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Multicenter Study
. 2018 Feb 1;153(2):123-129.
doi: 10.1001/jamasurg.2017.3422.

Oncologic Safety of Prophylactic Nipple-Sparing Mastectomy in a Population With BRCA Mutations: A Multi-institutional Study

James W Jakub  1 , Anne Warren Peled  2 , Richard J Gray  3 , Rachel A Greenup  4 , John V Kiluk  5 , Virgilio Sacchini  6 , Sarah A McLaughlin  7 , Julia C Tchou  8 , Robert A Vierkant  9 , Amy C Degnim  1 , Shawna Willey  10
Affiliations
Multicenter Study

Oncologic Safety of Prophylactic Nipple-Sparing Mastectomy in a Population With BRCA Mutations: A Multi-institutional Study

James W Jakub et al. JAMA Surg. .

Abstract

Importance: Nipple-sparing mastectomy (NSM) offers superior cosmetic outcomes and has been gaining wide acceptance; however, its role among patients with BRCA mutations remains controversial.

Objective: To report on the oncologic safety of NSM and provide evidence-based data to patients and health care professionals regarding preservation of the nipple-areolar complex during a risk-reducing mastectomy in a population with BRCA mutations.

Design, setting, and participants: We retrospectively reviewed the outcomes of 9 institutions' experience with prophylactic NSM from 1968 to 2013 in a cohort of patients with BRCA mutations. Patients with breast cancer were included if they underwent contralateral risk-reducing mastectomy; however, only the prophylactic side was considered in the analysis. Patients found to have an occult primary breast cancer at the time of risk-reducing mastectomy, those having variant(s) of unknown significance, and those undergoing free nipple grafts were excluded.

Main outcomes and measures: The primary outcome measure was development of a new breast cancer after risk-reducing NSM. Three reference data sources were used to model the expected number of events, and this was compared with our observed number of events.

Results: A total of 548 risk-reducing NSMs in 346 patients were performed at 9 institutions. The median age at NSM was 41 years (interquartile range, 34.5-47.5 years). Bilateral prophylactic NSMs were performed in 202 patients (58.4%), and 144 patients (41.6%) underwent a unilateral risk-reducing NSM secondary to cancer in the contralateral breast. Overall, 201 patients with BRCA1 mutations and 145 with BRCA2 mutations were included. With median and mean follow-up of 34 and 56 months, respectively, no ipsilateral breast cancers occurred after prophylactic NSM. Breast cancer did not develop in any patients undergoing bilateral risk-reducing NSMs. Using risk models for BRCA1/2 mutation carriers, approximately 22 new primary breast cancers were expected without prophylactic NSM. Prophylactic NSM resulted in a significant reduction in breast cancer events (test of observed vs expected events, P < .001).

Conclusions and relevance: Nipple-sparing mastectomies are highly preventive against breast cancer in a BRCA population. Although the follow-up remains relatively short, NSM should be offered as a breast cancer risk-reducing strategy to appropriate patients with BRCA mutations.

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Conflict of interest statement

Conflict of Interest Disclosures: None reported.

Figures

Figure 1.
Figure 1.. Use of Nipple-Sparing Mastectomy (NSM) in the Study Population of Patients With BRCA Mutations
Figure 2.
Figure 2.. Magnification View of Nipple Ducts
The inset demonstrates the transition of the lining of the nipple ducts from squamous at the orifice to cuboidal and eventually columnar at the lactiferous sinus. This figure is adapted from Chiba et al with permission from Current Surgery Reports.
See this image and copyright information in PMC

Comment in

References

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