1. Nipple sparing mastectomy --- an option for breast cancer ? 06/08/2011 Yam Po Chu Patricia Kwong Wah Hospital

2. Nipple Sparing Mastectomy History Advantages of nipple sparing mastectomy ( NSM ) Oncological safety Surgical techniques Clinical outcome Conclusion

3. History Freeman in 1962 : Subcutaneous mastectomy for benign breast lesions [1] Skin sparing mastectomy proven to be safe General belief of occult tumour in nipple –areola complex [2] [1] Freeman BS. Subcutaneous mastectomy for benign breast lesions with immediate or delayed prosthetic replacement. Plast Reconstr Surg Transplant Bull 1962; 30: 676–682. [2] Singletary SE, Robb GL. Oncologic safety of skin-sparing mastectomy. Ann Surg Oncol 2003;10:95–7.

4. Why consider nipple sparing ? Cosmesis, reduce sense of mutilation - excellent or good in 91.1% patient - body image and satisfaction Sensation of nipple Problems of reconstructed nipples : insensate and not erectile loss of projection and fade over time Jabor MA, Shayani P, Collins DR Jr, Karas T, Cohen BE. Nipple–areola reconstruction: satisfaction and clinical determinants. Plast Reconstr Surg 2002; 110: 457–463.

5. The nipple is the focal point of the breast and its reconstruction is often cited by women as making their breast reconstruction complete Wellisch DK, SchainWS, Noone RB, Little JWIII. The psychological contribution of nipple addition in breast reconstruction. Plast Reconstr Surg 1987; 80: 699–704.

6. High risk patients with bilateral prophylactic subcutaneous mastectomy : 1.2% had subsequent development of invasive carcinoma 0.2% occurred in the nipple areolar complex (NAC) Similar incidence in total mastectomy Oncological safety Hartmann LC, Schaid DJ, Woods JE, et al. Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. N Engl J Med 1999;340:77–84.

7. Oncological safety Invasive ductal carcinoma arising from the nipple is uncommon 5.6% - 31% NAC specimens contained occult tumour Variables in patient selection, definition of nipple involvement and pathological techniques Overall recurrence in the nipple <2% 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.

8. Case Selection Risk factors for nipple areola complex involvement Nodal positivity subareolar tumour location, distance from the areolar margin ( 2-4cm ) [1] multicentricity–involvement Nuclear grading [2] [1] Vyas JJ, Chinoy RF, Vaidya JS. Prediction of nipple and areola involvement in breast cancer. Eur J Surg Oncol 1998;24:15–16. [2] 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;6:609–613.

9. Case Selection T3 lesions involve the nipple-areola complex > 50% -ve axillary lymph node + peripheral tumours <2% missing an occult tumour with a NSM [1] Extended indication : Rusby at el Duct bundle could be completely excised in 96% of cases if a peripheral rim of 2mm of nipple skin and subcutaneous tissue is left [2] [1] FC, Smith BL. Nipple-sparing mastectomy: lessons from ex vivo procedures. Breast J 2008;14:464–70. [2] Rusby JE, Kirstein LJ, Brachtel EF, Michaelson JS, Koerner FC, Smith BL. Nipple-sparing mastectomy: lessons from ex vivo procedures. Breast J 2008;14:464–70.

10. Clinical data concerning the predictability of NAC involvement remain inconsistent Frozen sections of the subareolar tissue -- crucial decision for NAC preservation - 54.5% negative for malignancy in a series 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.

11. False negative rate 1- 4.6% when compared with definitive paraffin section [1] [2] [1]Crowe JP, Patrick RJ, Yetman RJ, Djohan R. Nipple-sparing mastectomy update: one hundred forty-nine procedures and clinical outcomes. Arch Surg 2008; 143: 1106–1110. [2]47 Regolo L, Ballardini B, Gallarotti E, et al Nipple sparing mastectomy: an innovative skin incision for an alternative approach. Breast 2008; 17: 8–11.

12. Case selection Prophylactic mastectomy in high risk patient Tumour < 4cm in size peripherally located ( > 2.5cm from nipple ) Negative axillary lymph nodes

13. Surgical Techniques 2-3mm thick nipple-areola flap with sparse or no ductal tissue presevation of the NAC and its blood supply Transareolar, perinipple incision with lateral extension Transareolar, transnipple incision Inferior-lateral mammary crease Nipple-sparing omega Envelope incision at the lateral border A frozen section analyse the areola and immediate reconstruction Stolier AJ, Grube BJ. Areola-sparing mastectomy : defining the risks. J Am Coll Surg 2005; 201:118-24.

14. Transareolar, perinipple incision with lateral extension

15. Transareolar, transnipple incision with medial and lateral extensions

16. Inferior-lateral mammary crease incision

17. Nipple-sparing omega (Mastopexy) Incision

18. Envelope incision at the lateral boder : - Allows excellent exposure of the axillary tail with good perfusion of nipple

19. Clinical outcome Necrosis and partial loss of the NAC 6% - 9.8% 3.7% total necrosis of the NAC with subsequent removal 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: 333–338.

20. This preserved areola underwent superficial necrosis, but the pigment returned 4 months later

21. Risk factors for nipple necrosis Age > 45, smoker Incisions > 30% of the areolar circumference Reconstruction with tissue expander is preferrable to fixed-volume implant Garwood ER, Moore D, Ewing C et al. Total skin-sparing mastectomy : complications and local recurrence rates in 2 cohorts of patients. Ann Surg 2009; 249:26-32.

22. Sensation in the preserved NAC 31% - 75% Lateral incision is preferrable Depigmentation 43% [1]Benediktsson KP, Perbeck L, Geigant E, Solders G. Touch sensibility in the breast after subcutaneous mastectomy and immediate reconstruction with a prosthesis. Br J Plast Surg 1997; 50: 443–449. [2]Yueh JH, Houlihan MJ, Slavin SA, et al. Nipple-sparing mastectomy: evaluation of patient satisfaction, aesthetic results, and sensation. Ann Plast Surg 2009; 62: 586–590.

23. Variants to improve outcome Preserve a pad of breast tissue behind the nipple with Intraoperative electron-beam radiotherapy [1] Areolar preserving with nipple removal 2/23 cases of NAC involvement had areolar involvement [2] [1] Petit JY, Veronesi U, Orecchia R, 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: 333–338. [2] Simmons RM, Brennan M, Christos P, et al. Analysis of nipple/ areolar involvement with mastectomy : can the areola be preserved ? Nn Surg Oncol 2002; 9 :65-8.

24. Mastopexy performed 1 week before NSM ensured maximum perfusion of the nipple-areolar complex.

25. Conclusion Nipple sparing mastectomy is oncologically safe in practice No definite concensus on clinical criteria for case selection : small tumours far from nipple and favourable pathological features Nipple necrosis may occur, partial necrosis can usually be treated conservatively No prospective study – selection bias and publication bias, further prospective cohort studies required