INTRODUCTION: The preservation of the nipple-areola complex (NAC) would significantly improve the aesthetic outcome in breast cancer patients undergoing skin-sparing mastectomy (SSM) and immediate breast reconstruction. However, there is much debate about the oncologic soundness of this approach. Therefore, we aim to answer this question by evaluating thin specimens of nipple and areola skin from our SSM patients for evidence of tumor involvement and the presence of ductal tissue within the dermis. METHODS: 46 patients undergoing SSM for breast cancer (including 17 also undergoing prophylactic contralateral SSM) were enrolled prospectively. 46 ipsilateral NAC and 17 contralateral NAC were dissected in a circumareolar fashion and subsequently defatted and thinned to < 10 mm using a No.15 scalpel. These specimens were sent to pathology along with the respective breast tissues. Pathologic evaluation consisted of: 1) description of the primary tumor including its size, location, and histology; 2) assessment of nodal status; and 3) measurement of the nipple and areola skin thickness along with an assessment of tumor involvement and the presence of mammary ductal tissue. An average of 3 sections were taken through each nipple and 6 sections through each areola. RESULTS: One of 46 (2.2%) areola specimens and five of 46 (10.9%) nipple specimens were involved with cancer. The one patient with areola involvement also had nipple involvement. Primary tumor extension into the NAC correlated with tumor size > 2 cm (p< 0.05) and a central/subareolar/diffuse location (p<0.05); no statistically significant correlation with nodal status or nuclear grade was noted. When examining the areola alone, 0% of patients with a peripherally located tumor, tumor size <2 cm, or <2 positive nodes had areola involvement. The average thickness of the areola and nipple specimens were 4.48 mm (± 1.96 mm) and 4.98 mm (± 2.30 mm) respectively. When assessing the presence of mammary ducts in these specimens, 7.9% of areolas vs. 85.6% of nipples were found to have ductal tissue within the dermis. However, looking specifically at specimens thinned to < 5 mm, 0% of areolas vs. 83.3% of nipples had ductal tissue. (p=0.001) DISCUSSION: Our results indicate that nipple preservation does not appear to be a viable option for SSM patients, given the small but significant risk of tumor involvement associated with the presence of residual ductal tissue throughout the dermis. On the other hand, our data support areola preservation in a subset of patients with peripheral, early stage breast cancer, when areola thinning to <5 mm is performed to exclude ductal tissue. If harvested in this manner and banked for use in later NAC reconstruction, native areola tissue can improve aesthetic outcome without compromising oncologic principles.
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