Preoperative predictors of nipple-areola complex involvement for patients undergoing mastectomy for breast cancer

Proper patient selection is important for nipple-sparing mastectomy, and we aimed to identify preoperative factors predictive of pathologic nipple-areola complex (NAC) involvement to assist with surgical planning.

We retrospectively reviewed a prospectively collected database of patients who underwent mastectomy for DCIS or invasive breast cancer at a single institution. Cases with NAC involvement, NAC(+), were compared with those without NAC involvement, NAC(-). Multivariate logistic regression analysis was performed to determine preoperative factors independently predictive of NAC involvement.

A total of 238 standard, 107 skin-sparing, and 47 nipple-sparing mastectomies were performed, and the NAC was pathologically involved in 16% (N = 62). Clinical NAC involvement, as determined by patient symptoms or physical exam, was present in 61% of NAC(+) but only 14% of NAC(-) cases (P < .0001) and carried a 92% negative predictive value (NPV). Preoperative imaging involved the NAC in 38% of NAC(+) but only 4% of NAC(-) cases (P < .0001) and carried an 89% NPV. NAC(+) tumors were larger, with mean size 3.3 cm versus 2.5 cm for NAC(-) tumors (P = .024). The mean tumor-to-nipple distance was 2.0 cm for NAC(+) versus 4.7 cm for NAC(-) tumors (P < .0001). On multivariate analysis, independent predictors of NAC involvement were the presence of clinical NAC involvement (odds ratio [OR] 5.11, 95% confidence interval [95% CI] 2.53-10.35) and imaging involvement of the NAC (OR 5.82, 95% CI 2.43-13.94).

Clinical and imaging abnormalities at the NAC are the only independent preoperative predictors of NAC pathology, and the absence of these factors conveys a low probability of NAC involvement.