Not Found
Locations

Find information on medical topics, symptoms, drugs, procedures, news and more, written for the health care professional.

Nipple-Sparing Mastectomy a Safe Choice for Many Patients—Commentary

8/15/2017 Faisal Al-Mufarrej, MD, Assistant Professor of Plastic and Reconstructive Surgery, Wayne State University School of Medicine; Mary Ann Kosir, MD, Professor of Surgery and Oncology, Wayne State University School of Medicine

In a recent report from the Massachusetts General Hospital, there were no breast cancer recurrences involving the nipple-areolar complex in 311 patients undergoing nipple-sparing mastectomy (NSM) with a median followup of 51 months [ref 1].

NSM has been shown to provide better aesthetic results and quality of life for patients with breast cancer when compared to non-nipple–sparing mastectomy techniques [ref 2, 3]. The adoption of NSM in treating breast cancer, however, has been mixed due to lack of prospective randomized trials, which are now unlikely given the procedure has been in use for over a decade. Instead, outcomes data are reported to assist evaluation of results.  This report supports the use of NSM for patients with breast cancer as long as it

  • Is not inflammatory
  • Does not involve the nipple-areolar complex
  • Is not associated with nipple discharge
  • Is not locally advanced with skin involvement 

In addition, NSM was precluded by the presence of elongated breasts (ptosis) or large breast size. 

The earliest reports of NSM demonstrated the effectiveness and safety of the technique in breast cancer prophylaxis in patients with genetic mutations (eg, BRCA) [ref 4]; however, it remains unclear whether NSM has acceptable recurrence rates in patients with known breast cancer in the setting of a known genetic predisposition.  This study included only 33 cancer patients with genetic mutations, so it is unclear whether NSM is appropriate, and these patients should be given that information in order to make an informed decision regarding the procedure. Similarly, the follow-up in this study and others is not long enough to determine the safety of NSM for patients with hormone receptor-positive cancers, so such patients should be advised of a possible increased risk of late recurrence.

While there are technical guidelines from the American Society of Breast Surgeons (ASBrS) [ref 5], variations in the technique of NSM remain and may impact not only cosmetic results and complication rates (particularly nipple necrosis), but also risk of recurrence [ref 2].  The group in this study did use a standardized technique, reducing this variable.  So, this report invigorates the review of strict inclusion criteria based on the breast cancer, and the technical details required. 

Within one year, clinical practice guidelines from NCCN have not only introduced NSM, but changed from stricter criteria (eg, the breast cancer should be more than 2 cm from nipple, Grade 1–2, node negative, HER2/neu negative, no lymphovascular invasion) to a more general statement that as long as early stage and biologically favorable (without further definition), then NSM may be applied [ref 6], while still including the criteria as reported from Mass General.  A registry of 2000 cases collected by the ASBrS still requires analysis, which may further clarify practice guidelines.  

Further standardization is required for aesthetic evaluation of ptotic and large breasts, which usually preclude the performance of NSM, although now, especially with the availability of intraoperative perfusion assessment tools [ref 7], there is active effort to combine mastopexy with NSM despite lack of standardization in non-ptotic breasts [ref 8].

The report moves the field forward by describing a standardized technical approach while broadening the eligibility for NSM.  The national guidelines, though, are still not mature.  There is enthusiasm for broadening indications for therapeutic NSM for the treatment of breast cancer after neoadjuvant chemotherapy, for patients with genetic mutations, and even for patients with large and/or ptotic breasts [ref 9].  However, while this evaluation continues, NSM can only be offered to breast cancer patients with the oncologic and aesthetic considerations as reported here.  

References

1. Smith BL, Tang R, Rai U, et al: Oncologic safety of nipple-sparing mastectomy in women with breast cancer.  J Am Coll Surg publication in process, 2017. doi: 10.1016/j.jamcollsurg.2017.06.013

2. Moyer HR, Ghazi B, Daniel JR, et al: Nipple-sparing mastectomy: Technical aspects and aesthetic outcomes.Ann Plast Surg. 68(5):446–450, 2012.

3. Bailey CR, Ogbuagu O, Baltodano PA, et alQuality-of-life outcomes improve with nipple-sparing mastectomy and breast reconstruction. Plast Reconstr Surg 140(2):219–226, 2017.

4. Hartmann LC, Schaid DJ, Woods JE, et alEfficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. N Engl J Med 340(2):77–84, 1999.

5. American Society of Breast Surgeons: Performance and Practice Guidelines for Mastectomy. Columbia, Maryland, American Society of Breast surgeons, 2014.

6. National Comprehensive Cancer Network: NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Breast Cancer.  Version 2.2017.  

7. Venturi ML, Mesbahi AN, Copeland-Halperin LR, et al: SPY Elite's ability to predict nipple necrosis in nipple-sparing mastectomy and immediate tissue expander reconstruction. Plast Reconstr Surg Glob Open  5(5):e1334, 2017.

8. Folli S, Mingozzi M, Curcio A, et al: Nipple-sparing mastectomy: An alternative technique for large ptotic breasts.  J Am Coll Surg 220:e65-e69, 2015. 

9. Galimberti V, Vicini E, Corso G, et al: Nipple-sparing and skin-sparing mastectomy: Review of aims, oncologic safety and contraindications. The Breast  publication in process, 2017. doi: 10.1016/j.breast.2017.06.034

breast surgery-tn

Nipple-Sparing Mastectomy a Safe Choice for Many Patients—Commentary

8/15/2017 Faisal Al-Mufarrej, MD, Assistant Professor of Plastic and Reconstructive Surgery, Wayne State University School of Medicine; Mary Ann Kosir, MD, Professor of Surgery and Oncology, Wayne State University School of Medicine

In a recent report from the Massachusetts General Hospital, there were no breast cancer recurrences involving the nipple-areolar complex in 311 patients undergoing nipple-sparing mastectomy (NSM) with a median followup of 51 months [ref 1].

NSM has been shown to provide better aesthetic results and quality of life for patients with breast cancer when compared to non-nipple–sparing mastectomy techniques [ref 2, 3]. The adoption of NSM in treating breast cancer, however, has been mixed due to lack of prospective randomized trials, which are now unlikely given the procedure has been in use for over a decade. Instead, outcomes data are reported to assist evaluation of results.  This report supports the use of NSM for patients with breast cancer as long as it

  • Is not inflammatory
  • Does not involve the nipple-areolar complex
  • Is not associated with nipple discharge
  • Is not locally advanced with skin involvement 

In addition, NSM was precluded by the presence of elongated breasts (ptosis) or large breast size. 

The earliest reports of NSM demonstrated the effectiveness and safety of the technique in breast cancer prophylaxis in patients with genetic mutations (eg, BRCA) [ref 4]; however, it remains unclear whether NSM has acceptable recurrence rates in patients with known breast cancer in the setting of a known genetic predisposition.  This study included only 33 cancer patients with genetic mutations, so it is unclear whether NSM is appropriate, and these patients should be given that information in order to make an informed decision regarding the procedure. Similarly, the follow-up in this study and others is not long enough to determine the safety of NSM for patients with hormone receptor-positive cancers, so such patients should be advised of a possible increased risk of late recurrence.

While there are technical guidelines from the American Society of Breast Surgeons (ASBrS) [ref 5], variations in the technique of NSM remain and may impact not only cosmetic results and complication rates (particularly nipple necrosis), but also risk of recurrence [ref 2].  The group in this study did use a standardized technique, reducing this variable.  So, this report invigorates the review of strict inclusion criteria based on the breast cancer, and the technical details required. 

Within one year, clinical practice guidelines from NCCN have not only introduced NSM, but changed from stricter criteria (eg, the breast cancer should be more than 2 cm from nipple, Grade 1–2, node negative, HER2/neu negative, no lymphovascular invasion) to a more general statement that as long as early stage and biologically favorable (without further definition), then NSM may be applied [ref 6], while still including the criteria as reported from Mass General.  A registry of 2000 cases collected by the ASBrS still requires analysis, which may further clarify practice guidelines.  

Further standardization is required for aesthetic evaluation of ptotic and large breasts, which usually preclude the performance of NSM, although now, especially with the availability of intraoperative perfusion assessment tools [ref 7], there is active effort to combine mastopexy with NSM despite lack of standardization in non-ptotic breasts [ref 8].

The report moves the field forward by describing a standardized technical approach while broadening the eligibility for NSM.  The national guidelines, though, are still not mature.  There is enthusiasm for broadening indications for therapeutic NSM for the treatment of breast cancer after neoadjuvant chemotherapy, for patients with genetic mutations, and even for patients with large and/or ptotic breasts [ref 9].  However, while this evaluation continues, NSM can only be offered to breast cancer patients with the oncologic and aesthetic considerations as reported here.  

References

1. Smith BL, Tang R, Rai U, et al: Oncologic safety of nipple-sparing mastectomy in women with breast cancer.  J Am Coll Surg publication in process, 2017. doi: 10.1016/j.jamcollsurg.2017.06.013

2. Moyer HR, Ghazi B, Daniel JR, et al: Nipple-sparing mastectomy: Technical aspects and aesthetic outcomes.Ann Plast Surg. 68(5):446–450, 2012.

3. Bailey CR, Ogbuagu O, Baltodano PA, et alQuality-of-life outcomes improve with nipple-sparing mastectomy and breast reconstruction. Plast Reconstr Surg 140(2):219–226, 2017.

4. Hartmann LC, Schaid DJ, Woods JE, et alEfficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. N Engl J Med 340(2):77–84, 1999.

5. American Society of Breast Surgeons: Performance and Practice Guidelines for Mastectomy. Columbia, Maryland, American Society of Breast surgeons, 2014.

6. National Comprehensive Cancer Network: NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Breast Cancer.  Version 2.2017.  

7. Venturi ML, Mesbahi AN, Copeland-Halperin LR, et al: SPY Elite's ability to predict nipple necrosis in nipple-sparing mastectomy and immediate tissue expander reconstruction. Plast Reconstr Surg Glob Open  5(5):e1334, 2017.

8. Folli S, Mingozzi M, Curcio A, et al: Nipple-sparing mastectomy: An alternative technique for large ptotic breasts.  J Am Coll Surg 220:e65-e69, 2015. 

9. Galimberti V, Vicini E, Corso G, et al: Nipple-sparing and skin-sparing mastectomy: Review of aims, oncologic safety and contraindications. The Breast  publication in process, 2017. doi: 10.1016/j.breast.2017.06.034