Nick Mulcahy

March 08, 2013

WASHINGTON, DC — Nipple sparing mastectomy — and its outstanding cosmetic results — appears to be a good prophylactic option for young women carrying a BRCA gene mutation, according to a new study.

However, there have been worries about using the procedure in these women, who are at high risk for breast cancer.

"Concerns have been raised about the oncologic safety of nipple-sparing in BRCA mutation carriers," explain the researchers, led by Lan Lei, MD, a research fellow at the Massachusetts General Hospital Cancer Center in Boston.

In other words, if the nipple and areola are left behind, might they be vulnerable to developing breast cancer?

Not likely in the short term, the researchers report.

They found that there was no disease recurrence or occurrence in the nipple or areola in 70 women with BRCA gene mutations who underwent nipple-sparing mastectomy — either therapeutically or prophylactically — at their center from 2006 to 2012. However, the mean follow-up time is only 11 months (range, 0 to 40).

These data were presented as a poster here at the Society of Surgical Oncology 66th Annual Cancer Symposium.

Long term, the risk for recurrence is also highly unlikely, said an expert not involved with the study.

The risk of a cancer developing in the nipple after this surgery is "negligible," said Edibaldo Silva, MD, PhD, FACS, professor of surgery at the University of Nebraska Medical Center in Omaha.

"You almost never see recurrence in the nipple," he told Medscape Medical News at the meeting. This study adds to the literature documenting the unlikelihood of occurrence/recurrence in the nipple with nipple-sparing mastectomy, he said.

Dr. Silva performs the procedure at his center. "It looks amazing," he said.

Nipple-sparing mastectomy is especially suitable for young women who are BRCA carriers because it makes the risk-reducing surgery more acceptable, said Dr. Silva.

That risk is considerable: BRCA gene mutations confer a 60% to 80% lifetime risk for breast cancer, say Dr. Lei and colleagues, citing other research.

Dr. Silva explained how the surgery works. The surgical incision occurs in the fold under the breast, exactly like breast augmentation surgery. The breast tissue is removed and the breast's outer layer of skin, including the nipple and areola, is left intact. Implants are then slid into place. The procedure is best for women with smaller or medium-sized breasts, he explained.

It is often hard to tell if the procedure took place, Dr. Silva noted. Patients "look the same when they wake up as when they went to sleep," he said.

The benefits of the surgery are broad, said Dr. Lei. "Really good cosmetic outcome enhances quality of life," she told Medscape Medical News.

DCIS in 1 Nipple

In the study, 70 women with a BRCA mutation — 41 with BRCA1 and 29 with BRCA2 — underwent bilateral nipple-sparing mastectomy.

The median age of the women was 41 years (range, 23 to 64). Of the 140 breast reconstructions, 72 involved single-stage implants and 60 involved tissue expanders; in the 8 remaining breasts, other types of reconstruction were used.

Only 27 of the breasts (19%) were removed because of known cancers; 113 were removed prophylactic (81%).

During 2 (2%) of the prophylactic procedures, an unexpected malignancy was found: 1 invasive ductal cancer and 1 ductal carcinoma in situ (DCIS). "Neither had tumor in excised nipple duct tissue," the researchers point out in their study abstract.

However, in 1 (4%) of the therapeutic mastectomies, DCIS was found in the excised nipple duct tissue and the nipple–areola complex was removed.

Dr. Lei explained that this patient had "very extensive" DCIS. The "disease had spread throughout the breast ducts and into the nipple" via the ducts, she noted. The researchers did not considered this a recurrence because the disease was discovered during the nipple-sparing mastectomy.

Local recurrences were found during 2 of the therapeutic mastectomies, but both were outside the nipple: 1 in the chest wall/axilla and 1 in the axilla alone.

Postoperative complications were infrequent in the 140 breasts: there were 2 cases (1%) of nipple necrosis, 2 cases (1%) of skin necrosis, 4 cases (3%) of hematoma, and 5 implants (4%) were lost because of infection.

Society of Surgical Oncology (SSO) 66th Annual Cancer Symposium. Presented March 7, 2013.