Patient selection and breast imaging

Abstract

Patient selection criteria for nipple-sparing mastectomy (NSM) are evolving as data accumulate showing acceptable locoregional recurrence rates and surgical outcomes. Currently, absolute contraindications to NSM are inflammatory breast cancer, Paget’s disease of the nipple, clinical or imaging evidence of nipple-areola complex (NAC) involvement, and a positive intraoperative frozen section of subareolar or nipple core specimen (if performed). Extensive tumor involvement of the skin is a contraindication, although NSM may be permissible in this situation with resolution of skin findings after neoadjuvant chemotherapy. Other risk factors for NAC involvement (large tumor size, retroareolar location, tumor-to-nipple distance <2 cm, multicentricity, extensive intraductal component, micropapillary carcinoma, axillary nodal metastasis, HER2 positivity, ER/PR negativity, lymphovascular invasion, high tumor grade) do not preclude NSM, but can be used to inform a patient about the risk of positive subareolar margin requiring NAC excision. BRCA 1/2 mutation carriers are candidates for risk-reducing or therapeutic NSM, with low risk of short-term recurrence or de novo cancer in the NAC, although long-term data are lacking. Prior or planned postoperative breast radiation, current smoking, and obesity are risk factors for technical complications after NSM, and should be considered in determining NSM candidacy. Very large or ptotic breasts pose a technical challenge to obtaining excellent cosmetic results after NSM, and modified approaches to NSM have been reported in such patients. In a surgeon’s early experience with NSM, it is advisable to select candidates without risk factors for technical complications. MRI is more sensitive than mammogram for detecting malignant NAC involvement, but should be undertaken selectively due to a high false positive rate. Subareolar mammotome biopsy and nipple delay procedure with subareolar biopsy have been proposed for preoperative histologic assessment of the NAC margin.