Tumor Involvement of the Nipple in Total Skin-Sparing Mastectomy: Strategies for Management

Abstract

Despite expanding indications for TSSM, it can be performed safely with low rates of nipple involvement. Over time, tumor involvement of the nipple has been treated with re-excision or other alternative approaches to NAC removal that preserve the aesthetic benefits of total skin-sparing approaches without an early adverse impact on local recurrence.

The Nipple is Just Another Margin

“…Many techniques have been described. Amara et al 2 perform inversion of the nipple and excision of the nipple tissue at the dermal junction, then core out the inside of the nipple as a separate specimen. They then mark the subareolar margin, deep only to the NAC on the mastectomy specimen, for pathologic examination.…”

“…9 When a technique similar to that of Amara et al 2 was used, sharply dividing breast tissue from under NAC skin and marking the subareolar tissue for analysis, the subareolar tissue specimen did not reliably contain ductal tissue. Rusby et al 9 hypothesized that the divided duct bundle retracted into the mastectomy specimen and therefore was not present in the sampled tissue from the surface of the mastectomy specimen.…”

“…Accurate nipple margin assessment on frozen section is difficult, and distinguishing benign atypia from intraductal carcinoma can be challenging, potentially resulting in unnecessary nipple excision. As Amara et al 2 and Rusby et al 9 suggest, permanent section analysis of nipple margins appears to be the best strategy for maximizing nipple preservation.…”

“…When a nipple margin specimen from an NSM is found to contain tumor, management options include complete excision of the NAC, full-thickness excision of the nipple with preservation of the areola (not described in the article of Amara et al 2 ), radiation of the retained nipple, or observation alone, with or without systemic therapy. Amara et al 2 add the option of re-excising the nipple margin with preservation of nipple skin.…”

“…Amara et al 2 add the option of re-excising the nipple margin with preservation of nipple skin. However, if the nipple margin is obtained in the manner described by Amara et al 2 or Rusby et al 9 there should be no residual nipple tissue or subareolar breast tissue to re-excise, and it seems possible that re-coring the nipple could compromise nipple viability, making this option less attractive.…”