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Certain breast cancers may be suitable for still controversial nipple-sparing mastectomy
Study data not conclusive, but may aid in decision-making process.
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Data from a recent study show that identifying pathological findings associated with nipple involvement may aid in the use of nipple-sparing mastectomy among women with breast cancer. According to the researchers, 79% of patients who underwent therapeutic mastectomy had nipples with no invasive carcinoma or ductal carcinoma in situ.
Due to controversy over the oncological safety of nipple-sparing mastectomy, researchers aimed to assess the frequency and patterns of occult nipple involvement in patients who underwent mastectomy to offer guidance for determining which nipples may be preserved without jeopardizing patient safety.
The contemporary, prospective cohort study included 316 consecutive mastectomy specimens with grossly unremarkable nipples. Therapeutic mastectomy accounted for 232 of cases and prophylactic for 84. All nipples were examined in coronal sections, including subareolar tissue. Using the tissue deep to the skin as potential retroareolar en-face resection margin, the researchers evaluated the extent and location of nipple involvement by carcinoma.
Results of the study were published in The Journal of Clinical Oncology.
Nipple involvement rates low
Seventy-nine percent of nipples from therapeutic mastectomy had no ductal carcinoma in situ, invasive carcinoma or lymphatic invasion, compared with 21% of nipples that were involved by one or more patterns of malignancy. Most nipple involvement consisted of ductal carcinoma in situ (62%).
Tumor size, tumor-nipple distance, HER2 amplification, growth patterns of the carcinoma, histological grade, the presence of lymphovascular invasion and carcinoma in axillary lymph nodes influenced the likelihood of nipple involvement, according to the researchers. According to multivariate analysis, tumor size (P=.0126), tumor-nipple distance (P=.0176) and HER2 amplification (P=.0047) were predictive of nipple involvement by carcinoma. They reported no statistical relationship between multifocality, estrogen receptor status, BRCA1 or BRCA2 mutations, neoadjuvant chemotherapy or age.
The researchers studied the retroareolar margins in 45 of 49 nipples involved by invasive carcinoma, ductal carcinoma in situ or carcinoma in lymphatics. The sensitivity of the retroareolar tissue to indicate involvement by carcinoma was 0.8, yielding a negative predictive value of 0.96 for the tissue to indicate the absence of nipple involvement.
The data demonstrate that none of the nipples from prophylactic mastectomy contained invasive carcinoma, ductal carcinoma in situ or carcinoma in lymphatics. However, ductal carcinoma was present in eight of the prophylactic mastectomy specimens and three nipples showed lobular neoplasia.
“The clinical relevance of lobular neoplasia in the nipple is uncertain, and the associations between tumor characteristics and nipple involvement by invasive carcinoma, lymphatic invasion or ductal carcinoma in situ were largely independent of lobular neoplasia,” the researchers wrote. “Multifocal tumors were associated with the presence of lobular neoplasia in the nipple (P=.0008), although multifocality was not associated with other forms of nipple involvement.”
According to Stephen B. Edge, MD, FACS, department of surgical oncology at Roswell Park Cancer Institute in Buffalo, N.Y., the risk for local or regional recurrence after mastectomy is serious and residual cancer rates as high as 30% to 40% should not be accepted.
“Therefore, barring clinical trials demonstrating safety, the use of nipple-sparing mastectomy in most women who receive mastectomy — those with medical indications based on tumor size and extent — should be strongly discouraged,” he wrote in an accompanying editorial.
Though the current study does not provide data regarding the safety of nipple-sparing mastectomy, Edge noted that their detailed data does offer the framework for future long-term studies, supports concerns about nipple-sparing mastectomy and will help women who might choose mastectomy over breast-conserving therapy for certain early peripheral cancers or for breast cancer prevention. – by Stacey L. Adams
Brachtel EF. J Clin Oncol. 2009;doi:10.1200/JCO.2008.20.8785.
Edge S. J Clin Oncol. 2009;doi:10.1200/JCO.2009.23.9996.
[This study] is based on a larger number of patients, and the message is clear: about 30% of patients with primary breast cancer might have microscopic nipple involvement; therefore, selecting patients for nipple-sparing mastectomy needs to rule out microscopic nipple involvement for optimal local control.
– Gabriel N. Hortobagyi, MD
Professor of Medicine,
Nellie B. Connally Chair in
Breast Cancer,
The University of Texas M.D. Anderson Cancer Center
