Predicting nipple-areolar involvement using preoperative breast MRI and primary tumor characteristics.

Abstract

40 Background: Preoperative assessment of the nipple-areolar complex (NAC) is invaluable when considering nipple-sparing mastectomy (NSM). We hypothesized that breast MRI could predict involvement of the NAC with tumor. Methods: We compiled clinical, pathologic and imaging data for patients who underwent preoperative breast MRI followed by mastectomy or NSM between 2006 and 2009. Blinded rereview of all MRI studies was performed by a breast MRI imager and compared to initial MRI findings. Multivariate analysis identified variables predicting NAC involvement with tumor. Results: Of 77 breasts, 18 (23%) had tumor involving or within 1 cm of the NAC. The sensitivity of detecting pathologically confirmed NAC involvement was 61% with history and/or physical exam, and 56% with MRI. Univariate analysis identified the following variables as significant for NAC involvement: large tumors close to the nipple on preoperative MRI, node-positive disease, invasive lobular carcinoma, advanced pathologic T stage, and neoadjuvant chemotherapy. On multivariate analysis, only tumor size > 2 cm and distance to the NAC < 2 cm on MRI maintained significance. Pearson correlation coefficient for MRI size compared to pathologic size was 0.53 (p<0.0001). Conclusions: MRI is not superior to thorough clinical evaluation for predicting tumor in or near the NAC. However, MRI-measured tumor size and distance from the NAC are correlated with increased risk of NAC involvement. Preoperative history and physical examination, tumor characteristics, plus breast MRI can aid the surgeon in planning for successful NSM.

MRI and intraoperative pathology to predict nipple–areola complex (NAC) involvement in patients undergoing NAC-sparing mastectomy

“…To the best of our knowledge, the only similar prospective study reported a sensitivity of 28% and a specificity of 100% for the initial MRI report, while a blinded re-review of all MRI scans Table 3 Diagnostic performance of preoperative MRI assessment, intraoperative pathological assessment and combined assessment on the prediction of NAC involvement. looking specifically for NAC involvement increased sensitivity to 56% and lowered specificity to 95% [19]. Our study confirms the crucial role of intra-operative pathological assessment of the NAC whose diagnostic performance was as good as that of the combined assessment (MRI + pathological), except for a lower sensitivity.…”

“…The higher figure of NAC involvement in the current series may be due to a pathological protocol specifically aimed at assessing tumour infiltration of SD and ND, whereas the protocol of our previous retrospective study relied on a standard pathological assessment of the NAC [18]. Indeed, other studies of NAC sparing mastectomy with similar criteria of pathological assessment show NAC involvement rates comparable to our current study [19]. In order to facilitate surgical planning, other groups have explored the relationship of several preoperative clinical and radiological parameters with the likelihood of NAC involvement (Table 4).…”

“…Data on preoperative assessment of the NAC by MRI are more encouraging [18,19]. In our previous retrospective study [18], by setting the cut-off of the tumour-NAC distance at 10 mm, MRI outperformed MX in the prediction of NAC involvement with a sensitivity of 100% versus 71% and a specificity of 66% versus 63% respectively.…”

“…The rates of tumour NAC involvement in the literature are inconsistent [14][15][16][17][18][19][20][21] likely due to different pathological protocols for NAC evaluation and variable accuracy of clinical and pathological data collection. For example, a recent systematic review of the literature showed that only 6.4% of the nipple cores of 2477 NAC sparing mastectomies were involved with tumour [13].…”

“…We recently showed that tumour-NAC distance measured by magnetic resonance imaging (MRI) of the breast is the key preoperative predictor of NAC involvement in a series of total mastectomies performed at our Institution [18]. Furthermore, intra-operative evaluation of the retro-areolar tissue is very sensitive for detecting cancer cells in the sub-areolar tissue with a false negative rate as low as 11.8% [19].…”