A Guide Algorithm For Management of Central.39

Original article 727
A guide algorithm for management of central quadrant breast

cancer at Cairo University Hospitals
Emad Khallaf, Yehia M. Safwat, Yehya Khodear, Kerolos A. Barsoum,
Youmna G. Sabry, Mahmoud A. Ameen
Downloaded from http://journals.lww.com/ejos by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
Breast Unit, Department of General Surgery, Background

Faculty of Medicine, Cairo University, Cairo, Oncoplastic techniques play an important role in managing centrally located breast
Egypt
cancer, as it gives the opportunity for wider surgical resection, which leads to
Correspondence to Mahmoud Abdelmonem
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/10/2024
adequate margins and good oncological outcome while maintaining great cosmetic
Ameen, MD, Giza, 11865, Egypt,
results and patient satisfaction. The objective of the current study is to assess the
Tel: 01002862709;
e-mail: mahmoudmon3m84@yahoo.com short-term oncological and aesthetic outcomes of oncoplastic techniques after
centrally located breast tumor resection.
Received: 5 March 2021
Revised: 12 March 2021
Patients and methods
Accepted: 12 March 2021 This study comprised 35 patients with central breast cancer who were treated at
Published: xx xx 2020 Kasr Al Ainy Teaching Hospital, Faculty of Medicine, Cairo University. The decision
The Egyptian Journal of Surgery 2021,
of surgery was taken by a multidisciplinary team. According to nipple–areola
40:727–737 complex (NAC) involvement, we classified the patients into two groups. The first
group included patients with evidence of NAC involvement and required resection
of the NAC. The second group included patients with no evidence of NAC
involvement, and preservation of the NAC was done. In each group, we used
the breast size (cup size) and the degree of breast ptosis to guide the selection of
the oncoplastic technique.
Results
Our sample had a mean age of 51.2±10 years and ranged from 35 to 74 years. A
total of 13 patients had a medium-sized breast with mild ptosis, hence underwent
round block technique. Moreover, 11 patients had a medium-sized breast with
moderate ptosis and underwent Grisotti mastopexy. In addition, in larger breasts,
reduction mammoplasty was the optimal procedure, whereas in tumors that had
extended to the upper pole of the breast (segment II), dome-shaped mastopexy
was the best option, especially in patients with large areolar discs more than 4 cm in
diameter. Regarding postoperative complications, four (11.4%) patients had a
seroma formation and three cases developed wound infection, whereas only
one case had a postoperative wound dehiscence and were treated conservatively.
Discussion
Preoperative radiological assessment was proved to be a very crucial element in
predicting the possibility of NAC involvement, by using both MRI and
mammography. The patients who had positive pathological invasion of NAC
postoperatively had a smaller distance between the tumor and NAC (<1.58 cm).
On the contrary, the patients who had a nipple-tumor distance more than or equal to
2.4 cm had a higher probability of negative invasion of NAC in pathological
assessment. Regarding the patients’ satisfaction toward the surgical procedure
done, 60% had excellent results, and it was mainly related to NAC preservation.
Keywords:
central breast tumors, oncoplastic breast surgery, retroareolar tumors
Egyptian J Surgery 40:727–737
© 2021 The Egyptian Journal of Surgery
1110-1121
limiting factors is the central breast tumors, which have

Introduction
been denied the opportunity of breast conservation,
Breast conservation surgery (BCS) combined with
given the possibility of multifocality, multicentricity,
postoperative radiotherapy has become the preferred
direct invasion of the nipple–areolar complex (NAC),
locoregional treatment for the majority of patients with
and aesthetic revulsion arising from the possible
early-stage breast cancer, with equivalent survival to
removal of the NAC [3]. It is not until later, when
that of mastectomy [1]. The success of BCS for breast
cancer is based on the belief of complete removal of
the cancer with adequate surgical margins, while This is an open access journal, and articles are distributed under the terms
of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
preserving the natural shape and appearance of License, which allows others to remix, tweak, and build upon the work
the breast. Achieving both goals together in the non-commercially, as long as appropriate credit is given and the new
same operation can be challenging [2]. One of the creations are licensed under the identical terms.
© 2021 The Egyptian Journal of Surgery | Published by Wolters Kluwer - Medknow DOI: 10.4103/ejs.ejs_78_21
728 The Egyptian Journal of Surgery, Vol. 40 No. 2, April-June 2021
the clinical trials have proved that breast conservative was clinical evidence of nipple involvement (nipple
surgery in centrally located tumor is similar to those retraction, nipple discharge, ulceration, and Paget
who undergo mastectomy in terms of local recurrence, disease) and/or imaging findings suggesting malignant
disease-free, or overall survival rates [4,5]. However, involvement of the nipple and subareolar tissues (lesion
the conventional conservative treatment or central to nipple distance <2 cm, best done by MRI).
quadrantectomies, which includes excision of the
NAC and the correspondent underlying cylinder of The decision of surgery was taken by a multidisciplinary
parenchyma down to the pectoralis fascia, may result in team, who are specialized in breast cancer, then it was
local glandular defects and poor esthetic outcome discussed with the patients, and their approval was
including obvious distortion of breast contour and documented by an informed consent. This study
scar contracture in most cases [6]. The failure of was approved the Ethical Committee for Researches
classical BCS techniques to offer solutions for of General Surgery Department, Cairo University
challenging scenarios has stimulated the growth and Hospital and the Research committee of Faculty of
advancement of new techniques in breast surgery medicine, Cairo University. According to NAC
during the past decade. Oncoplastic surgery has involvement, we classified the patients into two
emerged as a new approach to allow wide excision for groups. The first group included patients with
BCS without compromising the natural shape of the evidence of NAC involvement and required resection
breast. It is based upon integration of plastic surgery of the NAC. The second group included patients with
techniques for immediate breast reshaping after wide no evidence of NAC involvement, and preservation
excision for breast cancer [7]. Several oncoplastic of the NAC was done. In each group, we used the
techniques can be used to reconstruct the breast after breast size (cup size) and the degree of breast ptosis
central quadrantectomy. The choice of the oncoplastic to guide the selection of the oncoplastic technique.
technique depends on tumor size, NAC involvement,
the breast volume, and its ptotic degree [8]. The objective Oncoplastic surgical techniques
of the current study is to assess the short-term General considerations
oncological and aesthetic outcomes of oncoplastic The procedure started by preoperative markings before
techniques after centrally located breast tumor resection. anesthesia and with the patient standing. The
operation was done under general anesthesia with
the patient in supine position with both arms
Patients and methods abducted. Excision of the mass with 1 cm safety
This study comprised 35 patients with central breast margin was done. Following surgical excision, the
cancer who were treated at Kasr Al Ainy Teaching breast specimen was marked with sutures by the
Hospital, Faculty of Medicine, Cairo University, surgeon to retain orientation. Surgical margins were
between October 2015 and June 2018. All patients determined by macroscopic and histologic examination
with centrally located operable breast cancer were of frozen sections of the breast specimens. We used the
included in the study. Patients with peripheral tumors following techniques for breast reconstruction.
or eccentric tumors extending more than 2 cm beyond
the areolar edge, multicentric tumors, previous breast Grisotti mastopexy
irradiation, and pregnancy were excluded. Full history This technique was used in 11 patients with moderate-
taking and thorough physical examination of both size breasts (B, C) and moderate or severe ptosis and
breasts and axillae were done, including assessment of required resection of the NAC. The operation started
the size of the breast (cup size), the shape of the with marking of the areola outline, another 4-cm circle is
breast, breast ptosis, and previous operations (biopsies drawn just below the NAC, and also the inframammary
and previous surgery). Assessment of breast ptosis was fold was marked. The medial and lateral borders of the
done according to LaTrenta and Hoffman Classification flap were drawn extending from the medial and lateral
[9], which classifies breast ptosis into 3° [10]. margins of the areolar down to the inframammary
Investigations including routine laboratory tests, fold and converging distally to give a comma-
bilateral mammography and breast ultrasound, MRI, shaped appearance (Fig. 1a). Then complete de-
and metastatic workup were done. Histopathological epithelialization of the flap (except the new areola)
diagnosis of cancer was made before surgery using was done (Fig. 1b). Central quadrantectomy including
core needle biopsy; patients with Paget’s disease were NAC and tumor with a column of tissue from the
subjected to punch/wedge biopsy. An important part of subcutaneous layer down to the pectoral fascia was
preoperative patient assessment is to determine if the done (Fig. 1c) with marking the specimen peripheries
NAC is involved or not. NAC was not preserved if there for intraoperative frozen section analysis. Mobilization
Guide algorithm for management of central quadrant breast cancer Khallaf et al. 729
Figure 1
Grisotti technique (a) preoperative mapping. (b) Complete de-epithelialization of the flap (except the new areola). (c) Central quadrantectomy
defect. (d) Central quadrantectomy specimen including NAC. (e) Immediate postoperative view. NAC, nipple–areola complex.
of the flap was done using one of the following Figure 2

techniques:
(1) The medial margin of the flap was incised down to

the pectoral fascia with wide mobilization of the
flap from the pectoral fascia, and then, the flap was
advanced and rotated to fill the defect. This
technique was used in six cases.
(2) The dermis of the medial and lateral margins of the
flap was released to the required extent but keeping
its base on the pectoral fascia intact to preserve
blood supply. We found that this technique gives
better mobility of the flap, and the new areola
rests comfortably in its new position without the
comma-shaped deformity. We used this technique
in five cases.
Diagram showing preoperative drawing of Batwing (O) modification.
Breast tissue was approximated using 2/0 or 3/0 vicryl

sutures followed by skin closure with subcuticular 4/0 resembling original NAC instead of half a circle, so
absorbable sutures, and suction drain was used. giving better cosmetic outcome (Fig. 2). The technique
started with marking of the areola outline, and another
Batwing mastopexy 4-cm circle is drawn just below the NAC. A horizontal
This technique was used in patients with moderate-size tangent is drawn between both circles. From the center
breast (B, C), mild ptosis, and requiring resection of of both circles, two lines measuring (2–4 cm) are drawn
NAC. We did a modification in this technique called medially and laterally creating two triangles (Fig. 3a).
Batwing (O) modification; the aim of this modification The triangles are then de-epithelialized (Fig. 3b).
is to replace the resected NAC with a complete circle Central quadrantectomy including NAC and tumor
Figure 3
Batwing mastopexy (a) preoperative mapping. (b) De-epithelialization. (c) Central quadrantectomy defect. (d) Immediate postoperative view.
with a column of tissue from the subcutaneous layer Figure 4

down to the pectoral fascia was done (Fig. 3c), with
marking the specimen peripheries for intraoperative
frozen section analysis.
The upper borders of both triangles were incised, and

the resulting de-epithelialized triangles were put
underneath the skin laterally from the defect. The
defect was then closed by approximating the breast
tissue using vicryl 2/0 sutures followed by subcuticular
sutures using 4/0 absorbable sutures (Fig. 3d). Suction
drain was inserted.
Round block technique

It was used in 13 patients with lesions located within Round block technique (a) preoperative mapping. (b) Immediate
2 cm of the areolar margin, but not involving the NAC, postoperative view.
in small-size to moderate-size breasts. The technique
started by drawing two circles, one around areola and using the same plane for mastectomy. Excision of the
the other circle 1–2 cm outside the first one (Fig. 4a). mass in a wedge-shaped fashion directed radially
This 1–2 cm can be made more in larger tumors and if toward the NAC, and then mobilization from the
there was ptosis that required correction. If the original pectoralis fascia was done if needed. This was
areola was more than 4 cm, the inner circle was marked followed by closure of the defect using vicryl 2/0 or
as 4 cm using a cookie cutter. De-epithelialization of 3/0 sutures after adequate hemostasis. A purse string
the skin island between the two circles was done. using a 3-0 absorbable suture was placed around
Cutting through the dermis at the side of tumor the areola opening and was tightened and clamped
location was done. Then, the quadrant of breast at a size that approximates the original NAC.
tissue containing the target lesion was fully exposed Interrupted inverted 3-0 absorbable sutures are
placed subdermally around the NAC, at which time the and adjacent to the areola, encompassing the skin
purse-string suture is tied, and then, 4-0 subcuticular immediately overlying a breast malignancy (Figs 5a
sutures are used to close the wound (Fig. 4b). and 6). Resection of the skin island between the two
lines was done. Raising flaps in the same plane as
Crescent mastopexy resection mastectomy was done to facilitate excision of the mass.
This technique was used in two cases for resection of This was followed by wedge excision of the mass with
tumors located in the upper central quadrant between adequate safety margin. Suction drain was inserted.
10 and 2 o’clock positions in patients with small-size to Closure of the defect was done using 2/0 or 3/0 vicryl
moderate-size breasts. The technique started by sutures followed by 4/0 subcuticular sutures for skin
drawing two semiparallel ‘C-‘ shaped lines, superior closure (Fig. 5b).
Figure 5
Crescent mastopexy (a) preoperative mapping. (c) Intraoperative picture. (b) Immediate postoperative view.
Figure 6
(a) Preoperative markings for a patient with retroareolar mass extending to the upper inner quadrant underwent reduction mammoplasty (wise
pattern technique) with contralateral breast reduction. (b) Postoperative result after 4 weeks.
Patients who were node negative at presentation (N0)

Results
were subjected to sentinel lymph node biopsy at the time
A total of 35 patients were eligible for inclusion in our
of planned surgery using patent blue. Combined
study. All patients were diagnosed with primary breast
intradermal, periareolar, and peritumoral injection
cancer in the central region. None of them had a
techniques were used. If the sentinel node were
multicentric lesion by clinical or radiological
negative, no further axillary dissection was done.
assessments. Breast MRI was done for all patients.

However, if the sentinel node was positive, axillary
The patients had a mean age of 51.2±10 years old and
lymph node dissection (ALND) was completed (levels
ranged from 35 to 74 years. A total of 26 (74.3%)
I and II dissection). Patients who had initially node-
patients were luminal, seven (20%) patients were
positive axilla were subjected to ALND. All specimens

HER-2 enriched, whereas two patients were triple
were oriented and subjected to histopathology and
negative. Only four (11.4%) patients had a positive
immunohistochemical examination, including ER,
family history. Multiple variables were studied to
PR, and Her-2-neu. Margins were regarded as
predict NAC involvement before surgery (Table 1)
negative when permanent histological examination
(clinically, in the form of retraction / ulceration, and
found no cancer cells within a distance of 1 mm from
radiologically in the form of suspicious enhancement
excised tissue surface for invasive cancer and 2 mm for
and/or suspicious findings within 2 cm of the nipple on
duct carcinoma in situ. Postoperative clinical follow-up
MRI and/or diagnostic mammography, respectively),
was done at 3-month intervals and included palpation of
as this prediction subsequently affected the decision
the breast and axilla. Mammograms and ultrasound were
upon which NAC should be preserved or sacrificed.
done if there was any degree of clinical suspicion.
A total of 13 patients had a medium-sized breast with
Assessment of the cosmetic outcome
mild ptosis, hence underwent round block technique,
Subjective evaluation
whereas 11 patients had a medium-sized breast with
Assessment of the postoperative cosmetic results entails
moderate ptosis and underwent Grisotti mastopexy.
asking patients to rate the postoperative cosmetic
However, in larger breasts, reduction mammoplasty
result and their degree of satisfaction compared with
was the optimal procedure, and only one case was
the preoperative breast using a five-point scale (excellent,
subjected to this technique. On the contrary, in
5; good, 4; fair, 3; poor, 2; and bad, 1).
tumors that had extended to the upper pole of the
breast (segment II), Dome-shaped mastopexy was the
Objective evaluation
best option, especially in patients with large areolar
Objective assessment of the cosmetic result was
discs more than 4 cm in diameter; two cases were done
done by two surgeons rated on a visual analog scale
by this technique (Table 2). A total of 20 (57.1%)
from 1 (unacceptable result) to 10 (excellent result).
patients were clinically and radiologically node negative
Evaluation was based on five criteria, namely, breast
and underwent SLND. However, 15 (42.9%) patients
symmetry, glandular tissue defects, nipple and areola
underwent ALND. Overall, 74.3% of cases were
reconstruction, scar quality and/or retraction, and the
invasive duct carcinoma, whereas 14.3, 5.6, and 2.8%
resultant breast shape.
of cases were Paget’s, invasive lobular carcinoma (ILC),
and duct carcinoma in situ (DCIS), respectively
Statistical analysis was conducted using STATA 14.2
software (StataCorp LLC 4905 Lakeway Drive
College Station, Texas, USA). Continuous variables Table 1 Nipple–areola complex involvement in studied cases
were presented as mean and SD, and intergroup Items n (%)
differences were compared using t test. Skewed Site of the tumor
numerical data were presented as median and Retroareolar 33 (94.3)
average rank, and between-group differences were Retroareolar and other quadrants 2 (5.7)
compared using the Mann–Whitney U test [11]. Clinical involvement of NAC
Paired numerical data were compared using the No 19 (54.3)
Yes 16 (45.7)
paired t test. Categorical variables were presented
Radiological involvement of NAC
as number and percentage, and differences between
No 25 (71.4)
groups were compared using Pearson χ 2 test or Fisher’s Yes 10 (28.6)
exact test [12]. Ordinal data were compared using the Pathological involvement of NAC
χ 2 test for trend. Paired binary data were compared No 21 (60)
using the McNemar test. P values less than 0.05 were Yes 14 (40)
considered statistically significant. NAC, nipple–areola complex.
(Table 2). Patients with highly suspicious NAC regarding the aesthetic evaluation, the breast shape
involvement preoperatively were mostly subjected to and symmetry yielded a mean score of 7.8 points,
NAC resection after correlation with frozen section indicating that the overall results were satisfactory,
results. A total of 17 (48.5%) patients were subjected to where the highest scores had been attributed mainly
NAC resection, where 14 (82.3%) patients were proved to the techniques where the NAC is preserved, like
to be pathologically involved, whereas just three round block technique (RBT) and dome-shaped
(17.6%) proved to be free of tumor infiltration. mastopexy.
Regarding postoperative complications, four (11.4%) Tests of correlations

patients had a seroma formation and three cases Postoperative complications

developed wound infection, whereas only one case Seroma formation had a significant correlation with
had a postoperative wound dehiscence and was hypertension, as patients who had hypertension had a
treated conservatively. There were no reported cases higher incidence of postoperative seroma formation,
that had a flap necrosis (Fig. 7). with P value of 0.03. Moreover, patients with
radiological evidence of NAC involvement had a
Regarding cosmetic outcome assessment by patient higher incidence of postoperative seroma formation,
satisfaction, 21 (60%) patients had an excellent with P value of 0.03. Patients who underwent
satisfaction, whereas 10 (28.6%) patients gave a good central quadrantectomy had the highest incidence of
satisfaction. Four patients had a fair satisfaction, and postoperative seroma formation, with P value of 0.005.
no patients felt bad about the cosmetic outcome. Wound infection has a significant correlation with
Patients who had been subjected to round block and surgical technique, with P value of 0.014. Wound
dome-shaped technique gave higher satisfaction, as the dehiscence correlated to patient satisfaction, with
NAC was still preserved with also symmetrical both P value of 0.02. Patient satisfaction showed a strong
breasts. In the survey of surgeons (two surgeons) correlation with comorbidities such as diabetes
mellitus, with P value of 0.006. Surgical techniques
Table 2 Percentage of techniques used in central quadrant with lowest satisfaction rates correlated with central
cancers quadrantectomy and Batwing approaches, with P value
Items n (%) of 0.001 (Fig. 8). Wound infection, wound dehiscence,
Technique of surgery and postoperative seroma significantly affected patient
Batwing 2 (5.7) satisfaction, with P values of 0.0001, 0.02, and 0.009,
Bilateral wise pattern 1 (2.8) respectively. Patients were followed-up for a period
Central quadrantectomy 4 (11.5)
Crescent mastopexy 2 (5.7)
Dome shaped 2 (5.7) Figure 8
Grisotti 11 (31.4)
Round block 13 (37.1)
Figure 7
Bar chart showing patient satisfaction based on different surgical

Bar chart showing incidence of postoperative complications. techniques.
ranging from 3 to 12 months, with a mean±SD of 6.9 outcome. However, modified radical mastectomy
±4.0 months. None of the patients developed local (MRM) is difficult for patients to accept, for both
recurrence or distant metastasis. Clinical and psychological and aesthetic reasons. Recent studies
mammographic follow-up were easy in all cases and have reported that there are no significant
was not hampered by the reconstruction. differences between MRM and BCS with respect to
local recurrence, distant metastasis, and survival rate
Doctor’s opinion correlated with the surgical [13].

techniques, with P value of 0.005, and wound
infection, P value of 0.0001. Receiver operating However, it is worth mentioning in this context that
characteristic analysis for sensitivity and specificity of other authors reported in extended series of 298
preoperative radiological assessment showed that patients treated with oncoplastic surgery, 5-year
radiological involvement of NAC preoperatively had recurrence-free and overall survival rates of 93.7 and
an area under the curve of 0.64, sensitivity 42.8%, 94.6%, respectively [4]. Moreover, Simmons et al. [14]
specificity 81%, and P value of 0.12 (Fig. 9). have reported that the recurrence rate of patients with
centrally located breast cancer who underwent BCS
Using a Student t test, patients who had positive was 6.3%, a statistically insignificant rate as compared
pathological invasion of NAC postoperatively had with the recurrence rate of 4.5% in patients who
a smaller distance between the tumor and NAC underwent MRM.
(<1.58 cm). On the contrary, patients who had a
nipple-tumor distance more than or equal to 2.4 cm In our study, we did not report any case of local
had a higher probability of negative invasion of NAC recurrences or distant metastasis, which may be
in pathological assessment, with P value of 0.04 owing to the short time of follow-up, which actually
(Table 3). was not one of the main intentions of this effort, as our
main focus was to create a guideline for the treatment
of retroareolar breast tumors. However, proper
Discussion assessment of NAC involvement by MRI and
Retroareolar breast cancers were conventionally treated intraoperative frozen section is an additional
via modified radical mastectomy, because of the explanation of 0% recurrence in our cases.
possibility of multicentricity, which usually
accompanies these types of tumors (centrally located There is an increasing interest in the preservation of
tumors), and direct invasion of the NAC, necessitating the nipple and/or areola in hopes of achieving
subsequent resection, which leads to bad cosmetic improved cosmetic and functional outcomes; however,
Figure 9
the oncologic safety of NAC preservation is a major
concern, which is why, the identification of the possible
predictive factors for NAC involvement in patients with
breast cancer is crucial. Several series confirmed that
optimal preoperative patient selection and intraoperative
assessment of the NAC can result in low rates of
nipple resections with future long-term viability.
In our study, efforts have been done to classify patients

who were most likely to have NAC tumor involvement
from those who had free NAC, so as to facilitate the
decision of NAC preservation or resection. All patients
Table 3 The relation between both (nipple-tumor distance and

tumor size) and pathological invasion of nipple–areola
complex
Items Positive Negative P value
Mean SD Mean SD
ROC curve show sensitivity of preoperative radiological assessment
of NAC involvement in comparison with pathological NAC involve- Distance from tumor to NAC 1.58 1.2 2.4 1 0.04
ment. NAC, nipple–areola complex; ROC, receiver operating char- Tumor size 1.9 2 2.5 1.2 0.27
acteristic.
NAC, nipple–areola complex.
were assessed preoperatively by clinical examination to than 4 cm from the NAC and 0% frequency of
detect patients with clinically suspicious NAC who involvement was reported, whereas the presence of
may be manifested with nipple retraction, ulceration, tumor at 1-cm distance from the NAC had reported
and/or erosion. It was then proved that depending only frequency of 58% . Vyas et al. [19] have recommended
on clinical manifestations of NAC was not enough, that in cases where the tumor is more than 2.5 cm from
being an inefficient predictive factor for suspecting the NAC, preserving the NAC would be worthwhile,
NAC tumor involvement, as it gave 11.4% false- as this distance, in their study emerged as an
negative results, as patients who had normally independent risk factor and predictor for NAC
looking NAC were found to have pathologically involvement. However, a recent study was done by
involved nipples. However, 14.2% (5/35) of patients Piato et al. [15], which revealed that the most
gave false-positive impression of tumor involvement, important MRI characteristics to exclude the
but in fact, they were proved to be pathologically free. possibility of neoplastic involvement of the NAC in
Among 172 patients in a study done by Piato et al. [15], breast cancer patients rather than the distance of the
false-negative cases (17%) proved to have involved lesion from the NAC were the absence of enhancement
NAC without any clinical evidence. On the between the lesion and the nipple associated with the
contrary, patients (6%) who had retracted nipples absence of retraction of the nipple. The negative
were proved to be free of tumor, as false-positive cases. predictive value of the combination of the absence of
these two characteristics was 83.3%.
Additionally, preoperative radiological assessment
proved to be a very crucial element in predicting Karamchandani et al. [20] supported the importance of
the possibility of NAC involvement, by using both interpretation of MRI results preoperatively because of
MRI and mammography, and correlating their results its high sensitivity in detecting NAC involvement, as
properly, to calculate the approximate distance between among a total of 41 cases enrolled in the study, 35
the lesion and NAC, which was considered the most (85.4%) of 41 had concordance between pathologic and
accurate predictive tool in our study. Infiltrated nipples radiologic findings.
were confirmed to be pathologically involved in 14 (40%)
patients. Among which, tumors located at a distance of However, it could be noticed that the problem of the
2 cm or less in those patients were 11 (78.6%), whereas predictive factors are not consistent across studies, and
only three (21.4%) patients had a tumor-NAC distance some are even contradictory to each other. Our study
more than 2 cm. On the contrary, 21 (60%) patients has revealed histologically proved postoperative
proved to have pathologically free NAC by both frozen positive axillary nodes were found in only two of 14
and paraffin sections, of whom, 14 (66.7%) had tumor- patients who were proved to have infiltrated nipples.
NAC distance more than 2 cm, whereas less than 2 cm in Regarding the intrinsic subtypes of breast cancer (ER,
seven (33.3%) patients. Using a Student t test, patients PR, and Her-2-Neu) together with the histological
who had a positive pathological invasion of NAC type of the tumor particularly (DCIS), no significant
postoperatively had a smaller distance from tumor to implications on the probability of NI among our
NAC (<1.58 cm), whereas patients who had tumor-to- patients were found. Only one patient has been
NAC distance of more than or equal to 2.4 cm had reported to have DCIS compared with 13 patients
a higher probability of negative invasion of NAC in having invasive carcinoma. This is in contrary to
pathological assessment, with P value 0.04. As a result, it Suarez [21], who stated that, the majority of NAC
can be concluded that prediction of NAC involvement neoplastic involvement was affected by DCIS (59.5%),
depends largely on the tumor distance away from the followed by invasive carcinoma (35.1%).
nipple.
The most accurate method to predict neoplastic
Similar to our context, Smith et al. [16] have reported a involvement of the nipple was the subareolar frozen-
higher likelihood of NAC pathological infiltration, if section (nipple coring biopsy) examination
the nipple was clinically involved and/or the primary intraoperatively. Studies involving expressive cohorts
tumor was retroareolar or within 2 cm from NAC. In showed that the subareolar frozen-section examination
another detailed study, Lagios et al. [17] have found could yield false-negative rates between 1.3 and 9.3%
that the most important predictor of NAC infiltration [22]. Frozen section examination was performed in our
was the proximity of tumor to the nipple, as with 95% institute for all patients, on the excised mass together
of involved nipples, primary tumors lay within 2.5 cm with a subareolar biopsy (coring of the nipple), and the
of their edge. During univariate analysis, by Khan et al. safety margins were satisfactory in all patients included
[18] on 136 cases, all the cases studied had tumors more in our study.
The high incidence of NAC involvement associated excellent results (21 of 35 patients); 15 (71.4%) of
with retroareolar tumors necessitates, usually, NAC 21 patients were subjected to round block and
resection together with an adequate safety margin dome-shaped technique, as the NAC was still
around the tumor, which has yielded nonsatisfactory preserved with also symmetrical both breasts.
cosmetic results. In cases where NAC was not involved, Overall, 30% of patients were good and 15% fair. In
Flierl and Hanker [23] have reported satisfactory the survey of surgeons (two surgeons) regarding the
oncologic and cosmetic results, as simple aesthetic evaluation, the breast shape and symmetry
preservation of the breast mound for a feminine yielded a mean score of 7.8 points, indicating that the
body contour is the most essential requirement for overall results were satisfactory, where the highest
women. In our institute, patients with retroareolar scores had been attributed mainly to the techniques,
breast cancer were managed as follows: whenever where the NAC were still preserved like RBT and
there is a great suspicion of NAC involvement dome-shaped mastopexy. Dissatisfaction by the
preoperatively (suspicious enhancement and/or patients mainly related to the absence of NAC as
suspicious findings within 2 cm of the nipple proved the breast seemed to be amputated, asymmetry of
by MRI and/or mammography) in patients having both breasts, and the shape of the scar to some
large and/or ptotic breast, central quadrantectomy extent. Our cosmetic results have achieved almost
with or without remodeling was done. Overall, four the same results that have been reported in other
cases were subjected to central quadrantectomy without studies such as Moustafa and Fakhr [25]. Pasta et al.
remodeling through an elliptical incision, whereas 11 [8] have proposed another technique for involved NAC
cases were subjected to Grisotti technique. When (modified hemi-Batwing technique), which can be
lesions were found at a sufficient distance from the performed on centrally located breast tumors with
NAC in small breasts, RBT (13 cases) and crescent the inclusion of the NAC. The modified Batwing
mastopexy (two cases) were done. However, in larger technique was then introduced with the purpose of
breasts, reduction mammoplasty was the optimal getting better aesthetical outcomes. The realization of
technique; one case was subjected to this technique. rounded margins (no more sharp) has resulted in the
Sometimes tumors were found to be extended to the reproduction of the anatomic profile of the areola. On
upper pole of the breast (segment II). Dome-shaped the contrary, operating small breasts might be harder,
mastopexy was the best option in areolar discs more and so far, the aesthetic results could not be evaluated
than 4 cm in diameter; two cases were done in our for larger breasts. In our study, we proposed an
institute. However, in case of small areolar discs more algorithm using the breast size (cup size) and the
than 4 cm in diameter, Batwing mastopexy would be a degree of breast ptosis to guide the selection of the
suggested option, and we have done two cases with oncoplastic technique (Fig. 10).
Batwing mastopexy. Similar to our study, McCulley
et al. [24] have also used the central quadrantectomy
technique that largely depends on the tumor-to-breast Conclusion
size ratio, the degree of ptosis, and the preference of the Multiple oncoplastic breast surgery techniques can be
surgeon, through central elliptical excision of the tumor used safely for the resection of retroareolar breast
with direct closure of the defect. However, Grisotti tumors with satisfying cosmetic outcomes. The
technique has become more popularly used, especially choice of the optimum surgical technique for each
when there is adequate breast size or ptosis with the patient based upon multiple factors, such as breast
distance between the nipple and the inframammary size, degree of ptosis, and whether the NAC, has
fold being at least 8 cm. been involved with tumor or not. Based on the
aforementioned data, one can conclude that all
Furthermore, the same techniques have been applied in patients who present with retroareolar breast tumors,
a study conducted by Moustafa and Fakhr [25], with whether they are manifested with clinically involved
slightly higher rate of complications 5/20 (25.0). As in nipples or not, should be assessed by MRI, to detect the
our study, the postoperative complications were 8/35 distance between the tumor and the NAC and identify
(22.88%). Overall, four cases of postoperative seroma any other manifestations of involvement within 2 cm
were reported and had resolved after multiple from the NAC, like nonenhancement lesions and/or
aspirations. Additionally, one case of wound retracted nipples, together with intraoperative frozen
dehiscence was found during a purse-string suture section to the excised lesion and nipple coring biopsy,
procedure and three cases developed postoperative to select the appropriate procedure for each patient as
wound infection. Regarding the patients’ satisfaction previously described. However, further long-term
toward the surgical procedure done, 60% showed study is needed to assess the long-term outcome of
Figure 10
Guide for selection of oncoplastic technique.
these surgical procedures in terms of survival and 11 Chan YH. Biostatistics 103: qualitative data-tests of independence.
Singapore Med J 2003; 44:498–503.
recurrence.
12 Chan YH. Biostatistics 102: quantitative data − parametric & non-
parametric tests. Blood Press 2003; 140:79–00.
Financial support and sponsorship 13 Park HC, Kim HY, Kim MC, Lee JW, Chung HY, Cho BC, et al. Partial breast
Nil. reconstruction using various oncoplastic techniques for centrally located
breast cancer. Arch Plast Surg 2014; 41:520.
14 Simmons RM, Brennan M, Christos P, King V, Osborne M. Analysis of
Conflicts of interest nipple/areolar involvement with mastectomy: can the areola be preserved?.
Ann Surg Oncol 2002; 9:165–168.
There are no conflicts of interest.
15 Piato JR, Jales Alves de Andrade RD, Chala LF, de Barros N, Mano MS,
Melitto AS, et al. MRI to predict nipple involvement in breast cancer
patients. Am J Roentgenol 2016; 206:1124–1130.
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Original article 727

A guide algorithm for management of central quadrant breast

Breast Unit, Department of General Surgery, Background

limiting factors is the central breast tumors, which have

of the flap was done using one of the following Figure 2

(1) The medial margin of the flap was incised down to

Breast tissue was approximated using 2/0 or 3/0 vicryl

with a column of tissue from the subcutaneous layer Figure 4

The upper borders of both triangles were incised, and

Round block technique

Patients who were node negative at presentation (N0)

assessments. Breast MRI was done for all patients.

positive axilla were subjected to ALND. All specimens

(17.6%) proved to be free of tumor infiltration. mastopexy.

Regarding postoperative complications, four (11.4%) Tests of correlations

patients had a seroma formation and three cases Postoperative complications

Bar chart showing patient satisfaction based on different surgical

Doctor’s opinion correlated with the surgical [13].

In our study, efforts have been done to classify patients

Table 3 The relation between both (nipple-tumor distance and

Guide for selection of oncoplastic technique.

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