Role Of Nipple-sparing Mastectomy Research Articles

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.

Mastectomie avec conservation de la plaque aréolo-mamelonnaire et cancer du sein. Mise au point

The role of nipple-sparing mastectomy (NSM) for breast cancer is controversial as there is concern regarding its oncological safety and complication rate. We carried out a review of the literature to quantify the incidence of occult nipple malignancy in breast cancer, identify the factors influencing occult nipple malignancy, quantify locoregional recurrence rates and quantify NSM complication rates. A search of the literature was performed using PubMed. Keywords used were "mastectomy", "nipple involvement", "nipple-sparing mastectomy", "skin-sparing mastectomy" "occult nipple malignancy" "occult nipple disease" "breast cancer recurrence". Articles were analyzed regarding incidence of occult nipple malignancy, potential factors influencing the incidence of occult malignancy and recurrence/complications following NSM. The incidence of occult nipple disease was compared between groups using Chi(2) or Fisher's exact tests for categorical variables and Student's t-tests for continuous variables. P values were considered significant<0.05. We identified nearly 30studies compiling nearly 10000cases examining the rate of occult nipple malignancy and 23studies compiling 2300cases providing information on the rate of local recurrence after NSM. The overall rate of occult nipple malignancy was 11.5%. Primary tumour characteristics influencing occult nipple malignancy were tumour-nipple distance<2cm, grade, lymph node metastasis, lymphovascular invasion, HER2 positive, ER/PR negative, tumour size>5cm, retro-areolar/central location and multicentric tumours. The overall nipple recurrence rate following NSM was 0.9%, skin flap recurrence rate was 4.2%. Full and partial thickness nipple necrosis rates were 2.9% and 6.3% respectively. NSM for primary breast cancer is appropriate in carefully selected patients. All patients should have retro-areolar sampling. There is strong evidence to suggest that suitable cases are well circumscribed single or multifocal lesions that have a TND>2cm. Tumours should be graded 1-2 and not have LVI, axillary node metastasis or HER2 positivity.

A Novel Approach of INTRABEAM Intraoperative Radiotherapy for Nipple-Sparing Mastectomy With Breast Reconstruction

BackgroundDespite the advancement and increasing use of breast-conserving surgery, mastectomies, including nipple-sparing mastectomy (NSM), are still carried out in a portion of breast cancer patients. However, the role of NSM is still controversial, mainly because of concern about the oncologic safety of the nipple-areola complex (NAC). INTRABEAM (Carl Zeiss, Oberkochen, Germany) is the most widely used mobile intraoperative radiotherapy (IORT) device to date. This pilot study aims to broaden the application of the INTRABEAM system for breast cancer, investigating the feasibility of INTRABEAM IORT in NSM with breast reconstruction. Patients and MethodsFrom December 2012 to June 2013, 7 female patients with breast cancer were enrolled in the study. NSM with or without axillary dissection was performed first. After confirming negative retroareolar frozen section results and no poor local bleeding in the NAC, INTRABEAM IORT was carried out with a single dose of 16 Gy, followed by breast reconstruction. The complications and short-term outcomes were assessed. ResultsThe median radiation time was 13 minutes 14 seconds in the 7 cases. One patient complained of mild pain in the radiation field on the skin in the first 2 weeks. All 7 patients were followed for a median of 7 months. No acute radiation injury with symptoms (heart, lung, or hematologic system), NAC necrosis, local recurrence, or metastasis was observed. Although every patient had reduction in NAC sensitivity, the contours of the breasts (including the NAC) were satisfactory. ConclusionsINTRABEAM IORT may be a feasible and convenient approach for NSM with breast reconstruction in patients with breast cancer.

P0016 A novel approach of intrabeam intraoperative radiotherapy for nipple-sparing mastectomy with breast reconstruction

Background Despite the advancement and increasing use of breast-conserving surgery, mastectomies, including nipple-sparing mastectomy (NSM), are still carried out in a portion of breast cancer patients. However, the role of NSM is still controversial, mainly owing to the oncological safety of the nipple-areola complex (NAC). Intrabeam (Carl Zeiss, Germany) is the most widely used mobile intraoperative radiotherapy (IORT) device to date. This pilot study aims to broaden the application of Intrabeam system for breast cancer, investigating the feasibility of Intrabeam IORT in NSM with breast reconstruction. Methods From December 2012 to June 2013, seven female patients with breast cancer were enrolled in the study. NSM with or without axillary dissection was performed first. After confirming the presence of a negative retroareolar frozen section and that there was no local bleeding of the NAC, Intrabeam IORT was carried out, with a single dose of 16 Gy, followed by breast reconstruction. The complications and short-term outcomes were assessed. Findings The median radiation time was 13 min 14 s. One patient complained of mild pain in the radiation field on the skin in the first 2 weeks. All seven patients were followed up for a median of 7 months. No acute radiation injury with symptoms (heart, lung, or haematological system), NAC necrosis, local recurrence, or metastasis was observed. Although every patient had reduction in NAC sensitivity, the contours of the breasts (including the NAC) were satisfactory. Interpretation Intrabeam IORT may be a feasible and convenient approach for NSM with breast reconstruction in patients with breast cancer.

Abstract P4-14-03: Nipple-sparing mastectomy and intra-operative nipple biopsy: To freeze or not to freeze?

Abstract Background: Advances in breast cancer screening and treatment have fostered the use of surgical procedures that increasingly optimize cosmetic outcome, while ensuring oncologic safety remains the primary concern of the oncologic surgeon. The role of nipple-sparing mastectomy (NSM) for risk-reducing surgery and breast cancer is evolving. It can be difficult to demonstrate involvement of the nipple-areolar complex (NAC) preoperatively, and and in this report we examine the utility of intraoperative subareolar frozen section (FS). Methods: Records of patients undergoing NSM at the NYU Langone Medical Center from 2006–2011 were reviewed retrospectively. Use of subareolar FS was at surgeon's discretion. Results: 237 NSM were performed (146 prophylacytic, 91 theraputic). FC was not utilized in 58 mastectomies (28 prophylactic), with 2 (+) on paraffin. Among the remaining 180 mastectomies, 11 biopsies were (+)(7.2%); 5 subareolar biopsies were (+) on FS and paraffin histologic slides (PS)(2.8%); 6 were negative on FS and (+) on PS. Among the 3 prophylactic NSM with (+) subareolar biopsies there was 1 (+) FS, 1 (−) FS, and 1 with no FS performed. There were no false (+) FS. Four of the 5 patients with (+)FS underwent simultaneous excision of the NAC. The 5th patient had atypia on FS and DCIS on PS, and returned to the OR during the same hospitalization for removal of NAC. The remaining patients underwent subsequent excision of the NAC either during planned 2nd stage reconstruction or following completion of chemotherapy. 8 NAC were free of disease and 5 were positive for in situ or invasive disease. There has been no local recurrence in these patients to date. Conclusions: The rate of NAC involvement is low, 5.5% in this series, and FS, while utilized in the majority of these cases, detected only 46% of subareolar disease. While FS can direct intraoperative decision making, the predictive power is low, and these considerations must be addressed in preoperative patient discussions. Furthermore, among those patients with (+) subareolar biopsies, only 39% had residual disease on NAC excision. Thus, optimal oncologic management of the NAC must still be considered an unresolved issue. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-14-03.

Nipple-sparing mastectomy and subareolar biopsy: To freeze or not to freeze?

185 Background: Advances in breast cancer screening and treatment have fostered the use of surgical procedures that increasingly optimize cosmetic outcome, while ensuring oncologic safety remains the primary concern of the oncologic surgeon. The role of nipple-sparing mastectomy (NSM) for risk-reducing surgery and breast cancer is evolving. It can be difficult to demonstrate involvement of the nipple-areolar complex (NAC) preoperatively, and and in this report we examine the utility of intraoperative subareolar frozen section (FS). Methods: Records of patients undergoing NSM at the NYU Langone Medical Center from 2006-2011 were reviewed retrospectively. Use of subareolar FS was at surgeon’s discretion. Results: 237 NSM were performed (146 prophylacytic, 91 theraputic). FC was not utilized in 58 mastectomies (28 prophylactic), with 2 (+) on paraffin. Among the remaining 180 mastectomies, 11 biopsies were (+)(7.2%); 5 subareolar biopsies were (+) on FS and paraffin histologic slides (PS) (2.8%); 6 were negative on FS and (+) on PS. Among the 3 prophylactic NSM with (+) subareolar biopsies there was 1 (+) FS, 1 (-) FS, and 1 with no FS performed. There were no false (+) FS. Four of the 5 patients with (+)FS underwent simultaneous excision of the NAC. The 5th patient had atypia on FS and DCIS on PS, and returned to the OR during the same hospitalization for removal of NAC. The remaining patients underwent subsequent excision of the NAC either during planned 2nd stage reconstruction or following completion of chemotherapy. 8 NAC were free of disease and 5 were positive for in situ or invasive disease. There has been no local recurrence in these patients to date. Conclusions: The rate of NAC involvement is low, 5.5% in this series, and FS, while utilized in the majority of these cases, detected only 46% of subareolar disease. While FS can direct intraoperative decision making, the predictive power is low, and these considerations must be addressed in preoperative patient discussions. Furthermore, among those patients with (+) subareolar biopsies, only 39% had residual disease on NAC excision. Thus, optimal oncologic management of the NAC must still be considered an unresolved issue.

Prophylactic and Therapeutic Mastectomy in BRCA Mutation Carriers: Can the Nipple Be Preserved?

Use of nipple-sparing mastectomy (NSM) is increasing. We sought to look at the role of NSM in BRCA mutation carriers. Tissue from women with a BRCA1 or BRCA2 mutation who underwent mastectomy between March 1987 and June 2009 at a single institution was reviewed. The entire nipple-areolar complex (NAC) was excised and histologically evaluated. The presence of terminal duct lobular units (TDLUs) and premalignant or malignant lesions in the NAC was noted. Sixty-two NACs from 33 women (25 BRCA1, 8 BRCA2) were studied. TDLUs were present in 15 (24%) NAC specimens. No evidence of atypical hyperplasia, carcinoma in situ, or invasive carcinoma was found in any of the 33 prophylactic mastectomy specimens. Among the 29 breasts with cancer and available tissue, 2 (7%) had malignant findings and 1 (3%) had atypia in the NAC. One woman who underwent bilateral mastectomy for bilateral invasive carcinoma had one nipple with tumor within lymphatics, and her contralateral nipple had atypical lobular hyperplasia. A second woman had ductal carcinoma in situ involving a single major lactiferous duct. The probability of nipple involvement by premalignant or malignant lesions in the NAC of BRCA mutation carriers is low at time of prophylactic mastectomy, but higher (10%) in women undergoing therapeutic mastectomy. NSM may be appropriate and oncologically safe for selected women with BRCA mutations. However, 24% of NACs contained TDLUs, with only 8% found in the nipple papilla; the significance of this for long-term risk is unknown.

Role of nipple sparing mastectomy in modern breast surgery

Recently an increasing number of reports of clinical experience have been published on nipple-sparing mastectomy. By the preservation of uninvolved skin and the nipple areola complex, this surgical technique greatly facilitates immediate reconstruction and optimal aesthetic outcome. However, the procedure raises serious oncologic concerns regarding the risk of an occult or a newly formed primary tumor due to parenchyma left behind in the nipple and the retroareola. Despite the ever increasing popularity of the method, there is still no evidence based confirmation to it. According to data from scientific literature on nipple-sparing mastectomy, there is no straightforward consequence to be drawn on oncologic safety; therefore the procedure is not generally considered to be alternative to standard mastectomy. In the indication of risk reduction, justification of the intervention seems to be well supported, and is expected to foster a greater rate of acceptance of surgical prophylaxis in patients with higher risk diseases. The procedure should be carried out possibly in the framework of clinical trials, in well selected patients with suitable preoperative and postoperative examinations, applying precise techniques and adequate patient education, according to international guidelines. Further long-term results are needed to form a substantive expert opinion. Authors give a detailed description of the surgical techniques, and provide a wide review of the literature, for the first time in Hungarian language.

Bilateral DCIS following gynecomastia surgery. Role of nipple sparing mastectomy. A case report and review of literature

Bilateral ductal carcinoma in situ of breast is a very rare disease in men. Ductal carcinoma in situ (DCIS) is an abnormal proliferation that involves the ductal epithelium and it has the potential of evolving into an invasive tumour. Gynaecomastia (female like breast in men) is a benign condition though it is associated with a reported 3% incidence of unilateral invasive breast cancer.2 Synchronous bilateral breast cancer in association with gynaecomastia is exceptionally rare. The recommended treatment for DCIS in male is mastectomy. So far only 2 cases of bilateral DCIS in male patients has been reported in the literature treated with skin and nipple sparing mastectomies. We report another case of synchronous bilateral DCIS in a male treated with skin and nipple sparing mastectomies. A 44 year-old man with history of long-standing gynecomastia. He had no identifiable risk factor for the development of cancer. His pre operative assessment of breast including mammograms was normal. He underwent bilateral subcutaneous mastectomies, with subsequent incidental diagnosis of synchronous bilateral ductal carcinoma in situ. The case was discussed in multidisciplinary team meeting and the need for further surgery was felt including excision of nipple areola complex. However considering patient wishes, cosmetic outcome and recent literature it was decided to preserve nipple areola complex (NAC) with regular follow up evaluation. Our patient at completion of 18 months of treatment is doing well with no signs of local recurrence.