Annals of Surgical Oncology

, 18:3117

Nipple-Sparing Mastectomy for Breast Cancer and Risk-Reducing Surgery: The Memorial Sloan-Kettering Cancer Center Experience

  • Paulo de Alcantara Filho
  • Deborah Capko
  • John Mitchel Barry
  • Monica Morrow
  • Andrea Pusic
  • Virgilio S. Sacchini
American Society of Breast Surgeons

Abstract

Background

Nipple-sparing mastectomy (NSM) has been gathering increased recognition as an alternative to more traditional mastectomy approaches. Initially, questions concerning its oncologic safety limited the use of NSM. Nevertheless, mounting evidence supporting the practice of NSM for both prophylactic and oncologic purposes is leading to its more widespread use and broadened indications.

Methods

Using a prospectively maintained database, we reviewed our experience of 353 NSM procedures performed in 200 patients over the past 10 years.

Results

The indications for surgery were: 196 prophylactic risk-reduction (55.5%), 74 ductal carcinoma in situ (DCIS) (20.8%), 82 invasive cancer (23.2%), and 1 phyllodes tumor (0.5%). The nipple areolar complex (NAC) was entirely preserved in 341 mastectomies (96.7%). There were 11 patients (3.1%) who were found to have cancer at the nipple margin, warranting further excision. A total of 69 breasts (19.5%) had some degree of skin desquamation or necrosis, but only 12 (3.3%) required operative debridement, of which 3 breasts (1%) necessitated removal of a breast implant. Also, 6 patients (2%) were treated for infection. Of the 196 prophylactic NSMs, 11 specimens (5.6%) were found to harbor occult cancer (8 DCIS and 3 invasive cancers). One patient who underwent NSM for invasive ductal carcinoma in 2006 developed metastatic disease to her brain. No other recurrences are attributable to the 353 NSMs.

Conclusions

The trends demonstrate the increasing acceptance of NSM as a prophylactic procedure as well as for therapeutic purposes. Although NSM is not standard, our experience supports the selective use of NSM in both prophylactic and malignant settings.

References

  1. 1.
    Eldor L, Spiegel A. Breast reconstruction after bilateral prophylactic mastectomy in women at high risk for breast cancer. Breast J. 2009;15:S81–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Lostumbo L, Carbine NE, Wallace J. Prophylactic mastectomy for the prevention of breast cancer. Cochrane Database Syst Rev. 2010;(11):CD002748.Google Scholar
  3. 3.
    Morrow M, Mehrara B. Prophylactic mastectomy and the timing of breast reconstruction. Br J Surg. 2009;96:1–2.PubMedCrossRefGoogle Scholar
  4. 4.
    Rusby JE, Smith BL, Gui GP. Nipple-sparing mastectomy. Br J Surg. 2010;97:305–16.PubMedCrossRefGoogle Scholar
  5. 5.
    Cucin RL, Guthrie RH, Jr, Luterman A, Shires GT, Goulian D, Jr. Transplantation of the cryopreserved nipple-areolar complex. Ann Plast Surg. 1980;4:391–5.PubMedCrossRefGoogle Scholar
  6. 6.
    Rose JH, Jr. Carcinoma in a transplanted nipple. Arch Surg. 1980;115:1131–2.PubMedGoogle Scholar
  7. 7.
    Freeman BS. Subcutaneous mastectomy for benign breast lesions with immediate or delayed prosthetic replacement. Plast Reconstr Surg Transplant Bull. 1962;30:676–82.PubMedCrossRefGoogle Scholar
  8. 8.
    Freeman BS. Complications of subcutaneous mastectomy with prosthetic replacement, immediate or delayed. South Med J. 1967;60:1277–80.PubMedCrossRefGoogle Scholar
  9. 9.
    Voltura AM, Tsangaris TN, Rosson GD, Jacobs LK, Flores JI, Singh NK, et al. Nipple-sparing mastectomy: critical assessment of 51 procedures and implications for selection criteria. Ann Surg Oncol. 2008;15:3396–401.PubMedCrossRefGoogle Scholar
  10. 10.
    Garcia-Etienne CA, Cody HS, III, Disa JJ, Cordeiro P, Sacchini V. Nipple-sparing mastectomy: initial experience at the Memorial Sloan-Kettering Cancer Center and a comprehensive review of literature. Breast J. 2009;15:440–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Edge SB. Nipple-sparing mastectomy: how often is the nipple involved? J Clin Oncol. 2009;27:4930–2.PubMedCrossRefGoogle Scholar
  12. 12.
    Crowe JP, Patrick RJ, Yetman RJ, Djohan R. Nipple-sparing mastectomy update: one hundred forty-nine procedures and clinical outcomes. Arch Surg. 2008;143:1106–10; discussion 10.PubMedCrossRefGoogle Scholar
  13. 13.
    Petit JY, Veronesi U, Orecchia R, Rey P, Martella S, Didier F, et al. Nipple sparing mastectomy with nipple areola intraoperative radiotherapy: one thousand and one cases of a five years experience at the European institute of oncology of Milan (EIO). Breast Cancer Res Treat. 2009;117:333–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Gerber B, Krause A, Dieterich M, Reimer T, Kundt G. The oncological safety of skin sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction: an extended follow-up study. Ann Surg. 2009;249:461–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Sacchini V, Pinotti JA, Barros AC, Luini A, Pluchinotta A, Pinotti M, et al. Nipple-sparing mastectomy for breast cancer and risk reduction: oncologic or technical problem? J Am Coll Surg. 2006;203:704–14.PubMedCrossRefGoogle Scholar
  16. 16.
    Brachtel EF, Rusby JE, Michaelson JS, Chen LL, Muzikansky A, Smith BL, et al. Occult nipple involvement in breast cancer: clinicopathologic findings in 316 consecutive mastectomy specimens. J Clin Oncol. 2009;27:4948–54.PubMedCrossRefGoogle Scholar
  17. 17.
    Laronga C, Kemp B, Johnston D, Robb GL, Singletary SE. The incidence of occult nipple–areola complex involvement in breast cancer patients receiving a skin-sparing mastectomy. Ann Surg Oncol. 1999;6:609–13.PubMedCrossRefGoogle Scholar
  18. 18.
    Verma GR, Kumar A, Joshi K. Nipple involvement in peripheral breast carcinoma: a prospective study. Indian J Cancer. 1997;34:1–5.PubMedGoogle Scholar
  19. 19.
    Lagios MD, Gates EA, Westdahl PR, Richards V, Alpert BS. A guide to the frequency of nipple involvement in breast cancer. A study of 149 consecutive mastectomies using a serial subgross and correlated radiographic technique. Am J Surg. 1979;138:135–42.PubMedCrossRefGoogle Scholar
  20. 20.
    Menon RS, van Geel AN. Cancer of the breast with nipple involvement. Br J Cancer. 1989;59:81–4.PubMedCrossRefGoogle Scholar
  21. 21.
    Gulben K, Yildirim E, Berberoglu U. Prediction of occult nipple-areola complex involvement in breast cancer patients. Neoplasma. 2009;56:72–5.PubMedCrossRefGoogle Scholar
  22. 22.
    Tuttle TM, Habermann EB, Grund EH, Morris TJ, Virnig BA. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment. J Clin Oncol. 2007;25:5203–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Hartmann LC, Schaid DJ, Woods JE, Crotty TP, Myers JL, Arnold PG, et al. Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. N Engl J Med. 1999;340:77–84.PubMedCrossRefGoogle Scholar
  24. 24.
    Mislowsky A, Domchek S, Stroede C, Bergey MR, Sonnad SS, Wu L, et al. Breast cancer surgery trend changes since the introduction of BRCA1/2 mutation screening: a retrospective cohort analysis of 158 mutation carriers treated at a single institution. Ann Surg Oncol. 2011;18:745–51.PubMedCrossRefGoogle Scholar
  25. 25.
    Morimoto T, Komaki K, Inui K, Umemoto A, Yamamoto H, Harada K, et al. Involvement of nipple and areola in early breast cancer. Cancer. 1985;55:2459–63.PubMedCrossRefGoogle Scholar
  26. 26.
    Luttges J, Kalbfleisch H, Prinz P. Nipple involvement and multicentricity in breast cancer. A study on whole organ sections. J Cancer Res Clin Oncol. 1987;113:481–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Santini D, Taffurelli M, Gelli MC, Grassigli A, Giosa F, Marrano D, et al. Neoplastic involvement of nipple-areolar complex in invasive breast cancer. Am J Surg. 1989;158:399–403.PubMedCrossRefGoogle Scholar
  28. 28.
    Vyas JJ, Chinoy RF, Vaidya JS. Prediction of nipple and areola involvement in breast cancer. Eur J Surg Oncol. 1998;24:15–6.PubMedCrossRefGoogle Scholar
  29. 29.
    Benediktsson KP, Perbeck L. Survival in breast cancer after nipple-sparing subcutaneous mastectomy and immediate reconstruction with implants: a prospective trial with 13 years median follow-up in 216 patients. Eur J Surg Oncol. 2008;34:143–8.PubMedCrossRefGoogle Scholar
  30. 30.
    Petit JY, Veronesi U, Rey P, Rotmensz N, Botteri E, Rietjens M, et al. Nipple-sparing mastectomy: risk of nipple-areolar recurrences in a series of 579 cases. Breast Cancer Res Treat. 2009;114:97–101.PubMedCrossRefGoogle Scholar
  31. 31.
    Didier F, Radice D, Gandini S, Bedolis R, Rotmensz N, Maldifassi A, et al. Does nipple preservation in mastectomy improve satisfaction with cosmetic results, psychological adjustment, body image and sexuality? Breast Cancer Res Treat. 2009;118:623–33.PubMedCrossRefGoogle Scholar
  32. 32.
    Nahabedian MY, Tsangaris TN. Breast reconstruction following subcutaneous mastectomy for cancer: a critical appraisal of the nipple-areola complex. Plast Reconstr Surg. 2006;117:1083–90.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2011

Authors and Affiliations

  • Paulo de Alcantara Filho
    • 1
  • Deborah Capko
    • 1
  • John Mitchel Barry
    • 1
  • Monica Morrow
    • 1
  • Andrea Pusic
    • 2
  • Virgilio S. Sacchini
    • 1
  1. 1.Breast Service, Department of SurgeryMemorial Sloan-Kettering Cancer CenterNew York USA
  2. 2.Plastic and Reconstruction ServiceMemorial Sloan-Kettering Cancer CenterNew York USA

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