Annals of the Royal College of Surgeons of England (1990) vol. 72, 87-89
Mastectomy and breast reconstruction preserving the nipple C C R Bishop
MChir FRCS Senior Surgical Registrar
S Singh
FRCS Surgical Registrar
A G Nash FRCS Consultant Surgeon
St Helier Hospital, Carshalton, Surrey
Key words: Breast reconstruction; Nipple preservation
Total mastectomy and immediate reconstruction using the latissimus dorsi myocutaneous flap with nipple preservation has been performed in 87 women. The palpable tumours were ali more than 3 cm from the nipple. No recurrence in the preserved nipple was seen in 63 women who underwent the procedure for tumour recurrence after previous radiotherapy. Nipple recurrence occurred in 3 out of 24 women (12%) where the indication was multifocal disease and no radiotherapy was given. This non-irradiated group should either not have the nipple preserved or should undergo postoperative electron field therapy to the nipple-areolar complex.
Since the pioneering work of Sir Geoffrey Keynes (1,2), the treatment of carcinoma of the breast has moved towards less radical surgery (3-7). Three randomised controlled trials comparing mastectomy with limited surgery and radiotherapy have shown no difference in either overall or disease-free survival (8-10). However, the problem remains as to the best treatment for patients who subsequently develop local recurrence. We have previously reported our initial experience in treating such patients with total mastectomy and reconstruction using the latissimus dorsi flap (11). This myocutaneous flap was originally described by Tansini in 1896 (12), and allows the simultaneous reconstruction of the breast at the time of mastectomy (13). In order to improve the cosmetic result of this pro-
Correspondence to: Mr A G Nash FRCS, Consultant Surgeon, St Helier Hospital, Wrythe Lane, Carshalton, Surrey SM5 1AA
cedure we have preserved the nipple, together with the uninvolved skin of half the breast, in those patients where the palpable tumour was situated more than 3 cm from the nipple. Hitherto it has been considered necessary to remove the nipple when performing mastectomy because of the teaching of Sappey (14), who described the lymphatic drainage of the breast as being centripetal towards the subareolar plexus. However, the work of Turner-Warwick (15) and Handley (16) suggests that this is incorrect and that the lymphatic drainage is vertically downwards to the deep pectoral lymphatic plexus.
Patients and methods Between 1982 and 1988 a total of 87 women (aged 27-63 years) underwent total mastectomy and immediate breast reconstruction using the latissimus dorsi myocutaneous flap with preservation of the nipple. In 71 women the tumour was diagnosed on aspiration needle cytology and in 16 women surgical biopsy showed carcinoma. In all the women the tumour was situated at least 3 cm from the nipple, which was clinically normal. In addition there was no evidence of metastatic disease as assessed by chest radiography, liver ultrasound, bone scan, skeletal survey and full biochemical profile. These 87 women consist of two separate groups:
Group 1. Sixty-three women (mean age 47.7 years) in whom the indication for the operation was tumour recurrence after previous radiotherapy; 41 had had T1 or T2 tumours which had been treated by wide local excision and radiotherapy, those remaining were T3 tumours, 17 of which had been treated by wide local excision and radiotherapy and five by radiotherapy alone.
88
C C R Bishop et al.
recurrence occurred in the skin or axilla of two patients (3%) and metastatic disease developed in 19 patients (30%). No recurrence has been seen in the preserved nipple at a mean follow-up of 3.9 years. In the 24 patients who underwent the procedure for multifocal disease and received no radiotherapy (group 2), local recurrence occurred in one patient (4%) and metastatic disease in six patients (25%). In this group nipple recurrence developed in three patients (12%) at a mean follow-up of 3.8 years. The nipple recurrence was detected at 9 and 37 months following the reconstruction in two patients with multifocal invasive ductal carcinoma, and at 18 months in a patient with multifocal invasive lobular carcinoma.
(a)
Discussion
Figure 1. (a) Latissimus dorsi flap constructed and skin island tailored to fit defect in breast. (b) Appearance on 7th postoperative day.
Group 2. Twenty-four women (mean age 45.6 years) in whom the indication for operation was invasive carcinoma with multifocal disease; 19 had tumours of ductal origin, the remaining five had multifocal lobular tumours. The evidence for multifocal disease was either mammographic or histological following surgical biopsy. These patients had received no radiotherapy. The operation was performed with the patient in the lateral position. A total mastectomy with axillary clearance was carried out, preserving the nipple-areolar complex on either the superomedial or inferolateral skin flap of the breast, depending on the site of the tumour. The latissimus dorsi myocutaneous flap based on the thoracodorsal artery was mobilised, passed beneath the skin bridge into the mastectomy wound and sutured into position, tailoring the skin of the flap to the nippleareolar complex. A silicone implant was placed deep to the myocutaneous flap (Fig. 1).
Results
The technique of breast reconstruction following mastectomy is now well established (17,18) and simultaneous reconstruction with mastectomy for recurrence has been reported (11). However, preservation of the nipple is controversial because of the theoretical risk of developing recurrence in the preserved nipple. The question we sought to answer was whether the superior cosmetic result of preserving the nipple could be achieved without risking tumour recurrence. Kissen and Kark (19), in a retrospective histological analysis of 100 cases of operable breast cancer, found no microscopic involvement of the nipple-areolar complex if the tumour was situated more than 2 cm outside the areolar margin. We have seen no nipple recurrence in the group of patients in whom the procedure was performed for tumour recurrence following previous radiotherapy. However, in the group of patients where the indication for surgery was multifocal disease and no radiotherapy was given we have had a 12% recurrence rate in the preserved nipple. The follow-up period for these patients is still relatively short, but on the basis of these results we suggest that the superior cosmetic result produced by conservation of the areolar on half of the skin of the breast is an acceptable and logical extension in the treatment of recurrent peripheral breast tumours after radiation therapy. However, for multifocal ductal or lobular carcinoma either the nipple should not be preserved or it should be subjected to lateral electron field therapy.
References I Keynes G. The radium treatment of carcinoma of the breast. St Bartholomev's Hospital Reports 1927;60:91-3. 2 Keynes G. Radium treatment of primary carcinoma of the breast. Lancet 1928;ii:108.
3 Crile G. Treatment of breast cancer by local excision. AmJT Surg 1965;109:400. 4 Wise L, Mason AY, Ackerman LV. Local excision and
In the 63 patients who underwent the procedure for tumour recurrence after radiotherapy (group 1), further
irradiation: an alternative method for treatment of early mammary cancer. Ann Surg 1971;174:392-401.
Mastectomy and breast reconstruction preserving the nipple 5 Taylor H, Baker R, Fortt RW, Hermon-Taylor J. Sector mastectomy in selected cases of breast cancer. Br J Surg 1971;58: 161-3. 6 Atkins H, Hayward JL, Klugman DJ, Wayte AB. Treatment of early breast cancer: a report after 10 years of a clinical trial. Br Med j 1972;ii:423-9. 7 Calle R, Pilleron JP, Schlienger P, Vilcoq JR. Conservative management of operable breast cancer: ten years experience at the Foundation Curie. Cancer 1978;42:2045-53. 8 Veronesi U, Saccozzi R, Del Vecchio M et al. Comparing radical mastectomy with quadrantectomy, axillary dissection and radiotherapy in patients with small cancers of the breast. N Engl J Med 1981;305:6-11. 9 Sarrazin D, Le M, Rouesse J et al. Conservative treatment versus mastectomy in breast cancer. Tumours with macroscopic diameter of 20 millimetres or less. Cancer 1984;53: 1209-13. 10 Fisher B, Barrer M, Margolese T et al. Five year results of a randomised clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N EnglJ7 Med 1985;312:665-73. 11 Nash AG, Taylor PR. Breast reconstruction after failed conservation. Ann R Coll Surg Engl 1985;67:303-5.
89
12 Tansini I. R Forma Medica 1896;12:758-9. 13 Nash AG, Hurst PAE. Central breast carcinoma treated by simultaneous mastectomy and latissimus dorsi flap reconstruction. Br J Surg 1983;70:654-5. 14 Sappey PC. Anatomie, Physiologie, Pathologie des Vaisseaux Lymphatiques Considere Chez L'homme et les Vertebres. Paris: Lecosnier, 1885. 15 Turner-Warwick RT. The lymphatics of the breast. Br J Surg 1958;46:574-82. 16 Handley RS. The early spread of breast carcinoma and its bearing on operative treatment. BrJ7 Surg 1964;51:206-8. 17 Olivari N. The latissimus dorsi flap. Br J Plast Surg 1976;29: 126-8. 18 Skow J, Pilney F, Messenger M. Breast reconstruction following mastectomy with the latissimus dorsi musculocutaneous flap. Minn Med 1981;64:455-8. 19 Kissen MW, Kark AE. Nipple preservation during mastectomy. BrJ7 Surg 1987;74:58-61. Received 28 July 1989
READ THIS! Crisp AH. The relevance of anatomy and morbid anatomy for medical practice and hence for postgraduate and continuing medical education of doctors. Postgrad Med J 1989;65:221-3. When a subject is in the descriptive phase, trivial details often assume undue importance. We have all experienced or heard of self-important anatomy teachers and examiners who expected students to identify carpal bones by touch alone. We sometimes recited the origin, insertion and relation of muscles but did not understand their action or appreciate what would happen if they ceased to work. I personally found it relaxing but unedifying to pick fat from a formalised corpse in order to produce a 'clean' dissection for the weekly viva voce test. Additions to the medical curriculum have squeezed out anatomy. Clinicians complain that what is taught is insufficient and irrelevant. I taught anatomy when studying for the Primary FRCS and have recently been privileged to repeat the experience after an interval of 36 years. Things have changed! Anatomy is no longer the paramount subject. Our students no longer dissect. Teaching is, though, much more oriented towards their clinical needs. Clinical colleagues nevertheless remain critical of the content of the anatomy course. Morbid anatomy teaching at autopsy is also reduced because many fewer post-mortem examinations are performed. The careful observation, display, teaching and recording of the nineteenth-century pathologists such as Virchow at the Berlin Charite Hospital and Rokitansky at the Vienna General Hospital, where autopsies were carried out on every patient who died in the hospitals, have been lost to our students. Few educationalists encourage the traditional teaching of anatomy and morbid anatomy, except surgeons. It is of particular interest that support for these subjects comes from a psychiatrist, Professor Crisp. He was, though, Chairman of the Education Committee of the General Medical Council. He considers that dissection of the human body is an initiation into the role of a doctor and a prerequisite for proper examination of patients. Similarly, a study of morbid anatomy, carried out in the post-mortem room, is essential to the proper understanding of disease processes. He gives examples of the importance of this knowledge for all clinicians, not just for surgeons. Read it! R M KIRK
Mastectomy and breast reconstruction preserving the nipple C C R Bishop
MChir FRCS Senior Surgical Registrar
S Singh
FRCS Surgical Registrar
A G Nash FRCS Consultant Surgeon
St Helier Hospital, Carshalton, Surrey
Key words: Breast reconstruction; Nipple preservation
Total mastectomy and immediate reconstruction using the latissimus dorsi myocutaneous flap with nipple preservation has been performed in 87 women. The palpable tumours were ali more than 3 cm from the nipple. No recurrence in the preserved nipple was seen in 63 women who underwent the procedure for tumour recurrence after previous radiotherapy. Nipple recurrence occurred in 3 out of 24 women (12%) where the indication was multifocal disease and no radiotherapy was given. This non-irradiated group should either not have the nipple preserved or should undergo postoperative electron field therapy to the nipple-areolar complex.
Since the pioneering work of Sir Geoffrey Keynes (1,2), the treatment of carcinoma of the breast has moved towards less radical surgery (3-7). Three randomised controlled trials comparing mastectomy with limited surgery and radiotherapy have shown no difference in either overall or disease-free survival (8-10). However, the problem remains as to the best treatment for patients who subsequently develop local recurrence. We have previously reported our initial experience in treating such patients with total mastectomy and reconstruction using the latissimus dorsi flap (11). This myocutaneous flap was originally described by Tansini in 1896 (12), and allows the simultaneous reconstruction of the breast at the time of mastectomy (13). In order to improve the cosmetic result of this pro-
Correspondence to: Mr A G Nash FRCS, Consultant Surgeon, St Helier Hospital, Wrythe Lane, Carshalton, Surrey SM5 1AA
cedure we have preserved the nipple, together with the uninvolved skin of half the breast, in those patients where the palpable tumour was situated more than 3 cm from the nipple. Hitherto it has been considered necessary to remove the nipple when performing mastectomy because of the teaching of Sappey (14), who described the lymphatic drainage of the breast as being centripetal towards the subareolar plexus. However, the work of Turner-Warwick (15) and Handley (16) suggests that this is incorrect and that the lymphatic drainage is vertically downwards to the deep pectoral lymphatic plexus.
Patients and methods Between 1982 and 1988 a total of 87 women (aged 27-63 years) underwent total mastectomy and immediate breast reconstruction using the latissimus dorsi myocutaneous flap with preservation of the nipple. In 71 women the tumour was diagnosed on aspiration needle cytology and in 16 women surgical biopsy showed carcinoma. In all the women the tumour was situated at least 3 cm from the nipple, which was clinically normal. In addition there was no evidence of metastatic disease as assessed by chest radiography, liver ultrasound, bone scan, skeletal survey and full biochemical profile. These 87 women consist of two separate groups:
Group 1. Sixty-three women (mean age 47.7 years) in whom the indication for the operation was tumour recurrence after previous radiotherapy; 41 had had T1 or T2 tumours which had been treated by wide local excision and radiotherapy, those remaining were T3 tumours, 17 of which had been treated by wide local excision and radiotherapy and five by radiotherapy alone.
88
C C R Bishop et al.
recurrence occurred in the skin or axilla of two patients (3%) and metastatic disease developed in 19 patients (30%). No recurrence has been seen in the preserved nipple at a mean follow-up of 3.9 years. In the 24 patients who underwent the procedure for multifocal disease and received no radiotherapy (group 2), local recurrence occurred in one patient (4%) and metastatic disease in six patients (25%). In this group nipple recurrence developed in three patients (12%) at a mean follow-up of 3.8 years. The nipple recurrence was detected at 9 and 37 months following the reconstruction in two patients with multifocal invasive ductal carcinoma, and at 18 months in a patient with multifocal invasive lobular carcinoma.
(a)
Discussion
Figure 1. (a) Latissimus dorsi flap constructed and skin island tailored to fit defect in breast. (b) Appearance on 7th postoperative day.
Group 2. Twenty-four women (mean age 45.6 years) in whom the indication for operation was invasive carcinoma with multifocal disease; 19 had tumours of ductal origin, the remaining five had multifocal lobular tumours. The evidence for multifocal disease was either mammographic or histological following surgical biopsy. These patients had received no radiotherapy. The operation was performed with the patient in the lateral position. A total mastectomy with axillary clearance was carried out, preserving the nipple-areolar complex on either the superomedial or inferolateral skin flap of the breast, depending on the site of the tumour. The latissimus dorsi myocutaneous flap based on the thoracodorsal artery was mobilised, passed beneath the skin bridge into the mastectomy wound and sutured into position, tailoring the skin of the flap to the nippleareolar complex. A silicone implant was placed deep to the myocutaneous flap (Fig. 1).
Results
The technique of breast reconstruction following mastectomy is now well established (17,18) and simultaneous reconstruction with mastectomy for recurrence has been reported (11). However, preservation of the nipple is controversial because of the theoretical risk of developing recurrence in the preserved nipple. The question we sought to answer was whether the superior cosmetic result of preserving the nipple could be achieved without risking tumour recurrence. Kissen and Kark (19), in a retrospective histological analysis of 100 cases of operable breast cancer, found no microscopic involvement of the nipple-areolar complex if the tumour was situated more than 2 cm outside the areolar margin. We have seen no nipple recurrence in the group of patients in whom the procedure was performed for tumour recurrence following previous radiotherapy. However, in the group of patients where the indication for surgery was multifocal disease and no radiotherapy was given we have had a 12% recurrence rate in the preserved nipple. The follow-up period for these patients is still relatively short, but on the basis of these results we suggest that the superior cosmetic result produced by conservation of the areolar on half of the skin of the breast is an acceptable and logical extension in the treatment of recurrent peripheral breast tumours after radiation therapy. However, for multifocal ductal or lobular carcinoma either the nipple should not be preserved or it should be subjected to lateral electron field therapy.
References I Keynes G. The radium treatment of carcinoma of the breast. St Bartholomev's Hospital Reports 1927;60:91-3. 2 Keynes G. Radium treatment of primary carcinoma of the breast. Lancet 1928;ii:108.
3 Crile G. Treatment of breast cancer by local excision. AmJT Surg 1965;109:400. 4 Wise L, Mason AY, Ackerman LV. Local excision and
In the 63 patients who underwent the procedure for tumour recurrence after radiotherapy (group 1), further
irradiation: an alternative method for treatment of early mammary cancer. Ann Surg 1971;174:392-401.
Mastectomy and breast reconstruction preserving the nipple 5 Taylor H, Baker R, Fortt RW, Hermon-Taylor J. Sector mastectomy in selected cases of breast cancer. Br J Surg 1971;58: 161-3. 6 Atkins H, Hayward JL, Klugman DJ, Wayte AB. Treatment of early breast cancer: a report after 10 years of a clinical trial. Br Med j 1972;ii:423-9. 7 Calle R, Pilleron JP, Schlienger P, Vilcoq JR. Conservative management of operable breast cancer: ten years experience at the Foundation Curie. Cancer 1978;42:2045-53. 8 Veronesi U, Saccozzi R, Del Vecchio M et al. Comparing radical mastectomy with quadrantectomy, axillary dissection and radiotherapy in patients with small cancers of the breast. N Engl J Med 1981;305:6-11. 9 Sarrazin D, Le M, Rouesse J et al. Conservative treatment versus mastectomy in breast cancer. Tumours with macroscopic diameter of 20 millimetres or less. Cancer 1984;53: 1209-13. 10 Fisher B, Barrer M, Margolese T et al. Five year results of a randomised clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N EnglJ7 Med 1985;312:665-73. 11 Nash AG, Taylor PR. Breast reconstruction after failed conservation. Ann R Coll Surg Engl 1985;67:303-5.
89
12 Tansini I. R Forma Medica 1896;12:758-9. 13 Nash AG, Hurst PAE. Central breast carcinoma treated by simultaneous mastectomy and latissimus dorsi flap reconstruction. Br J Surg 1983;70:654-5. 14 Sappey PC. Anatomie, Physiologie, Pathologie des Vaisseaux Lymphatiques Considere Chez L'homme et les Vertebres. Paris: Lecosnier, 1885. 15 Turner-Warwick RT. The lymphatics of the breast. Br J Surg 1958;46:574-82. 16 Handley RS. The early spread of breast carcinoma and its bearing on operative treatment. BrJ7 Surg 1964;51:206-8. 17 Olivari N. The latissimus dorsi flap. Br J Plast Surg 1976;29: 126-8. 18 Skow J, Pilney F, Messenger M. Breast reconstruction following mastectomy with the latissimus dorsi musculocutaneous flap. Minn Med 1981;64:455-8. 19 Kissen MW, Kark AE. Nipple preservation during mastectomy. BrJ7 Surg 1987;74:58-61. Received 28 July 1989
READ THIS! Crisp AH. The relevance of anatomy and morbid anatomy for medical practice and hence for postgraduate and continuing medical education of doctors. Postgrad Med J 1989;65:221-3. When a subject is in the descriptive phase, trivial details often assume undue importance. We have all experienced or heard of self-important anatomy teachers and examiners who expected students to identify carpal bones by touch alone. We sometimes recited the origin, insertion and relation of muscles but did not understand their action or appreciate what would happen if they ceased to work. I personally found it relaxing but unedifying to pick fat from a formalised corpse in order to produce a 'clean' dissection for the weekly viva voce test. Additions to the medical curriculum have squeezed out anatomy. Clinicians complain that what is taught is insufficient and irrelevant. I taught anatomy when studying for the Primary FRCS and have recently been privileged to repeat the experience after an interval of 36 years. Things have changed! Anatomy is no longer the paramount subject. Our students no longer dissect. Teaching is, though, much more oriented towards their clinical needs. Clinical colleagues nevertheless remain critical of the content of the anatomy course. Morbid anatomy teaching at autopsy is also reduced because many fewer post-mortem examinations are performed. The careful observation, display, teaching and recording of the nineteenth-century pathologists such as Virchow at the Berlin Charite Hospital and Rokitansky at the Vienna General Hospital, where autopsies were carried out on every patient who died in the hospitals, have been lost to our students. Few educationalists encourage the traditional teaching of anatomy and morbid anatomy, except surgeons. It is of particular interest that support for these subjects comes from a psychiatrist, Professor Crisp. He was, though, Chairman of the Education Committee of the General Medical Council. He considers that dissection of the human body is an initiation into the role of a doctor and a prerequisite for proper examination of patients. Similarly, a study of morbid anatomy, carried out in the post-mortem room, is essential to the proper understanding of disease processes. He gives examples of the importance of this knowledge for all clinicians, not just for surgeons. Read it! R M KIRK
