Tumor-to-Nipple Distance in Selecting Patients for Nipple-sparing Mastectomy

Abstract

Introduction: Nipple-sparing mastectomy (NSM) is a valid option for carefully selected cases. Oncologic guidelines have not been established, but proximity of the tumor to the nipple, tumor size, lymph node involvement, and neoadjuvant chemotherapy have been suggested as contraindications to nipple preservation. This study describes our experience with NSM in relation to these factors, in particular distance of tumor from the nipple, to help establish evidence-based guidelines for NSM. Method: All NSM procedures performed at our institution between 2014 and 2018 were reviewed. The tumor-to-nipple distance was measured for each patient using mammography, ultrasound, or magnetic resonance imaging. All patients underwent a frozen section (FS) biopsy of the base of the nipple during surgery, and if cancer was detected, the procedure was converted to a skin-sparing mastectomy. Patients were followed for postoperative complications and cancer recurrence. Results: Sixty-eight patients (98 breasts) underwent NSM with immediate reconstruction. Fifty-three patients (78%) underwent the procedure for breast cancer. Nipple involvement was detected on FS in 1 patient and on permanent pathology after a negative FS in 1 patient. Forty-three percent of our patients had a tumor-to-nipple distance of ≤2 cm. During a mean follow-up of 32.5 months (±19.4 months), no locoregional recurrences were observed; however, distant metastasis occurred in 3 patients. Conclusions: When histologic examination from the base of the nipple is negative (either by FS or permanent pathology), NSM can be considered oncologically safe. Lack of nipple involvement by preoperative clinical and imaging assessment and intraoperative FS is sufficient to classify patients as suitable for NSM.

Hyperbaric Oxygen Therapy for Complications in Nipple-Sparing Mastectomy with Breast Reconstruction: A Systematic Review

“…Following established protocols for patient selection is vital when considering individuals for NSM candidacy. These protocols commonly involve criteria such as the absence of nipple involvement, tumor size, clinical examination results, lymph node involvement, and anatomical considerations [ 9 ].…”

“…Another parameter investigated for performing an NSM procedure is the tumor-to-nipple distance (TND). There is no strict range for TND, as it varies depending on the guidelines consulted [ 9 ]. A retrospective study compared patients who had a TND greater than 1 cm to those with a TND greater than 2 cm and found that there was no significant difference in the rate of NAC preservation among each group.…”

“…Another retrospective study revealed similar results, concluding that TND, along with factors such as tumor size and multicentric cancers, should not be absolute exclusion criteria for NSM. However, favorable limits for these factors can be easily determined using further imaging studies, such as an MRI [ 9 ].…”

A systematic review of oncological outcomes after nipple‐sparing mastectomy for breast cancer

“…Whilst residual breast tissue is left behind in both SSM and NSM, 30 NSM also involves leaving a small amount of ductal tissue behind the nipple which could harbour occult malignancy or develop breast cancer in the future. Occult involvement of the NAC occurs in less than 5% of patients undergoing therapeutic mastectomy, and is associated with tumour size, grade, distance from the tumour to the nipple, and nodal positivity 7,31–34 . Consequently, an intra‐operative sample of retro‐areolar tissue may be sent for frozen section to exclude involvement.…”

“…Occult involvement of the NAC occurs in less than 5% of patients undergoing therapeutic mastectomy, and is associated with tumour size, grade, distance from the tumour to the nipple, and nodal positivity. 7,[31][32][33][34] Consequently, an intra-operative sample of retro-areolar tissue may be sent for frozen section to exclude involvement.…”