Nipple-sparing mastectomy: initial experience at the Memorial Sloan-Kettering Cancer Center and a comprehensive review of literature.

Success achieved with skin-sparing mastectomy has led surgeons to reconsider the necessity of nipple-areola complex removal. This study reports our short- and mid-term postoperative outcomes with nipple-sparing mastectomy (NSM) and an updated review of reported literature. Data were retrospectively abstracted from medical records at our institution. Patients underwent NSM based on patient preference, oncologic criteria, and cosmesis. A literature review was undertaken through a PUBMED search and selected based on title and abstract relevance. Twenty-five patients underwent 42 NSMs at our institution from July 2000 to October 2005. Patient mean age was 44 years (29-59 years). Indications for mastectomy were: 34 (81%) for prophylaxis, 5 (12%) for invasive ductal carcinoma, 2 (5%) for ductal carcinoma in situ, and 1 (2%) for a malignant phyllodes tumor. One prophylactic mastectomy specimen showed ductal carcinoma in situ in the retroareolar tissue, and the nipple-areola complex was removed at a second operation. Mean tumor size in cases with invasive carcinoma (n = 5) was 1.9 cm (0.7-2.5 cm). All tumors were peripherally located, and no cases showed occult nipple involvement. The nipple-areola complex was entirely preserved in 39 (93%) mastectomies. One nipple-areola complex was surgically removed, and two (5%) cases had partial loss due to infection or ischemia. Cosmetic result from surgeon's assessment was excellent in 30 mastectomies, good in 7, acceptable in 3, and poor in 2, with slight nipple asymmetry in 8 cases. At a median follow-up of 10.5 months (range, 0.4-56.4 months), the 39 nipple-areola complexes were intact and there were no local or systemic recurrences in cases treated for cancer. NSM represented approximately 1% of all mastectomies performed at our institution during the reported period. It was mostly used for prophylaxis and for the treatment of malignant tumors in few selected cases. NSM can be performed with a high success rate of nipple-areola complex preservation. Conclusions about the oncologic safety of this procedure cannot be drawn from our study due to small size series and short follow-up. However, available published data show that NSM can be safely performed for breast cancer treatment in carefully selected cases. Further studies and longer follow-up are necessary to refine selection criteria for NSM.

Outcomes for women with ductal carcinoma-in-situ and a positive sentinel node: a multi-institutional audit.

BACKGROUND: A positive sentinel lymph node (SLN) has been reported in 6% to 13% of patients with ductal carcinoma in situ (DCIS). Although it is well established that nodal status for invasive disease is prognostically important, the clinical relevance of a positive SLN in patients with DCIS remains undetermined. METHODS: SLN biopsy was performed on 470 high-risk patients with DCIS (22% of all patients with DCIS) at 3 institutions. Of these, 43 (9%) had SLN metastases. Pathology findings of positive cases were reviewed, and follow-up was obtained. At 2 of the 3 institutions, data were also collected on DCIS patients who had negative findings on SLN biopsy. For these 414 patients, univariate analyses of tumor characteristics were performed to identify factors associated with node positivity. RESULTS: Extensive disease requiring mastectomy (p = 0.02) and the presence of necrosis (p = 0.04) were associated with an increased risk of nodal positivity. Three (7%) of the 43 SLN-positive patients had macrometastases (pN1), 4 (9%) had micrometastases (pN1mi), and 36 (84%) had single tumor cells or small clusters (pN0(i+)). Of the 25 women that underwent completion axillary dissection, one was found to have a macrometastasis. On pathological review of the primary lesion, 2 (5%) of 43 patints were found to have microinvasion, and 2 (5%) lymphovascular invasion. Nine of 43 (21%) high-risk DCIS patients with a positive SLN and 9/470 (2%) of all high-risk DCIS patients were upstaged to AJCC stage I or II as a result of the SLN biopsy. At a median (range) follow-up of 27 (3-88) months, 1 patient had developed hepatic metastases. This patient had immunohistochemistry detected isolated tumor cells in her SLN (N0(i+)), and upon pathologic review, was found to have high-grade DCIS with microinvasion. CONCLUSION: SLN biopsy for high-risk DCIS patients is a mean of detecting those who may have unrecognized invasive disease and therefore are at risk for distant disease.