Sparing the Nipple During Mastectomy

By Virginia M. Mohlere

Surgeons successfully spared the nipple-areolar complex in this patient, who had surgery to remove breast cancer 6 months earlier.

In recent years, skin-sparing mastectomy has gained acceptance for the treatment of early-stage breast cancer and for prophylactic treatment in women at high risk of developing the disease. However, even though skin-sparing mastectomy allows breast surgeons to find a better balance between good oncologic results and good cosmetic results, nipple reconstruction remains a challenge. Nipples surgically created from skin grafts can flatten, tattooed areolae can lose color, and reconstructed nipples have no erectile capability and, worse, little or no sensation.

But recent studies by M. D. Anderson researchers and others have found that the incidence of nipple involvement in early-stage breast cancer ranges widely and that when primary tumors are at least 2 cm away from the nipple, the rate of nipple involvement is only about 6% (Laronga et al., Ann Surg Oncol 1999;6:609–13). Thus, preservation of a nipple-areolar complex (NAC) may be considered in select patients with breast cancer or those who are considering mastectomy for prevention. Unfortunately, researchers do not know the risk of local recurrence if the patient undergoes NAC-sparing mastectomy for oncologic purposes. Nevertheless, in the past few years, breast cancer surgeons have begun to consider saving the NAC using a variety of surgical techniques during skin-sparing mastectomy.

Saving the NAC is tricky. The goal is to preserve the appearance of the nipple, along with the hope there may be sensation and erectile function. However, the NAC is supplied by a complex group of blood vessels and nerves. Even in a skin-sparing mastectomy, it is difficult to save enough vessels and nerves to allow the NAC to live.

Because the surgery is so complex, NAC-sparing mastectomies performed in an oncologically safe fashion have been performed for only a few years. This means that there are very few comprehensive data about the best approaches, most appropriate patients, and outcomes. To determine outcome, Gildy Babiera, M.D., an associate professor in M. D. Anderson’s Department of Surgical Oncology, and her colleagues have embarked on a prospective study of NAC-sparing mastectomy. They will use intraoperative frozen-section and final histopathologic examination and follow-up to monitor rates of NAC involvement and breast cancer recurrence, as well as collect data on NAC survival.

Procedure and patients

To start the NAC-sparing mastectomy, the location of the incision is determined. Factors that influence the site of incision include previous scars, the location of the tumor, and access to blood vessels important for reconstruction and cosmesis.

After the incision is made, skin flaps are created and the breast tissue is oriented and marked before being removed. The specimen is sent for pathologic review, and the tissue underneath the NAC is microscopically examined during the surgery. If it is deemed cancer-free, the NAC and surrounding skin are left intact. Patients undergo immediate breast reconstruction. Follow-up includes visits at 1, 3, and 6 months and 1, 2, and 5 years and consists of a physical examination and, if needed, imaging or biopsy procedures.

Patient selection is critical to achieving the best results both oncologically and in terms of each patient’s satisfaction with her reconstructed breast. “We don’t claim to work miracles here,” Dr. Babiera said as she described the importance of making sure that patients are well informed and have realistic expectations: given the level of difficulty of the surgery, not every NAC will remain viable, and cancer recurrence is a possibility. “First we treat the cancer,” Dr. Babiera said, “and if in 1 or 2 years you have a living nipple, that’s a freebie.”

Dr. Babiera’s group hopes to enroll 30 women in the NAC-sparing mastectomy study; so far, they have enrolled 15 patients with 22 breasts requiring surgery. Women who may be candidates for the trial are those undergoing prophylactic mastectomy with immediate reconstruction and those with stage 0, I, or II cancer who are candidates for skin-sparing mastectomy with immediate reconstruction. In addition, primary tumors must be located 2.5 cm or more from the NAC.

Women who are not eligible include:

• smokers
• those with cancer of the NAC, subareolar tumors, or tumors less than 2.5 cm from the NAC
• those with inflammatory breast cancer or cancer involving the breast skin
• those with collagen vascular disease or Paget’s disease of the nipple
• those desiring reduction mammoplasty as part of reconstruction
  
• those with a history of previous surgery involving a periareolar incision
• those with a body mass index greater than 40 kg/m²
• those with a prior history of breast irradiation

For more information, call Dr. Babiera at 713-745-1563.

Other articles in OncoLog, December 2008 issue:

• Mantle Cell Lymphoma
• In Brief
• House Call: Taking Medicine? Be Aware of Food-Drug Interactions

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