title: Tumor Involvement of the Nipple in Total Skin-Sparing Mastectomy: Strategies for Management.
abstract: 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.
authors.affiliation: Division of Breast Surgery, Department of Surgery, UCSF Carol Franc Buck Breast Care Center, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Dominic
authors.initials: D
authors.lastname: Amara
authors.affiliation: Division of Breast Surgery, Department of Surgery, UCSF Carol Franc Buck Breast Care Center, University of California, San Francisco, San Francisco, CA, USA.|Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Anne Warren
authors.initials: AW
authors.lastname: Peled
authors.affiliation: Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Frederick
authors.initials: F
authors.lastname: Wang
authors.affiliation: Division of Breast Surgery, Department of Surgery, UCSF Carol Franc Buck Breast Care Center, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Cheryl A
authors.initials: CA
authors.lastname: Ewing
authors.affiliation: Division of Breast Surgery, Department of Surgery, UCSF Carol Franc Buck Breast Care Center, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Alvarado
authors.affiliation: Division of Breast Surgery, Department of Surgery, UCSF Carol Franc Buck Breast Care Center, University of California, San Francisco, San Francisco, CA, USA. Laura.Esserman@ucsfmedctr.org.
authors.forename: Laura J
authors.initials: LJ
authors.lastname: Esserman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / 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*; D062109:Dermatologic Surgical Procedures; D005260:Female; D006801:Humans; D016462:Mammaplasty; D015414:Mastectomy, Subcutaneous; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009364:Neoplasm Recurrence, Local; D018365:Neoplasm, Residual; D009558:Nipples / Q000473:pathology / Q000601:surgery*; D059351:Organ Sparing Treatments; D018714:Radiotherapy, Adjuvant; D012086:Reoperation; D012189:Retrospective Studies; D055815:Young Adult