Subcutaneous mastectomy with conservation of the nipple-areola Skin: broadening the indications

TY - JOUR

T1 - Subcutaneous mastectomy with conservation of the nipple-areola Skin: broadening the indications

AU - Paepke, Stefan

AU - Schmid, Rainer

AU - Fleckner, Stefanie

AU - Paepke, Daniela

AU - Niemeyer, Markus

AU - Schmalfeldt, Barbara

AU - Jacobs, Volker R

AU - Kiechle, Marion

PY - 2009/8

Y1 - 2009/8

N2 - BACKGROUND: Numerous authors take multiple predictive factors into account to decide whether or not the nipple-areola complex (NAC) can be conserved during mastectomy. These factors include the tumor-nipple distance, tumor size, axillary lymph node status, and lymphovascular invasion. Thus only a very limited percentage of patients can keep their NAC. If the breast gland tissue and all milk ducts can be separated completely from the nipple-areola skin (NA-skin) during subcutaneous mastectomy (SCM), conservation of the NA-skin is feasible even in the case of large, central, and retroareolar tumors.PATIENTS AND METHODS: From July 2003 to May 2006, we performed 109 SCMs on 96 patients. Total mastectomy was indicated in 94 of these breasts, in 16 because of extensive ductal carcinoma in situ, and 78 breasts with invasive carcinoma required additional axillary dissection resulting in indication for modified radical mastectomy. At least 33 of the breasts had malignancy underneath the skin within the areolar margin (centrally located tumors). After dissection of all the breast tissue, the skin envelope with the areola is turned inside out and all milk ducts and any tissue beneath the areola are precisely dissected under the surgeon's visual control. Frozen sections and HE histopathologic examination of this retroareolar tissue next to the skin are requested to decide whether the NA-skin can be preserved or not. This study was registered on the www.clinicaltrials.com website and has the following identification number ID: NCT00641628.RESULTS: We found it necessary to dissect the NA-skin in 13 of 109 breasts (12%), altering the procedure to a skin sparing mastectomy. Necrosis of the NA-skin requiring surgical intervention occurred in only 1 of the conserved 96 breasts. After follow-up of 20 to 54 months (median: 34 months), no recurrence within the nipple-areola region was observed. One local recurrence on the chest wall and 1 axillary recurrence were detected. Of 96 patients, 2 developed distant metastases. One death was recorded. Occasionally, partial necrosis of the nipple occurred, with residual depigmentation of the skin but a good or excellent cosmetic result was maintained in most cases.CONCLUSION: SCM with NAC-skin conservation may be performed according to total mastectomy indications if an intraoperative frozen section (and the corresponding HE histopathology) of the tissue next to the nipple-areola skin is free of tumor. The remaining contraindications for SCM are: extensive tumor involvement of the skin, inflammatory breast cancer, and a clinically suspicious nipple.

AB - BACKGROUND: Numerous authors take multiple predictive factors into account to decide whether or not the nipple-areola complex (NAC) can be conserved during mastectomy. These factors include the tumor-nipple distance, tumor size, axillary lymph node status, and lymphovascular invasion. Thus only a very limited percentage of patients can keep their NAC. If the breast gland tissue and all milk ducts can be separated completely from the nipple-areola skin (NA-skin) during subcutaneous mastectomy (SCM), conservation of the NA-skin is feasible even in the case of large, central, and retroareolar tumors.PATIENTS AND METHODS: From July 2003 to May 2006, we performed 109 SCMs on 96 patients. Total mastectomy was indicated in 94 of these breasts, in 16 because of extensive ductal carcinoma in situ, and 78 breasts with invasive carcinoma required additional axillary dissection resulting in indication for modified radical mastectomy. At least 33 of the breasts had malignancy underneath the skin within the areolar margin (centrally located tumors). After dissection of all the breast tissue, the skin envelope with the areola is turned inside out and all milk ducts and any tissue beneath the areola are precisely dissected under the surgeon's visual control. Frozen sections and HE histopathologic examination of this retroareolar tissue next to the skin are requested to decide whether the NA-skin can be preserved or not. This study was registered on the www.clinicaltrials.com website and has the following identification number ID: NCT00641628.RESULTS: We found it necessary to dissect the NA-skin in 13 of 109 breasts (12%), altering the procedure to a skin sparing mastectomy. Necrosis of the NA-skin requiring surgical intervention occurred in only 1 of the conserved 96 breasts. After follow-up of 20 to 54 months (median: 34 months), no recurrence within the nipple-areola region was observed. One local recurrence on the chest wall and 1 axillary recurrence were detected. Of 96 patients, 2 developed distant metastases. One death was recorded. Occasionally, partial necrosis of the nipple occurred, with residual depigmentation of the skin but a good or excellent cosmetic result was maintained in most cases.CONCLUSION: SCM with NAC-skin conservation may be performed according to total mastectomy indications if an intraoperative frozen section (and the corresponding HE histopathology) of the tissue next to the nipple-areola skin is free of tumor. The remaining contraindications for SCM are: extensive tumor involvement of the skin, inflammatory breast cancer, and a clinically suspicious nipple.

KW - Breast Neoplasms

KW - Carcinoma, Ductal, Breast

KW - Carcinoma, Intraductal, Noninfiltrating

KW - Cohort Studies

KW - Disease-Free Survival

KW - Female

KW - Humans

KW - Mammaplasty

KW - Mastectomy, Subcutaneous

KW - Patient Selection

KW - Retrospective Studies

KW - Treatment Outcome

U2 - 10.1097/SLA.0b013e3181b0c7d8

DO - 10.1097/SLA.0b013e3181b0c7d8

M3 - SCORING: Journal article

C2 - 19638905

VL - 250

SP - 288

EP - 292

JO - ANN SURG

JF - ANN SURG

SN - 0003-4932

IS - 2

ER -