Oncoplastic Central Partial Mastectomy and Neoareolar Reduction Mammoplasty with Immediate Nipple Reconstruction: An Initial Report of a Novel Option for Breast Conservation in Patients with Subareolar Tumors

  • Angelena Crown
  • Flavio G. Rocha
  • Janie W. GrumleyEmail author
Breast Oncology



Breast-conserving therapy (BCT) has been associated with better quality of life and cosmetic outcomes than mastectomy. However, subareolar cancers abutting the nipple–areolar complex (NAC) present a unique cosmetic and oncologic challenge. Oncoplastic central partial mastectomy and neoareolar reduction mammoplasty with immediate nipple reconstruction is a novel technique that can permit BCT for these patients.


This study enrolled consecutive patients with central tumors during 2017–2018 who underwent central partial mastectomy reconstructed with neoareolar reduction mammoplasty and immediate nipple reconstruction. Patient demographics, imaging and pathology size, margin width, mastectomy and reexcision rates, and cosmesis were evaluated.


The study identified 23 sequential patients. The average patient age was 60.5 ± 12.3 years, and the average body mass index was 29.4 ± 5.7 kg/m2. The mean lesion size was 51.5 ± 43.0 mm on preoperative imaging, and the average disease span shown by the final pathology was 59.5 ± 45.3 mm. “No ink on tumor” was achieved for 22 patients (95.7%). In 13 patients (56.5%), the margins were inadequate for ductal carcinoma in situ (DCIS) (n = 12) or invasive cancer (n = 1). Good to excellent cosmetic results were achieved for 21 patients (95.5%). Complications occurred for six patients (26.1%), including three patients with ischemia of the reconstructed NAC.


The single-stage operation described in this report can allow patients with cancers abutting the NAC to consider BCT. This technique allows patients to avoid mastectomy and to minimize the number of operations required for reconstruction while maximizing cosmetic outcomes. In the study cohort, the presence of extensive DCIS resulted in a significant need for reexcision, which could be performed successfully without compromise to cosmetic outcome.



We have no disclosures.


  1. 1.
    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;305:6–10.CrossRefGoogle Scholar
  2. 2.
    Van Dongen J, Bartelink H, Fentiman I, et al. Randomized clinical trial to assess the value of breast-conserving therapy in stage I and II breast cancer: EORTC 10801 trial. Monogr Natl Cancer Inst. 1992;11:8–15.Google Scholar
  3. 3.
    Lichter A, Lippman M, Danforth D, et al. Mastectomy versus breast-conserving therapy in the treatment of stage I and II carcinoma of the breast: a randomized trial at the National Cancer Institute. J Clin Oncol. 1992;10:976–82.CrossRefGoogle Scholar
  4. 4.
    Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347:1233–41.CrossRefGoogle Scholar
  5. 5.
    Vaidya JS, Wenz F, Bulsara M, et al. Risk-adapted targeted intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT: a randomised trial. Lancet. 2014;282:603–13.CrossRefGoogle Scholar
  6. 6.
    Veronesi U, Orecchia R, Maisonneuve P, et al. Intraoperative radiotherapy versus external radiotherapy for early breast cancer (ELIOT): a randomised controlled equivalence trial. Lancet Oncol. 2013;14:1269–77.CrossRefGoogle Scholar
  7. 7.
    Lagendijk M, van Egdom LSE, van Veen FEE, et al. Patient-reported outcome measures may add value in breast cancer surgery. Ann Surg Oncol. 2018;25:3563–71.CrossRefGoogle Scholar
  8. 8.
    Chand ND, Browne V, Paramanathan N, et al. Patient-reported outcomes are better after oncoplastic breast conservation than after mastectomy and autologous reconstruction. Plast Reconstr Surg Glob Open. 2017;5:e1419.CrossRefGoogle Scholar
  9. 9.
    Fisher ER, Gregorio R, Redmond C, et al. Pathologic findings from the National Surgical Adjuvant Breast Project (protocol no. 4) I: observations concerning the multicentricity of mammary cancer. Cancer. 1975;35247–54.Google Scholar
  10. 10.
    Wilson LD, Beinfield M, McKhann CF, et al. Conservative surgery and radiation in the treatment of synchronous ipsilateral breast cancers. Cancer. 1993;72:137–42.CrossRefGoogle Scholar
  11. 11.
    Leopold KA, Recht A, Schnitt SJ, et al. Results of conservative surgery and radiation therapy for multiple synchronous cancers of one breast. Int J Radiat Oncol Biol Phys. 1989;16:11–6.CrossRefGoogle Scholar
  12. 12.
    Kurtz JM, Jacquemier J, Amalric R, et al. Breast-conserving therapy for macroscopically multiple cancers. Ann Surg. 1990;212:38–44.CrossRefGoogle Scholar
  13. 13.
    Rosen PP, Fracchia AA, Urban JA, et al. Residual mammary carcinoma following simulated partial mastectomy. Cancer. 1975;35:739–47.CrossRefGoogle Scholar
  14. 14.
    Fisher B, Bauer M, Margolese R, et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med. 1985;312:665–73.CrossRefGoogle Scholar
  15. 15.
    Danoff B, Pajak T, Solin L, et al. Excisional biopsy, axillary node dissection, and definitive radiotherapy for stages 1 and 2 breast cancer. Int J Radiat Oncol Biol Phys. 1985;11479–83.Google Scholar
  16. 16.
    Dale PS, Giuliano AE. Nipple–areola preservation during breast-conserving therapy for subareolar breast carcinomas. Arch Surg. 1996;131:430–3.CrossRefGoogle Scholar
  17. 17.
    Bussieres E, Guyon F, Thomas L, et al. Conservation treatment in subareolar breast cancers. Eur J Surg Oncol. 1996;22:267–70.CrossRefGoogle Scholar
  18. 18.
    Galimberti V, Zurrida S, Zanini V, et al. Central small size breast cancer: how to overcome the problem of nipple and areola involvement. Eur J Cancer. 1993;29A:1093–6.CrossRefGoogle Scholar
  19. 19.
    Crown A, Wechter DG, Grumley JW. Oncoplastic breast-conserving surgery reduces mastectomy and postoperative reexcision rates. Ann Surg Oncol. 2015;22:3363–8.CrossRefGoogle Scholar
  20. 20.
    De La Cruz L, Blankenship SA, Chatterjee A, et al. Outcomes after oncoplastic breast-conserving surgery in breast cancer patients: a systematic literature review. Ann Surg Oncolol. 2016;23:3247–58.CrossRefGoogle Scholar
  21. 21.
    Clough KB, Kaufman GJ, Nos C, et al. Improving breast cancer surgery: a classification and quadrant per quadrant atlas for oncoplastic surgery. Ann Surg Oncol. 2010;17:1375–91.CrossRefGoogle Scholar
  22. 22.
    Santos G, Urban C, Edelweiss MI, et al. Long-term comparison of aesthetical outcomes after oncoplastic surgery and lumpectomy in breast cancer patients. Ann Surg Oncol. 2015;22:2500–8.CrossRefGoogle Scholar
  23. 23.
    Yiannakopoulou EC, Mathelin C. Oncoplastic breast-conserving surgery and oncological outcome: systematic review. Eur J Surg Oncol. 2016;42:625–30.CrossRefGoogle Scholar
  24. 24.
    Tenofsky PL, Dowell P, Topalvoski T, et al. Surgical, oncologic, and cosmetic differences between oncoplastic and nononcoplastic breast-conserving surgery in breast cancer patients. Am J Surg. 2014;207(3):398–402; discussion 402. Scholar
  25. 25.
    Campbell EJ, Romics L. Oncological safety and cosmetic outcomes in oncoplastic breast conservation surgery: a review of the best level of evidence literature. Breast Cancer Targets Ther. 2017;9 521–30.Google Scholar
  26. 26.
    Chatterjee A, Gass J, Krishnabhai P, et al. A consensus definition and classification system of oncoplastic surgery developed by the American Society of Breast Surgeons. Ann Surg Oncol. 2019.
  27. 27.
    Crown A, Scovel LG, Rocha FG, et al. Oncoplastic breast-conserving surgery is associated with a lower rate of surgical-site complications compared to standard breast conserving surgery. Am J Surg. 2019;217:138–41.Google Scholar
  28. 28.
    Losken A, Styblo TM, Carlson GW, et al. Management algorithm and outcome evaluation of partial mastectomy defects treated using reduction or mastopexy techniques. Ann Plast Surg. 2007;59:235–42.CrossRefGoogle Scholar
  29. 29.
    Asban A, Homsy C, Chen L, et al. A cost-utility analysis comparing large-volume displacement oncoplastic surgery to mastectomy with single-stage implant reconstruction in the treatment of breast cancer. Breast. 2018;41:159–64.CrossRefGoogle Scholar
  30. 30.
    Chatterjee A, Asban A, Jonczyk M, et al. A cost-utility analysis comparing large-volume displacement oncoplastic surgery to mastectomy with free-flap reconstruction in the treatment of breast cancer. Am J Surg. 2019. Scholar
  31. 31.
    Silverstein MJ, Savalia N, Khan S, et al. Extreme oncoplasty: breast conservation for patients who need mastectomy. Breast J. 2015;21:52–9.CrossRefGoogle Scholar
  32. 32.
    Crown A, Laskin R, Rocha FG, et al. Extreme oncoplasty: expanding indications for breast conservation. Am J Surg. 2019;217:851–6.CrossRefGoogle Scholar
  33. 33.
    Crown A, Handy N, Rocha FG, et al. Oncoplastic reduction mammaplasty: an effective and safe method of breast conservation. Am J Surg. 2018;215:910–15.CrossRefGoogle Scholar
  34. 34.
    Yun IS, Lew DH, Tark KC, et al. Nipple reconstruction with modified C–V flap:C–U flap. J Korean Soc Aesth Plast Surg. 2008;14:75–8.Google Scholar
  35. 35.
    Moran MS, Schnitt SJ, Giuliano AE, et al. Society of Surgical Oncology–American Society for Radiation Oncology–American Society of Clinical Oncology Consensus Guideline on margin for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. Ann Surg Oncol. 2014;21:704–16.CrossRefGoogle Scholar
  36. 36.
    Ganz PA, Cecchini RS, White JR, et al. Patient-reported outcomes (PROs) in NRG oncology/NSABP B-39/RTOG 0413: A randomized phase III study of conventional whole breast irradiation (WBI) versus partial breast irradiation (PBI) in stage 0, I, or II breast cancer. J Clin Oncol. 2019;37:508.CrossRefGoogle Scholar
  37. 37.
    Sparano JA, Gray RJ, Makower DF, et al. Adjuvant chemotherapy guided by a 21-gene expression assay in breast cancer. N Engl J Med. 2018;1379:111–21.CrossRefGoogle Scholar
  38. 38.
    Rosenkrantz KM, Ballman K, McCall L, et al. The feasibility of breast-conserving surgery for multiple ipsilateral breast cancer: an initial report from ACOSOG Z11102 (Alliance) trial. Ann Surg Oncol. 2018;25:2858–66.CrossRefGoogle Scholar
  39. 39.
    Lai HW, Huang RH, Wu YT, et al. Clinicopathologic features related to surgical margin involvement, reoperation, and residual cancer in primary operable breast cancer: an analysis of 2050 patients. Eur J Surg Oncol. 2018;44:1725–35.CrossRefGoogle Scholar
  40. 40.
    Lai HW, Chen CJ, Lin YJ, et al. Does breast magnetic resonance imaging combined with conventional imaging modalities decrease the rates of surgical margin involvement and reoperation? A case-control comparative analysis. Med Baltim. 2016;95:3810.CrossRefGoogle Scholar
  41. 41.
    Proulx F, Correa JA, Ferré R, et al. Value of preoperative breast MRI for the size assessment of ductal carcinoma in situ. Br J Radiol. 2016;89:1058.20.CrossRefGoogle Scholar
  42. 42.
    Murphy BL, Boughey JC, Keeney MG, et al. Factors associated with positive margins in women undergoing breast conservation surgery. Mayo Clin Proc. 2018;93:429–35.CrossRefGoogle Scholar
  43. 43.
    Sanchez C, Brem RF, McSwain AP, et al. Factors associated with reexcision in patients with early-stage breast cancer treated with breast conservation surgery. Am Surg. 2010;76:331–4.Google Scholar
  44. 44.
    Fitzgerald S, Romanoff A, Cohen A, et al. Close and positive lumpectomy margins are associated with similar rates of residual disease with additional surgery. Ann Surg Oncol. 2016;23:4270–6.CrossRefGoogle Scholar
  45. 45.
    Fayanju OM, Ren Yi, Thomas SM, et al. The clinical significance of breast-only and node-only pathologic complete response (pCR) after neoadjuvant chemotherapy (NACT): a review of 20,000 breast cancer patients in the National Cancer Data Base (NCDB). Ann Surg. 2018;268:591–601.Google Scholar
  46. 46.
    Boughey JC, Peintinger F, Meric-Bernstam F, et al. Impact of preoperative versus postoperative chemotherapy on the extent and number of surgical procedures in patients treated in randomized clinical trials for breast cancer. Ann Surg. 2006;244:464–70.Google Scholar
  47. 47.
    Mamtani A, Barrio AV, King TA, et al. How often does neoadjuvant chemotherapy avoid axillary dissection in patients with histologically confirmed nodal metastases? Results of a prospective study. Ann Surg Oncol. 2016;23:3467–74.CrossRefGoogle Scholar
  48. 48.
    Boughey JC, McCall LM, Ballman KV, et al. Tumor biology correlates with rates of breast-conserving surgery and pathologic complete response after neoadjuvant chemotherapy for breast cancer: findings from the ACOSOG Z1071 (Alliance) prospective multicenter clinical trial. Ann Surg. 2014;260:608–14; (discussion 614–6).Google Scholar
  49. 49.
    Kim JY, Park HS, Kim S, et al. Prognostic normogram for prediction of axillary pathologic complete response after neoadjuvant chemotherapy in cytologically proven node-positive breast cancer. Med Baltim. 2015;94:e1720.CrossRefGoogle Scholar
  50. 50.
    Pilewskie M, Zabor EC, Mamtani A, et al. The optimal treatment plan to avoid axillary lymph node dissection in early-stage breast cancer patients differs by surgical strategy and tumor subtype. Ann Surg Oncol. 2017;24:3527–33.CrossRefGoogle Scholar
  51. 51.
    Pezzi CM, Kukora JS, Audet IM, et al. Breast conservation using nipple–areolar resection for central breast cancers. Arch Surg. 2004;139:32–7.CrossRefGoogle Scholar
  52. 52.
    Haffty BG, Wilson LD, Smith R, et al. Subareolar breast cancer: long-term results with conservative surgery and radiation therapy. Ing J Radiat Oncol Biol Phys. 1995;33:53–7.CrossRefGoogle Scholar
  53. 53.
    Fowble B, Solin LJ, Schultz DJ, et al. Breast recurrence and survival related to primary tumor location in patients undergoing conservative surgery and radiation for early-stage breast cancer. Int J Radiat Oncol Biol Phys. 1992;23:933–9.CrossRefGoogle Scholar
  54. 54.
    Huang J, Barbara L, BNrouwers M, et al. Does delay in starting treatment affect outcomes of radiotherapy? A systematic review. J Clin Oncol. 2003;21:555–63.Google Scholar
  55. 55.
    Punglia RS, Saito AM, Neville BA, et al. Impact of interval from breast conserving surgery to radiotherapy on local recurrence in older women with breast cancer: retrospective cohort analysis. BMJ. 2010;340:c845.Google Scholar
  56. 56.
    Lohrisch C, Paltiel C, Gelmon K, et al. Impact on survival of time from definitive surgery to initiation of adjuvant chemotherapy for early-stage breast cancer. J Clin Oncol. 2006;24:4888–94.CrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Angelena Crown
    • 1
  • Flavio G. Rocha
    • 1
  • Janie W. Grumley
    • 2
    Email author
  1. 1.Department of General, Thoracic and Vascular SurgeryVirginia Mason Medical CenterSeattleUSA
  2. 2.Providence Saint John’s Health CenterJohn Wayne Cancer InstituteSanta MonicaUSA

Personalised recommendations