Risk of Malignancy in the Areola
While few have looked at the anatomy of the areola as a separate entity, even fewer have attempted to identify the risk of cancer of the areola apart from that of the nipple. Simmons et al undertook a retrospective analysis of 217 mastectomy specimens looking for malignant involvement of the nipple, areola, or both by serial sectioning.12 They found that the areola was only involved in 2 of 217 patients (0.9%) and both specimens had large (>5 cm), centrally located tumors. Similar results were published by Banerjee et al, who found areolar involvement in 2 of 219 (0.9%) mastectomy patients.13 Paget disease isolated to the areola is extremely rare, but has been described in the literature.14
Based on the results of their pathologic analysis of mastectomy specimens, Simmons et al performed ASMs on women for DCIS and small peripheral infiltrating carcinomas, and for prophylactic mastectomy.15 Patients with inflammatory carcinoma, invasive cancer directly beneath the nipple, and locally advanced disease were excluded. One of 4 incisions was used in all cases: tennis racquet, s-shaped, inverted T inframammary crease, or a triple incision (Fig. 67-2). The choice of incision was based upon size of the breast and areola, whether or not a reduction mammoplasty was performed on the opposite breast, and surgeon preference. The procedure resected the nipple, any previous biopsy scar, and all breast parenchyma leaving the areola and a maximum amount of skin for reconstruction immediately to follow. Sentinel node biopsies were performed for patients with carcinoma. A touch prep cytologic evaluation16 of the underside of the areolar flaps was performed on 2 patients with DCIS and microinvasion resulting in negative cytology. Obviously, any gross extension of tumor into the areola or positive touch prep cytology required conversion to a SSM. The flaps were assessed for viability and converted to a SSM if perfusion to the areola was compromised. There were good cosmetic results with no instances of flap necrosis (Fig. 67-3).
Schematic representation of incisions used for ASM (small purple line indicates line of incision). A. Linear intra-areola incision with extra-areola extension. B. S-shaped intra-areola incision. C. Inverted-T inframammary crease incision. D. Triple incision with inframammary crease, peri-nipple, and axillary incisions. [Reproduced from Simmons RM, Hollenbeck ST, Latrenta GS. Areola-sparing mastectomy with immediate breast reconstruction. Ann Plast Surg. 2003;51(6):547-551.]
Cosmetic outcomes for ASM. [Reproduced, with permission, from Simmons RM, Hollenbeck ST, Latrenta GS. Areola-sparing mastectomy with immediate breast reconstruction. Ann Plast Surg. 2003;51(6):547-551.]
Simmons et al published 2-year follow-up on 12 of these patients receiving 17 ASMs with immediate reconstructions.17 Of all the procedures performed, 4 were for DCIS; 3 were for peripherally located, infiltrating carcinomas less than 2 cm; and 10 were for prophylaxis. Patients were followed for complications and recurrence. Ten patients underwent sentinel node biopsy and none were positive. All patients had negative histologic margins. None of the patients had chemotherapy of radiation. Two patients with DCIS and microinvasion underwent intraoperative subareolar touch-prep cytological evaluation with negative results. There was only 1 postoperative complication—a wound infection which resolved with oral antibiotics. With a median of 24 months follow-up, there were no recurrences.
Though the data generated by Simmons et al are compelling, they lack the power to generate a consensus among practitioners. Key to success when performing ASM is patient selection. Simmons et al currently recommend an ASM for prophylaxis, DCIS, and small, peripherally located infiltrating carcinoma, but not for inflammatory carcinoma, invasive cancer directly beneath or involving the NAC, or locally advanced disease. There is no consensus in the literature; additional studies and further follow-up are needed to establish the ASM as the standard of care for a select patient population.