Nipple-sparing mastectomy in association with intra operative radiotherapy (ELIOT): A new type of mastectomy for breast cancer treatment.
BACKGROUND
Breast-conserving surgery has become the standard approach for about 80% of patients treated for primary breast cancer in most centres. However, mastectomy is still required in case of multicentric and/or large tumours or where recurrences occur after conservative treatment. When a total mastectomy is performed, the removal of the nipple areola complex (NAC) is a strongly debated issue. In fact, although removal of the NAC greatly increases the patient's sensation of mutilation, and the risk of tumor involvement of the areola is reported as a very variable percentage, NAC excision still remains the standard treatment.


METHODS
From March 2002 to September 2003, 106 nipple sparing mastectomies (NSM) were peformed in 102 patients, 63% of whom had invasive carcinoma and 37% of whom had in situ carcinoma. Four patients underwent bilateral surgery. In all cases, a large or multicentric tumour and/or diffuse microcalcifications, clinically distant from the NAC, were present. During surgery, the tissue under the areola was routinely sampled to exclude the presence of tumor. If disease-free at the frozen sections, the NAC was spared and a NSM was performed. Additionally, a total dose of 16 Gy of radiotherapy (ELIOT) was delivered intraoperatively in the region of the NAC. All the patients underwent an immediate plastic breast reconstruction.


RESULTS
In eleven patients (10.4%), the breast tissue under the areola resulted infiltrated at the definitive histological examination: in 10 cases a single or multiple foci of in situ carcinoma and in one case an invasive component were present. Eleven patients (10.4%) developed a superficial skin areolar slough followed by spontaneous healing, and 5 patients (4.7%) lost their NAC due to total necrosis. Among these, one patient had a poor cosmetic result on the NAC with asymmetrical location and required further surgical removal and reconstruction with tattoo and local flap in a better position. When rating the results from 0 (bad) to 10 (excellent), on average, the colour of the areola was rated 9/10, the sensitivity of nipple 3/10, the overall aesthetic result was rated 8/10 by both the surgeon and the patients. Early radiodystrophy (pigmentation) was observed in eight cases (7.5%). After an average follow up of 13 months, one local recurrence, located under the clavicula, far from the NAC, was observed. The preliminary results of the psychological study show a very high satisfaction with the preservation of the nipple (97.6 %), with younger women expressing a higher satisfaction than older counterparts.


CONCLUSIONS
In selected cases, NSM with ELIOT of NAC has so far permitted good local control of the disease and satisfactory cosmetic results. Wider surgical experience is required to minimise the risk of leaving tumor cells in the region of the spared NAC and a longer follow up is necessary to evaluate the long term tumor recurrence rate at the NAC.
Petit
Jean Yves
JY
Division of Plastic Surgery, European Institute of Oncology, Milan, Italy. jean.petit@ieo.it
Veronesi
Umberto
U
Orecchia
Roberto
R
Luini
Alberto
A
Rey
Piercarlo
P
Intra
Mattia
M
Didier
Florence
F
Martella
Stefano
S
Rietjens
Mario
M
Garusi
Cristina
C
DeLorenzi
Francesca
F
Gatti
Giovanna
G
Leon
Maria Elena
ME
Casadio
Chiara
C
D001943:Breast Neoplasms / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery*; D002278:Carcinoma in Situ / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery; D018270:Carcinoma, Ductal, Breast / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery; D002285:Carcinoma, Intraductal, Noninfiltrating / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery; D018275:Carcinoma, Lobular / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery; D005260:Female; D006801:Humans; D016462:Mammaplasty; D008408:Mastectomy / Q000379:methods*; D009361:Neoplasm Invasiveness / Q000473:pathology; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery; D009558:Nipples / Q000473:pathology / Q000601:surgery*