The Place of Nipple-Sparing Mastectomy in the Treatment of Breast Cancer: Review of the Literature

Introduction: Mastectomy with conservation of the nipple-areola complex (NAC) in breast cancer care has been controversial with regards to the oncological safety of this procedure and the risk of complications including NAC necrosis. Aim: The objective of this study is to assess, through a literature review, the safety and reliability of a conservative NAC mastectomy in breast cancer treatment, paying attention to the rate of local recurrence and complications. Methods: A review of the literature was conducted from PubMed data, and articles published between January 2007 and December 2017, using the terms “nipple-sparing mastectomy”, “breast cancer”, “local recurrence”, “necrosis of the nipple”, “global complications”. The articles were analyzed with regards to the following parameters of evaluation: local recurrence, recurrence rate at NAC level, global complication rates and nipple necrosis rates. Results: In the 36 studies we selected, the average rate of local recurrence was 3.23%. The average rate of recurrence at the NAC was 0.81%. The average rate of complications was 20%. The average rate of necrosis of the NAC was 5.9%. The main factors of these recurrences were the tumor size > 5 cm and tumor stage > stage II. Conclusion: Conservative mastectomy of the nipple-areola complex offers an aesthetic advantage and oncological safety in carefully selected patients with breast cancer.

Nipple-sparing Mastectomy in Breast Cancer： From an Oncologic Safety Perspective

Objective：To evaluate the oncologic safety of nipple-sparing mastectomy （NSM） for breast cancer patients based on current literature.Data Sources：A comprehensive literature search ofMedline,Embase databases was conducted for studies published through March 2014.Study Selection：Our search criteria included English-language studies that focused on NSM at nipple-areola complex （NAC） involvement,patient selection,and recurrence.Prophylaxis NSM,case series or reports that based on very small population were excluded.In the end,42 studies concerning NSM and oncological safety were included into the review.Results：NSM is a surgical procedure that allows the preservation of the skin and NAC in breast cancer patients or in patients with prophylactic mastectomy.However,the oncologic safety and patient selection criteria associated with NSM are still under debate.The incidence of NAC involvement of breast cancer in recent studies ranges from 9.5% to 24.6%,which can be decreased through careful patient selection.Tumour-nipple distance,tumour size,lymph node involvement and molecular characteristics can be evaluated preoperatively by clinical examinations,imaging studies and biopsies to predict the risk of NAC involvement.Currently,there is no available standard protocol for surgical approaches to NSM or pathological examination of NSM specimens.The local recurrence （ranges from 0% to 24%） of NSM is not significantly higher than that of traditional mastectomy in selected patients based on long-term follow-up.The role of radiotherapy in NSM is still controversial and is not universally accepted.Conclusions：NSM appears to be oncologically safe following careful patient selection and assessment of margins.

Investigation of the current situation of nipple-sparing mastectomy:a large multicenter study in China(CSBrs-003)

Background:Mastectomy techniques have been extended to nipple-sparing mastectomy(NSM).This study aimed to assess the actual application of NSM in China and identify the factors influencing postoperative complications.Methods:The clinical data of 615 patients(641 surgeries)undergoing NSM from January 1st,2018 to December 31st,2018 at 28 centers nationwide were retrospectively analyzed to obtain the rate of NSM and investigate factors related to NSM surgery.Results:The proportion of NSM surgery performed in this study was 2.67%(17/641).Malignant breast tumors accounted for the majority of NSM surgery(559/641,87.2%).A total of 475(77.3%)patients underwent NSM combined with reconstructive surgery.The rate of reconstruction decreased with age in our study,and implants were the most common option(344/641,53.7%)in reconstruction.Radial incision was the most selected method regardless of reconstruction.However,for those who underwent reconstruction surgery,18.4%(85/462)of cases also chose curvilinear incision,while in the simple NSM surgery group,more patients chose circumareolar incision(26/136,19.1%).The tumor-to-nipple distance(TND)influenced postoperative complications(P=0.004).There were no relationships between postoperative complications and tumor size,tumor location,histologic grade,molecular subtype,nipple discharge,and axillary lymph nodes.Conclusions:NSM surgery is feasible and only TND influenced postoperative complications of NSM surgery.But the proportion of NSM surgery performed is still low in nationwide centers of China.The selection criteria for appropriate surgical methods are important for NSM in clinical practice.To optimize clinical applications of NSM,further multicenter prospective randomized controlled studies are needed.

Immediate nipple-areola-sparing mastectomy reconstruction: An update on oncological and reconstruction techniques

Nipple-sparing mastectomy(NSM) is a safe technique in patients who are candidates for conservation breast surgery. However, there is worry concerning its oncological safety and surgical outcome in terms of postoperative complications. The authors reviewed the literature to evaluate the oncological safety, patient selection, surgical techniques, and also to identify the factors influencing postoperative outcome and complication rates. Patient selection and safety related to NSM are based on oncological and anatomical parameters. Among the main criteria, the oncological aspects include the clinical stage of breast cancer, tumor characteristics and location including small, peripherally located tumors, without multicentricity, or for prophylactic mastectomy. Surgical success depends on coordinated planning with the oncological surgeon andcareful preoperative and intraoperative management. In general, the NSM reconstruction is related to autologous and alloplastic techniques and sometimes include contra-lateral breast surgery. Choice of reconstructive technique following NSM requires accurate consideration of various patient related factors, including: breast volume, degree of ptosis, areola size, clinical factors, and surgeon's experience. In addition, tumor related factors include dimension, location and proximity to the nipple-areola complex. Regardless of the fact that there is no unanimity concerning the appropriate technique, the criteria are determined by the surgeon's experience and the anatomical aspects of the breast. The positive aspects of the technique utilized should include low interference with the oncological treatment, reproducibility, and long-term results. Selected patients can have safe outcomes and therefore this may be a feasible option for early breast cancer management. However, available data demonstrates that NSM can be safely performed for breast cancer treatment in selected cases. Additional studies and longer follow-up are necessary to define consistent selection criteria for NSM.

Nipple-Areola Sparing Mastectomy Followed by Immediate Breast Reconstruction in 126 Patients

This study is to explore the indications, procedures, effectiveness, and feasibility of nipple-areola sparing mastectomy followed by immediate breast reconstruction. The nipple-areola sparing mastectomy followed by immediate breast reconstruction was performed in 126 patients with breast cancer from June 2005 to October 2011. The cosmetic outcomes of the reconstructed breasts were evaluated according to objective and subjective criteria. Meanwhile, the postoperative complications were observed and the therapeutic efficacies were followed up. All the operations were successful. Six patients experienced mild complications early after surgery and were resolved after symptomatic treatment. Both the subjective and objective evaluation for the aesthetic outcomes yielded a satisfactory rate of 97.62% during the 6-80-month follow-up. No recurrence or metastasis was found in 118 cases. Nipple-areola sparing mastectomy followed by immediate breast reconstruction is a simple and effective option for significantly improving the cosmetic outcomes and quality of life of patients, without serious complications or impact on the comprehensive treatment and long-term effect against breast cancer.