What is the recommended approach for treating a retroareolar malignancy, considering breast-conserving surgery (BCS)?

Treatment Approach for Retroareolar Malignancy with Breast-Conserving Surgery

Breast-conserving surgery (BCS) is a feasible and oncologically safe alternative to mastectomy for patients with retroareolar breast cancer, provided that clear surgical margins can be achieved and followed by whole breast radiation therapy. 1, 2

Patient Selection and Evaluation

• Retroareolar location alone is not an absolute contraindication to BCS, though it requires careful surgical planning and patient counseling 3
• BCS should be considered when:
  • Tumor is unifocal (not multicentric) 1
  • Adequate breast size relative to tumor size allows for good cosmetic outcome 1
  • Clear surgical margins can be achieved 1
• Contraindications to BCS in retroareolar malignancy include:
  • Multicentric disease 1, 4
  • Large tumor in a small breast where resection would cause significant cosmetic deformity 1
  • Inability to achieve clear margins 1

Surgical Approach

• Central quadrantectomy with complete removal of the nipple-areola complex (NAC) is the standard approach for retroareolar tumors 3, 2
• The procedure should include:
  • Excision of the tumor with the NAC down to the pectoralis fascia 5
  • Adequate safety margins (at least 2 mm for invasive disease, >2 mm preferred for in situ disease) 1
  • Sentinel lymph node biopsy for axillary staging in clinically node-negative disease 1
• Specimen orientation with sutures or clips is essential for accurate pathological assessment 3
• Careful histological assessment of resection margins is mandatory; if margins are positive, re-excision is necessary 1, 3

Reconstruction Options

• Oncoplastic techniques should be employed to maintain good cosmetic outcomes 1, 6
• Options for reconstruction after NAC removal include:
  • Pedicled dermoglandular flap from the upper outer quadrant 5
  • Infero-laterally based skin-glandular flap 6
  • Anterior intercostal perforator flaps for selected patients 7
• Closure of breast tissue may reduce saucer-like defects, though cosmetic results with NAC sacrifice will be less than optimal 1

Adjuvant Therapy

• Whole breast radiation therapy is mandatory after BCS for retroareolar malignancy 1
• Systemic therapy decisions should be based on tumor biology (ER/PR/HER2 status) and risk factors, not the retroareolar location 1, 4

Outcomes and Follow-up

• Local recurrence rates after BCS for retroareolar tumors are comparable to those after mastectomy (4.8-9.1% vs. 4.0-4.8%) 8
• Cosmetic outcomes after BCS with reconstruction are reported as excellent in 80% of patients and good in 13.3-20% 5, 2
• Regular follow-up with clinical examination and imaging is essential to detect local recurrence 1

Common Pitfalls to Avoid

• Underestimating the importance of clear surgical margins; inadequate margins increase local recurrence risk 1, 3
• Failing to perform meticulous hemostasis, which can lead to hematoma formation and complicate follow-up imaging 1, 3
• Omitting radiation therapy after BCS, which is essential for local control 1
• Not discussing reconstruction options with patients before surgery 1

The evidence clearly demonstrates that BCS with NAC removal and appropriate reconstruction techniques, followed by radiation therapy, provides oncologically safe outcomes with good cosmetic results for patients with retroareolar malignancy 5, 2, 8.