Safely expanding the use of nipple-sparing mastectomy in BRCA mutation carriers.

This past year, I presented data supporting the safety of nipple-sparing mastectomy (NSM) to a Latin American audience. After the talk, one of the participants thanked me for the talk but she was disheartened that the local medical oncologist described my presentation to his colleagues as nothing less than blasphemy. Although recently more accepting of NSM, our medical community also questions the oncologic safety of NSM. Should it be limited to prophylactic procedures? Is it safe for women with more advanced disease or with BRCA mutations? Women with BRCA mutations have a significant lifetime risk of developing breast cancer, and it is wellestablished that prophylactic mastectomy significantly reduces that risk. For BRCA mutation carriers diagnosed with cancer, bilateral mastectomies are typically performed due to the high risk of second breast cancer events. Many of these women are young at the time of surgery but, regardless of age, improving cosmetic results with reconstruction make this aggressive surgery more palatable. NSM can successfully reduce cancer risk and it also offers an improved cosmetic outcome with reconstruction; a woman’s native nipple is typically cosmetically superior to a reconstructed nipple. However, the high breast cancer risk associated with a BRCA mutation mandates that the surgery be as effective as possible at reducing future breast cancer events. In the article that accompanies this editorial, Yao et al. report on a series of 397 NSMs performed at two different institutions on 201 women with documented BRCA1 and BRCA2 mutations. This retrospective study adds to a growing body of literature supporting the safety of NSM in general, but it is especially valuable due to its focus on women with BRCA mutations, on whom there is limited data. This study is also unique in that it includes these highrisk women undergoing NSM for cancer treatment (n = 51, 25%) in addition to women undergoing prophylactic surgery only (n = 150, 75%). In order to answer the question of whether NSM is safe for women with BRCA mutations, it is important to first define the procedure, and to contrast it to subcutaneous mastectomy, which is not an oncologic procedure. During a subcutaneous mastectomy, a thick skin flap (and therefore breast tissue) is left behind with the nipple and areolar complex (NAC). Despite the intentional retention of some breast tissue, prophylactic subcutaneous mastectomies have actually been associated with low rates of subsequent cancer. However, a modern NSM aims to remove as much breast parenchyma as possible, up to the base of the nipple and often including a core of tissue within the nipple. Done appropriately, the NSM only differs from the now wellaccepted skin-sparing mastectomy in the preservation of the areolar skin and the skin of the nipple. If the NAC is retained, how often is this tissue involved with cancer recurrence or with new cancer development? Yao et al. nicely summarize the available data regarding nipple recurrence in Table 4 of their article. Large series of NSM have now been reported, with low rates of cancer recurrence overall and with NAC recurrences occurring only rarely. Indeed, of the over 3,000 patients included in Table 4, less than 1 % developed disease in the retained NAC. These studies did not focus on women with BRCA mutations. In the current study, four patients of the entire cohort experienced disease recurrence; the only isolated inbreast event occurred in a patient whose NSM was performed for risk reduction. One patient experienced a simultaneous distant and in-breast recurrence, and two patients experienced isolated axillary recurrences. No Society of Surgical Oncology 2014