The Incidence of Occult Nipple-Areola Complex Involvement in Breast Cancer Patients Receiving a Skin-Sparing Mastectomy

Background: Surgical treatment of breast cancer traditionally has included resection of the nipple-areola complex (NAC), in the belief that this area had a significant probability of containing occult tumors. The purpose of this study was to investigate the true incidence of NAC involvement in patients who underwent a skin-sparing mastectomy (SSM) and to determine associated risk factors.Methods: A retrospective chart review was conducted of 326 patients who had a SSM at our institution from 1990 to 1993. NAC involvement was reviewed in 286 mastectomy specimens. The charts were analyzed for tumor size, site, histology, grade, nodal status, recurrence, survival, and NAC involvement.Results: Occult tumor involvement in the NAC was found in 5.6% of mastectomy specimens (16 patients). Four patients would have had NAC involvement identified on frozen section if they had been undergoing a skin-sparing mastectomy with preservation of the NAC. There were no significant differences between NAC-positive (NAC+) and NAC-negative (NAC-) patients in median tumor size, nuclear grade, histologic subtype of the primary tumor, or receptor status. There were significant differences in location of the primary tumor (subareolar or multicentric vs. peripheral) and positive axillary lymph node status. NAC involvement was not a marker for increased recurrence or decreased survival.Conclusions: Occult NAC involvement occurred in only a small percentage of patients undergoing skin-sparing mastectomies. NAC preservation would be appropriate in axillary node-negative patients with small, solitary tumors located on the periphery of the breast.Presented at the 52nd Annual Meeting of the Society of Surgical Oncology, Orlando, Florida, March 4–7, 1999.     

保留乳头乳晕复合体乳腺癌根治即刻胸大肌包裹假体植入乳房重建

目的 探讨保留乳头乳晕复合体(NAC)的乳腺癌改良根治术即刻胸大肌包裹假体植入乳房重建的可行性.方法 对28例0、I、II期乳腺癌行保留皮肤的乳腺癌改良根治术后,即刻于胸大肌后方植入硅胶假体重建乳房,并根据冰冻切片结果决定是否保留NAC.结果 28例早期乳腺癌均保留了NAC,术后随访2～18个月(中位随访期:15个月),外观良好,双侧乳房对称,优良率达96.5%;均无局部复发或远处转移,无明显术后并发症.结论 保留NAC的乳腺癌改良根治术后用硅胶假体行即刻乳房重建,能达到满意的乳房美容效果,是治疗早期乳腺癌安全可行的方法.     

乳房重建手术中乳头乳晕复合体的保护及技术要点

传统的乳房切除术要求切除乳头乳晕复合体（NAC）。该术式无论后续重建与否,都无法满足病人的美观需求。随着乳房重建技术的发展,保留NAC的即刻乳房重建手术具有优越的美学效果,越来越多的乳腺癌病人可以在术后保持形体的完整与美观,如何在乳房重建手术中更好地保护NAC成为乳腺外科医生关注的焦点之一。术者应具有强烈的NAC保护意识,精细掌握NAC后方乳管及血供特点,合理设计手术切口,尽可能降低术后乳头缺血、坏死等并发症的发生率。     

Subareolar breast cancers

BACKGROUND: Despite the high rate of pathologic involvement of the nipple-areola complex (NAC) with subareolar cancers and the suboptimal cosmetic results when lumpectomy removes the NAC, breast conservation surgery has been extended to include these patients. METHODS: Ninety-five patients with subareolar cancers operated on between 1979 and 1998 were identified and the relationships between the pathologic findings, treatment, and outcome were studied. RESULTS: Clinical involvement of the NAC (P = 0.001), clinical presentation (P <0.001, mammographic calcium or Paget's disease), and pathologic tumor size (P = 0.019) were significantly related to pathologic involvement of the NAC in univariate analysis. After consideration for clinical NAC involvement, no other variable was significantly related to pathologic NAC involvement in multivariate analysis. Thirty-three patients underwent mastectomy, and 62 were treated with breast conservation. Radiation therapy (P = 0.005), clinical (P = 0.031), and pathologic (P = 0.037) involvement of the NAC were significantly related to local disease-free survival in breast conservation patients in univariate analysis. After consideration for radiation therapy in multivariate analysis, clinical involvement of the NAC was the only additional variable significantly related to local recurrence in breast conservation patients. Clinical or pathologic involvement of the NAC was not significantly associated with local and distant recurrence after mastectomy. No other variable was significantly related to local outcome in univariate analysis in patients treated with mastectomy. CONCLUSIONS: Subareolar cancers can be successfully treated with breast conservation surgery provided adjuvant radiation therapy is always given. Clinical involvement of the nipple-areola complex is associated with high risk of local failure when treated with breast conservation without radiation therapy.     

保留NAC的改良根治术并一期乳房重建术治疗早期乳腺癌的临床效果

目的:探讨保留乳头乳晕复合体(NAC)的乳腺癌改良根治术并一期乳房重建术治疗早期乳腺癌的安全性及可行性。方法:将2010-2014年乳腺癌患者170例,根据患者意愿分别行保留NAC的乳腺癌改良根治术并一期乳房重建术(观察组,102例),与未保留NAC的皮下乳腺癌改良根治术(对照组,68例)。比较两组术后相关指标、患者对乳房重建的满意度、生活质量情况及随访期间不良事件以及复发、转移发生率。结果:两组术后创面引流时间及引流量无统计学意义差异(均P0.05)。观察组患者术后满意率(97.06%vs.51.47%)、FACT总评分(150.89±25.34)vs.(100.24±18.47)、生活质量高水平率(83.33%vs.51.47%)均高于对照组(均P0.05)。两组不良事件发生率、远处转移率及复发率相似,组间无统计学差异(均P0.05)。结论:保留NAC的改良根治术并一期乳房重建术治疗早期乳腺癌安全、可行,且在术后美学效果、改善患者生活质量方面明显优于未保留NAC的皮下乳腺癌改良根治术。     

侧胸壁脂肪筋膜肌肉瓣在乳腺癌术后即刻乳房成形中的应用

目的:探讨保留乳头乳晕复合体(NAC)的乳腺癌改良根治术后应用侧胸壁脂肪筋膜肌肉瓣即刻乳房成形的适应证、疗效及可行性。方法:对43例扁平或小乳房、IIIA期前的乳腺癌患者行保留NAC的乳腺癌改良根治术,术中即刻应用侧胸壁脂肪筋膜肌肉瓣乳房成形或同时联合假体乳房重建,术后评价美容效果,观察并发症,对治疗效果进行随访。结果:43例患者均成功手术。平均手术时间1.7(1.3~2.2)h,平均住院时间17(13~24)d,术后平均住院时间13(10~18)d。术后随访2~12个月,无乳头坏死,组织瓣感染2例;无局部复发及远处转移;患者总体满意度8.5分,乳房外观客观评价良好率86.0%(37/43)。结论:保留NAC的乳腺癌改良根治术后即刻应用侧胸壁脂肪筋膜肌肉瓣修复重塑乳房外形具有操作方便、手术快捷、技术可行的特点,特别适合于扁平小乳房、IIIA期前的乳腺癌患者。     

Patient-subjective cosmetic outcomes following the varying stages of tissue expander breast reconstruction: the importance of completion

IntroductionTissue expander breast reconstruction consists of three major surgical steps: placement of the expander after mastectomy, exchange of the expander for an implant, and nipple-areola complex reconstruction. The evolution of patient satisfaction throughout this process has not been evaluated. Here we performed a stratified analysis of patient-subjective cosmetic outcomes during the stages of breast reconstruction.MethodsTwenty-eight consecutive tissue expander-implant reconstructions were performed by the senior author using human acellular dermis. Cosmetic outcomes were assessed after each reconstructive stage using a validated Breast Evaluation Questionnaire consisting of questions related to breast size, shape and firmness in three separate contexts: intimate or sexual activities, leisure or social activities, and professional or job-related activities.ResultsEighteen patients underwent unilateral reconstruction, while 10 underwent bilateral reconstruction. Satisfaction scores were statistically higher following Stage I and II procedures for bilateral reconstructions. For unilateral reconstructions, there was a statistically significant elevation in scores following Stage II. The addition of nipple-areola reconstruction resulted in the highest scores for both unilateral and bilateral reconstructions. These score elevations were significant (p < 0.05) in nearly every measured context for unilateral reconstructions and as such, the significant differences in scores between unilateral and bilateral cohorts after stages I and II were nearly eliminated after completion of the entire reconstructive process.ConclusionSatisfaction with tissue expander reconstruction is significantly affected by the patients’ stage during the reconstructive process. Completion of all three stages, including nipple-areolar complex reconstruction, achieves maximal patient satisfaction. For unilateral reconstructions, completion of the entire reconstructive process, including contralateral symmetry procedures and nipple-areolar complex reconstruction, results in cosmesis scores that are similar to those in bilateral cases.     

Skin-sparing mastectomy with immediate breast reconstruction: The M. D. Anderson cancer center experience

Background: Skin-sparing mastectomy with immediate reconstruction has become popular with patients because, compared with delayed reconstruction, it improves the cosmetic result, reduces cost and anesthetic risk, and in one stage completes most of the surgical treatment that the patient will ever require for treatment of her breast cancer. In the past, reconstruction was often delayed because of an unwarranted fear of locoregional recurrence or because the patient, having to live for some time with a flat chest wall, would be more appreciative of her reconstruction. This concept is now considered unacceptable, and many women regard this attitude as evidence of a lack of concern for the psychological impact of mastectomy. Method: Provided that the breast skin is not involved with or close to the tumor, we prefer to perform the mastectomy with removal of only the nipple-areolar complex and the tumor biopsy scar. The mastectomy is otherwise the same as a standard modified radical mastectomy with removal of all breast tissue and a level I–II axillary node dissection. Our preference is to use the transverse rectus abdominis myocutaneous flap with a microvascular anastomosis because it provides a better blood supply, reduces abdominal wall muscle sacrifice, and eliminates the bulge from tunneling required by a pedicled flap. Result: Using the skin-sparing technique with immediate reconstruction in 545 patients with early-stage breast cancer, our overall incidence of regional recurrence was 2.6%. Of 95 patients who were followed for >four years, the recurrence rate was 4.2%. Conclusions: Regional recurrence after skin-sparing mastectomy is a function of the biology of the tumor and the stage of the disease and is not affected by the use of immediate reconstruction or skin-preservation mastectomy.     

Patient satisfaction following nipple-areola complex reconstruction and dermal tattooing as an adjunct to autogenous breast reconstruction

Following mastectomy, nipple-areola complex (NAC) reconstruction is seen as the final step in creating a reconstructed breast which closely resembles the original. Multiple surgical techniques, of varying complexity and usefulness, are available for NAC reconstruction. The principal criterion for successful NAC reconstruction is symmetry of position, size, colour, and projection. This study evaluates patients’ subjective satisfaction following NAC reconstruction and dermal tattooing, as well as objective comparison of colour match. Two techniques for NAC reconstruction were used; the modified star flap (n = 18) or the skate flap (n = 8) with full thickness skin grafting. All patients undergoing NAC reconstruction were surveyed via questionnaire and asked to rate their satisfaction using a standard scale. Objective colour matching was carried out using a computer programme to compare post-tattooing photographs. Patient satisfaction was rated as very good or excellent for position, size, and colour match in all cases. There was no difference between those who had star flap or skate flap reconstructions. There was, however, a lower satisfaction with projection amongst those who had undergone skate flaps. This study shows a high level of patient satisfaction and good colour match following NAC reconstruction and dermal tattooing.     

A new oncoplastic technique with immediate nipple reconstruction for central breast tumors using Würinger's septum-based flap

IntroductionCentrally located breast tumors represent a challenge for both oncological and reconstructive surgeons, mainly due to the necessity of nipple-areola complex (NAC) removal. We describe an original oncoplastic solution utilizing a displacement flap technique with immediate nipple reconstruction.MethodsSince 2008, we developed an oncoplastic technique using a septum-based island flap for the reconstruction of central breast defects, including the NAC. This technique is based on the Würinger's septum which is centered around the intercostal perforators. A retrospective study was performed collecting data on patient characteristics, oncological features, and outcomes. Patient satisfaction was reported using a Likert scale.ResultsReconstruction was successfully realized in 15 patients (14 immediate and one delayed post-lumpectomy correction). In immediate surgery, the excision margins were all free of tumor. Minor complications occurred in three patients; one small area of skin necrosis was managed by secondary intention, and two cases of partial nipple necrosis were treated by debridement under local anesthesia. Contralateral symmetrization surgery was performed on nine patients. Patient satisfaction scored high.ConclusionIn comparison with the previous oncoplastic techniques used for reconstructing central defects, the septum-based island flap has increased flexibility, provides better projection, and can be combined with immediate NAC reconstruction.     

胸大肌筋膜在乳腺癌乳房切除后即刻乳房重建中的应用

目的:探讨胸大肌筋膜在乳腺癌乳房切除后即刻乳房重建中的应用价值。方法:回顾分析2014年5月—2016年9月接受保留乳头乳晕复合体的皮下腺体切除与即刻乳房重建的18例早期乳腺癌患者临床资料。患者均采用胸大肌及其筋膜覆盖并包裹假体行乳房重建,即首先从自胸骨旁及锁骨下向外侧游离剥离胸大肌筋膜,然后在胸大小肌之间植入假体,最后用游离的胸大肌筋膜缝合胸大肌外侧缘,牢固包裹假体。结果:18例乳房重建手术均取得成功,经过12~40个月随访,所有患者未发现复发、转移,重建乳房对称性好、形态自然,未发现假体移位、挛缩,术后外观评价优良率100%。结论:对于部分早期乳腺癌患者,实施保留乳头乳晕复合体的皮下腺体切除、利用胸大肌及其筋膜覆盖假体的即刻乳房重建方法简单易行,重建乳房美容效果好,并发症少。     

Applicability of the nipple-areola complex-sparing mastectomy: a prediction model using mammography to estimate risk of nipple-areola complex involvement in breast cancer patients

The purpose of this study was to develop a prediction model that can be used to identify breast cancer patients at lowest risk for neoplastic nipple-areola complex (NAC) involvement to offer total NAC-sparing mastectomy with immediate reconstruction. Medical records, pathology slides, and mammograms were reviewed for all breast cancer patients treated with total mastectomy at Rhode Island Hospital between 2000 and 2004. The distance between the nipple and the closest tumor margin was measured using mammography. NAC involvement was identified in 42% of the 31 study patients. Mammographic distance, pathologic stage, and tumor size were identified as independent predictors of malignant NAC involvement by multivariate analysis (rho < 0.05). Based on these predictors, a linear discriminant score, the NAC Involvement Score (NACIS), was computed to distinguish between the presence and absence of NAC involvement. For individual patients, positive NACIS values (> or = -0.3665) were associated with NAC involvement with a sensitivity of 92%, specificity of 77%, and negative predictive value of 93%. These preliminary findings indicate that the NACIS formula may be a useful clinical tool for selecting low-risk patients for total NAC-sparing mastectomy with immediate reconstruction.     

Preoperative Predictors of Nipple–Areola Complex Involvement for Patients Undergoing Mastectomy for Breast Cancer

Background  

Proper patient selection is important for nipple-sparing mastectomy, and we aimed to identify preoperative factors predictive of pathologic nipple-areola complex (NAC) involvement to assist with surgical planning.     

Can Montgomery tubercles impact aesthetic 3D nipple-areolar complex tattooing? An anatomical,quantitative analysis of breast cancer patients

PurposeWe aimed to establish a relationship between the amount of Montgomery tubercles (MTs) per nipple-areolar complex (NAC) given patient characteristics such as age, BMI, menopausal status, race/ethnicity, and NAC size to better inform current 3D NAC tattooing practices.MethodsPreoperative photographs of patients pursuing breast reconstruction after mastectomy in 2010 through 2018 were reviewed. The number of MTs on each native NAC was quantified. The impact of patient factors on the quantity of MTs was evaluated via Pearson correlation and bivariate analyses.ResultsTwo hundred and eleven patients (399 breasts) were reviewed. On average, patients had 5.0 ± 5.2 MTs (range, 0–25 MTs). Number of MTs did not correlate with patient age, BMI, or NAC size. Premenopausal females were more likely than postmenopausal females to have a greater number of MTs per breast (p-value = 0.0183).ConclusionsPostmastectomy patients desiring a more “youthful” NAC may consider additional MTs when pursuing 3D NAC tattooing.     

Nipple areola complex conservation in immediate breast reconstruction: prospective study of 66 cases

OBJECTIVE OF THE STUDY: Our objective is to define a sub-group of patients in whom skin-sparing mastectomy with immediate reconstruction and preservation of the nipple-areola complex is technically and oncologically feasible without increasing the risk of complications and local recurrence. PATIENTS AND METHODS: Between September 1999 and December 2005, 66 patients presenting an in situ and/or invasive breast carcinoma justifying a mastectomy underwent immediate breast reconstruction preserving the skin and nipple-areolar complex. RESULTS: After a median follow-up of 37 months, definitive conservation of the nipple-areolar complex with good esthetic results was achieved in 71% of the cases. CONCLUSION: This preliminary study provides encouraging results in a selected patient population but requires a longer term follow-up in order to draw definitive conclusions on the oncological safety preserving the nipple-areolar complex.     

Transposition technique for correction of a malpositioned nipple-areola complex after reconstruction following a nipple-sparing mastectomy: a case report

We developed a novel transposition technique for the correction of an asymmetric nipple-areola complex (NAC) due to breast mound reconstruction after a nipple-sparing mastectomy. The technique was composed of a rotation flap and an advancement flap. In this study, we describe a case of a 35-year-old woman with a malpositioned NAC located at the upper lateral position with a vertical scar in the lateral area of the breast treated by this technique, with a follow-up period of 12 years. In this case, established techniques were difficult to apply as there were thin underlying subcutaneous tissue and scars near the NAC. This technique may be useful in such a case and is an additional option in the correction of a malpositioned NAC from the upper lateral position to the ideal position on a breast mound.     

保留乳头乳晕的乳腺癌改良根治术159例报告

目的 总结保留乳头乳晕复合体( nipple-areola complex,NAC)的乳腺癌改良根治术经验,以期提高手术成功率。方法 对1998年1月至2009年12月行保留NAC乳腺癌改良根治术的159例患者的临床病理资料进行回顾。结果 159例患者中成功实施保留NAC乳腺癌改良根治术141例(88.68％)。术中放弃保留NAC而改变为乳腺癌改良根治术或根治术14例(8.81％),其中4例(2.52％)为术中发现NAC缺血,5例(3.14％) NAC有癌浸润,2例(1.26％)为重度不典型增生,3例(1.89％)因术中发现Ⅲ级淋巴结肿大而更改术式;术后乳头完全坏死导致手术失败4例(2.52％)。术后并发症：乳头部分缺血坏死16例(10.06％),皮瓣坏死、感染11例(6.92％),皮下积液10例(6.29％)。患者均获得随访,随访时间15 ～96个月（中位随访时间51个月）。术后局部复发5例(3.14％),远处转移2例(1.26％),NAC及其基底部未见复发。结论 保留NAC乳腺癌改良根治术在严格入组条件和手术流程的情况下是安全的术式,导致改变术式的常见原因为NAC癌浸润、NAC缺血坏死及术中分期改变等。     

乳腺癌患者皮肤微转移灶的临床意义

目的 探讨检测乳腺癌患者皮肤微转移灶的临床意义。方法 从皮肤距肿瘤最近点及乳头乳晕复合体正中切面取材，分别进行常规病理及细胞角蛋白单抗免疫组织化学法（immunohistochemistry，IHC）检测60例乳腺癌患者标本。结果60例乳腺癌中，常规病理检测出有乳头乳晕复合体浸润的3例（占5，0％），IHC检测出7例（占11．7％），两者间有统计学意义（X^2=2.25，P〈0．05）；常规病理检查及IHC法均检测出4例有皮肤浸润（占6．7％），其中3例两种方法均证实皮肤和乳头乳晕复合体同时有癌浸润。结论 IHC对乳头乳晕复合体的微转移灶的检出率高于常规病理，皮肤及乳头的受累率较低，如无受累，可行保留皮肤的乳房切除术。     

Mammographic distance as a predictor of nipple-areola complex involvement in breast cancer

BACKGROUND: Although involvement of the nipple-areola complex (NAC) occurs in a minority of patients with breast cancer, standard skin-sparing mastectomy requires its removal. To assist in patient selection for NAC preservation we evaluated NAC involvement and correlated this with preoperatively available clinical data. METHODS: Patients with invasive breast cancer or ductal carcinoma in situ undergoing mastectomy from 1998 to 2005 were reviewed retrospectively. The NAC had been evaluated with multiple thin sections. Pathologic data including NAC involvement were analyzed. The mammographic tumor distance from the nipple was measured in 2 standard views. RESULTS: There were 302 patients enrolled, of which 10% were noted to have NAC involvement. This correlated negatively with tumor distance from the nipple (P < .05). A logistic regression equation was derived from the data, with NAC involvement as the dependent variable and distance from the nipple as the independent variable. The equation predicted involvement of the NAC when the distance was less than 4.96 cm with a sensitivity of 82% and a negative predictive value of 97%. CONCLUSIONS: A majority of patients are candidates for NAC preservation. The mammographic distance between the tumor and the nipple is independently predictive of NAC involvement and is useful as an equation variable.