Original scientific article
Nipple-Sparing Mastectomy for Breast Cancer and Risk Reduction: Oncologic or Technical Problem?

https://doi.org/10.1016/j.jamcollsurg.2006.07.015Get rights and content

Background

We evaluated the risks and benefits of nipple-sparing mastectomy in a multiinstitutional experience in the settings of risk-reducing surgery and breast cancer treatment.

Study Design

We analyzed data on 123 patients who had undergone nipple-sparing mastectomy with breast reconstruction for prophylaxis (n = 55), treatment of breast cancer (n = 41), or both (n = 27) at four large centers.

Results

Median patient age was 45 years (range 22 to 70 years). There were 192 procedures (69 bilateral, 54 unilateral). Forty-four patients had invasive cancer; 20 had ductal carcinoma in situ (DCIS); 4 had phyllodes tumor. In all of these patients, the nipple tissue was cancer free on pathologic review. Median followup was 24.6 months (range 2.0 to 570.4 months). Local recurrence developed in two patients: one had DCIS in the upper-outer quadrant, with 71.8 months of followup; the other’s cancer was invasive, in the upper-outer quadrant, with 6 months of followup. Distant metastasis developed in a third patient, who died 50 months after the procedure. Breast cancer developed in two patients after prophylactic mastectomy: one in the upper-outer quadrant at 61.8 months; one in the axillary tail at 24.4 months. No patients had recurrences in the nipple-areolar complex. Necrosis of the nipple was reported in 22 of 192 patients (11%) and it was judged minimal (less than one-third total skin of nipple) in 13 of 22 patients (59%). Overall cosmesis was judged by the patient and surgeon as good to excellent in the majority of patients. Level of satisfaction with cosmetic results was similar between prophylactic and treatment patients.

Conclusions

The risk of local relapse was very low in our series of nipple-sparing mastectomies performed for DCIS or invasive cancer. Nipple-sparing mastectomy in the risk-reducing and breast cancer-treatment settings may be feasible in selected patients and should be the subject of additional prospective clinical trials.

Section snippets

Protocol

We retrospectively analyzed data on 123 patients who underwent nipple-sparing mastectomy with breast reconstruction for either prophylaxis or treatment of breast cancer at Memorial Sloan-Kettering Cancer Center, New York; the Department of Obstetrics and Gynecology, Sao Paulo University, Sao Paulo, Brazil; the European Institute of Oncology, Milan, Italy; or the Department of Surgical Sciences, University of Padua, Padua, Italy.

Assignment

Patient records were retrieved from clinical databases at these

Results

Fourteen patients who underwent nipple-sparing mastectomy for invasive cancer or DCIS, and had cancers > 1 cm away from the areola, showed involvement of the retroareolar ducts, mainly by DCIS, at final pathology. In these patients, the nipple and areolar complex was removed during an additional procedure within 40 days after the nipple-sparing procedure. These 14 patients were excluded from our study (Table 1).

One hundred twenty-three patients underwent nipple-sparing mastectomy: 55 for

Discussion

Subcutaneous mastectomy for primary breast cancer or risk reduction is not a new procedure. In 1962, Freeman13, 14 pioneered this surgical procedure, but it was eventually abandoned because of the high rate of complications and lingering questions about its oncologic safety. Many of these early concerns have been addressed.1, 8 Frequently cited in the literature, the classic subcutaneous mastectomy, which is a nipple-sparing procedure, has been criticized because of the increased likelihood of

Acknowledgment

We would like to thank Jane V Fey, MPH and Myra Partridge for their help in the writing and preparation of this article.

References (44)

  • J.Y. Petit et al.

    The nipple-sparing mastectomy: early results of a feasibility study of a new application of perioperative radiotherapy (ELIOT) in the treatment of breast cancer when mastectomy is indicated

    Tumori

    (2003)
  • S.S. Kroll et al.

    A comparison of outcomes using three different methods of breast reconstruction

    Plast Reconstr Surg

    (1992)
  • G.S. LaTrenta et al.

    Breast reduction

  • W. Holzgreve et al.

    Surgical complication and follow-up evaluation of 163 patients with subcutaneous mastectomy

    Aesthetic Plast Surg

    (1987)
  • B.S. Freeman

    Subcutaneous mastectomy for benign breast lesion with immediate or delayed prosthetic replacement

    Plast Reconstr Surg

    (1962)
  • B.S. Freeman

    Complications of subcutaneous mastectomy with prosthetic replacement, immediate or delayed

    South Med J

    (1967)
  • S.A. Slavin et al.

    Skin-sparing mastectomy and immediate reconstruction: oncologic risks and aesthetic results in patients with early-stage breast cancer

    Plast Reconstr Surg

    (1998)
  • S.S. Kroll et al.

    Local recurrence risk after skin-sparing and conventional mastectomy: a 6-year follow-up

    Plast Reconstr Surg

    (1999)
  • H. Medina-Franco et al.

    Factors associated with local recurrence after skin-sparing mastectomy and immediate breast reconstruction for invasive breast cancer

    Ann Surg

    (2002)
  • R.M. Simmons et al.

    Local and distant recurrence rates in skin-sparing mastectomies compared with non-skin-sparing mastectomies

    Ann Surg Oncol

    (1999)
  • K.C. Shestak et al.

    Assessment of long-term nipple projection: a comparison of three techniques

    Plast Reconstr Surg

    (2002)
  • C.N. Verheyden

    Nipple-sparing total mastectomy of large breast: the role of tissue expansion

    Plast Reconstr Surg

    (1988)
  • Cited by (287)

    • Comparison of subpectoral versus dual-plane implant based immediate breast reconstruction after nipple-areola sparing mastectomy

      2021, Annales de Chirurgie Plastique Esthetique
      Citation Excerpt :

      Over the last two decades both therapeutic and risk reducing mastectomy rates showed steady increase [1,2]. In parallel, expander or implant-based immediate breast reconstruction (IBR) gained popularity [3–7]. Synthetic meshes and biological materials such as acellular dermal matrix (ADM), titanium coated polypropylene mesh and polyglactin mesh have been used in implant based immediate breast reconstruction (IBR) to cover and support the inferior aspect of the breast pocket [8–13].

    View all citing articles on Scopus

    Competing Interests Declared: None.

    View full text