Oncologic Safety of Prophylactic Nipple-Sparing Mastectomy in Patients With BRCA Mutations Original Investigation Research radiotherapy: a single center study at a Japanese 27. Stolier AJ, Wang J. Terminal duct lobular units 30. Torresan RZ, dos Santos CC, Okamura H, institution. Med Oncol. 2013;30(1):481. are scarce in the nipple: implications for Alvarenga M. Evaluation of residual glandular tissue prophylactic nipple-sparing mastectomy: terminal after skin-sparing mastectomies. Ann Surg Oncol. 25. Reynolds C, Davidson JA, Lindor NM, et al. duct lobular units in the nipple. Ann Surg Oncol. 2005;12(12):1037-1044. Prophylactic and therapeutic mastectomy in BRCA 2008;15(2):438-442. mutation carriers: can the nipple be preserved? 31. Wei CH, Scott AM, Price AN, et al. Psychosocial Ann Surg Oncol. 2011;18(11):3102-3109. 28. Askew JB Jr. Nipple micro-anatomy: ductal and sexual well-being following nipple-sparing epithelial types. J Am Coll Surg. 2012;214(3):377. mastectomy and reconstruction. Breast J. 2016;22 26. Rosen PP, Tench W. Lobules in the nipple: (1):10-17. frequency and significance for breast cancer 29. Chiba A, Jakub JW, Hieken TJ. Nipple-sparing treatment. Pathol Annu. 1985;20(pt 2):317-322. mastectomy: to spare or not to spare? Curr Surg Rep. 2016;4(5):17. doi:10.1007/s40137-016-0138-1 Invited Commentary Nipple-Sparing Risk-Reducing Mastectomy in BRCA Carriers Helen M. Johnson, MD; Jan H. Wong, MD Whether a proportional reduction in the volume of breast tis- els, up to 22 breast cancers would have been predicted to have sue proportionately reduces the risk of developing breast can- been diagnosed in their cohort. cer has been seriously debated in light of the recognition that Can this risk reduction be attributed solely to reduction in most patients undergoing pro- the number of breast cancer cells? All of these individuals were phylactic mastectomy have re- known BRCA carriers, and it is likely many had risk-reducing sidual breast tissue, includ- salpingo-oophorectomy. What, if any, effect this may have on the Related article page 123 ing terminal ductal units in the risk of developing breast cancer was not examined in this report. 1,2 3 skin flaps. Animal studies from 1986 suggested that the risk Although it seems intuitive that reducing the volume of of developing mammary tumors was not proportionately re- breast tissue would likely reduce the risk of developing breast duced by the amount of breast tissue removed. Thus, it was rec- cancer, BRCA carriers have germline mutations. Any residual ommended that if absolute protection was desired, a total mas- breast tissue remains at the same inherent risk of developing tectomy, including the nipple-areolar complex, was required. breast cancer. BRCA mutations result in potentially harmful 4,5 However, several observational studies have shown a breaks in DNA strands that can promote genomic instability greater than 90% reduction in the risk of developing breast can- and lead to cancer. Does the reduction in the number of breast cer in women who underwent prophylactic mastectomy, usu- cancer cells at risk simply represent a reduction in the statis- ally either total mastectomy or skin-sparing mastectomy. Given tical chance of a harmful event occurring? If so, might a lon- the superior cosmetic results of nipple-sparing mastectomy ger period of follow-up demonstrate just a delay in the future (NSM) with immediate reconstruction, NSM has become an development of breast cancer after a statistical increase in the increasingly popular risk-reduction strategy. number of harmful events attains a certain threshold? The re- 7 7 The study by Jakub and colleagues demonstrates the ben- port by Jakub and colleagues is reassuring that, at least in the efit of risk-reducing surgery extended to patients with known short-term, NSM provides substantial risk reduction in BRCA BRCA gene mutations and who have undergone NSM. In this mutation carriers. Because many of these procedures are per- study, no breast cancer events occurred in patients who un- formed in younger individuals with a substantial future cu- derwent bilateral risk-reducing NSM at a median follow-up of mulative risk of developing breast cancer, continued and long- 36 months, a period in which using several predictive mod- term follow-up is critical. ARTICLE INFORMATION after skin-sparing mastectomies. Ann Surg Oncol. 5. Hartmann LC, Sellers TA, Schaid DJ, et al. 2005;12(12):1037-1044. Efficacy of bilateral prophylactic mastectomy in Author Affiliations: Department of Surgery, BRCA1 and BRCA2 gene mutation carriers. J Natl Brody School of Medicine, East Carolina University, 2. Goldman LD, Goldwyn RM. Some anatomical Cancer Inst. 2001;93(21):1633-1637. Greenville, North Carolina. considerations of subcutaneous mastectomy. Plast Reconstr Surg. 1973;51(5):501-505. 6. Djohan R, Gage E, Gatherwright J, et al. Patient Corresponding Author: Jan H. Wong, MD, satisfaction following nipple-sparing mastectomy Department of Surgery, Brody School of Medicine, 3. Wong JH, Jackson CF, Swanson JS, et al. Analysis and immediate breast reconstruction: an 8-year East Carolina University, 600 Moye Blvd, of the risk reduction of prophylactic partial outcome study. Plast Reconstr Surg. 2010;125(3): Greenville, NC 27834 (email@example.com). mastectomy in sprague-dawley rats with 818-829. 7,12-dimethylbenzanthracene-induced breast Published Online: September 13, 2017. cancer. Surgery. 1986;99(1):67-71. 7. Jakub JW, Peled AW, Gray RJ, et al. Oncologic doi:10.1001/jamasurg.2017.3438 safety of prophylactic nipple-sparing mastectomy 4. Rebbeck TR, Friebel T, Lynch HT, et al. Bilateral Conflict of Interest Disclosures: None reported. in a population with BRCA mutations: prophylactic mastectomy reduces breast cancer a multi-institutional study [published online risk in BRCA1 and BRCA2 mutation carriers: the REFERENCES September 13, 2017]. JAMA Surg. doi:10.1001 PROSE Study Group. J Clin Oncol. 2004;22(6): 1. Torresan RZ, dos Santos CC, Okamura H, /jamasurg.2017.3422 1055-1062. Alvarenga M. Evaluation of residual glandular tissue jamasurgery.com (Reprinted) JAMA Surgery February 2018 Volume 153, Number 2 129 © 2017 American Medical Association. All rights reserved.
JAMA Surgery – American Medical Association
Published: Feb 13, 2018
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