable in appropriately obtained tissue samples; that leaving the nipple behind does not need to leave a lot of breast tissue behind; that the nipple is not a favored site of recurrence; and that local recurrence rates are quite low in selected breast cancer patients treated with nipple-sparing mastectomy. There has been concern, however, that BRCA gene mutation carriers may be at greater than average risk for new primary breast cancers if the nipple is preserved. Available case series are small and follow-up is short, but thus far, there is no signal to suggest that this is the case. Thorough, oncologically sound nipple-sparing mastectomy appears safe in BRCA gene mutation carriers.

Oncologic Safety of Immediate Breast Reconstruction for Invasive Breast Cancer Patients: A Matched Case Control Study.

PurposeThe purpose of this study was to compare locoregional recurrence-free survival (LRFS) and disease-free survival (DFS) between patients undergoing mastectomy and immediate breast reconstruction (IBR) and those undergoing mastectomy alone.MethodsA retrospective review of patients who underwent mastectomy and immediate breast reconstruction for resectable invasive breast cancer between 2002 and 2010 at a single center was conducted. These cases were matched to patients who underwent mastectomy alone in the same time period, performed by 1:2 matching. Matching control variables included age, tumor size, axillary lymph node metastasis, and estrogen receptor status. Overall, 189 patients were identified in the IBR group, and 362 patients were matched to this group.ResultsIn the IBR group, 75 patients (39.7%) underwent conventional total mastectomy, 78 (41.3%) underwent skin-sparing mastectomy (SSM), and 36 (19.0%) underwent nipple-sparing mastectomy (NSM). The IBR group was significantly younger than the control group (41.9 and 45.1 years, respectively) (p=0.032), in spite of matching between three age groups. The DFS rates were similar between the IBR group and mastectomy alone group, at 92.0% and 89.9%, respectively, at 5-year follow-up (log-rank test, p=0.496). The 5-year LRFS was 96.2% in the IBR group and 96.4% in the mastectomy alone group (log-rank test, p=0.704), similar to data from previous reports. Subgroup analyses for SSM or NSM patients showed no differences in LRFS and DFS between the two groups. Additionally, in stage III patients, IBR did not cause an increase in recurrence.ConclusionIBR after mastectomy, including both SSM and NSM, had no negative impact on recurrence or patient survival, even in patients with advanced disease.

Expanded Indications and Improved Outcomes for Nipple-Sparing Mastectomy Over Time.

Demand for nipple-sparing mastectomy (NSM) has increased. The authors' initial NSM guidelines included risk reduction and cancers 2 cm or smaller located more than 2 cm from the nipple. The relative contraindications included obesity, large and/or ptotic breasts, and prior radiation. This study aimed to evaluate changes over time in NSM indications, surgical approach, and early outcomes. After institutional review board approval, the study identified 354 patients scheduled for 588 NSMs, 341 (96%) of whom underwent 566 NSMs. Changes across time [early (2009-2010), mid (2011-2012), and recent (2013-6/2014)] were assessed using tests for linear trend. For patients undergoing reconstruction, NSMs increased from 24% (early) to 40% (recent) (p = 0.004). Among the NSM patients, average body mass index, proportion with bra cup sizes of C or larger, and prior radiation increased significantly over time. Performance of NSM for tumors 2 cm or less from the nipple increased from 5 to 18%, and after neoadjuvant therapy, from 8 to 21.5% (p = 0.02). Use of inframammary, radial, and reduction-type incisions increased over time, together with intraoperative laser angiography (both p < 0.0001). Concomitantly, the overall complication rate, complications requiring treatment, and postoperative nipple loss decreased. During a median follow-up period of 19 months, five locoregional recurrences (LRR) were observed, for an estimated 2-year LRR rate of 1.7% [95% confidence interval (CI), 0-3.9%]. Over time, the indications for NSM expanded in terms of patient characteristics, tumor stage, and prior therapy, whereas the complication rates decreased. Excellent short-term outcomes suggest that NSM is a reasonable approach for many risk-reduction and cancer patients without disease in the nipple-areolar complex. Further study is needed to assess long-term aesthetics, patient satisfaction, and oncologic safety.

Abstract P2-13-02: Nipple sparing mastectomy in patients with BRCA1 and BRCA2 mutations

Abstract Introduction: Nipple sparing mastectomy (NSM) is now performed with increasing frequency in both therapeutic and prophylactic breast surgery. The role of NSM in BRCA1 and BRCA2 mutation carriers has not been well described. The aim of this study was to review our experience with NSM in this high-risk population. Methods: A review of the breast database was performed to identify all patients with documented BRCA mutations who underwent NSM at Memorial Sloan Kettering Cancer Center. Data extracted from the database included patient demographics, type of mutation, indication for surgery, type of reconstruction, and complications. For patients undergoing therapeutic mastectomy, data on disease stage, axillary procedures, and follow-up were also extracted. Results: 177 NSMs (88 bilateral, 1 unilateral) were performed in 89 female patients with a documented BRCA mutation between September 2005 and December 2013. There were 56 patients with BRCA1 mutation, 26 with BRCA2 mutation, and 7 with genetic variants of uncertain significance. 26 patients had a therapeutic NSM for breast cancer (stage 0: n=6; stage 1: n=15; stage 2: n=5) and concurrent contralateral prophylactic mastectomy (CPM). The mean tumor size was 1.46cm (range, 0.1-3.5cm), and all were node negative following sentinel lymph node biopsy. 63 patients had NSM for prophylaxis. The mean age of patients undergoing therapeutic NSM was 41 years (range, 26-59) and prophylactic NSM was 39 years (25-59). There was an incidental diagnosis of ductal carcinoma in situ (DCIS) in 4 women undergoing CPM and 4 patients undergoing prophylactic NSM, including 1 patient diagnosed with bilateral DCIS, and an incidental diagnosis of atypia in 8 patients undergoing prophylactic NSM. In 26 patients undergoing therapeutic NSM, at median follow-up of 2.34 years (range, 0.45-6.06) there were no local or regional recurrences. One patient developed distant metastases and subsequently died from her disease, and 1 other patient died from metastatic ovarian cancer. In 63 patients undergoing prophylactic NSM, at median follow-up of 2.15 years (range, 0.11-8.14) there were no newly diagnosed breast cancers or deaths. Following NSM, 5 patients (5.6%) required subsequent excision of the nipple-areolar complex (3 cases for close or positive DCIS on final histology, 1 case for infection with necrosis, and 1 case for ongoing nipple discharge). All 89 patients had immediate breast reconstruction (tissue expander: n=80; permanent implant: n=8; autologous (DIEP) flap: n=1). Postoperative complications are shown in Table 1. Postoperative complications following 177 nipple sparing mastectomies performed in 89 patients with BRCA mutations No. of Breasts; n (%)No. of Patients; n (%)Skin desquamation68 (38.4)40 (44.9)Necrosis requiring debridement18 (10.2)13 (14.6)Infection7 (4.0)7 (7.9)Hematoma3 (1.69)3 (3.4)Complication requiring implant or tissue expander removal6 (3.4)6 (6.7) Conclusion: NSM is an acceptable choice for patients with BRCA gene mutations undergoing therapeutic or prophylactic mastectomy with no evidence of compromise to oncological safety. This report shows an acceptable complication rate, and patients rarely required subsequent excision of the nipple-areolar complex. Citation Format: Aidan T Manning, Andrea Pusic, Caitlin Wood, Anne Eaton, Michelle Stempel, Deborah Capko, Virgilio Sacchini. Nipple sparing mastectomy in patients with BRCA1 and BRCA2 mutations [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-13-02.

Abstract P2-13-27: Nipple sparing mastectomy: Risks of wound complication in the setting of neo-adjuvant or adjuvant chemotherapy and/or radiation therapy

Abstract Background: Surgical care of breast cancer has evolved significantly over the past 40 years. Nipple sparing mastectomy (NSM) and skin sparing mastectomy (SSM) have become an increasingly used surgical management for women with malignant breast disease. To date, there are limited recommendations about the role of NSM in patients receiving aggressive adjuvant therapy. The purpose of this investigation is to determine whether NSM in the setting of neo-adjuvant or adjuvant chemotherapy and/or radiation therapy increased the risks for wound complications. Methods: A retrospective chart review of nipple sparing mastectomies at a single institution was performed from 2007 to 2014. Multiple data points including neo-adjuvant or adjuvant chemotherapy and/or radiation therapy, obesity, smoking history, and type of reconstructive surgery were examined in detail. Results: We counted the procedures by breasts affected and identified 76 NSM in the time period which met criteria. Of the 76 NSMs, 27 breasts received neo-adjuvant(20) or adjuvant chemotherapy and/or radiation(7) therapy. 21 breasts in the NSM group developed wound complications including skin flap necrosis (5), total nipple necrosis and loss (11) hematoma (2) infection(2) and seroma(1). The complications were seen in 11 in the non adjuvant treated setting (14%) and 9 (33%) in the adjuvant therapy setting. Conclusions: Nipple sparing mastectomy are emerging as safe and adequate options for the management of malignant breast disease. Our results show there is a significant risk of wound complication associated with neo-adjuvant and adjuvant chemotherapy and radiation therapy in the setting of nipple sparing mastectomy. We are pursuing the development of new surgical techniques and guidelines to reduce these risks in these high risk patients. Citation Format: Selyne Samuel, Rebecca Viscusi, Amy Waer, Victor Gonzalez, Pavani Chalasani, Craig Hurst, Ethan Larson, Robert Livingston, Michele Ley. Nipple sparing mastectomy: Risks of wound complication in the setting of neo-adjuvant or adjuvant chemotherapy and/or radiation therapy [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-13-27.

Abstract P2-18-08: Nipple-sparing mastectomy for patients with multifocal breast cancer

Abstract Introduction: Cosmetic outcome is one of the most important goals of surgical treatment for breast cancer. Therefore, to maximize the cosmetic outcome for patients who require a mastectomy, the actions that can be taken from an oncologically safe perspective must be considered. Recent reports have suggested that nipple-sparing mastectomy (NSM) is oncologically as safe as a standard mastectomy and provides a better cosmetic outcome. However, little is known about the outcome of NSM for patients with multifocal breast cancer. Aim: To determine the oncological and technical outcomes of NSM for patients with multifocal breast cancer compared with NSM for patients with unifocal breast cancer using retrospective long-term follow-up data. Patients and Methods: We retrospectively analyzed 799 patients with primary breast cancer who underwent NSM, including 45 patients with multifocal breast cancer and 754 patients with unifocal breast cancer. The indications for NSM in this study were defined as any stage, any tumor size and any tumor–areola distance. Briefly, NSM was performed when no involvement of the nipple areola complex was revealed by radiographic and clinical examinations. Our surgical notes for NSM comprised a thick skin flap method for conserving the breast volume using subcutaneous fat and avoiding surgical complications including nipple necrosis. No patients received radiotherapy. We compared the local recurrence rate (LRR), disease-free survival (DFS), breast cancer-specific survival (BCSS) and overall survival (OS) between the 45 multifocal breast cancer and 754 unifocal breast cancer cases. Results: The numbers of multifocal breast cancer cases in stages 0, 1, 2A, 2B, 3 and 4 were 1, 17, 12, 8, 7 and 0, respectively. The corresponding numbers of unifocal breast cancer cases were 18, 288, 223, 117, 102 and 6, respectively. The median follow-up periods of the multifocal and unifocal breast cancer cases were 108 and 98 months, respectively. No nipple necrosis was recorded in either group (0/45, 0/754). Regarding NSM for patients with multifocal breast cancer, there were 8 patients (17.7%) with local recurrence, including 4 (8.9%) at the nipple and 4 (8.9%) at the skin flap. In NSM for patients with unifocal breast cancer, there were 63 patients (8.3%) with local recurrence, including 26 (3.4%) at the nipple and 37 (4.9%) at the skin flap. There were significant differences between NSM for patients with multifocal and unifocal breast cancer in the LRR (17.7% vs. 8.3%, p = 0.03) and DFS (10 yr, 72.4% vs. 83.8%, p = 0.04), but no significant differences in the BCSS (10 yr, 83.6% vs. 90.9%, p = 0.18) and OS (10 yr, 83.6% vs. 89.5%, p = 0.32). Conclusions: The present results suggest that NSM for patients with multifocal breast cancer can be technically performed as safely as NSM for patients with unifocal breast cancer. Our long-term follow-up data show that survival after NSM for multifocal breast cancer is equal to that after NSM for unifocal breast cancer. However, careful local observation after NSM is required. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-18-08.

Abstract P6-08-01: Analysis of patient-reported outcomes following nipple-sparing mastectomy and implant reconstruction

Abstract Background: Nipple-sparing mastectomy (NSM) is gaining popularity among women undergoing prophylactic and therapeutic mastectomy. Using the BREAST-Q, a validated condition-specific patient-reported outcome instrument which measures postsurgical patient satisfaction and health-related quality of life (HR-QoL), we sought to determine whether satisfaction and HR-QoL differ between patients undergoing NSM and skin-sparing mastectomy (SSM) with immediate implant reconstruction. Methods: From 2005 to 2012, a total of 572 patients underwent mastectomy; of these 261 patients (46%) had NSM. All mastectomy patients were mailed the BREAST-Q reconstruction questionnaire consisting of 3 scales (scored 0-100): Satisfaction with Breasts, Satisfaction with Outcome, and Psychosocial Well-Being. Excluded from this analysis were males, autologous tissue reconstruction, and conversion from NSM to SSM. Comparisons were made between NSM and SSM groups using univariable analysis and multivariable linear regression models (MVA). Results: The BREAST-Q completion rate was 27% with a median time from surgery to survey of 36 months (range 4 to 86). Women undergoing NSM, compared to SSM, were younger (mean 46 v 50 years; p = 0.01), more likely to be married (80% v 52%; p = 0.001), have bilateral mastectomies (79% v 59%; p = 0.01), and had less time between surgery and BREAST-Q completion (median 25 v 49 months; p&amp;lt;0.001). 19 NSM patients (25%) and 7 SSM patients (13%) underwent prophylactic mastectomy (p = 0.07). There were no differences regarding tumor characteristics or treatment. Patients undergoing NSM, compared to SSM, had a higher unadjusted mean score for Satisfaction with Breasts (71 v 60; p&amp;lt;0.001), Satisfaction with Outcome (80 v 69; p = 0.003), and Psychosocial Well-Being (84 v 74; p = 0.006). On MVA analysis, NSM (compared to SSM) was associated with greater Satisfaction with Breasts (adjusted mean difference: +13, 95% Confidence Interval[CI]: 6-21, p = 0.001), Satisfaction with Outcome (adjusted mean difference: +17, 95% CI: 7-27, p = 0.001), and Psychosocial Well-Being (adjusted mean difference: +12, 95% CI: 3-22, p = 0.013), after controlling for age at mastectomy, marital status, laterality, cancer vs. non-cancer diagnosis, post-mastectomy radiation treatment, and time from mastectomy to BREAST-Q completion. Not being married (adjusted mean difference: +8, 95% CI: 2-15, p = 0.014) and having a bilateral mastectomy (adjusted mean difference: +8, 95% CI: 1-14, p = 0.029) were also significant predictors of increased Satisfaction with Breasts. Conclusion: These findings suggest that, in the setting of implant reconstruction, NSM is associated with higher patient satisfaction with their breasts, overall outcome, and improved emotional/social well being. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-08-01.

Nipple-Sparing Mastectomy in Patients with a History of Reduction Mammaplasty or Mastopexy

INTRODUCTION: Nipple-sparing mastectomy has gained popularity, but the question remains whether it can be offered safely to women with prior history of reduction mammaplasty or mastopexy. Presented is our updated experience with offering nipple-sparing mastectomy to this patient population. METHODS: Patients at our institution who had reduction mammaplasty or mastopexy prior to nipple-sparing mastectomy were identified and their records reviewed. Outcomes measured include nipple-areolar complex viability, mastectomy flap necrosis, infection, cancer in the nipple-areolar complex and breast cancer recurrence. RESULTS: The records of our nipple-sparing mastectomy patients from 2006 through 2012 were reviewed. We present eleven patients (n=19 breasts) who underwent nipple-sparing mastectomy following reduction mammaplasty or mastopexy. Seventeen breasts had reduction mammaplasties while the remaining two had mastopexies. In all cases, reduction mammaplasty or mastopexy were in the patient’s surgical history and not performed as part of a planned two stage nipple-sparing mastectomy procedure. The mean age of the patients was 47.5 and the mean BMI was 27.6. None of the patients in this subset were diabetic, and one patient was a smoker. Twelve breasts had therapeutic resections, and seven were for prophylactic indications. Average time elapsed between reduction mammaplasty or mastopexy and nipple-sparing mastectomy was 104.3 months (range, 33 days to 40 years). Fourteen patients were reconstructed immediately with tissue expanders, one with a latissimus dorsi flap with immediate implant and four with immediate transverse rectus abdominis myocutaneous free flaps. Prior reduction mammaplasty or mastopexy incisions were used in all cases. Complications included one hematoma requiring evacuation, one breast with mastectomy flap necrosis, and one displaced implant requiring revision. There were no positive subareolar biopsies. Nipple viability complications included a partial necrosis rate of 15.8% (3/19). Mean follow-up time was 14.5 months. CONCLUSION: Our updated experience demonstrates that the outcomes of nipple-sparing mastectomy in patients with a history of reduction mammaplasty or mastopexy are comparable to the standards for patients who undergo nipple-sparing mastectomy alone.

Impact of Surgical Techniques, Biomaterials, and Patient Variables on Rate of Nipple Necrosis after Nipple-Sparing Mastectomy

Nipple-sparing mastectomy is appropriate for selected patients with early-stage breast cancer or high breast cancer risk. However, the postoperative rate of nipple necrosis is relatively high (10 to 30 percent). This study analyzed the impact of clinicopathologic and surgical variables on partial and total nipple necrosis rates after nipple-sparing mastectomy and compared overall complication rates between nipple-sparing and skin-sparing mastectomy. The study included 233 cases; 113 had nipple-sparing mastectomy and immediate breast reconstruction and 120 were matched cases of skin-sparing mastectomy and immediate reconstruction performed at the authors' institution from September of 2003 through May of 2011. The overall complication rate was 28 percent for nipple-sparing mastectomy and 27 percent for skin-sparing mastectomy (p > 0.99). In patients who did not have axillary surgery (those undergoing risk-reducing mastectomy), the overall rate was significantly higher in the nipple-sparing group (26 percent versus 9 percent; p = 0.06). However, in patients who had axillary surgery (either sentinel lymph node biopsy or axillary lymphadenectomy), the rate did not differ between the two groups. For nipple-sparing mastectomy, the overall incidence of any (partial or total) nipple necrosis was 20 percent. Only two cases (2 percent) had total necrosis. Larger breasts (C cup or larger) were associated with a higher rate of nipple necrosis (p = 0.003). The authors found no significant difference in the overall incidence of complications in patients who had nipple-sparing mastectomy or skin-sparing mastectomy. Exclusion of axillary lymphatic surgery in nipple-sparing mastectomy patients did not decrease the incidence of complications.

Prevalence of Terminal Duct Lobular Units and Frequency of Neoplastic Involvement of the Nipple in Mastectomy

Breast cancer treatment has greatly evolved from radical mastectomy to more cosmetically acceptable and less-debilitating surgeries. Nipple-sparing mastectomy is increasingly done for both cancer treatment and risk reduction. The frequency of terminal duct lobular units (TDLUs) and occult neoplastic epithelial proliferation in grossly/clinically unremarkable nipples (GUNs) is not well investigated. To describe frequency of TDLUs and occult and overt neoplastic nipple involvement. Nipples from 105 consecutive specimens (90 therapeutic, 15 prophylactic) were studied. Sixty-five nipples were entirely submitted to evaluate frequency of TDLUs; the rest had 1 vertical section submitted. Terminal duct lobular unit was seen in 17 GUNs (26%). Six had TDLU in the base, 6 had it in the papilla, and 5 in both. Four GUNs showed lobular carcinoma in situ (1), Paget disease (1), and pagetoid extension of underlying malignancy (2). Grossly/clinically abnormal nipples had Paget disease (2), lymphovascular invasion (2), invasive carcinoma (4), and pagetoid extension (5). Involved nipples were closer to tumor (mean, 1.1 versus 3.2 cm, P < .001), had larger underlying tumors (mean, 4.3 versus 2.6 cm, P = .03) and of higher grade (P = .04), and more often had lymph node metastases (91% versus 44%, P = .007). No pathologic abnormalities were found in prophylactic mastectomy nipples. Terminal duct lobular units were seen in 26% of nipples. They were frequently seen in the nipple papilla. Occult neoplastic epithelial proliferation was seen in 5% of grossly/clinically unremarkable therapeutic mastectomy nipples. Pagetoid extension was the dominant spread of underlying malignancy. Overall, the nipple was more often involved by larger and higher-grade tumors located closer to the nipple. All prophylactic mastectomies had unremarkable nipples. These findings should be considered while selecting patients for nipple-sparing mastectomy.

Nipple-Sparing Mastectomy in Patients with a History of Reduction Mammaplasty or Mastopexy

Nipple-sparing mastectomy has gained popularity, but the question remains of whether it can be offered safely to women with a history of reduction mammaplasty or mastopexy. The authors present their experience with nipple-sparing mastectomy in this patient population. Patients at the authors' institution who had reduction mammaplasty or mastopexy before nipple-sparing mastectomy were identified. Outcomes measured include nipple-areola complex viability, mastectomy flap necrosis, infection, presence of cancer in the nipple-areola complex, and breast cancer recurrence. The records of the nipple-sparing mastectomy patients at the authors' institution from 2006 through 2012 were reviewed. The authors identified 13 breasts in eight patients that had nipple-sparing mastectomy following reduction mammaplasty or mastopexy. Within this subset of patients, the mean age was 46.6 years and the mean body mass index was 25.1. Nine of 13 breasts had therapeutic resections, whereas the remaining four were for prophylactic indications. Average time elapsed between reduction mammaplasty or mastopexy and nipple-sparing mastectomy was 51.8 months (range, 33 days to 11 years). In all cases, prior reduction mammaplasty/mastopexy incisions were used for nipple-sparing mastectomy. Ten breasts underwent reconstruction immediately with tissue expanders, one with a latissimus dorsi flap with immediate implant and two with immediate abdominally based free flaps. Complications included one hematoma requiring evacuation and one displaced implant requiring revision. There were no positive subareolar biopsy results, and the nipple viability was 100 percent. Mean follow-up time was 10.5 months. The authors' experience demonstrates that nipple-sparing mastectomy can be offered to patients with a history of reduction mammaplasty or mastopexy with reconstructive outcomes comparable to those of nipple-sparing mastectomy alone. Therapeutic, IV.

The Use of Nipple-Sparing Mastectomy in Patients With Breast Cancer

Breast cancer is the most common cancer diagnosed in women. Nipple-sparing mastectomy (NSM) offers the opportunity to preserve the breast envelope and the nipple-areolar complex by removing only breast tissue and avoiding multiple surgical procedures for reconstruction. The objective of this article is to review the oncologic and surgical concerns with NSM, along with the appropriate selection of patients and potential postoperative complications. A review of the literature was conducted through MEDLINE®, PubMed, and Google Scholar, focusing on recent research. The findings revealed that although the oncologic safety of NSM continues to be debated, indications are strong that cancer recurrence rates are low and the aesthetic motivation is high for carefully screened patients. From those findings, considerations for patient education regarding risks and expectations are described. Nurses in a variety of cancer care settings can use this information to address the concerns of patients making decisions regarding surgical options and adjusting to postoperative body image expectations and changes.

Do Clinicopathological Features of the Cancer Patient Relate with Nipple Areolar Complex Necrosis in Nipple-Sparing Mastectomy?

The selections of nipple-sparing mastectomy (NSM) are principally depending on oncologic indication and oncologic safety. The main complication of NSM is nipple areolar complex (NAC) necrosis, and it is usually related to surgical technique. However, the patients' clinicopathological factors should be also considered. We retrospectively reviewed 934 consecutive NSM patients during 2002-2007 at the European Institute of Oncology, Milan, Italy. We identified a group of patient who had NAC excision because of NAC necrosis and compared this group with those who had successful NAC conservation. We analyzed the association between the risk of NAC necrosis and the clinicopathological features of the patients. Among 934 NSM, 772 were invasive cancers and 162 were in situ cancers. Of the 934, 40 NAC (4.2%) were removed during the postoperative period because of necrosis. When we considered age, BMI, menopausal status, smoking status, tumor size, axillary lymph node status, in situ or invasive cancer histology, presence of extensive situ component, grading, estrogen receptor, progesterone receptor, HER2/neu overexpression, Ki-67 proliferative index, and peritumoral vascular invasion, no association was observed between patients' clinicopathological features and NAC necrosis incidence. In our study, clinicopathological features have no significant impact on necrosis complication in therapeutic NSMs. Positive retroareolar margin is the risk of necrosis. Further studies are required to avoid bias due to the different cancer treatments such as different reconstruction techniques and intraoperative radiation protocols. The correlation between breast morphology and NAC necrosis should also be investigated in the future.

A Comparison of Clinical and Pathologic Assessments for the Prediction of Occult Nipple Involvement in Nipple-Sparing Mastectomies

Nipple-sparing mastectomy (NSM) for both risk reduction and cancer is increasing. In the cancer setting, most studies suggest the use of both clinical and intraoperative biopsy criteria in patient selection. This study examines the use of both biopsy and clinical criteria in women undergoing total nipple-removing mastectomy. The study consisted of 58 patients undergoing total mastectomy without nipple sparing. Biopsies of the subareola tissue (SA), proximal nipple (NC) contents and radial sections of the residual nipple (NR) were examined microscopically. Tumor size and distance from the nipple were also noted. Using clinical criteria alone, the false negative rate was 53.8% and a false positive rate of 44.4%. When adding subareola and nipple core biopsies to clinical criteria the false negative rate fell to 7.7% but the false positive rate remained at 44.4%. When using only SA and NC biopsies to predict occult nipple involvement, the false negative rate was 11.8%. In 4 cases the NC was positive while the SA was negative for cancer and in 6 cases the SA was positive and NC negative. In 2 cases both the NC and SA biopsies were negative while the NR was positive. This study supports a more limited role in the use of clinical criteria for evaluating patients for NSM. This maximizes the number of patients who are candidates for NSM with minimal risk of nipple involvement. It was also noted that intraoperative biopsies are not totally reliable in predicting occult nipple involvement.

Experience and outcomes of nipple-sparing mastectomy following reduction mammoplasty.

193 Background: Breast cancer resection strives for less radical approaches that offer superior aesthetic results without compromising oncologic safety. Nipple-sparing mastectomy (NSM) has gained popularity, but usually has been offered to smaller breasted and minimally ptotic women without history of extensive breast surgery. We present a series of nine nipple-sparing mastectomies following reduction mammoplasty. Methods: Charts of patients who underwent NSM following reduction mammoplasty at the NYU Medical Center from 2006 through 2011 were reviewed. Outcomes measured include post-operative complications, breast cancer recurrence, presence of cancer in the nipple-areolar complex, and nipple-areolar complex viability. Results: In total, the records of 235 (145 prophylactic, 90 therapeutic) NSM patients at NYU Medical Center were reviewed. Six patients for a total of 9 breasts had NSM following reduction mammoplasty. This subset of patients had a mean age of 46.2, mean BMI of 25.1, no history of diabetes and 1 smoker. Seven of 9 breasts were therapeutic resections and 2 of 9 were prophylactic. Time elapsed between reduction mammoplasty and NSM ranged from 33 days to 11 years. The majority of resections were in Stage 0 patients (6/9) with 1/9 in Stage I and 2/9 in Stage IIA. In all cases, prior reduction mammoplasty incisions were utilized for NSM. Eight patients were reconstructed immediately with tissue expanders, and 1 patient had a latissimus dorsi flap with immediate implant. Complications included 1 hematoma requiring evacuation and 1 displaced implant requiring revision. There were no positive subareolar biopsies and 100% nipple viability. Mean follow-up time was 9.4 months. Conclusions: Our experience demonstrates that NSM can be offered following reduction mammoplasty with comparable reconstructive outcomes to NSM alone. Reduction mammoplasty followed by NSM has potential as a reconstructive tool in prophylactic cases unsuited for primary NSM.

Experience with nipple-sparing mastectomy after prior whole-breast radiation.

173 Background: Nipple-sparing mastectomy (NSM) is being performed more frequently for risk reduction and breast cancer treatment. Prior whole breast irradiation (WBI) has been considered a contraindication to NSM. This study reviews our NSM experience following prior WBI. Methods: We reviewed our prospective mastectomy database from April 2007 to April 2012 for patients undergoing NSM. Ten patients out of a total 169 NSM were identified that underwent NSM following prior WBI. Data collected included incision type, follow-up, complications, cosmesis, and recurrence. Results: Of the ten NSM patients who received prior WBI, 6 had recurrent ipsilateral breast cancer at the lumpectomy site, 3 developed contralateral breast cancers and opted for bilateral NSM, and 1 patient opted for bilateral NSM after finding a BRCA mutation following BCT. Mean patient age was 53. Two patients had comorbities: 1 hyperlipidemia and 1 former smoker. Three of 10 (30%) developed complications, with 2 partial necrosis of nipple-areola complex (NAC) and 1 complete loss of the NAC (Table). No patient required return to the operating room (local resection in the office was performed for the complete NAC loss) and all patients had good final cosmesis. All patients underwent immediate reconstruction: 5 tissue expanders (TE), 2 DIEP and 3 TRAM flaps. Mean follow up is 23 months with no local recurrences to date. Conclusions: This study demonstrates that NSM with immediate reconstruction can be performed in selected patients with prior WBI with an acceptable rate of nipple preservation and good cosmesis. NAC preservation is the ultimate goal in patients undergoing NSM. Current studies are ongoing to identify risk factors that may be associated with nipple necrosis. [Table: see text]

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

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

Impact of mammary ductoscopy in breast surgery

Mammary ductoscopy (MD) allows visualization of the lactational duct and the morphology of various ductal pathologies can be identified. It provides a new approach for clinical research. The main impact of MD is on the modification of the extent of surgery. MD was used to guide the extent of duct excision in patients with pathological nipple discharge. Multiple duct lesions detected by MD can be excised completely. MD was also used to guide resection in breast-conserving surgery for breast cancer. There was less proximal margin involvement with the use of MD. MD also helps to spare unnecessary surgery. In patients with nipple discharge, duct excision can be avoided in those with a normal ductoscopy. Nipple-sparing mastectomy (NSM) is cosmetically superior to traditional mastectomy but there are concerns about the oncological safety with nipple-areola preservation. MD can be employed to exclude major duct involvement and this may help to select patients for NSM. We are currently studying the role of MD in identifying major duct involvement in potential patients undergoing NSM. MD has technical limits. MD cannot examine the distal duct and biopsy facility is limited. No therapeutic facility is available at present but these technical limits will be resolved when the next generation of MD is available. In conclusion, MD has made a significant impact on breast surgery. The technology is developing and with continued research, the role of MD in breast surgery will continue to expand.