First Attempts to Perform New Nipple-Saving Mastectomy Surgery
Reviewed study: "First Attempts to Perform New Nipple-Saving Mastectomy Surgery" by J.P. Petit, Primary Therapy of Early Breast Cancer Conference, St. Gallen, Switzerland, January 2005, Abstract #S20
Background and importance of the study: Most women with early-stage breast cancer can be treated with lumpectomy followed by radiation therapy as an alternative to total removal of the breast (mastectomy). But some women with breast cancer choose mastectomy for personal reasons. Or mastectomy may be required to treat a large cancer or many small cancers throughout a wide area of the breast.
Some women choose not to have breast reconstruction after mastectomy. They may use a prosthesis inside their bra so that both sides look the same. Others accept the lack of symmetry.
Many women do pursue breast reconstruction to restore the shape and symmetry of the breasts. Some women do this during their initial breast cancer surgery, and others wait. Doctors sometimes suggest that women with more advanced disease put off reconstruction until the rest of their treatment is over and the risk of the cancer coming back has lessened.
There are two possible steps to reconstruction. You can have just the breast mound replaced, or you can also re-create a new nipple, usually from skin from another part of the body. Once the new nipple skin and the dark area around it (the areola) settle into their new "home," the color of this skin can be enhanced by tattooing.
For many women, the nipple and areola may be the most difficult to lose. These structures define the appearance of the breast and can provide significant sexual excitement and satisfaction (and indirect stimulation for partners). Many women accept the loss of the nipple as one of many significant sacrifices they had to make to get breast cancer behind them. But quite a number of women decide to have the nipple built and tattooed.
After mastectomy, and also after reconstruction, the breast area or new breast may feel numb and lack sensation. Unfortunately, surgery to re-create a new breast and nipple area doesn't bring back the normal sensitivity.
But does mastectomy always mean you must lose your nipple and areola? Italian researchers have developed a new type of nipple-saving mastectomy that preserves these structures. In the study reported here, the researchers offered preliminary results of using this new kind of mastectomy.
Study design and results: The researchers offered this surgery to 301 women with cancers in the part of the breast that is not next to the nipple/areola area. To improve the odds against the cancer coming back, women received radiation to the nipple and areola DURING surgery, after the breast was removed.
The women had either:
- large cancers (the size was not specified),
- many cancers (the number was not specified), or
- widely dispersed microcalcifications (areas that show up as white, calcium-like deposits on a mammogram and may indicate cancer).
None of these cancers or microcalcifications was near the nipple/areola area.
During the surgery, the surgeon carefully removed all visible breast tissue from the back of the nipple and areola. The breast tissue was sent to a pathologist for rapid analysis. While a woman was still in the operating room, the pathologist told the surgeon whether cancer cells were in the tissue next to the nipple or areola in the preliminary exam. If the pathologist did find tumor cells, then the surgeon did a standard mastectomy that removed the nipple/areola. Thirty-five of the 301 women scheduled for the nipple-sparing surgery had to have complete mastectomies.
Then the pathologists performed a more detailed study of the removed breast tissue after surgery was completed. They found cancer cells underneath the preserved areolas of 25 of the women who had had nipple-saving surgery. Those women then had to have another surgery to remove the nipple and areola.
Of the remaining 241 women who had nipple-sparing mastectomy, 24 had some of their areola skin cells die and peel off. Eventually the tissue healed with skin care. Nine others lost their nipples and areolas because the tissue was too compromised by the surgery and radiation and was unable to recover.
The researchers had the surgeons and patients rate the color of the areola, sensitivity of the nipple, and overall appearance on a scale of 0 (bad) to 10 (excellent). (The researchers did not say when the patients did the rating.) The patients gave a slightly higher average rating than the surgeons for color (9 vs. 8) and appearance (8 vs. 7). Nipple sensitivity was rated as 2 (it must be assumed this is the patients' rating).
The short follow-up didn't allow the researchers to find out how the appearance and the sensation of the nipple/areola hold up over time. They also don't know how many women had the breast cancer come back around the preserved nipple/areola.
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What breastcancer.org says about this article…
First Attempts to Perform New Nipple-Saving Mastectomy Surgery
This is an early report of the first use of nipple-saving mastectomy. The study raises far more questions than it answers, and no published paper is available to offer important details.
In fact, the ultimate value and risk of this technique are completely unclear. Can the procedure be done without increasing the risk of the breast cancer coming back? Is the appearance and function of the saved nipple/areola worth the risk?
Also, much more needs to be known about the diagnosis and treatment techniques. For example:
- Why did this study specifically include women with large cancers or many cancers? Is it because women with smaller disease didn't require mastectomy? It's a little discouraging that about 10% of the patients had to have another surgery because cancer cells were found too close to the areola after the nipple-sparing mastectomy was done. Perhaps a sensitive radiology test, such as MRI, might be able to better select women with no signs of cancer anywhere near the nipple.
- How exactly was the surgery performed? How was the nipple/areola separated from the rest of the breast tissue? Was the nerve underneath it—which provides its sensation—kept intact? How was it connected to its blood supply—or was the blood supply cut off (in which case it would be difficult to end up with a healthy nipple)? Is there a "right way" to handle the nerve to the nipple in order to preserve nipple sensation? Assuming the nipple was put on top of a reconstructed breast mound, how was the reconstruction done? If a second surgery was required to remove the nipple/areola when it turned out to have cancer cells on its back surface, how was that surgery performed?
- How did pathologists define negative, close, or positive margins in this study? Did the margin have to be positive in order to do the second surgery to remove the nipple/areola?
- Was only one dose of radiation given? How much? What technique was used (electron or photon), and over how large an area? Since this study included women with "large" cancers, many might have required radiation to the breast area after mastectomy. Was this given, and if so, how? Did the radiation given in the operating room to the nipple/areola interfere with the ability to give additional radiation later?
These are just some of the questions raised by this study.
It would certainly be great to help women save their nipples/areolas as long as they can get a good cosmetic and functional result without risking cancer recurrence. Until more solid information is available on this technique, you can choose to forgo the nipple/areola reconstruction, go ahead with it, or even use latex external nipples that are pressed against the breast area or mound. You can read more about your options here.
We feel it is important to share with you the abstracts presented at recent conferences on important topics like this one, but they only provide us with very basic information. Stay tuned to Breastcancer.org to see what additional studies will reveal about nipple-saving mastectomy.