by Donald S. Mowlds, MD, MBA (@DonaldMowldsMD)
In the early 18th century, French surgeon Jean Louis Petit proposed that breast skin, including the nipple-areolar complex, be left behind if it was free from tumor involvement. Unfortunately, he was branded a heretic and his principles were quickly dismissed. For the next two and a half centuries, the radical mastectomy and its inherent disfigurement predominated as the gold standard for the surgical management of breast cancer. Through decades of research and refinement, less morbid surgical techniques emerged such that Petit’s vision was considered as a non-inferior alternative. Early reports demonstrated equivalent early survival and local recurrence rates between the nipple-sparing and modified radical mastectomy. However, little additional proof existed at that time to quell concerns surrounding the persistence of breast tissue beneath the nipple, as it was feared that this may harbor occult cancer.1 Preservation of the native nipple-areolar complex, however, is undoubtedly ideal, a notion supported by numerous studies demonstrating that preservation of the nipple-areolar complex results in a significant improvement in perceived body image, satisfaction with nipple appearance and retention of sensitivity along with a decreased sense of mutilation.2-4
In their article, “A Novel Approach to the Management of Margin-positive DCIS in Nipple-sparing Mastectomy” in Plastic and Reconstructive Surgery: Global Open (www.prsglobalopen.com), Dr. Becker et al. propose a novel method for addressing retroareolar ductal carcinoma in-situ (DCIS) in patients undergoing nipple-sparing mastectomy. The article details the treatment course of a 50-year-old female patient who underwent bilateral nipple-sparing mastectomy for a unilateral grade II infiltrating ductal carcinoma. Intraoperative frozen section evaluation of the retroareolar tissue margin was positive for DCIS, a finding that traditionally warrants removal of the nipple-areolar complex and conversion to a traditional skin-sparing mastectomy. Postoperatively, the pathology results and management options were discussed with the patient who reaffirmed her decision to retain her nipple as long as any remaining cancerous tissue could be removed.
The residual retroareolar ductal tissue was approached through a vertical incision located at the center of the nipple in order to maximally preserve the already tenuous blood supply to the nipple-areolar complex (Figure 2). Following resection of the remaining glandular tissue, platelet-rich plasma was infiltrated and the wound closed. Nipple viability and cosmesis, as assessed by the authors 6 days postoperatively, were excellent.
This article seems to challenge the previously held dogma that nipple-sparing mastectomy is reserved for patients with small, peripherally located tumors.5 The authors suggest a more assertive approach to retroareolar involvement by the tumor margins. As such, it adds to the wealth of literature in support of the nipple-sparing mastectomy and its modifications as an oncologically acceptable option for women with more advanced breast disease. The authors’ method for the surgical removal of tumor-involved retroareolar tissue is an important tool for surgeons to consider that both preserves patient autonomy and avoids disfigurement.
1. Hinton CP, Doyle PJ, Blamey RW, et al. Subcutaneous mastectomy for primary operable breast cancer. Br J Surg. 1984;71:469–472
2. Wagner JL, Fearmonti R, Hunt KK, et al. Prospective evaluation of the nipple-areolar complex sparing mastectomy for risk reduction and for early-stage breast cancer. Ann Surg Oncol. 2012;19:1137-1144.
3. Lohsiriwat V, Rotmensz N, Botteri E, et al. Do clinicopathological features of the cancer patient relate with nipple areolar complex necrosis in nipple-sparing mastectomy? Ann Surg Oncol. 2013;20:990-996
4. De Alcantara Filho P, Capko D, Barry JM, et al. Nipple-sparing mastectomy for breast cancerand risk-reducing surgery: the memorial Sloan-Kettering Cancer Center experience. Ann Surg Oncol. 2011;18:3117-3122.
5. Spear SL, Hannan CM, Willey SC, Cocilovo C. Nipple-sparing mastectomy. Plast Reconstr Surg. 2009; 123(6):1665-1673.