- Email: [email protected]
Nipple sparing subcutaneous mastectomy: Sixty-six months follow-up
EJSO 32 (2006) 937e940
www.ejso.com
Nipple sparing subcutaneous mastectomy: Sixty-six months follow-up F. Caruso a, M. Ferrara a, G. Castiglione a, G. Trombetta a, L. De Meo a, G. Catanuto a,*, G. Carillio b a b
Department of Surgical Oncology, Humanitas Centro Catanese di Oncologia, Via Dabormida 64, 95100 Catania, Italy Department of Medical Oncology, Humanitas Centro Catanese di Oncologia, Via Dabormida 64, 95100 Catania, Italy Accepted 26 May 2006 Available online 7 July 2006
Abstract Aim: Validation of oncological and reconstructive efficacy of nipple sparing subcutaneous mastectomy. Methods: We enrolled 50 patients on behalf of Humanitas Centro Catanese di Oncologia fulfilling appropriate reconstructive and oncological criteria to undergo nipple sparing subcutaneous mastectomy. We preferably selected women with medium sizeesmall breast affected by early stage breast cancer peripherally located with intra-operative negative frozen section of the major ducts. Results: fourty-six patients were alive after a mean follow-up of 5.5 years. We observed a single case of local recurrence in the nipple successfully treated with local excision. Five patients presented metastatic disease. One is currently alive, 4 died because of progressive disease. Conclusions: Our study supports other findings regarding safety and efficacy of nipple sparing subcutaneous mastectomy for selected patients. Ó 2006 Elsevier Ltd. All rights reserved. Keywords: Nipple sparing mastectomy; Skin sparing mastectomy; Breast reconstruction; Nipple reconstruction
Introduction Preservation of natural breast appearance following mastectomy and reconstruction is the most challenging item for the onco-plastic surgeon.1 The nipple areola complex (NAC) can be considered as a crucial determinant of breast appearance for its role in expressing several aspects of femininity.2 Reconstructive surgery in this case is often unsatisfactory.3e6 The nipple flattens, tattooed areolas lose their pigments, the typical conical shape of the NAC and Montgomery’s tubercle cannot be reconstructed, and finally there is none of the sensibility of the healthy nipple. There is debate about the possibility to extend preservation of the breast envelope to include nipple areola complex.7e10 While skin sparing procedures have gained acceptable validation over the years,11e16 preservation of retro-areolar major ducts causes many concerns regarding its oncological safety.17 * Corresponding author. Tel.: þ39 095 7339000. E-mail address: [email protected] (G. Catanuto). 0748-7983/$ - see front matter Ó 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2006.05.013
In our study we propose a rationale for nipple sparing subcutaneous mastectomy validated during a long-term follow-up. Patients and methods We enrolled 50 patients from January 1994 to December 2004 to undergo nipple sparing subcutaneous mastectomy. We admitted women affected by early stage breast cancer or borderline conditions, peripherally located in the breast (more than 2 cm far from NAC in US-scan and mammography assessments), without clinical involvement of NAC. Absence of cancerous cells in the retro-areolar ducts had to be confirmed with intra-operative frozen section. All these patients were unsuitable for breast conservation either for multicentricemultifocal disease, or because of extensive microcalcifications. We included in our study only small- and medium-size breasts with none or minimal ptosis possibly with healthy skin (Table 1). The operation was performed by a single onco-plastic surgeon using a 2-stage reconstructive technique.
F. Caruso et al. / EJSO 32 (2006) 937e940
938
Table 1 Nipple sparing mastectomy: oncological and reconstructive criteria Oncological criteria
Invasive early stage breast cancer unsuitable for breast conservation periferally located Multicentric/multifocal carcinoma with no evidence of nipple involvement Extensive ductal carcinoma in situ Prophylactic (risk reducing mastectomy)
Reconstructive criteria
Small to moderate size breast Moderate or minimal ptosis Juvenile healthy skin
Surgical technique We used 3 possible approaches to remove the glandular tissue. - Direct incision: the surgeon excises an elliptic area of skin over to tumour location undermining the entire breast envelope to remove as much as possible of the entire gland. - Radial incision: performed following the breast equator in order to preserve the infero-medial pedicles that provide vascularity to skin flaps. - Infra-mammary fold crease incision: access in this case is placed in order to avoid any scar on the visible surface of the breast. We sent ducts tissue for intra-operative frozen section. In any positive case we modified our technique in an areolarsparing procedure if even a few retro-areolar samples were free of disease. Breast reconstruction was performed with a conventional 2-stage expandereimplant technique. A single patient in our series required a Holmstrom flap reconstruction with implants. We left the choice of contra-lateral symmetrization to patients’ decision. Axillary dissection or sampling in selected cases can be carried out through the same incision of mastectomy. When this is too far to allow easy access we suggest a second incision beside the lateral border of pectoralis major. Reconstructive outcome evaluation has been performed by surgeon according to Hidalgo’s criteria.18 Further treatment and follow-up All patients treated by nipple sparing subcutaneous mastectomy whose tumour stage required adjuvant treatment, underwent conventional therapy including radiotherapy. We used ultrasound scan of the NAC to study retroareolar residual tissue to routine follow-up examination. Results Population We pre-operatively scheduled 56 patients to undergo 58 nipple sparing mastectomies (2 bilateral cases). Following
intra-operative frozen section, 3 patients (1 bilateral case) were removed from the study because of the presence of disease in the nipple ducts. One more nipple was lost in the immediate post-operative time due to necrosis. Two women were lost to follow-up after the operation. Fifty women treated with nipple sparing mastectomy were regularly followed up for a mean time of 66 months (range 9e140). Median age was 42 (range 28e68). Mean operative time was 150 min. All specimens presented surgical adequate margins without cancerous proliferation in the retro-areolar breast ducts. We subdivided cases according to the stages of disease (AJCC staging system): 8 were Stage 0, 24 Stage I, 18 Stage II, 1 Stage III. Sixteen cases presented with multicentric localization. We investigated other prognostic factors: 39 cases were oestrogen and progesterone receptors positive (or at least for one of the two parameters), 7 were totally negative. Lymph vascular invasion was shown in 13 cases (Table 2). Twelve patients underwent adjuvant chemotherapy and 21 underwent adjuvant hormonal treatment (tamoxifene). In 3 cases radiotherapy was required on the basis of post-operative tumour staging. Oncologic outcome Of the 50 assessable patients, 1 local relapse and 5 distant metastases were diagnosed, with a 12% of overall recurrence rate. One tumour was recurred locally in the nipple and was successfully treated with NAC excision. Table 2 Characteristics of the assessable patients No. of patients/no. of cases
50/51
Mean follow-up time (months/years)
66/5.5
Mean tumour diameter (cm) Tumour type Invasive Non-invasive Tumour stage 0 (pTis/phylloid tumour) I (pT1) II (pT2 or N1) III (pT3 N1)
1.6 30 21 8 24 18 1
Histological grade 1 2 3
18 18 15
Hormone receptors ER/PgR þ/þ / þ/ /þ Unknown Multicentricity
30 7 7 2 5 16
Lymphovascular invasion
13
F. Caruso et al. / EJSO 32 (2006) 937e940
939
Among women with systemic disease, 4 died of progressive disease and another one is currently alive with disease. The other 44 women were still alive with no evidence of disease after a mean follow-up of 5.5 years. The 5.5-year actuarial disease-free survival for patients treated by nipple sparing mastectomy was 88%, with an overall survival of 92% (Table 3). When testing into 2 separate groups for local recurrence and distant metastasis, the 5.5-year estimated disease-free survival was 98% and 90%, respectively.
Gerber et al.7 in 2003 compared nipple sparing mastectomy to skin sparing and radical modified techniques. They did not find significant differences in the outcome. Recently Petit et al.8,9 published 2 series on this item. Clinical and intra-operative negativity for nipple involvement was required. A 16-Gy intra-operative beam was delivered to the NAC to preserve a pad of retro-areolar tissue and improve NAC survival.
Reconstructive outcome
According to data reported in literature we offered nipple sparing technique to women affected by peripheral early stage breast cancer not eligible for conservation. Among them we selected those with medium size or small breasts and none or minimal ptosis. In our opinion large envelopes cannot be filled with tissue expanders in the first surgical stage. In such cases distortion of NAC position can lead to unpleasant results. We preferred radial or infra-mammary fold incisions. The first is more likely to preserve flaps vascularization, the latter produce nearly invisible scars. Our results in terms of overall survival, distant and local recurrence rate are comparable to those reported for skin sparing mastectomies.12e17 We had a single case of nipple recurrence that appeared in a lady who received further excision and is currently free of disease after 36 months. Our observations concur with that of Gerber et al.7 who reported a long-term survival in a similar case. We did not give radiotherapy to NAC only because of the ultra-conservative technique as suggested by Petit and colleagues.8,9 We believe that once nipple is completely peeled and its dermis exposed the left residual glandular tissue is comparable to that of skin sparing mastectomies. It can be argued that this can lead to an impaired vascularization but we reported only a single case of nipple necrosis. Reconstructions were performed using a 2-stage procedure with anatomical implants. We gained in this way satisfying cosmetics. We considered latissimus dorsi as a second choice for complicated cases. Its use could improve cosmetics in a single operation but carries risks of severe biomechanical complications.
We reported severe complications on 3 cases with implant exposure followed by its removal. Aesthetic quality of nipple sparing mastectomy was assessed according to the Hidalgo’s criteria.18 Breast reconstruction after nipple sparing mastectomy was considered excellent in 9 patients, good in 25 cases, because of asymmetry of the areolar position or retained distant scar, fair in 7 women due to partial skin slough and capsular contracture, poor in 6 surgical interventions, and not valuable in the left cases for non-surgery-related problems. The aesthetic result was judged to be excellent or good by most of the patients too. Temporary expander was removed after a median time of 7 months (range 3e13). During the second surgical stage we performed contra-lateral symmetrization in 48 patients. Discussion Mastectomy and nipple areola complex preservation In current clinical practice nipple sparing mastectomy is considered a block to oncological radicalism. Many authors investigated this technique but currently there is no consensus on its safety on long-term follow-up.19e22 Several studies of nipple involvement during breast cancer have tried to identify predictors of possible invasion. Rates on mastectomy specimen are extremely variable from 0 to 50% depending on tumour size, positioning and characteristics.23e25 Lesions far from the NAC and small in size rarely demonstrated invasion of major ducts.26e28
Nipple sparing mastectomy in our experience
Critical aspects Table 3 Efficacy of oncological treatment on the assessable patients Recurrent patients Locally recurrent patients
6 1
Distant metastases
5
Median time to recurrence (year) 5.5-Year disease-free survivors local recurrence-free survivors distant recurrence-free survivors
1 44 49 45
5.5-Year overall survivors
46
Although our study supports safety of nipple sparing mastectomy some issues are still debatable. Evidences provided from retrospective studies like this one are statistically weak. A randomised trial comparing nipple sparing mastectomy with conservative treatment should be offered to a subset of patients that might have indications for both techniques. Data provided from such study could validate oncological safety. Intra-operative frozen section did not allow accurate preoperative surgical planning. New modern devices like nipple vacuum assisted biopsy could solve this item.29
940
F. Caruso et al. / EJSO 32 (2006) 937e940
Lack of nipple sensibility following entire glandular removal is almost unavoidable. There is no chance at the moment to overcome this issue. Petit et al.9 reported poor sensation in 48% of women although psychological assessment demonstrated full satisfaction for the large majority of them. Conclusions Our study supports with quite a long-term follow-up (66 months) the hypothesis that nipple areola complex can be preserved in selected patients. Larger studies are required for validation and to investigate evolution of locally recurrent disease. Once nipple sparing will be accepted into standard clinical care we will provide candidates to mastectomy with a dramatic increase in quality of life. References 1. Dean NR, Neild T, Haynes J, Goddard C, Cooter RD. Fading of nipple areolar reconstructions: the last hurdle in breast reconstruction? Br J Plast Surg 2002;55:574–81. 2. Wellisch DK, Schain WS, Noone RB, Little 3rd JW. The psychological contribution of nipple addition in breast reconstruction. Plast Reconstr Surg 1987;80:699–704. 3. Spear SL, Arias J. Long-term experience with nipple areola tattooing. Ann Plast Surg 1995;35:232–6. 4. Bostwick 3rd. Nipple reconstruction using the CeV flap technique: a long-term evaluation. Plast Reconstr Surg 2001;108:361–9. 5. Little 3rd JW, Munasifi T, McCulloch DT. One-stage reconstruction of a projecting nipple: the quadrapod flap. Plast Reconstr Surg 1983;71: 126–33. 6. Bhatty MA, Berry RB. Nipple areola reconstruction by tattooing and nipple sharing. Br J Plast Surg 1997;50:331–4. 7. Gerber B, Krause A, Reimer T, et al. Skin sparing mastectomy with conservation of the nipple areola complex and autologous reconstruction is an oncologically safe procedure. Ann Surg 2003;238:120–7. 8. Petit JY, Veronesi U, Orecchia R, et al. The nipple sparing mastectomy: early results of a feasibility study of a new application of peri-operative radiotherapy (ELIOT) in the treatment of breast cancer when mastectomy is indicated. Tumori 2003;89:288–91. 9. Petit JY, Veronesi U, Orecchia R, et al. Nipple sparing mastectomy in association with intra operative radiotherapy (ELIOT): a new type of mastectomy for breast cancer treatment. Breast Cancer Res Treat 2005;27:1–5. 10. Palmieri B, Baitchev G, Grappolini S, Costa A, Benuzzi G. Delayed nipple sparing modified subcutaneous mastectomy: rationale and technique. Breast J 2005;11:173–8.
11. Carlson GW, Bostwick 3rd J, Styblo TM, et al. Skin sparing mastectomy. Oncologic and reconstructive considerations. Ann Surg 1997; 225:570–5. 12. Carlson GW, Styblo TM, Lyles RH, et al. The use of skin sparing mastectomy in the treatment of breast cancer: the Emory experience. Surg Oncol 2003;12:265–9. 13. Spiegel AJ, Butler CE. Recurrence following treatment of ductal carcinoma in situ with skin sparing mastectomy and immediate breast reconstruction. Plast Reconstr Surg 2003;111:706–11. 14. Kroll SS, Khoo A, Singletary SE, et al. Local recurrence risk after skin sparing and conventional mastectomy: a 6-year follow-up. Plast Reconstr Surg 1999;104:421–5. 15. Slavin SA, Schnitt SJ, Duda RB, et al. Skin sparing mastectomy and immediate reconstruction: oncologic risks and aesthetic results in patients with early-stage breast cancer. Plast Reconstr Surg 1998;102: 49–62. 16. Rubio IT, Mirza N, Sahin AA, et al. Role of specimen radiography in patients treated with skin sparing mastectomy for ductal carcinoma in situ of the breast. Ann Surg Oncol 2000;7:544–8. 17. Simmons RM, Brennan M, Christos P, King V, Osborne M. Analysis of nipple/areolar involvement with mastectomy: can the areola be preserved? Ann Surg Oncol 2002;9:165–8. 18. Hidalgo DA. Breast augmentation: choosing the optimal incision, implant, and pocket plane. Plast Reconstr Surg 2000;105:2202–16. 19. Kissin MW, Klark AE. Nipple preservation during mastectomy. Br J Surg 1987;74:58–61. 20. Abbes M, Caruso F, Bourgeon Y. Subcutaneous mastectomy. A review of 130 cases. Int Surg 1988;73:107–11. 21. Bishop CC, Singh S, Nash AG. Mastectomy and breast reconstruction preserving the nipple. Ann R Coll Surg Engl 1990;72:87–9. 22. Watts GT, Caruso F, Waterhouse JA. Mastectomy with primary reconstruction. Lancet 1980;2:967. 23. Andersen JA, Pallesen RM. Spread to the nipple and areola in carcinoma of the breast. Ann Surg 1979;189:367–72. 24. Santini D, Taffurelli M, Gelli MC, et al. Neoplastic involvement of nippleeareolar complex in invasive breast cancer. Am J Surg 1989; 158:399–403. 25. 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. 26. Verma GR, Kumar A, Joshi K. Nipple involvement in peripheral breast carcinoma: a prospective study. Indian J Cancer 1997;34:1–5. 27. Morimoto T, Komaki K, Inui K, et al. Involvement of nipple and areola in early breast cancer. Cancer 1985;55:2459–63. 28. 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. 29. Govindarajulu S, Narreddy S, Shere MH, Ibrahim NB, Sahu AK, Cawthorn SJ. Pre-operative mammotome biopsy of ducts beneath the nipple areola complex. Eur J Surg Oncol 2006;32:410–2.
www.ejso.com
Nipple sparing subcutaneous mastectomy: Sixty-six months follow-up F. Caruso a, M. Ferrara a, G. Castiglione a, G. Trombetta a, L. De Meo a, G. Catanuto a,*, G. Carillio b a b
Department of Surgical Oncology, Humanitas Centro Catanese di Oncologia, Via Dabormida 64, 95100 Catania, Italy Department of Medical Oncology, Humanitas Centro Catanese di Oncologia, Via Dabormida 64, 95100 Catania, Italy Accepted 26 May 2006 Available online 7 July 2006
Abstract Aim: Validation of oncological and reconstructive efficacy of nipple sparing subcutaneous mastectomy. Methods: We enrolled 50 patients on behalf of Humanitas Centro Catanese di Oncologia fulfilling appropriate reconstructive and oncological criteria to undergo nipple sparing subcutaneous mastectomy. We preferably selected women with medium sizeesmall breast affected by early stage breast cancer peripherally located with intra-operative negative frozen section of the major ducts. Results: fourty-six patients were alive after a mean follow-up of 5.5 years. We observed a single case of local recurrence in the nipple successfully treated with local excision. Five patients presented metastatic disease. One is currently alive, 4 died because of progressive disease. Conclusions: Our study supports other findings regarding safety and efficacy of nipple sparing subcutaneous mastectomy for selected patients. Ó 2006 Elsevier Ltd. All rights reserved. Keywords: Nipple sparing mastectomy; Skin sparing mastectomy; Breast reconstruction; Nipple reconstruction
Introduction Preservation of natural breast appearance following mastectomy and reconstruction is the most challenging item for the onco-plastic surgeon.1 The nipple areola complex (NAC) can be considered as a crucial determinant of breast appearance for its role in expressing several aspects of femininity.2 Reconstructive surgery in this case is often unsatisfactory.3e6 The nipple flattens, tattooed areolas lose their pigments, the typical conical shape of the NAC and Montgomery’s tubercle cannot be reconstructed, and finally there is none of the sensibility of the healthy nipple. There is debate about the possibility to extend preservation of the breast envelope to include nipple areola complex.7e10 While skin sparing procedures have gained acceptable validation over the years,11e16 preservation of retro-areolar major ducts causes many concerns regarding its oncological safety.17 * Corresponding author. Tel.: þ39 095 7339000. E-mail address: [email protected] (G. Catanuto). 0748-7983/$ - see front matter Ó 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2006.05.013
In our study we propose a rationale for nipple sparing subcutaneous mastectomy validated during a long-term follow-up. Patients and methods We enrolled 50 patients from January 1994 to December 2004 to undergo nipple sparing subcutaneous mastectomy. We admitted women affected by early stage breast cancer or borderline conditions, peripherally located in the breast (more than 2 cm far from NAC in US-scan and mammography assessments), without clinical involvement of NAC. Absence of cancerous cells in the retro-areolar ducts had to be confirmed with intra-operative frozen section. All these patients were unsuitable for breast conservation either for multicentricemultifocal disease, or because of extensive microcalcifications. We included in our study only small- and medium-size breasts with none or minimal ptosis possibly with healthy skin (Table 1). The operation was performed by a single onco-plastic surgeon using a 2-stage reconstructive technique.
F. Caruso et al. / EJSO 32 (2006) 937e940
938
Table 1 Nipple sparing mastectomy: oncological and reconstructive criteria Oncological criteria
Invasive early stage breast cancer unsuitable for breast conservation periferally located Multicentric/multifocal carcinoma with no evidence of nipple involvement Extensive ductal carcinoma in situ Prophylactic (risk reducing mastectomy)
Reconstructive criteria
Small to moderate size breast Moderate or minimal ptosis Juvenile healthy skin
Surgical technique We used 3 possible approaches to remove the glandular tissue. - Direct incision: the surgeon excises an elliptic area of skin over to tumour location undermining the entire breast envelope to remove as much as possible of the entire gland. - Radial incision: performed following the breast equator in order to preserve the infero-medial pedicles that provide vascularity to skin flaps. - Infra-mammary fold crease incision: access in this case is placed in order to avoid any scar on the visible surface of the breast. We sent ducts tissue for intra-operative frozen section. In any positive case we modified our technique in an areolarsparing procedure if even a few retro-areolar samples were free of disease. Breast reconstruction was performed with a conventional 2-stage expandereimplant technique. A single patient in our series required a Holmstrom flap reconstruction with implants. We left the choice of contra-lateral symmetrization to patients’ decision. Axillary dissection or sampling in selected cases can be carried out through the same incision of mastectomy. When this is too far to allow easy access we suggest a second incision beside the lateral border of pectoralis major. Reconstructive outcome evaluation has been performed by surgeon according to Hidalgo’s criteria.18 Further treatment and follow-up All patients treated by nipple sparing subcutaneous mastectomy whose tumour stage required adjuvant treatment, underwent conventional therapy including radiotherapy. We used ultrasound scan of the NAC to study retroareolar residual tissue to routine follow-up examination. Results Population We pre-operatively scheduled 56 patients to undergo 58 nipple sparing mastectomies (2 bilateral cases). Following
intra-operative frozen section, 3 patients (1 bilateral case) were removed from the study because of the presence of disease in the nipple ducts. One more nipple was lost in the immediate post-operative time due to necrosis. Two women were lost to follow-up after the operation. Fifty women treated with nipple sparing mastectomy were regularly followed up for a mean time of 66 months (range 9e140). Median age was 42 (range 28e68). Mean operative time was 150 min. All specimens presented surgical adequate margins without cancerous proliferation in the retro-areolar breast ducts. We subdivided cases according to the stages of disease (AJCC staging system): 8 were Stage 0, 24 Stage I, 18 Stage II, 1 Stage III. Sixteen cases presented with multicentric localization. We investigated other prognostic factors: 39 cases were oestrogen and progesterone receptors positive (or at least for one of the two parameters), 7 were totally negative. Lymph vascular invasion was shown in 13 cases (Table 2). Twelve patients underwent adjuvant chemotherapy and 21 underwent adjuvant hormonal treatment (tamoxifene). In 3 cases radiotherapy was required on the basis of post-operative tumour staging. Oncologic outcome Of the 50 assessable patients, 1 local relapse and 5 distant metastases were diagnosed, with a 12% of overall recurrence rate. One tumour was recurred locally in the nipple and was successfully treated with NAC excision. Table 2 Characteristics of the assessable patients No. of patients/no. of cases
50/51
Mean follow-up time (months/years)
66/5.5
Mean tumour diameter (cm) Tumour type Invasive Non-invasive Tumour stage 0 (pTis/phylloid tumour) I (pT1) II (pT2 or N1) III (pT3 N1)
1.6 30 21 8 24 18 1
Histological grade 1 2 3
18 18 15
Hormone receptors ER/PgR þ/þ / þ/ /þ Unknown Multicentricity
30 7 7 2 5 16
Lymphovascular invasion
13
F. Caruso et al. / EJSO 32 (2006) 937e940
939
Among women with systemic disease, 4 died of progressive disease and another one is currently alive with disease. The other 44 women were still alive with no evidence of disease after a mean follow-up of 5.5 years. The 5.5-year actuarial disease-free survival for patients treated by nipple sparing mastectomy was 88%, with an overall survival of 92% (Table 3). When testing into 2 separate groups for local recurrence and distant metastasis, the 5.5-year estimated disease-free survival was 98% and 90%, respectively.
Gerber et al.7 in 2003 compared nipple sparing mastectomy to skin sparing and radical modified techniques. They did not find significant differences in the outcome. Recently Petit et al.8,9 published 2 series on this item. Clinical and intra-operative negativity for nipple involvement was required. A 16-Gy intra-operative beam was delivered to the NAC to preserve a pad of retro-areolar tissue and improve NAC survival.
Reconstructive outcome
According to data reported in literature we offered nipple sparing technique to women affected by peripheral early stage breast cancer not eligible for conservation. Among them we selected those with medium size or small breasts and none or minimal ptosis. In our opinion large envelopes cannot be filled with tissue expanders in the first surgical stage. In such cases distortion of NAC position can lead to unpleasant results. We preferred radial or infra-mammary fold incisions. The first is more likely to preserve flaps vascularization, the latter produce nearly invisible scars. Our results in terms of overall survival, distant and local recurrence rate are comparable to those reported for skin sparing mastectomies.12e17 We had a single case of nipple recurrence that appeared in a lady who received further excision and is currently free of disease after 36 months. Our observations concur with that of Gerber et al.7 who reported a long-term survival in a similar case. We did not give radiotherapy to NAC only because of the ultra-conservative technique as suggested by Petit and colleagues.8,9 We believe that once nipple is completely peeled and its dermis exposed the left residual glandular tissue is comparable to that of skin sparing mastectomies. It can be argued that this can lead to an impaired vascularization but we reported only a single case of nipple necrosis. Reconstructions were performed using a 2-stage procedure with anatomical implants. We gained in this way satisfying cosmetics. We considered latissimus dorsi as a second choice for complicated cases. Its use could improve cosmetics in a single operation but carries risks of severe biomechanical complications.
We reported severe complications on 3 cases with implant exposure followed by its removal. Aesthetic quality of nipple sparing mastectomy was assessed according to the Hidalgo’s criteria.18 Breast reconstruction after nipple sparing mastectomy was considered excellent in 9 patients, good in 25 cases, because of asymmetry of the areolar position or retained distant scar, fair in 7 women due to partial skin slough and capsular contracture, poor in 6 surgical interventions, and not valuable in the left cases for non-surgery-related problems. The aesthetic result was judged to be excellent or good by most of the patients too. Temporary expander was removed after a median time of 7 months (range 3e13). During the second surgical stage we performed contra-lateral symmetrization in 48 patients. Discussion Mastectomy and nipple areola complex preservation In current clinical practice nipple sparing mastectomy is considered a block to oncological radicalism. Many authors investigated this technique but currently there is no consensus on its safety on long-term follow-up.19e22 Several studies of nipple involvement during breast cancer have tried to identify predictors of possible invasion. Rates on mastectomy specimen are extremely variable from 0 to 50% depending on tumour size, positioning and characteristics.23e25 Lesions far from the NAC and small in size rarely demonstrated invasion of major ducts.26e28
Nipple sparing mastectomy in our experience
Critical aspects Table 3 Efficacy of oncological treatment on the assessable patients Recurrent patients Locally recurrent patients
6 1
Distant metastases
5
Median time to recurrence (year) 5.5-Year disease-free survivors local recurrence-free survivors distant recurrence-free survivors
1 44 49 45
5.5-Year overall survivors
46
Although our study supports safety of nipple sparing mastectomy some issues are still debatable. Evidences provided from retrospective studies like this one are statistically weak. A randomised trial comparing nipple sparing mastectomy with conservative treatment should be offered to a subset of patients that might have indications for both techniques. Data provided from such study could validate oncological safety. Intra-operative frozen section did not allow accurate preoperative surgical planning. New modern devices like nipple vacuum assisted biopsy could solve this item.29
940
F. Caruso et al. / EJSO 32 (2006) 937e940
Lack of nipple sensibility following entire glandular removal is almost unavoidable. There is no chance at the moment to overcome this issue. Petit et al.9 reported poor sensation in 48% of women although psychological assessment demonstrated full satisfaction for the large majority of them. Conclusions Our study supports with quite a long-term follow-up (66 months) the hypothesis that nipple areola complex can be preserved in selected patients. Larger studies are required for validation and to investigate evolution of locally recurrent disease. Once nipple sparing will be accepted into standard clinical care we will provide candidates to mastectomy with a dramatic increase in quality of life. References 1. Dean NR, Neild T, Haynes J, Goddard C, Cooter RD. Fading of nipple areolar reconstructions: the last hurdle in breast reconstruction? Br J Plast Surg 2002;55:574–81. 2. Wellisch DK, Schain WS, Noone RB, Little 3rd JW. The psychological contribution of nipple addition in breast reconstruction. Plast Reconstr Surg 1987;80:699–704. 3. Spear SL, Arias J. Long-term experience with nipple areola tattooing. Ann Plast Surg 1995;35:232–6. 4. Bostwick 3rd. Nipple reconstruction using the CeV flap technique: a long-term evaluation. Plast Reconstr Surg 2001;108:361–9. 5. Little 3rd JW, Munasifi T, McCulloch DT. One-stage reconstruction of a projecting nipple: the quadrapod flap. Plast Reconstr Surg 1983;71: 126–33. 6. Bhatty MA, Berry RB. Nipple areola reconstruction by tattooing and nipple sharing. Br J Plast Surg 1997;50:331–4. 7. Gerber B, Krause A, Reimer T, et al. Skin sparing mastectomy with conservation of the nipple areola complex and autologous reconstruction is an oncologically safe procedure. Ann Surg 2003;238:120–7. 8. Petit JY, Veronesi U, Orecchia R, et al. The nipple sparing mastectomy: early results of a feasibility study of a new application of peri-operative radiotherapy (ELIOT) in the treatment of breast cancer when mastectomy is indicated. Tumori 2003;89:288–91. 9. Petit JY, Veronesi U, Orecchia R, et al. Nipple sparing mastectomy in association with intra operative radiotherapy (ELIOT): a new type of mastectomy for breast cancer treatment. Breast Cancer Res Treat 2005;27:1–5. 10. Palmieri B, Baitchev G, Grappolini S, Costa A, Benuzzi G. Delayed nipple sparing modified subcutaneous mastectomy: rationale and technique. Breast J 2005;11:173–8.
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