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Spare the Nipple: A Systematic Review of Tumor Nipple-Distance and Oncologic Outcomes in Nipple-Sparing Mastectomy

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Preserving the nipple-areolar complex (NAC) in breast cancer surgery improves patient satisfaction and quality of life. The oncologic safety of NSM in tumors < 2 cm from the nipple remains in question. We conducted a systematic review to determine whether TND < 2 cm was associated with increased risk of LRR in patients undergoing NSM.

Methods

We included studies of invasive or in situ breast cancer < 2 cm from NAC undergoing NSM which reported LRR rates. LRR rates were stratified by TND and culminated across studies. Cohort study quality was assessed using Newcastle–Ottawa Criteria. Meta-analysis was not possible due to heterogeneity in reporting survival outcomes.

Results

We identified seven retrospective cohort studies with 2295 patients and 18 case series with 3507 patients. Direct tumor involvement of NAC was considered an absolute contraindication to NSM in all studies. In cohort studies, median follow-up was 31–112 (range 14–204) months. Cohorts with TND < 2 cm did not have a significantly higher rate of LRR. Amongst case series, 275 patients had TND < 2 cm. Combined LRR in case series was 2.6%, with median follow-up 10.4–71 (range 0–158) months.

Conclusions

Our systematic review did not identify TND < 2 cm as a significant risk factor for LRR. NSM appears oncologically safe in select patients with TND < 2 cm. Given the improved quality of life associated with NSM compared to skin-sparing mastectomy, we suggest NSM as the procedure of choice in appropriately selected patients.

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Acknowledgement

SY, NR, and DL designed the search protocol. SY and EL conducted the literature search, reviewed articles, extracted data from selected articles, and performed quality assessments. NR, DL, DO, and LP provided manuscript review and editing.

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Authors and Affiliations

  1. Department of Surgery, University of Alberta Hospital, Edmonton, AB, Canada

    Susie Youn MD, Esther Lee MD, Lashan Peiris MD, David Olson MD, David Lesniak MD & Nikoo Rajaee MD

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  1. Susie Youn MD
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Correspondence to Susie Youn MD.

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Appendices

Appendix 1: Search Criteria Applied to Medline and EMBASE Databases. Date of Last Search December 4, 2021

  1. 1.

    Exp Recurrence/ or exp Neoplasm Recurrence, Local/or recurrence.mp.

  2. 2.

    Exp recurrent disease/

  3. 3.

    1 or 2

  4. 4.

    Nipples/

  5. 5.

    Tumor-nipple distance.mp. [mp=ti, ab, ot, nm, hw, fx, kf, ox, px, rx, ui, sy, tn, dm, mf, dv, dq]

  6. 6.

    Nipple-areol*.mp. [mp=ti, ab, ot, nm, hw, fx, kf, ox, px, rx, ui, sy, tn, dm, mf, dv, dq]

  7. 7.

    Nipple-sparing.mp. [mp=ti, ab, ot, nm, hw, fx, kf, ox, px, rx, ui, sy, tn, dm, mf, dv, dq]

  8. 8.

    Exp nipple/ or nipple.mp. or exp nipple-sparing mastectomy/

  9. 9.

    4 or 5 or 6 or 7 or 8

  10. 10.

    exp Breast Neoplasms/su [Surgery]

  11. 11.

    Exp breast cancer/su [Surgery]

  12. 12.

    10 or 11

  13. 13.

    3 and 9 and 12

  14. 14.

    Limit 14 to yr = “2000–2021”

Appendix 2: Study Quality Scoring System Based on Newcastle–Ottawa Cohort Study Criteria

  1. A.

    Representativeness of exposed cohort: 1 point if included all consecutive patients with TND < 2 cm in cohort of patients undergoing nipple-sparing mastectomy

  2. B.

    Selection of nonexposed cohort: 1 point patients with TND > 2 cm selected from same community as patients with TND ≤ 2 cm

  3. C.

    Ascertainment of exposure: 1 point if TND measured on preoperative imaging

  4. D.

    Demonstrating that outcome of interest was not present at beginning of study: 1 point if study excluded patients with previous breast cancers or recurrent breast cancer.

  5. E.

    Comparability of cohorts: 2 points if matched by T-stage, nodal status, and hormone receptor and HER2 status; 1 point if adjusted for age and pathology; 0 points if no comparison data provided

  6. F.

    Assessment of outcome: 1 point if surveillance protocol included imaging and physical exam.

  7. G.

    Follow-up long enough for study outcomes to occur: 1 point if median follow-up at least 3 years

  8. H.

    Adequacy of follow-up for cohorts: 1 point if < 10% of patients lost to follow-up

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Youn, S., Lee, E., Peiris, L. et al. Spare the Nipple: A Systematic Review of Tumor Nipple-Distance and Oncologic Outcomes in Nipple-Sparing Mastectomy. Ann Surg Oncol 30, 8381–8388 (2023). https://doi.org/10.1245/s10434-023-14143-6

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