Nipple-sparing Mastectomy Offers Better Cosmetic and Psychological Outcomes for Patients With Breast Cancer
Nipple-sparing mastectomy (NSM) is associated with better body self-image.
SAN ANTONIO, TX—Women who underwent nipple-sparing mastectomy (NSM) and immediate breast reconstruction had better body image and sexual functioning compared with women who underwent SS-PM, although both groups had comparable levels of cancer-related distress and perception of breast cancer risk. These findings were presented in an education session at the San Antonio Breast Cancer Symposium.1
Preserving the nipple areola complex (NAC) in breast reconstruction after mastectomy has been shown to reduce the risk of local recurrence of disease, with or without localized radiation therapy. In addition, nipple-sparing mastectomies (NSMs) offer good cosmetic outcomes, can improve psychological outcomes for patients, and reduces the risk of local recurrence.
Postsurgical evaluation of the cosmetic results achieved with NSM demonstrate overall ratings of excellent to good from both patients and surgeons. Complications leading to revisions include NAC necrosis, severe radodystrophy, mild depigmentation, facing of the areola, and asymmetry and capsular contracture.
Psychological questionnaire was administered to 310 patients who underwent NSM and 143 patients who underwent NAC reconstruction (control group). Asked about satisfaction with the appearance of their nipple, 152 NSM respondents were more likely to respond quite a bit (35%), much (a little more than 25%), or very much (15%). Satisfaction with nipple sensitivity was low in both groups, but significantly higher in the control group (not at all: NSM, almost 40%; control, more than 60%). Difficulty looking at themselves naked or being seen naked by their partner were low in both groups as well (not at all: NSM, 50% and more than 40%, respectively; control, 40% and 35%, respectively). However, a significant number of respondents in both groups reported their feeling of mutilation as a little (NSM, more than 45%; control, almost 30%).
In 2013, 820 breast reconstruction after mastectomy were performed in patients with invasive carcinoma or in situ disease, 451 of which were NSMs. Subcutaneous mastectomy is a 50-year-old procedure, and advances in surgical technique allow for a more radical glandular removal in the retro areolar area, explained Jean-Yves Petit, of the Istituto Europeo di Oncologia (EIO). In the technique described by Petit, a layer of glandular tissue should be left beneath the NAC to avoid NAC necrosis; however, this has potential for risk of local recurrence.
Nipple core biopsy is obtained and immediate breast reconstruction with a prosthesis and a mesh commences. Significant risk factors associated with local recurrence in cases of invasive carcinomas include grade, over expression/amplification of HER2, and breast cancer molecular subtype luminal B. Risk factors in cases of intraepithelial neoplasia were age younger than 45 years, absence of estrogen receptors, grade, HER2 overexpression, and high Ki-67.4
Although several ducts originate from the base of the areola, most are concentrated in the axis of the nipple; therefore, a subtotal removal of the duct can be performed but the extent of duct resection in the nipple determines whether intraoperative radiotherapy is needed. ELIOT radiation technique (one shot at 45 Gy) on the remaining glandular tissue can be administered to complete the cancer treatment. At EIO, radiotherapy is administered to the NAC only in cases of nonradical cancer resection.
1. Petit JY. Nipple sparing mastectomy: technique, psychological indications and cancer safety. Oral presentation at: San Antonio Breast Cancer Symposium; December 8-12, 2015; San Antonio, TX.