“Conservative mastectomy”the nipple sparing tecnique

Alberto LuiniSenology Division

European instiute of Oncology-Milan

Milan Conservation Programme (1970-

2010)

Phase 1 -

Phase 2 -

Phase 3 -

Phase 4 -

Conservation of the breast

Conservation of axillary nodes

Partial intraoperative radiotherapy (ELIOT)

Conservative mastectomy+ELIOT

Improvement in diagnosis (ultrasonography, MRI)

total mastectomies

EIO 2000 200523% 28%

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Timing of Reconstruction

- Always immediate

- Delayed only if:

- Locally advanced disease

- Concomitant diseasesA.Luini

SSM + immediate reconstruction with prosthesis or expander is nowadays the standard treatment, except for:- Inflammatory cancer- Locally advanced disease- Poor general conditions

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Skin Sparing Mastectomy + immediate reconstruction with prosthesis

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Immediate reconstruction does not affect the prognosis

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677 Total mastectomies + adjuvant treatment (no RT)

518 immediate rec. 159 no rec.

(76.5%) (23.5%)

Median follow up 70 months

(range 13-144) A. Luini

Multivariate analysis (median f.u. 70 m.)

(518 immediate reconstructions vs 159 without reconstruction)

Petit JY et al, Breast Cancer Res Treat, 2008 A. Luini

Immediate reconstruction:Immediate reconstruction:

The Nipple Sparing The Nipple Sparing ApproachApproach

EIO NSM 84%

of the mastectomies

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IndicationsIndications

Multifocal/multicentric cancer Multifocal/multicentric cancer

Extensive microcalcifications Extensive microcalcifications

Contraindications or refusal to Contraindications or refusal to primary medical treatmentprimary medical treatment

Negative retroareolar frozen Negative retroareolar frozen sectionsection

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ContraindicationsContraindications

Involvement of the central Involvement of the central quadrantquadrant

Paget’s disease Paget’s disease

Pathological nipple dischargePathological nipple discharge

Microcalcifications close to the Microcalcifications close to the nipplenipple

Previous radiotherapy Previous radiotherapy A. Luini

AdvantagesAdvantages Oncologic radicality: skin removal Oncologic radicality: skin removal

as a quadrantectomy and of the as a quadrantectomy and of the whole glandular tissue (except a whole glandular tissue (except a thin retroareolar portion)thin retroareolar portion)

Intraoperative radiotherapy on Intraoperative radiotherapy on the nipple areola complex (16Gy)the nipple areola complex (16Gy)

Immediate reconstruction with a Immediate reconstruction with a good cosmetic result (very good cosmetic result (very similar to a “good” similar to a “good” quadrantectomy)quadrantectomy) A. Luini

a layer of glandular a layer of glandular tissue should be tissue should be left beneath the left beneath the NAC NAC to avoid NAC necrosis

Subcutaneous mastectomy

a fifty year old technique !

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Surgical technique

a) Conservation of the retroareolar glandular tissue

b) Conservation of the retroareolar subcutaneous vascular plexus

Surgical technique

a) Sterile LINAC collimator

c) Lead and alluminium protective disc

d) Pectoralis major muscle

ELIOT ELIOT (16 Gy)(16 Gy)

Nipple Sparing Mastectomy

on the remaining glandular tissue to complete the cancer treatment

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Nipple-sparing mastectomy

Irradiated area

Irradiated area A. Luini

NSM + prosthesis + contralateral breast

augmentation

2 weeks 5 monthsA. Luini

Type of reconstruction

Anatomic prosthesis 68%

Expanders 19%

Round prosthesis 5%

TRAM 8%A. Luini

Nipple Sparing Mastectomy

Definitive prostheses 73%

Immediate left reconstruction with implant

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Nipple Sparing Mastectomy

Expanders 19%

Two-step implant reconstruction A. Luini

Nipple Sparing Mastectomy

TRAM 8%

Immediate pedicled TRAM reconstruction

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RESULTS

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1060 NSM in 1023 patients

37 bilateral ( March 2002 - March 2007) infiltrating : 63% in situ : 37% infiltrating : 63% in situ : 37%

despite frozen section negative…

86 final histology positive (8%)

(70 in situ, 16 invasive)43 NAC removed (local anesth.)

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Complications (1060 NSM)

Immediate

NAC necrosis 8.8%

Infections 2.0%

Delayed

Capsular contracture15%

Radiodystrophy 7.5%A. Luini

NAC necrosis

Partial 58 (5%) Total 26 (3,8%)

Secondary reconstructio

n A.Luini

NAC necrosis

Spontaneous healing with a TRAM

Infections

21 cases 2%

42 prostheses removed 4%

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Capsular contracture

157 capsulotomies 15%

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ELIOT ELIOT (16 Gy)(16 Gy)

nipple sparing mastectomy

But … 206 cases received a delayed radiotherapy the day after surgery

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Prosthesis removal

2,815,56

0

1

2

3

4

5

6

Eliot Del. Radiotherapy

p = 0.0829 A. Luini

Capsular contracture

5,22 7,78

0

1

2

3

4

5

6

7

8

Eliot Del. Radiotherapy

p = 0.3179 A. Luini

Cosmetic results

minimum follow up 1 year, scale 0 - 10

Good result (score 7-10)

Patient evaluation

82.3%

Surgeon evaluation 84.8%A. Luini

NAC sensibility

At one year, scale 0 - 10

score 0-3 48.0%

score 4-6 32.8%

score 7-10 18.8%

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Fig.1 Did you find it difficult to look at your self naked? Fig.2 Do you find it difficult being seen naked by your partner?

Do you feel your body less whole (disabled) as a result of the surgery? Quanto si è sentita mutilata come conseguenza dell’intervento?

1060 NSM in 1023 patientsInvasive carcinoma 63%In situ carcinoma 37%

ONCOLOGICAL RESULTS MEDIUM FOLLOW UP 20 MONTHS (RANGE 1-

70)

EVENTS

Local recurrenceLocal recurrence 13 (1.2%)13 (1.2%)

Distant metastasesDistant metastases 36 36 (3.5%) (3.5%)

DeathsDeaths 3 (0.3%) 3 (0.3%)

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Local recurrences

13 cases (1.2 %)

All distant from the NAC

(10 tumor bed, 3 upper quadrant)

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Nipple sparing mastectomy with intraoperative

radiotherapy is a safe procedure to reduce the

psychological trauma due to mastectomy in selected

cases

Conclusion

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