Tumor Involvement of the Nipple in Total Skin-Sparing Mastectomy: Strategies for Management.

Background: Despite a growing body of literature on oncologic and reconstructive outcomes after total skin-sparing mastectomy (TSSM), some questions related to this approach remain unanswered, including strategies for managing tumor involvement of the nipple while maintaining the aesthetic benefits of TSSM.

Methods: A prospectively maintained database of patients undergoing TSSM and immediate breast reconstruction from 2005 to 2013 was reviewed. Outcomes included tumor involvement of resected nipple tissue and subsequent management, recurrences after nipple involvement, and trends in management of involved nipple tissue.

Results: The study included 1176 breasts in 751 patients treated with TSSM. The follow-up period was 31.3 months. The nipple-areolar complex (NAC) of 32 breasts (2.7 %) had a positive margin or involvement of nipple tissue. Of these breasts, 56 % contained invasive cancer, and 44 % had in situ disease. Management included repeat excision (11 cases, 34 % of cases), radiation of the NAC (as part of the postmastectomy breast field) without further excision (5 cases, 16 %), complete NAC removal (8 cases, 25 %), and no further treatment (8 cases, 25 %). Management by complete NAC skin excision significantly decreased during the study period (p = 0.003). The overall local recurrence rate was 6.2 %. No patients had recurrence in the preserved NAC skin.

Conclusions: Despite expanding indications for TSSM, it can be performed safely with low rates of nipple involvement. Over time, tumor involvement of the nipple has been treated with re-excision or other alternative approaches to NAC removal that preserve the aesthetic benefits of total skin-sparing approaches without an early adverse impact on local recurrence.