Portal sobre cirugía del cáncer de mama

Extreme preservation of the Nipple-Areola Complex in Central Tumors of the Breast

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Preservation of the NAC is one of the most important decisions during an oncoplastic procedure in the woman with a central tumour in the breast due to the great importance that this structure has for body image and local control of the process. The conflict for its preservation lies in the degree of damage of the structure and the adjacent tissue, both in the procedures that conserve it in situ as well as in those that use it as a free graft. Interest in preserving this anatomic structure has increased studies on mastectomy specimens for the purpose of selecting patients with a low probability of neoplastic involvement of the NAC, thereby increasing oncological safety in preserving or re-implanting it. These studies have shown, on the one hand, that neoplastic invasion of the areola is exceptional (<1%), since it does not contain mammary parenchyma ducts and, on the other, that involvement of the NAC presents in 3 anatomical patterns:

Involvement of the nipple only. This involves neoplastic changes in the nipple regardless of the original tumour. This is the least common form (less than 2%) and it may be considered the same as Paget’s disease, that is, a condition of the final pathway of the lactiferous duct at its opening in the nipple without intermediate disease to the original tumour

Paget´s Disease

Involvement of the subareolar tissue. This is the most frequent form (21%) and it is related to direct extension of the tumour (by proximity) and lymphatic dissemination. In these circumstances, preservation of the NAC is only possible with a section of the surgical sample over the neoplasm, confirmed by microscopic examination of the borders. In these cases, in order to preserve the NAC, it is advisable to remove it and reimplant it as a free graft

– Involvement of the subareolar tissue and the nipple. In these cases, the disease directly affects the final branch of the lactiferous duct in the nipple (13% of surgical samples), which makes preservation and/or reimplantation of the NAP unadvisable. In the majority of cases, there is a tumour proximal to the NAC and it is involved by continuity. In other cases, it involves multifocal processes with an increased in situ component in which dissemination occurs through the lactiferous ducts themselves. These patients are not candidates for NAC preservation or reimplantation and they would be better served by reconstruction using elements provided by an advancement flap (Grisotti-type). A second option is preservation of the areola, only when it is not involved, and reconstruction of the nipple using the skin provided by a local flap

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