SKIN SPARING AND NIPPLE SPARING MASTECTOMY
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This document discusses skin sparing mastectomy (SSM) and nipple sparing mastectomy (NSM). It provides details on the anatomy of the breast and history of breast cancer treatment. SSM aims to remove all breast tissue while preserving the skin and NAC. NSM further preserves the nipple. Selection criteria for NSM include small tumor size and distance from NAC. Outcomes of SSM and NSM are similar to MRM with acceptable morbidity. Complication rates of NSM include nipple necrosis around 7% and occult nipple involvement around 10%. Frozen section of subareolar tissue during NSM helps guide decision for NAC removal. Overall, SSM and NSM provide improved cosmetic
SKIN SPARING AND NIPPLE SPARING MASTECTOMY
- 1. PROF.S.SUBBIAH et al. Skin sparing and Nipple sparing mastectomy Department of Surgical Oncology Centre for Oncology GRH,Royapettah
- 2. PROF.S.SUBBIAH et al. Breasts & Women • Breasts - not considered as parts of body alone • Symbol of femininity and motherhood • Self confidence • Loss of breast change in social behavior, eating behavior, depression
- 3. PROF.S.SUBBIAH et al. Anatomy of breast • Modified sweat gland • Within the superficial fascia of the anterior chest wall • Second rib to sixth or seventh rib • Sternal border medially to the midaxillary line laterally
- 4. PROF.S.SUBBIAH et al. Blood supply to breast
- 5. PROF.S.SUBBIAH et al. Anatomy of nipple • Fat free area under NAC • 15–20 lactiferous ducts converge in a radial direction on the tip of nipple • The dermis of the skin merges with superficial fascia which envelops the parenchyma of the breast • Colour of NAC - by blood vessels lying close to surface in long dermal papillae • At puberty and with each pregnancy - increase in the melanin content of the basal cells • Subareolar plexus of lymphatics
- 6. PROF.S.SUBBIAH et al. History of breast cancer • 3600 yrs ago • No treatment for 1700 yrs • Hippocrates - not to excise - in 400 BC • Galen - Black bile theory or humoral theory Coagulam of black bile • Escharotomy - 1st century AD • Guillotine approach - Renaissance period • Mastectomy - 17th and 18th century
- 7. PROF.S.SUBBIAH et al. Evolution of concepts in breast cancer treatment No treatment Escharotomy Guillotine Radical mastectomy Modified radical mastectomy BCS SSM NSM
- 8. PROF.S.SUBBIAH et al. Radical mastectomy • William Steward Halsted - in 1882 • 0% perioperative mortality • 3 yr local recurrence rate - 6 % • 3 yr locoregional recurrence rate - 22% • 5 yr survival 45% (twice when compared to untreated patients) • Willie Mayer
- 10. PROF.S.SUBBIAH et al. Extended radical mastectomy • Removal of more regional lymph nodes • Supraclavicular, internal mammary & mediastinal nodes • Increased morbidity and mortality • Abandoned
- 11. PROF.S.SUBBIAH et al. Modified radical mastectomy • Patey and Dyson - 1940 • Preservation of pectoralis major • 50% patients needed skin grafting • No difference in outcome • Conclusion : Without systemic treatment, mortality is hardly affected by type and extent of local treatment • Because in a high percentage of patients, the disease is systemic on presentation
- 12. PROF.S.SUBBIAH et al. Modified radical mastectomy • Auchincloss in 1970 - horizontal incision • Madden - vertical incision • Preservation of both pectoral muscles • Equally effective • Less morbidity • Gold standard technique
- 13. PROF.S.SUBBIAH et al. Breast conserving surgery • Fisher - disease was systemic from beginning - microscopic metastases were present in most patients - impact of extensive surgery on survival was minimal • BCS - in 1990 • Breast conserving surgery + radiotherapy was equally as effective as mastectomy
- 14. PROF.S.SUBBIAH et al. MRM --> Breast conservation • One size fits all concept - proven wrong • Now Tailor made approach for each individual patients
- 15. PROF.S.SUBBIAH et al. Skin sparing mastectomy • Toth and Lambert - 1991 • Initially major concern regarding the amount of residual breast tissue remaining on the longer skin flaps, inframammary fold, and axillary tail • Barton et al disproved it • Well-planned incisions • To allow immediate reconstruction • Better breast contour and cosmetic results
- 16. PROF.S.SUBBIAH et al. Skin sparing mastectomy
- 17. PROF.S.SUBBIAH et al. Skin sparing mastectomy - 4 types • Type 1 - only nipple areola complex removed • Type 2 - NAC is removed along with skin overlying the tumour & biopsy site as one specimen • Type 3 - Similar to type 2 but resected separately leaving intact tissue in between • Type 4 - NAC is removed along with certain amount of skin using wise pattern breast reduction skin incision
- 18. PROF.S.SUBBIAH et al. Type -1 Type - 4
- 19. PROF.S.SUBBIAH et al. Skin sparing mastectomy • Indications : Just like any other mastectomy • Small and medium size breasts - Types 1 to 3 SSM • Large ptotic breasts - Type 4 SSM • Absolute contraindications : 1. Skin involvement by the tumour 2. Inflammatory carcinoma
- 20. PROF.S.SUBBIAH et al. Results of SSM • Recurrence after SSM - 3.8% to 10.4% For NSSM - 1.7% to 11.5% • No statistically significant difference between the two groups • Skin flap ischemia and necrosis - 11% (same as NSSM)
- 21. PROF.S.SUBBIAH et al. SSM - Benefits • Reduced postmastectomy deformity and improved breast shape • Scars are better and reduced • Need for extensive tissue expansion and for myocutaneous flaps is minimal • Immediate reconstruction has a beneficial impact on patient’s psychology
- 22. PROF.S.SUBBIAH et al. Nipple sparing mastectomy • Freeman in 1962 - for benign diseases • Total skin sparing mastectomy • Patient's dissatisfaction regarding shape of the reconstructed NAC, lack of projection and color match --> concept of NSM
- 23. PROF.S.SUBBIAH et al. NSM - Criteria for patient selection 1. Prophylactic mastectomy 2. Management of Cancer Size of tumour <3 cm Distance from nipple areola complex >2-4 cm No bloody nipple discharge Clinically no involvement of nipple areola Frozen section from subareolar area negative Not centrally located tumours
- 24. PROF.S.SUBBIAH et al. NSM - Criteria for patient selection • Debatable Lymph node status Preoperative chemotherapy /radiotherapy • Not advisable based on tumour biology ER(-), PR (-), LVI (+) • Absolute contraindications 1. Skin involvement by the tumour 2. Inflammatory carcinoma
- 25. PROF.S.SUBBIAH et al. Rare indications of NSM 1. Phyllode tumours 2. Stromal hyperplasia 3. Previous silicone injection 4. Dense breasts 5. Mastodynia
- 26. PROF.S.SUBBIAH et al. Occult nipple involvement Overall - 25% (De Vita - 58%) By this selection criteria - 10%
- 27. PROF.S.SUBBIAH et al. NSM - Incisions
- 28. PROF.S.SUBBIAH et al. NSM - Technique • Dermis and epidermis of the nipple are left behind • But all the ducts are removed from the lumen of the nipple • Distal part of the ducts is sent for frozen section • If it is positive convert to SSM by removing the NAC
- 29. PROF.S.SUBBIAH et al. Subareolar frozen section • Sensitivity - 91% • Specificity - 98% • False negative rate - 8.7% • Occult carcinoma in retained NAC - 1.2 to 5.9% - Most often DCIS • Debate regarding role of Frozen section - as it distorts the specimen • Some centers - NAC managed in second stage if HPE is positive
- 30. PROF.S.SUBBIAH et al. • 48 studies • 6615 cases
- 31. PROF.S.SUBBIAH et al. NSM - outcomes • Locoregional recurrence rate - 1.8% • Distant metastasis rate - 2.2 % • Most reconstructions - Implant and/or tissue expander • Only 13.8% used autologous tissue • Overall pooled complication rate - 22% Two-stage reconstruction (expander to implant) - 52.8% One stage reconstruction (direct to implant) - 16.7% Autologous reconstruction - 23.7 %
- 32. PROF.S.SUBBIAH et al. Nipple necrosis • Nipple necrosis rate - 7% Before 2010 - 10.22% After 2010 - 6.46% • Based on incision types Highest in transareolar - 81.82% Least in previous mastopexy incision - 4.76%
- 33. PROF.S.SUBBIAH et al. Erectile function & sensation of NAC • Nerves traveling along the chest wall from lateral edge of sternum to medial aspect of NAC • Wagner et al • Measured nipple erection preoperatively and at 6 & 12 mon after NSM • Nipple erection was preserved in the majority of patients
- 34. PROF.S.SUBBIAH et al. NSM/SSM/MRM • Meta analysis • 20 studies • 5594 patients • No significant difference in DFS, OS and LRR
- 35. PROF.S.SUBBIAH et al. Two stage NSM 1. NAC is detached from underlying lactiferous glands through a periareolar incision 2. NSM after 2-3 weeks • Subareolar biopsy is performed during the first operation • Drawbacks of frozen section are eliminated
- 36. PROF.S.SUBBIAH et al. ELIOT • Electron beam intraoperative radiotherapy • Petit and Veronasi • Radiosurgical treatment combining subcutaneous mastectomy with IORT • Total necrosis of NAC - 3.5% • Partial necrosis - 5.5% • Prosthesis removal - 4.3% • Same result as post-op RT
- 37. PROF.S.SUBBIAH et al. Take home message • Tailor made approach for breast cancer • Reconstruction considered as an integral part of breast cancer surgeries • SSM and NSM needs careful selection of patients • Similar oncological outcome with acceptable morbidity for SSM and NSM compared to MRM • NSM should include frozen section of subareolar area
- 38. PROF.S.SUBBIAH et al. Thank you