What is the treatment approach for retroareolar (behind the areola) malignancies considered for Breast-Conserving Surgery (BCS)?

Treatment Approach for Retroareolar Malignancies Considered for Breast-Conserving Surgery

Retroareolar malignancies may require excision of the nipple-areolar complex to ensure adequate tumor margins and avoid devascularization, but this does not preclude breast-conserving surgery as a treatment option. 1

Assessment and Surgical Planning

• Retroareolar location alone is not an absolute contraindication to breast-conserving surgery (BCS), though it requires careful surgical planning 1, 2
• Tumors in the subareolar area may require excision of the nipple-areolar complex (NAC) to ensure adequate tumor margins and avoid devascularization 1, 3
• The decision between NAC-sacrificing BCS versus mastectomy should be discussed with the patient, weighing cosmetic outcomes against oncologic safety 1
• Preoperative imaging should carefully assess the extent of disease, particularly to rule out multicentricity which would be a contraindication to BCS 1, 2

Surgical Techniques for Retroareolar Tumors

• Central quadrantectomy with NAC resection is the standard approach for retroareolar tumors when BCS is selected 4
• The surgical procedure should remove a cylinder of breast tissue reaching down to the pectoral muscle with adequate margins (typically aiming for at least 1 cm) 4, 5
• For small lesions in the immediate subareolar area, partial areolar excision with careful approximation may provide adequate tissue removal while preserving some of the NAC 1, 3
• Oncoplastic techniques should be considered to optimize cosmetic outcomes after central resections 6, 4

Reconstruction Options

• Advancement of an infero-laterally based skin-glandular flap is an effective reconstruction technique after central quadrantectomy 4
• Closure of breast tissue may reduce the occurrence of a saucer-like defect, though the overall cosmetic result with nipple-areolar sacrifice will be less than optimal 1
• For selected cases, the trans-axillary retro-mammary gland route approach can be considered to minimize visible scarring on the breast 7

Oncological Outcomes

• Local recurrence rates for retroareolar cancers treated with BCS are comparable to those treated with mastectomy (approximately 9.1% vs 4.0% in one study, which was not statistically significant) 8
• Distant recurrence rates are also similar between BCS and mastectomy for retroareolar tumors 8
• BCS must be followed by adjuvant radiation therapy to optimize local control 2, 5

Important Considerations and Pitfalls

• Meticulous hemostasis is critical during surgery to prevent hematoma formation, which can compromise cosmetic outcomes and complicate follow-up imaging 1, 3
• Specimen orientation by the surgeon with sutures or clips is important for accurate pathological assessment 1
• The specimen should not be sectioned before submission to pathology to ensure accurate margin assessment 1
• Ensure that surgical margins are clear; if margins are positive, re-excision is necessary before proceeding with radiation 2, 5
• BCS for retroareolar tumors should not delay the start of adjuvant treatment nor hamper clinical and mammographic follow-up 4

Algorithm for Decision-Making

1. Confirm single focus disease (rule out multicentricity) 2
2. Assess tumor size relative to breast size (large tumor in small breast may require mastectomy) 1
3. Determine if NAC preservation is possible:
   • If tumor is not directly involving NAC: attempt BCS with NAC preservation 3
   • If tumor involves NAC: perform central quadrantectomy with NAC removal 4
4. Consider oncoplastic techniques for reconstruction 6, 4
5. Ensure clear margins (≥1 cm ideal) 4, 5
6. Proceed with adjuvant radiation therapy 2