The use of postoperative radiation after nipple sparing mastectomy

Nipple-sparing mastectomy (NSM) is a surgical procedure designed to reduce the disabling psychological effects of radical mastectomy. The preservation of the nipple-areola complex (NAC) produces a better result of the breast reconstruction, but some concerns exist of increasing the risk for local recurrence (LR). To reduce this risk a restricted inclusion criteria is suggested. In case of patients with high or intermediate risk the use of radiation therapy (RT) is also recommended, but a current standard for radiation after NSM is not available. In the literature, with few exceptions, there are few reports detailing indication and technique of radiation after NSM. There is a general consensus that post-mastectomy radiation therapy (PMRT) should be considered for patients with four or more positive axillary lymph nodes, primary tumour size 5 cm or more, T4 disease for skin involvement and positive margin. Almost all of these patients are candidate to receive external beam radiotherapy to the chest wall and to the supraclavicular/axillary region, less to the internal mammary chain. PMRT could be omitted in elderly patients with poor clinical conditions or co-morbidities that substantially reduce the life expectancy. Because the indications of NSM have been progressively extended also to larger or multi-centric tumours, this procedure has been criticised because of the increased risk of recurrence behind the areola due to the remaining glandular tissue, especially the terminal ducts, kept to preserve its blood supply, and especially in case of more advanced tumours. To reduce this concern, adjuvant RT after NSM should be administered in high risk patients who meet the criteria for current recommendations, but in other cases, such as in patients with intermediate risk or lower stage, the indication should be discussed on individual.