Nipple preservation in breast cancer mastectomies: is it possible? – 05/03/2022

The treatment of breast cancer has evolved a lot in the last 30 years. If before receiving the diagnosis of a tumor in the breast was synonymous with mutilation of the breasts, today the reality is different. Although decisions about treatments involve many factors – from personal characteristics to the genetic analysis of the tumor – surgical treatment is increasingly accurate and the goal is the search for the least invasive surgical approach possible.

The current gold standard for most early cases is conservative surgery (the name given to surgery that removes only the tumor and a minimal margin of safety around it), which tends to cause little or no cosmetic changes. Annual screening through mammography is the main way to detect cancer early, and the earlier it is diagnosed, the greater the chances of cure and the use of less aggressive surgical techniques.

Still, a mastectomy is often necessary. This is the name given to the surgery that completely removes the mammary gland (which may or may not involve the removal of skin and/or nipple). The indications are diverse and depend on the size of the tumor, the breast volume, the presence of high-risk genetic mutations for cancer, the presence of several tumors in the same breast, among others.

There are also several techniques used. In a simple mastectomy, for example, the surgeon removes the entire breast, including the nipple, areola, and skin. In skin-sparing mastectomy, the breast tissue, nipple, and areola are removed, but most of the skin is preserved and used for immediate reconstruction, usually with silicone implants or expanders.

There is also skin- and nipple-sparing mastectomy, an option for women with some favorable conditions, including the presence of tumors distant from the skin and nipple. This is the preferred option whenever technically possible and with adequate oncological safety, guaranteeing immediate reconstruction of the breast with a prosthesis in most cases and a more anatomical breast appearance, with the presence of the areola and nipple.

“The concept of breast beauty is closely linked to symmetry. The nipple is an identity of the breast. Often, when it needs to be removed, the woman seeks an aesthetic reconstruction and/or even gets tattoos. That’s why it’s so important to seek for the conservation of the nipple in the surgery”, said the gynecologist and mastologist Danielle Martin Matsumoto, from Hospital Israelita Albert Einstein and coordinator of the Mastology Improvement Program at the hospital.

Frozen biopsy during surgery

In skin- and nipple-sparing mastectomy, it is very important to seek intraoperative confirmation that the nipple is not affected by parts of the tumor. So, during surgery, the surgeon removes a piece of tissue from the area behind the nipple and performs a “frozen biopsy” during the surgical procedure. The material is analyzed by the pathologist at the time, and will indicate to the surgeon if there is a tumor in the nipple or not, guiding the medical conduct.

“If this is not done on time and the final result of the analysis of the surgical piece is positive after ten, 15 days of surgery, it is very frustrating and exhausting for the woman. She has just undergone surgery and will have to redo the procedure. procedure to remove the nipple. This is the advantage of the frozen biopsy”, explained Danielle.

A study recently published in the American Journal of Clinical Pathology confirmed the importance of performing a frozen biopsy of the nipple tissue during surgery to predict whether there is residual carcinoma in the region and, from then on, to support surgeons whether it will be possible to preserve the nipple or not.

The researchers evaluated the results of 1,026 nipple-sparing mastectomies (570 performed on diseased breasts and 456 prophylactically), and arrived at a number of 7.2% positive biopsies. “The study confirms what has been the routine of surgical practice for many years. The freezing technique is the gold standard and is routinely performed, both in the public and private network. Eventually, in services where there is no pathologist available, it cannot be performed, but with an increased risk for a second surgical approach if the final evaluation is positive. Nipple conservation is the result that we always pursue, as long as there is oncological safety for it”, said the mastologist.

One of the problems of the technique is that the accuracy of the frozen section is not the same as that of the anatomopathological examination – it is estimated that in about 10% of cases there is a risk of the result being a false-negative or a false-positive. “All samples must go for anatomopathological examination after surgery. In the freezing technique, the pathologist makes an initial assessment of some cells. We expect a 100% correct result, but there may be a discrepancy”, he pondered.

most common cancer

Breast cancer is the one with the highest incidence (excluding only non-melanoma skin cancer) and the one that kills the most women every year in Brazil, according to data from the National Cancer Institute (Inca), which estimates that 66,280 new cases of the disease have been diagnosed. in 2021. There is no specific cause for this type of cancer, but the risk increases from the age of 50.

Although the Ministry of Health recommends that screening be carried out by women over 50 years old every two years, medical societies recommend that the exam be performed from the age of 40, annually.

“Unfortunately, Brazil is made up of several Brazils. In the private world, the chance of a woman discovering breast cancer early and undergoing conservative surgery is much higher than in the public network. early and increase the chances of more conservative surgeries”, he concluded.

About Jenni Smith

She's our PC girl, so anything is up to her. She is also responsible for the videos of Play Crazy Game, as well as giving a leg in the news.

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