Researchers examine 21-year series of nipple sparing mastectomy cases and find no cancers

Nipple sparing mastectomy (NSM) involves the removal of the breast tissue while keeping intact the breast skin and nipple areola complex, which includes the nipple and darker pigmented circle of skin that surrounds it. The breast is usually reconstructed immediately.

A long standing concern with this type of surgery is that cancer cells might be left under the nipple, posing a threat over time. To examine the effectiveness of NSM, surgeons conducted a review of patient records for all women receiving the surgery at Georgetown University Hospital (GUH) between 1989 and 2010 including surgeries to either prevent or treat breast cancer. The results are published in the November issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons.

"Our findings were reassuring. Of the 162 surgeries performed, we found no cancer recurrences and no new cancers in those receiving NSM," says Scott Spear, M.D., professor of plastic surgery at Georgetown University Medical Center and chairman of the department of plastic surgery at GUH. "The nipple-sparing technique is not appropriate for every patient depending upon their anatomy and type of breast pathology. Careful selection of the right patient for NSM is an important element of success."

Some patients who received NSM at Georgetown had early-stage cancer or DCIS, which can become an invasive cancer if not treated properly. In fact, while the majority of women with early cancers typically have a lumpectomy, many women choose to have a mastectomy.

Georgetown breast cancer surgeon Shawna C. Willey, M.D., says the first priority always is to treat or prevent the cancer. "We need to be able to offer women options that they know will successfully treat or prevent their cancer while at the same time, preserve their quality of life whether it be in their appearance or psychologically. Nipple sparing mastectomy goes a long way toward reaching that goal." Willey is chief of breast cancer surgery at GUH, and she and Spear are members of the Georgetown Lombardi Comprehensive Cancer Center.

One step credited for why cancers didn't develop later is that biopsies were done on the tissue that remained under the nipple area after the NSM. If abnormal cells in this tissue were identified, as it was in four cases reviewed, either the nipple or entire nipple areola complex later were removed.

A second concern for this kind of surgery is that the nipple areola complex (NAC) might not receive enough blood after the tissue and blood vessels below it are removed causing necrosis or tissue death. Researchers say the records showed three NACs became necrotic and required removal. Four other NACs had partial necrosis requiring surgery though the nipple and majority of the areola was spared.

"What we've learned from this review is that our established procedures and patient-selection protocol lead to favorable results," confirms Spear. "As more data become available, I think we'll see nipple sparing mastectomy play a larger role, particularly in the prevention setting."

This work was not supported by any external funding. In addition to Spear and Willey, authors include Elizabeth D. Feldman, M.D., Costanza Cocilovo, M.D., Mary Sidawy, M.D., Ali Al-Attar, M.D., Ph.D., Catherine Hannan, M.D., Laura Seiboth, M.D., and Maurice Y. Nahabedian, M.D. Spear and Nahabedian are paid consultants to Lifecell and Allergan Corporations. None of the remaining authors report having personal financial interests related to the study.