Feasible Nipple Preservation Techniques for Breast Cancer with Slight Nipple Retraction

The advent of breast-conserving therapy has dramatically improved quality of life of breast cancer patients [1, 2]. Breast-conserving therapy with nipple resection is also available as a feasible option in breast cancer surgeries, but the cosmetic outcome of it is much inferior to that of standard breast-conserving therapy. Breast-conserving therapy, therefore, had once been indicated only for breast cancers located apart from the nipple-areolar complex in order to get both good local control and better cosmetic outcome.

Besides bloody nipple discharge [3], nipple retraction highly suggests the cancer infiltration to the tissue with collagen fibers near the nipple-areolar complex. In addition, it is well known that the more abundant the fibrous component at tumor edges is, the less distinct the tumor margins are. Breast surgeons, therefore, have thus far treated even breast cancers showing only slight nipple retraction not with nipple-preserving surgery but with mastectomy.

We herein report a case of breast cancer with slight nipple retraction successfully operated with our nipple-preserving techniques. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000540892).

A 62-year-old woman with right invasive ductal breast cancer (estrogen receptor positive, progesterone receptor positive, human epidermal growth factor type 2 negative, Ki-67 labeling index of 28%) was referred to our hospital for the treatment of her breast cancer. On her first visit to our hospital, the patient had slight nipple retraction (Fig. 1a) and a breast cancer just under the nipple-areolar complex in her right breast. All image modalities including mammography (Fig. 2a), ultrasonography (Fig. 2b), and magnetic resonance imaging (Fig. 2c) showed a breast cancer under the nipple, slight nipple retraction, no direct cancer infiltration to the nipple-areolar complex, and no lymphadenopathy. In addition to these image findings, the patient’s strong request for favorable cosmesis made us operate the patient with nipple-preserving mastectomy, sentinel node biopsy, and immediate breast reconstruction using extended latissimus dorsi musculocutaneous flap. Sentinel node biopsy pathologically showed no lymph node metastases. Immediate breast reconstruction was safely done after the successful completion of nipple-preserving mastectomy. Details of our nipple preservation techniques were as follows: (1) a quasi-complete skin flap was made in a thick flap manner except for the nipple-areolar complex area; (2) sub-nipple mammary gland was fully skeletonized using the curved mosquito forceps (Fig. 3a, b); (3) the skeletonized sub-nipple mammary gland was pinched with the Mayo scissors followed by pushing the scissors toward the nipple base as close as possible with the scissors’ blades kept open (Fig. 3c); (4) nipple base was resected using the Mayo scissors on pulling the mammary gland toward the opposite direction of the nipple. These procedures made the nipple base depressed as if a hole had been dug in (Fig. 3d). Frozen section and postoperative pathological study showed clear surgical margins (Fig. 3e) and no lymph node metastasis. After operation, the nipple showed temporal color change due to superficial dermal necrosis of the nipple (Fig. 1b) but spontaneously healed without leaving any sequelae (Fig. 1c). The patient received adjuvant chemotherapy due to nuclear grade 3 of the breast cancer and has been well without any recurrences on endocrine therapy for 20 months.

Nipple retraction in breast cancer occurs by the same mechanism as pleural indentation often seen in lung adenocarcinomas [4]. Nipple retraction and pleural indentation do not occur when cancer cells only spread to the nipple and pleura. Malignant tumors, especially adenocarcinomas, can shrink on scar formation with massive collagen fiber production in the tumor, leading to nipple retraction and pleural indentation. Nipple retraction, therefore, suggests the presence of invasive breast cancer cells near the nipple, but does not directly imply cancer infiltration to the nipple-areolar complex.

We have found that total nipple necrosis is caused not by nipple ischemia but by nipple congestion [5‒7]. Venous return from the nipple-areolar complex highly correlates with the nipple congestion and is ensured by the preservation of subcutaneous fat under and around the nipple-areolar complex. In other words, subcutaneous fat preservation around the nipple-areolar complex enables us to maximally resect the mammary gland without nipple necrosis. However, various sentinel node studies have clarified that lymphatic flow is highest in the subareolar region [8‒10]. Subcutaneous fat preservation, therefore, needs careful evaluation about lymphatic permeation in each breast cancer. Breast surgeons, therefore, should apply our nipple-preserving techniques only to breast cancers with no or little lymphatic permeation.

The most critical point of the nipple-preserving surgery is nipple base resection. Careless and/or poor operative procedures can easily damage the nipple-areolar complex and the surrounding skin. Blunt dissection using the curved mosquito forceps is very useful in delicate skeletonization of the sub-nipple mammary gland even to surgical trainees. Furthermore, not electrocautery but scissors use on nipple base resection can lead to definitely avoid unexpected damage to the nipple-areolar complex.

Our nipple-preserving techniques can safely resect nipple base even for breast cancer patients with slight nipple retraction.

This article does not contain any studies involving human participants or animals performed by any of the authors. Ethical approval was not required for this case study in accordance with local or national guidelines. Written informed consent was obtained from the patient for the publication of this case report and accompanying images.

The authors have no conflicts of interest to declare.

The authors have no funding sources to declare.

H.M. designed the study concept. S.O. drafted the manuscript.

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.