1. Nipple Sparing Mastectomy
Margaret Thompson MD
Breast Surgery Oncology
September 25, 2018

2. HOW FAR HAVE WE COME?
Mastectomy pre anesthetic and pre antiseptic era

3. Radical Mastectomy

4. Breast Conserving Surgery (BCS)
Lumpectomy +/- SLNB/ALND
Gold standard for early breast cancer
Most commonly performed breast procedure worldwide
Provides enhanced cosmetic results
Less postoperative pain
Shorter recovery time

5. Why Are More Women Electing Prophylactic Mastectomies?
Increasing cancer awareness
Expansion of mammographic screening
Availability of BRCA 1 & 2 genetic testing
Development of statistical models for breast cancer risk stratification

6. Skin-Sparing Mastectomy (SSM)
Described in 1991
Resection of
Nipple-areola complex (NAC)
Any existing biopsy scars
Breast parenchyma
+/- SLNB/ALND
TOTAL BILATERAL MASTECTOMY WITH RECONSTRUCTION IN PROGRESS

7. Total Skin-Sparing Mastectomy (TSSM) = Nipple Sparing Mastectomy
NAC significant to woman’s body image & QOL
Growing public & surgeon interest in < radical & > cosmetic approaches
Conservation of breast skin & NAC
Provides best natural envelope for reconstruction
Preserving nipple, inframammary fold, & breast contour
↓ need for contralateral breast procedures to achieve symmetry
Preop
8 mths postop

8. Clinical arguments for & against the adoption of nipple sparing mastectomy (NSM)
Oncological safety & equivalency not defined in RCTs
No defined/standard incision, operative technique, or intra- op nipple assessment
High rate of nipple loss/sensitivity
Paucity of data XRT
Unproven appropriateness in BRCA 1/2
For
Scarcity of TDL
Cosmetic benefit
↓surgical procedures / anesthesia
Intraop XRT ↓ necrotic NAC
No difference in OS
Surveillances of reconstructed breast w/mammo & breast MRI

9. Oncologic Safety of NSM in Therapeutic Setting
No prospective randomized controlled trials evaluating safety & oncological effectiveness of NSM vs traditional breast surgery.

10. Opponents of NSM argue that nipple involvement in mastectomy specimens is high , ranging from 0-58%. And as such removal of th NAC is obligatory in all cases.

11. Sappey’s drawing of the superficial lymphatics of upper torso & female breast (1874)
This belief is primarily based on Sappey’s theory of centripetal lymphatic drainage which states all breast tissue drains toward the subareolar plexus.
If indeed Sappeys theory is correct, NSM would leave prominent retroareolar draining lymphatics behind and is oncologically unsound.

12. However, Turner-Warwich in 1959 demonstrated that lymphatic drainage of the breast is not towards the nipple but rather downwards towards the deep pectoral lymphatic plexus implying that preseration of the NAC may be safe.

13. TDLUs in the nipple? TDLU TDLU’s in the nipple? When TDLUs present
Basic reacting unit in all dysplastic, metaplastic, hyperplastic, anaplastic & neoplastic lesions of human breast is terminal duct lobular unit
Wellings Path Res Pract 1980
TDLU’s in the nipple?
Montagna failed to ID TDLUs in nipple
Br J Der 1970
TDLUs in up to 9% mastectomy specimens
Love, Cancer 2004; Taneri, EurSurgRes2005
When TDLUs present
Mostly located near base of nipple
No TDLUs found at tip when biopsy performed
Base of nipple intra-op biopsy
NAC preservation may not necessarily ↑ LRR
Wellings et al utilized who mount methodology and su gross microscopic exam to analyze 196 breaste specimens and concluded “the basic reacting unit in practically all dysplastic, metaplastic, hyperplastic, anaplastic, and neoplastic lesios of the human beast is the terminal duct lobular unit”.
Which rasies the ?, does leaving behind the NAC in NSM necessarily imply risk of LRR is increased?
Yes if there were TDLUs w/in the nipple .
Histological studies performed by Montana et al failed to ID any TDLUs in the nipple ,
Yet other authors have IDs TDLUs in up to 9% of mastectomy specimens.
Perhaps more importantly, when TDLUs were present, they were universally located near the base of the nipple and no TDLUS were found at the tip whenever bx was performed.
These findings suggest that as long as an I/O bx of the base of nipple is performed, NAC preservation may not increase rate of LRR.

14. Going back to table showing nipple involvement in mastectomy specimens is high , ranging from 0-58%.
Unfortunately lack of uniformity of these studies in regard to pt selection , tumor characteristics and sampling of specimens makes results highly variable.

15. Retrospective analysis of LRR patterns in pts who have undergone NSM show that LRR rates 0-8.5% are comparable to those following BCS and these recurrences are NOT centered around the NAC

16. N= 2,182 NSM, 2007 – 2016 w/cancer or risk reduction
Long term outcomes 311 NSM for Stages 0-3 BCs
240 (77%) NSM were for invasive cancer
71 (23%) DCIS
At 51m f/u 17 developed a recurrence
11 (3.7%) LRR & 8 (2.7%) DR
2 patients had simultaneous LRR & DR
2 breast cancer-related deaths in patients with isolated distant recurrences
Smith et al, JAmCollSurg.2017

17. Smith et al, JAmCollSurg.2017
DFS 3 yrs & 5 yrs

18. Smith et al JAmCollSurg.2017
No patient in 2,182 NSM cohort had recurrence in retained NAC
Smith et al
JAmCollSurg.2017

19. Smith et al, JAmCollSurg.2017
The Smith results are c/w those of other recent NSM series. LRR range from 0 to 4.6% at 10 to 60 months. Only 2 modern studies report any NAC recurrrences, and their rates are quite low at 0.7% and 0.8%.

20. TSSM & Immediate Breast Reconstruction Wang et al, 2014
Reviewed all cases
Comorbidities, treatment, postop complications, & outcomes
LR, DR, OS analyzed
633 patients (981 cases)
Median f/u time 29 m (14-54)
Imm breast recon: TEI (89%), pedicleTRAM (5%), free flap (5%), perm implant (0.3%), lat flap (0.2%)
Post op complications ↓ over time

21. 3%
Overall 5-year cumulative incidences of recurrence were 3.0 %(locoregional) and 4.2 %(distant), and there were no recurrences in the NAC skin

22. 4.2%
Overall 5-year cumulative incidences of recurrence were 3.0 %(locoregional) and 4.2 %(distant), and therewere no recurrences in the NAC skin

23. Overall Survival after TSSM by Clinical Stage
93%
Overall 5 year survival was 93%
Specifically 97% for stage 0; 98% stage I; 96% for stage II; 74% stage III ds, and 33% for stage IV ds

24. Indications for NSM High risk BRCA carriers Small tumors
Tumors > 2 cm (?) from NAC
No skin / NAC involvement
Smaller / non ptotic breast
No LVI, axillary LN+, EIC

25. Contraindications of NSM
Inflammatory breast cancer
Large / ptotic breast
Delayed reconstruction
Smokers/diabetics
Tumor < 2 cm (?) from NAC
NAC involvement

34. Complications Bleeding Seroma Infection Tissue necrosis
Capsular contracture

35. Follow up after NSM Same as simple & skin sparing mastectomy
No screening imaging needed
No mammogram , no US, no MRI
Consider US / MRI for +complaints/findings
F/u according to ASCO recommendations based on primary diagnosis

36. NSSM Summary
For most women with breast cancer BCS is the preferred option.
The coordinated use of systemic therapy can maximize the odds of BCS in most women.
NSSM is an ideal option for prophylactic mastectomy and for well selected CA patients who have no choice but mastectomy.

37. NSSM Summary
Oncologically safe in well selected patients with invasive cancer or DCIS
An excellent option for prophylactic mastectomy
All of the well established BCS data has suggested that nipple removal does not confer a survival advantage
NAC recurrence as sole site of LR is very rare
LR in mastectomy flaps with or without NAC preservation is comparable in selected patient trials
Cosmetic results particularly in prophylactic mastectomy cases are superior
Psychological benefit may be substantial

38. Thank You