Management of Retroareolar Lesions Based on Distance from Skin and NAC Involvement
For retroareolar lesions, excision of the nipple-areolar complex (NAC) is recommended when the tumor is located less than 5 mm from the NAC to ensure adequate tumor margins and avoid devascularization. 1, 2
Diagnostic Evaluation for Retroareolar Lesions
- Complete history, physical examination, and diagnostic breast imaging are essential first steps for evaluating lesions in the nipple-areolar complex 1
- Ultrasound with special techniques (standoff pad, warm gel, peripheral compression) is valuable for evaluating the retroareolar region 1
- MRI is recommended when biopsy of the nipple-areolar complex is positive for Paget's disease to define disease extent 1
Decision Algorithm Based on Distance from Skin and NAC
When NAC Preservation is Possible:
- Tumors located more than 5 mm from the NAC may be candidates for NAC-sparing procedures 3
- NAC-sparing is appropriate for peripherally located, early-stage, biologically favorable cancers 4
- Radiologic distance between tumor and nipple is independently predictive of NAC involvement and assists in patient selection 3
When NAC Resection is Necessary:
- Tumors located less than 5 mm from the NAC typically require NAC resection to ensure adequate margins 1, 2
- Pathologic evidence of nipple infiltration is found in approximately 60% of central breast tumors, supporting the need for NAC resection in close proximity cases 5
- Tumors in the immediate subareolar area may require excision of the NAC to ensure adequate tumor margins and avoid devascularization 4, 1
Surgical Approaches Based on Tumor Location
For Tumors Requiring NAC Resection:
- Central quadrantectomy with NAC resection removing a cylinder of breast tissue down to the pectoral muscle is recommended 5
- A free safety margin of at least 10 mm should be the goal during resection 5
- Reconstruction using an infero-laterally based skin-glandular flap can provide satisfactory cosmetic results 5
For Small Subareolar Lesions:
- Partial areolar excision with careful approximation can provide adequate tissue removal while preserving the NAC for small lesions 4, 1
- For lesions in the immediate subareolar area, this approach can maintain good cosmesis 1
Outcomes and Follow-up
- Local recurrence rates are similar between mastectomy (4.5%) and lumpectomy (6.3%) approaches for central and retroareolar tumors 6
- Patients treated with breast conservation should undergo whole-breast radiation 1
- A radiation boost should be considered to the site of the resected NAC and any associated resected cancer site 1
- Follow-up should include interval history and physical examination every 6-12 months for 5 years and then annually 1
- Yearly diagnostic mammography is recommended, with the first follow-up mammogram performed 6-12 months after completion of radiation therapy 1
Important Considerations and Pitfalls
- The main complication of NAC-sparing procedures is NAC necrosis, which occurs in approximately 4.2% of cases 7
- Positive retroareolar margin is a risk factor for necrosis complications 7
- Meticulous hemostasis is critically important to prevent hematoma formation, which can further compromise blood supply 4
- When performing skin incisions for these procedures, radial incisions at the three o'clock and nine o'clock positions and in the lower breast often provide better cosmetic results 8