Subareolar Biopsy Research Articles

Long-Term Cancer Recurrence Rates following Nipple-Sparing Mastectomy: A 10-Year Follow-Up Study.

Despite the increased use of nipple-sparing mastectomies, there are limited data examining long-term cancer recurrence rates in these patients. The objective of this study was to analyze breast cancer recurrence in patients who underwent therapeutic nipple-sparing mastectomy with a median of 10 years of follow-up. All patients undergoing nipple-sparing mastectomy at a single institution were retrospectively reviewed temporally to obtain a median of 10 years of follow-up. Patient demographic factors, mastectomy specimen pathologic findings, and oncologic outcomes were analyzed. Univariate analysis was performed to identify independent risk factors for locoregional recurrence. One hundred twenty-six therapeutic nipple-sparing mastectomies were performed on 120 patients. The most frequently observed tumor histology included invasive ductal carcinoma (48.4 percent) and ductal carcinoma in situ (38.1 percent). Mean tumor size was 1.62 cm. Multifocal or multicentric disease and lymphovascular invasion were present in 31.0 percent and 10.3 percent of nipple-sparing mastectomy specimens, respectively. Sentinel lymph node biopsy was performed in 84.9 percent of nipple-sparing mastectomies, and 17.8 percent were positive. The rate of positive frozen subareolar biopsy was 7.3 percent ( n = 82) and that of permanent subareolar pathology was 9.5 percent ( n = 126). The most frequently observed pathologic tumor stages were stage I (44.6 percent) and stage 0 (33.9 percent). The incidence of recurrent disease was 3.17 percent per mastectomy and 3.33 percent per patient. On univariate analysis, no demographic, operative, or tumor-specific variables were independent risk factors for locoregional recurrence. Overall recurrence rates are low in patients undergoing nipple-sparing mastectomy at a median follow-up of 10-years. Close surveillance should remain a goal for patients and their providers to promptly identify potential recurrence. Risk, III.

PC20. LONG-TERM CANCER RECURRENCE RATES FOLLOWING NIPPLE-SPARING MASTECTOMY: A 10-YEAR FOLLOW UP STUDY

PURPOSE: Although nipple-sparing mastectomy (NSM) is a widely accepted and popular technique, limited data exists examining long-term cancer recurrence rates associated with it. This study sought to analyze rates of breast cancer recurrence in patients who underwent therapeutic NSM with a median of 10 years of follow-up. METHODS: A single institution retrospective review identified all patients who underwent NSM with a median of 10-years of follow-up. Analysis focused on patient demographics, mastectomy specimen pathology, and oncologic outcomes including cancer recurrence. Independent risk factors for locoregional recurrence were assessed via univariate logistic regression. RESULTS: 158 therapeutic NSMs were performed on 152 patients. Invasive ductal carcinoma (48.7%) and ductal carcinoma in situ (35.4%) were the most common tumor types seen on pathology. Multifocal/multicentric disease and lymphovascular invasion were present in 34.1% and 12.8% of specimens, respectively. Sentinel lymph node biopsy rate was 82.9%, with 15.2% reported as positive. Rates of positive frozen and permanent subareolar biopsy were 5.4% and 8.3%, respectively. Low cancer stages were overwhelmingly more common, with stage I and stage 0 representing 40.5% and 35.4% of the population, respectively. Incidence of recurrent disease was 3.2% per mastectomy and 3.3% per patient. Univariate analysis did not identify any variables that were independent risk factors for locoregional recurrence. CONCLUSION: At a median of 10 years of follow-up, overall cancer recurrence rates are low in patients who undergo NSM, further suggesting the safety of this technique. Regardless, close surveillance should remain a goal to ensure prompt detection of any sign of recurrence.

Preoperative Ultrasound-guided Sub-areolar Biopsy in Predicting Occult Nipple Involvement in Breast Cancer Patients: Proposal for a Methodological Approach

The prediction of a sub-areolar tissue infiltration in breast cancer (BC) patients could be helpful in selecting the best functional outcome according to several reconstructive oncoplastic or radical techniques. This study aims to evaluate the diagnostic performance of preoperative ultrasound (US) guided sub-areolar biopsy (SAB) in detecting occult nipple involvement, in comparison with the definitive pathological examination of tissue after surgery.We prospectively recorded clinical and pathological data of 46 consecutive patients scheduled for breast conserving surgery or nipple-areola sparing mastectomy. All cases underwent preoperative SAB and the results were compared with the histopathology of the dissected tumors and their biological characteristics. All parameters were correlated with nipple involvement by univariate and multivariate analysis.The sensitivity, specificity, overall accuracy, positive predictive value, and negative predictive value of the SAB examination for nipple staging were 60%, 97.5%, 75% and 95.2%, respectively. According to the clinicopathological features, the bivariate analysis did not show a significant interaction between patient age, tumor size or type, lymph node status, lymphatic vascular invasion, histologic grade, ER, PR, Ki-67 status, HER2 amplification, multifocal or multicentric disease and positive NAC assessment (p>0.05).A preoperative sample of retroareolar tissue obtained by US-guided biopsy could be considered a reproducible, mini-invasive diagnostic procedure useful to facilitate immediate breast reconstruction with implants or through conservative oncoplastic approaches, thereby guiding clinical practice.

Subareolar Tissue Biopsy Predicts Occult Nipple Involvement in Nipple-Sparing Mastectomies.

Subareolar tissue is examined during nipple-sparing mastectomy (NSM) to minimize the risk of occult malignancy within the preserved nipple. A positive subareolar tissue biopsy typically warrants subsequent nipple excision. We study the factors associated with a positive subareolar tissue biopsy, the rate of residual malignancy in subsequent nipple excisions, and the value of subareolar tissue biopsy intraoperative frozen section (IOF). We identified 1,026 consecutive NSMs with separately submitted subareolar tissue biopsies over a 5.5-year period. Clinicopathologic data were reviewed. We examined concordance rates between subareolar tissue biopsy and subsequent nipple excisions as well as IOF diagnosis and permanent control diagnosis. Among cases of therapeutic NSM, the rate of a positive subareolar tissue biopsy was 7.2%. Multifocal/multicentric disease (P = .0005), presence of lymphovascular invasion (P = .033), and nodal involvement (P = .006) were significantly associated with a positive subareolar tissue biopsy. Thirty-nine of 41 cases with positive subareolar biopsies underwent subsequent nipple excision, with 20 (51%) showing residual carcinoma. Among all IOF samples, 9 (3.3%) showed a discrepancy between the IOF and permanent diagnoses, mostly because of false-negatives. A positive subareolar tissue biopsy predicts residual carcinoma in the excised nipples in 51% of cases. IOF is accurate and reliable.

Abstract P6-14-07: The evolving role of pre-pectoral acellular dermal matrix -assisted approach in implant-based immediate breast reconstruction following conservative mastectomy: A prospective observational study

Abstract Background: The recent development of acellular dermal matrix (ADM) devices has enhanced implant-based breast reconstruction (IBR) surgery following nipple-sparing mastectomy (NSM) for therapeutic and risk-reducing purposes leading to improved aesthetics. In the traditional sub-pectoral approach, coverage of the implant is provided by the pectoral muscles superiorly and the ADM inferiorly. The need to eliminate breast animation, reduce post-operative dysfunctional pain and the risk of capsular contracture, have stimulated surgeons to investigate the feasibility of placing the implant over the pectoralis major muscle with complete coverage with ADM thus introducing a novel pre-pectoral approach. The aim of this study was to evaluate the short clinical outcomes and patients’ satisfaction after NSM combined with ADM-assisted immediate IBR. Materials and Methods: Thirty consecutive patients underwent 40 pre-pectoral ADM-assisted IBR following NSM (61% therapeutic and 39% risk-reducing). A peri-areolar incision was used in all cases. A fixed volume microtextured (Mentor) or nanotextured (Sebbin) implant was used in 32 single stage procedures (80%) and a microtextured tissue expander was used in 2-stage reconstruction in 8(20%). A fenestrated ADM (SurgiMend) was used to provide full coverage of the implant. A drain and prophylactic antibiotics and anti-thromboembolism measures were used in all cases. All patients were followed up regularly in the outpatient department and were invited to complete a bespoke satisfaction questionnaire. Results: A total of 9 (22.5%) patients had prior radiotherapy (RT) or post-mastectomy RT (PMRT). Seventeen patients (56.7%) received adjuvant or neoadjuvant chemotherapy. The median hospital stay was 2 days (range: 2-4 days). The final surgical margins and subareolar biopsy were clear in all cases. After a median follow up of 12 months (6-24 months), we observed no cases of local recurrence, or loss of implant or nipple. There was one wound complication (2.5%). None of the patients developed grade 3/4 capsular contracture, however a significant degree of rippling of the upper pole requiring autologous fat grafting was seen in 2 cases (5%). Twenty-three patients completed the questionnaire and reported a median satisfaction score of 9 out of 10 with the unclothed appearance, 10 out of 10 with the clothed appearance and 10 out of 10 with the overall body image. Conclusions: Our study lends further support to the growing body of evidence that pre-pectoral ADM-assisted IBR following NSM is reliable and safe. It is associated with a low incidence of capsular contracture and high patient’s satisfaction. Neither prior RT nor PMRT represent contraindications to this approach. Citation Format: Salim Tayeh, Hiba El Hage Chehade, Aisling Manson, Kefah Mokbel. The evolving role of pre-pectoral acellular dermal matrix -assisted approach in implant-based immediate breast reconstruction following conservative mastectomy: A prospective observational study [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-14-07.

Abstract OT3-06-01: Prevention and management of residual breast tissue following radical mastectomy and skin-sparing and nipple-sparing mastectomy in oncologic and high-risk breast cancer patients - A multicentre questionnaire study

Abstract 1. Background As the presumed oncological risk of skin-sparing (SSM) and nipple-sparing mastectomy (NSM) putatively relies on remaining fibroglandular tissue within the nipple-areolar-complex and the skin flap complete resection of breast parenchyma is of uttermost importance. Contrary, residual fibroglandular tissue has been detected in up to 50% of breast specimens following NSM and 13% after SSM. Studies focusing on the prevention and management of residual breast tissue (RBT) are scarce. 2. Trial design and eligibility criteria A prospective multicenter questionnaire study addressing the subjects preventive measures, targeted flap thickness and detection and management of RBT will be performed. Certified breast care centres in Austria, Germany, Switzerland, England and the United States of America will be contacted via E-mail and asked to participate in the study. The following questions will be asked via a web-based questionnaire: I. General data including institution, profession, number of operations the institution/ the participating surgeon performs in 1 year II. Preventive Measures i. In case of NSM/SSM do you determine the thickness of the subcutaneous tissue preoperatively? ii. In case of NSM or SSM do you mark sites where fibroglandular breast tissue approximates closely to the skin preoperatively? iii. Do you perform a frozen subareolar biopsy in the course of NSM? iv. What do you use for breast tissue preparation to separate breast tissue from the pectoralis major muscle/from the skin? III.Flap thickness i. What is your target flap thickness when you perform NSM/SSM in patients with breast cancer/in high-risk patients? ii. Are there factors that influence your target flap thickness? IV. Detection of residual breast tissue i. Do you screen for residual breast tissue following radical ME/NSM/SSM? ii. What imaging modality do you use for aftercare? iii. Is the imaging modality you use for aftercare patient-dependent or standardized? iv. When do you perform the first breast imaging in the course of aftercare after the completion of reconstruction in patients with breast cancer/in high-risk patients? V. Management of residual breast tissue i. Is residual breast tissue an indication for reoperation in a patient with breast cancer and negative resection margins/in a high-risk patient? ii. Is residual breast tissue an indication for post-mastectomy radiotherapy in a patient with breast cancer and negative resection margins? iii. In case of residual breast tissue do you intensify your follow-up care? 3. Aims The primary objective of the study is to assess the applied preventive and treatment measures of RBT following mastectomy in oncologic and high-risk breast cancer patients in certified breast care centres in Austria, Germany, Switzerland, England and the USA. Based on these expert opinions guidelines for the course of action regarding RBT will be developed. 4. Statistical methods Descriptive statistics will be performed. Citation Format: Christine Deutschmann, Georg Pfeiler. Prevention and management of residual breast tissue following radical mastectomy and skin-sparing and nipple-sparing mastectomy in oncologic and high-risk breast cancer patients - A multicentre questionnaire study [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr OT3-06-01.

Nipple-sparing mastectomy using a hemi-periareolar incision with or without minimal medial-lateral extensions; clinical outcome and patient satisfaction: A single centre prospective observational study

BackgroundNipple-sparing mastectomy (NSM) is becoming a viable oncoplastic option. There is debate regarding the best approach that balances oncological safety with aesthetics. In this study, we describe an approach involving a hemi-periareolar incision and evaluate its safety and outcomes. MethodsPatients treated at single center between 2012 and 2015 were observed prospectively. After a histologically negative subareolar biopsy, immediate reconstruction with implant and acellular dermal matrix was performed after NSM. Primary end points were wound complications and explantation. Secondary end points included local recurrence, quality of life, patient satisfaction, and esthetic outcome. ResultsSixty-three patients were included with 92 procedures. Twenty-seven percent received chemotherapy and 12.7% received radiotherapy. Mean follow-up was 27.6 months. There were only 2 wound complications, and no recurrences. Mean outcome scores were promising (Breast Q = 88%, subjective esthetic = 9.2, objective esthetic = 9.3, hardening = 2.6). ConclusionsNSM via a hemi-periareolar incision is oncologically safe with a low-complication rate and high patients' satisfaction.

Cost Analysis of Intraoperative Subareolar Frozen Section During Nipple-Sparing Mastectomy.

Permanent paraffin subareolar biopsy during nipple-sparing mastectomy (NSM) tests for occult cancer at the nipple-areolar complex. Intraoperative subareolar frozen section can provide earlier detection intraoperatively. Cost analysis for intraoperative subareolar frozen section has never been performed. NSM cases from 2006-2013 were reviewed. Patient records including financial charges were analyzed. Of 480 subareolar biopsies for NSM from 2006-2013, 21 were abnormal (4.4 %). A total of 307 of the subareolar biopsies included intraoperative frozen section. Of the 307, 12 (3.9 %) were abnormal with 7 of 12 detected on intraoperative frozen section. The median baseline charge for an intraoperative subareolar frozen section was $309 for an estimated total cost of $94,863 in 307 breasts. The median baseline charge for interval operative resection of a nipple-areolar complex following an abnormal subareolar pathology result was $11,021. Intraoperative subareolar biopsy avoided an estimated six return trips to the operating room for savings of $66,126. At our institution, routine use of intraoperative frozen section resulted in an additional $28,737 in healthcare charges or $95 per breast. We present the first cost analysis to evaluate intraoperative subareolar frozen section in NSM. This practice obviated an estimated six return trips to the operating room. With our institutional frequency of abnormal subareolar pathology, intraoperative frozen sections resulted in a marginal increased charge per mastectomy.

Oncologic outcome and technical consideration of nipple-sparing mastectomy in breast cancer: The St. Marianna experience with 384 patients.

e12024 Background: Nipple-sparing mastectomy (NSM) is an increasingly utilized surgical option for breast cancer. However, the oncologic safety is controversial. We evaluated the oncologic outcome of 384 patients underwent NSM. Methods: A retrospective chart review was performed of 384 patients undergoing NSM during January 2000 to December 2011. In our institute, the indication of NSM is no suspicious infiltration to nipple-areolar complex by preoperative MRI imaging, and negative subareolar biopsy by intraoperative frozen section. We collected the data included patient age, the size of tumor, number of metastatic lymph node, histologic type, subtype, biomarker, and adjuvant therapies, analyzed as the risk factors of the nipple-areola recurrence. Results: Three hundred ninety-seven breasts in 384 patients underwent NSM. Thirty-four cases underwent nipple-areolar complex removal because of positive biopsies. One hundred fifty patients underwent immediate reconstructions and 9 patients underwent delayed re...

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.

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 Lateral Inframammary Fold Incision for Nipple-Sparing Mastectomy: Outcomes from Over 50 Immediate Implant-Based Breast Reconstructions

Nipple-sparing mastectomy (NSM) as a therapeutic or prophylactic procedure for breast cancer is rapidly gaining popularity as the literature continues to support it safety. The lateral inframammary fold (IMF) approach provides adequate exposure and eliminates visible scars on the anterior surface of the breast, making this incision cosmetically superior to radial or periareolar approaches. We reviewed 55 consecutive NSMs performed through a lateral IMF incision with immediate implant-based reconstruction, with or without tissue expansion, between June 2008 and June 2011. Prior to incision, breasts were lightly infiltrated with dilute anesthetic solution with epinephrine. Sharp dissection, rather than electrocautery, was used as much as possible to minimize thermal injury to the mastectomy flap. When indicated, acellular dermal matrix was placed as an inferolateral sling. Subsequent fat grafting to correct contour deformities was performed in select patients. Three-dimensional (3D) photographs assessed changes in volume, antero-posterior projection, and ptosis. Mean patient age was 46 years, and mean follow-up time was 12 months. Twelve mastectomies (22%) were therapeutic, and the remaining 43 (78%) were prophylactic. Seven of the nine sentinel lymph node biopsies (including one axillary dissection) (78%) were performed through the lateral IMF incision without the need for a counter-incision. Acellular dermal matrix was used in 34 (62%) breasts. Average permanent implant volume was 416 cc (range 176-750 cc), and average fat grafting volume was 86 cc (range 10-177 cc). In one patient a positive intraoperative subareolar biopsy necessitated resection of the nipple-areola complex (NAC), and in two other patients NAC resection was performed at a subsequent procedure based on the final pathology report. Mastectomy flap necrosis, requiring operative debridement, occurred in two breasts (4%), both in the same patient. One of these breasts required a salvage latissimus dorsi myocutaneous flap to complete the reconstruction. Three nipples (6%) required office debridement for partial necrosis and operative reconstruction later. No patient had complete nipple necrosis. No statistically significant differences existed between therapeutic and prophylactic mastectomies for developing partial skin and/or nipple necrosis (p = 0.35). Three episodes (5%) of cellulitis occurred, which responded to antibiotics without the need for explantation. Morphological outcomes using 3D scan measurements showed reconstructed breasts were larger, more projected, and less ptotic than the preoperative breasts (196 versus 248 cc, 80 versus 90 mm, 146 versus 134 mm, p < 0.01 for each parameter). Excellent results can be achieved with immediate implant-based reconstruction of NSM through a lateral IMF incision. NAC survival is reliable, and complication rates are low.

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.

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.

Surgical Delay of the Nipple–Areolar Complex: A Powerful Technique to Maximize Nipple Viability Following Nipple-Sparing Mastectomy

Nipple-sparing mastectomy (NSM) improves cosmetic outcome of mastectomy, but many patients are not candidates for this procedure because of concerns about nipple-areolar viability. Surgical delay is a technique that has been used for more than 400 years to improve survival of skin flaps. We used a surgical delay procedure to improve nipple viability in patients who were identified to be at high risk for nipple necrosis following NSM. Patients at high risk for nipple necrosis following NSM underwent a surgical delay procedure 7-21 days prior to mastectomy. Subareolar biopsy and sentinel node biopsy, if indicated, were performed at the time of the delay procedure. Nipple viability was assessed before and after NSM. If the subareolar biopsy revealed malignancy, the NAC was removed at the time of mastectomy. 31 NAC in 20 patients underwent surgical delay. All of the NAC subjected to a surgical delay survived following the delay procedure. In 2 patients, the subareolar biopsy was positive and 3 NAC were removed at the time of mastectomy (1 for purposes of symmetry). Of the 28 delayed NAC left at the time of NSM, all survived the post-mastectomy course. A procedure to surgically delay the NAC 7-21 days prior to NSM is demonstrated to ensure viability of NAC in patients previously thought to be at high risk for nipple loss.

Nipple-Sparing Mastectomy for Prophylactic and Therapeutic Indications

Nipple-sparing mastectomy remains controversial and its adoption has been slow because of oncologic and surgical concerns. A retrospective study evaluated all nipple-sparing mastectomies performed at a single institution for therapeutic or prophylactic indications for which records were available. Between 1989 and 2010, 162 nipple-sparing mastectomies were performed in 101 women. Forty-nine (30 percent) were performed for therapeutic purposes on 48 patients. A subareolar biopsy specimen was taken in 39 of 49 breasts (80 percent); four (10 percent) revealed ductal carcinoma in situ, and the nipple or nipple-areola complex was later removed. Four of 49 breasts (8 percent) in the therapeutic group had ischemic complications involving the nipple-areola complex, one of which (2 percent) was excised. With a mean follow-up of 2 years 6 months (range, 5 months to 9 years 5 months), no patients developed cancer in the nipple-areola complex. The remaining 113 mastectomies (70 percent) were performed prophylactically on 80 patients. The subareolar tissue was biopsied in 80 breasts (71 percent). One biopsy revealed lobular carcinoma in situ; none had ductal carcinoma in situ or invasive cancer. Two nipple-areola complexes (1.8 percent) were ischemic and excised. With a mean follow-up of 3 years 7 months (range, 5 months to 20 years 6 months), no patients developed new primary cancers in the nipple-areola complex. Nipple-sparing mastectomy can be safe in properly selected patients. A subareolar biopsy can effectively identify nipple-areola complexes that may harbor cancerous cells. Ischemic complications resulting in nipple loss can be minimized, and long-term follow-up suggests that this technique deserves further investigation in properly selected patients. Therapeutic, IV.

Nipple-sparing mastectomy: Evaluation of oncologic safety and aesthetic outcomes in 94 patients.

97 Background: The surgical treatment of breast cancer has evolved from radical mastectomy to breast conservation therapy. Today we have another therapeutic dilemma: how to manage the nipple-areolar complex (NAC) in mastectomy offering patients better aesthetic results with oncologic safety. Methods: We analyzed data on 125 consecutive nipple- or skin-sparing mastectomies (SSM) with immediate reconstruction with tissue expander, prosthesis or autologous tissue performed in 94 patients from 2003 to 2010 in a tertiary referral hospital. Nipple-sparing mastectomy (NSM) was performed for treatment disease (n= 94) and prophylaxis of contralateral breast or symmetrization in selected cases (n= 31). Results: Mean patients age was 46.8 years (range 27 to 69 years) and mean follow-up time was 27.2 months (range 2 weeks to 81 months). Twelve patients were stage 0, 41 stage I, 35 stage II A and B and 7 stage III. There were 125 nipple- or areola-sparing mastectomies (31 bilateral and 94 unilateral), including 112 NSM and 13 SSM. On pathologic review, 12 breasts had carcinoma in situ, 83 invasive carcinoma, and 31 breasts were cancer free. Thirteen nipples (13.8%) were compromised by tumor on subareolar biopsy and were removed. The location and type of incision was variable according to the tumor site and previous patient scar. Periareolar incision with prolongation along the inferior pole of breast was the preferred method. Patients with positive axillary node (27.5%) received adjuvant radiotherapy. There was no nipple necrosis. One patient presented local relapse in the skin-sparing group within 24 months. Conclusions: These data demonstrate that NSM is oncologically safe and can be performed with all types of breast reconstruction.

Nipple-Sparing Mastectomy in 99 Patients With a Mean Follow-up of 5 Years

The safety and practicality of nipple-sparing mastectomy (NSM) are controversial. Review of a large breast center's experience identified 99 women who underwent intended NSM with subareolar biopsy and breast reconstruction for primary breast cancer. Outcome was assessed by biopsy status, postoperative nipple necrosis or removal, cancer recurrence, and cancer-specific death. NSM was attempted for invasive cancer (64 breasts, 24 with positive lymph nodes), noninvasive cancer (35 breasts), and/or contralateral prophylaxis (50 breasts). Twenty-two nipples (14%) were removed because of positive subareolar biopsy results (frozen or permanent section). Seven patients underwent a pre-NSM surgical delay procedure because of increased risk for nipple necrosis. Reconstruction used transverse rectus abdominis myocutaneous flaps (56 breasts), latissimus flaps with expander (35 breasts), or expander alone (58 breasts). Of 127 retained nipples, 8 (6%) became necrotic and 2 others (2%) were removed at patient request. There was no nipple necrosis when NSM was performed after a surgical delay procedure. At a mean follow-up of 60.2months, all 3 patients with recurrence had biopsy-proven subareolar disease and had undergone nipple removal at original mastectomy. There were no deaths. Five-year recurrence rate is low when NSM margins (frozen section and permanent) are negative. Nipple necrosis can be minimized by incisions that maximize perfusion of surrounding skin and by avoiding long flaps. A premastectomy surgical delay procedure improves nipple survival in high-risk patients. NSM can be performed safely with all types of breast reconstruction.