Annals of Surgical Oncology 9:165-168 (2002)
© 2002 Society of Surgical Oncology
Analysis of Nipple/Areolar Involvement With Mastectomy: Can the Areola Be Preserved?
Rache M. Simmons, MD, FACS,
Meghan Brennan, RN, ONP, MSN, OCN,
Paul Christos, MPH, MS,
Valencia King, BS and
Michael Osborne, MD FACS
From the Departments of Surgery (RMS, MO) and Public Health (PC), Weill Medical College of Cornell University (VK); the New York Presbyterian Hospital (RMS, MO); and the Strang Weill Cornell Breast Center (MB), New York, New York.
Correspondence: Address correspondence and reprint requests to: Rache M. Simmons, MD, FACS, 425 E. 61st St., 8th Floor, New York, NY 10021; Fax: 212-821-0832; E-mail: rms2002{at}med.cornell.edu
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ABSTRACT
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Background: Skin-sparing mastectomy (SSM), which involves the resection of the nipple/areolar complex with the breast parenchyma, improves the aesthetic outcome for breast cancer patients. Most patients undergoing SSM desire reconstruction of the nipple/areolar complex for symmetry. These data explore the possibility of preserving the areola in selected mastectomy patients.
Methods: A retrospective analysis of 217 mastectomy patients was conducted to determine the frequency of malignant nipple and/or areola involvement. The association between nipple and/or areola involvement and prognostic factors, including tumor size, stage, nuclear grade, axillary nodal status, and tumor location, was evaluated.
Results: The overall frequency of malignant nipple involvement was 23 of 217 (10.6%). In a subgroup of patients with tumors <2 cm, peripheral tumors, and with two positive nodes or less, the incidence of nipple involvement was 6.7%. When the nipple and areolar involvement were analyzed separately, only 2 of 217 patients had involvement of the areola (0.9%). All patients with areolar involvement had stage 3 breast cancer and were located centrally in the breast.
Conclusions: We conclude from these data that nipple preservation is not a reasonable option for mastectomy patients. However, preservation of the areola with mastectomy in selected patients warrants further study.
Key Words: Areola preservation • Skin-sparing mastectomy • Nipple involvement • Breast reconstruction
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INTRODUCTION
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The cosmetic result of mastectomy and immediate reconstruction can be greatly improved by the resection of less skin with skin-sparing incisions.1 The technique of skin-sparing mastectomy (SSM) has been defined as the resection of the nipple/areolar complex, any existing surgical biopsy scars, and the entire breast parenchyma.2 Multiple studies have shown that SSM results in no higher incidence of local recurrence2–5 or distant recurrence2,4 than a traditional non-SSM. These data explore the incidence of nipple/areolar malignant involvement in patients with breast cancer and the possibility of areolar preservation in selected patients undergoing mastectomy.
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METHODS
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A retrospective analysis of 217 patients treated with mastectomy from 1990 to 1998 was conducted to determine the frequency of malignant involvement of the nipple, areola, or both. Malignant involvement of the nipple or areola was defined as invasive carcinoma, ductal carcinoma in situ, or Paget’s disease. These patients included those treated with SSMs and non-SSMs. Patients with clinical involvement were not excluded from the study.
Chi-square analysis (or Fisher’s exact test) was used to evaluate the association between nipple/areola involvement and prognostic factors, including tumor size, stage, nuclear grade, axillary nodal status, and tumor location. Exact 95% confidence intervals were calculated to quantify the precision of the estimates, and P values are two sided, with statistical significance evaluated at the .05 alpha level.
The nipple/areolar pathologic sectioning was conducted by resecting the button of the nipple from the areolar base, by bread-loaf sectioning of the nipple at 3-mm intervals, and by tangential sectioning of the remaining nipple/areolar base.
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RESULTS
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The overall frequency of malignant involvement of the nipple among the patients was 23 (10.6%) of 217. Several subsets were analyzed to investigate a category of patients with little or no nipple malignant involvement (Table 1). Even in small tumors (<1 cm), the presence of malignancy was noted in 9.75% of patients. When comparing patients with tumors <2 cm with patients with tumors 
2 cm, nipple involvement occurred in 12.1% and 8.9%, respectively (P = .45). There was nipple tumor involvement in patients of all nuclear grades, with the presence of malignancy noted in 13.8%, 8.2%, and 9.8% of patients with a nuclear grade of 1, 2, or 3, respectively (P = .73).
Of the 71 patients with axillary lymph node metastases, the median number of positive nodes was 3. Within the node-positive patients, 38 of 71 had three or fewer positive nodes, and 33 of 71 patients had more than three positive nodes. Of the group with three or fewer nodes involved, 0% had malignant areolar involvement and 5.3% had nipple involvement. In the group with three or more nodes involved, 3 (9%) of 33 had nipple involvement of tumor, and 2 (6%) of 33 had areolar involvement (P = .24).
When categorized by stage of tumor, the nipple was involved in 15.6% of stage 0 patients. There was no significant difference by stage, with nipple involvement detected in 11.0% of patients with stage 0 and 1 tumors and in 9.1% of patients with stage 2 and 3 tumors (P = .65).
The only variable that reliably predicted nipple involvement was the location of the breast cancer. The nipple was involved in only 6.4% of patients with tumors located in the lower inner, lower outer, upper inner, or upper outer quadrants of the breast, compared with 27.3% of patients with tumors located in central, diffuse, or retroareolar areas of the breast (P = .0003; Table 2). This was also observed for patients with tumors <2 cm and with those located in the lower inner, lower outer, upper inner, or upper outer quadrants versus those located in the central/diffuse/retroareolar area, with a 6.7% vs. 29.6% rate of malignant nipple involvement, respectively (P = .004).
When the nipple and areolar involvement were analyzed separately, only 2 (.9%) of 217 patients had involvement of the areola. Both patients with areola involvement had large (>5 cm) tumors located in the central/diffuse/retroareolar area and had more than two positive axillary nodes. Histologically, one of these tumors was an infiltrating ductal carcinoma, and the other was an infiltrating lobular carcinoma. Only patients with stage 3 had areolar involvement. Both patients with areolar involvement also had nipple involvement (Table 3).
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DISCUSSION
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The cosmetic result of mastectomy and immediate reconstruction can be greatly improved by the resection of less skin with skin-sparing incisions. Multiple studies have shown that SSMs have no higher incidence of local recurrence2–5 or distant recurrence2,4 than traditional non-SSMs. Historically, SSMs have included resection of the nipple and areola because of the reportedly high incidence of malignant cells contained within the nipple/areolar complex and the assumed increased recurrence risk should the complex not be removed. Several studies have shown malignant involvement of the areola/nipple to be present in 5.6% to 43% of mastectomy specimens6–12; however, none of these studies separated the respective involvement of the nipple and the areola. In this analysis, in which the malignant involvement of the areola versus nipple was analyzed separately, areolar involvement was detected in <1% of patients and only in those with diffuse invasive carcinomas and multiple positive axillary lymph nodes. No patient with stage 0, 1, or 2 breast carcinoma had areolar involvement. All patients with areolar involvement also had involvement of the nipple.
These data support the use of areola-sparing mastectomy with surgical excision of the breast and the nipple as a potential treatment for selected patients. Even in prophylactic mastectomies, leaving the nipple would justify some concern because of its lining of ductal cells. Any one of these ductal cells could potentially develop into a future breast cancer. The areolar disk differs from the nipple because it does not contain breast parenchymal ducts.
We have changed our SSM technique in selected patients, such as those with ductal carcinoma in situ and those undergoing prophylactic mastectomy, to also spare the skin of the areola. Sentinel node biopsy is still performed if indicated. We have performed this technique of areolar-sparing mastectomy on breasts with ductal carcinoma in situ and on prophylactic mastectomies. We have not, to date, performed this technique on patients with small peripheral invasive carcinoma, although they would be reasonable candidates according to these data. The nipple is still resected intact with the entire breast parenchyma. The surgical incisions used in this approach are an S incision or an extension of the inverted T reduction–type incision (Figs. 1–3). At the time of reconstruction, the areola is assessed for viability. If the viability of the areolar tissue is questionable, it is resected, and the procedure is converted to a standard SSM. All patients whose tissue was considered viable and who underwent areolar-sparing mastectomy have had successful recovery without necrosis or epidermolysis of the areola. Any data on areolar sensation would be too premature for evaluation at this time.
For one patient with ductal carcinoma in situ and microinvasion, touch preparation cytology was performed on the posterior surface of the areola. On intraoperative evaluation, these cytological smears showed no malignant cells. This cytological test has been shown to be quite sensitive in detecting carcinoma cells on a tissue surface.13–15 A negative touch preparation cytology gives support to the oncological validity of this procedure.
Patients undergoing areolar-sparing mastectomy would be observed clinically in a similar fashion to patients undergoing SSM, with particular attention to the physical examination of the areolar disk. Any suspected recurrence would be diagnosed and managed in the same way as a skin recurrence with an SSM. A larger series of patients with follow-up data is ongoing to evaluate the long-term data on this areolar-sparing procedure.
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CONCLUSIONS
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This retrospective analysis of mastectomy specimens shows that even in the most favorable subgroup, the rate of malignant nipple involvement was 6.7%. We conclude from these data that nipple preservation does not offer a reasonable option for mastectomy patients. However, because of the observed rare malignant involvement of the areola in this study, preservation of the areola with mastectomy in selected patients warrants further study.
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Acknowledgments
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Supported by the Russell Breast Cancer Fund, the Finnell Breast Cancer Fund, the Levy Breast Cancer Fund, and the Fashion Footwear Association of New York Breast Cancer Research Fund.
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Footnotes
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Presented at the 54th Annual Meeting of the Society of Surgical Oncology, Washington, DC, March 15–18, 2001.
Received for publication April 20, 2001.
Accepted for publication October 2, 2001.
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ABSTRACT
INTRODUCTION
