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Letters to the Editor |
Departments of Surgery
Radiology, University College London Medical School, 67-73 Riding House Street, London W1P 7LD, United Kingdom
Editor:
The article by Dr Giess and colleagues (1) in the June 1998 issue of Radiology described mammographic, ultrasonographic, and histopathologic features of 35 retroareolar breast tumors in a retrospective analysis. Histopathologic nipple-areolar involvement was low in this study (14%), but the true incidence is not known since histopathologic evidence was not available in all cases. Histopathologic nipple involvement is more commonly seen when there is clinical involvement, the tumor is within 2.0–2.5 cm of the nipple, or the tumor is retroareolar (2,3). Since most of these cases usually manifest clinically (78% in this study), the current radiologic challenge is determination of their local extent rather than their detection.
Preoperative recognition of involvement of the nipple in cases of retroareolar breast cancer is of critical importance in selecting patients who may be suitable for nipple-preserving breast-conservation surgery. Likewise, in patients with nipple lesions, it is imperative to look for concurrent breast lesions that would preclude breast-conservation surgery and may require mastectomy to achieve adequate local control. Distinct features of the normal nipple-areolar complex on contrast material–enhanced magnetic resonance (MR) images have recently been described (4) and include superficial linear dermal enhancement above a nonenhancing zone. MR imaging may be more accurate than mammography in assessing the retroareolar complex (5,6), but Dr Giess and colleagues have not commented on its place in imaging.
To determine the value of MR imaging in the clinical management of retroareolar lesions, we propose to prospectively image all central breast lesions and determine whether nipple involvement can be accurately predicted with MR imaging. Outcome measures would include resection margin status in cases of breast conservation and histopathologic nipple involvement if the nipple has been excised. However, ultimately, a prospective series of patients should undergo preoperative MR imaging and be subsequently randomly assigned to either the using or the not using MR findings group to decide on nipple preservation preoperatively. This would help answer the crucial question: Can the use of preoperative MR imaging reduce local recurrence rates in patients with retroareolar breast cancer who undergo breast-conservation surgery?
References
Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021
Department of Radiology, New York Hospital-Cornell Medical Center, New York, NY
Drs Douek and Hall-Craggs propose to prospectively study whether preoperative breast MR imaging in patients with retroareolar malignancies can accurately depict histopathologic involvement of the nipple. If so, they propose using MR imaging to determine the need for surgical excision of the nipple, with the stated aim of decreasing local recurrence rates in this patient population. None of the patients in our recent retrospective review of retroareolar malignancies (1) had undergone preoperative MR imaging; we therefore have no personal experience with its utility in this clinical setting.
Although histopathologic studies (2–5) have demonstrated an increased incidence of microscopic involvement of the nipple by retroareolar tumors, two large studies (6,7) in the radiation therapy literature have demonstrated similar local recurrence rates for retroareolar tumors treated with wide local excision and adequate radiation therapy compared with tumors elsewhere in the breast. Most of the patients in these studies had preservation of the nipple-areolar complex. Therefore, although patients with retroareolar tumors may have microscopic tumor involvement of the nipple, this does not appear to change the probability of recurrence if they undergo appropriate surgery and radiation therapy.
Preoperative MR imaging for retroareolar tumors may, however, be instrumental in surgical planning. If MR imaging can be used to predict extensive histopathologic nipple involvement, the surgeon may choose to resect the nipple-areolar complex at lumpectomy or perform mastectomy rather than wait to determine the margin status from a wide local excision. In addition, since retroareolar tumors can be multicentric (2–5,8), preoperative MR imaging may play a role in detecting additional subclinical tumor foci, which might affect clinical management.
Drs Douek and Hall-Craggs cite two studies (9,10) in suggesting that MR imaging may be more accurate than mammography in assessing the retroareolar complex. The first study (9) contained only four cases of multicentric tumor with histopathologically proved Paget disease, all of which were demonstrated with MR imaging; mammography demonstrated nipple involvement in one. In the second study (10), no data are given on the number of cases in which nipple-areolar involvement was demonstrated with MR imaging compared with mammography, although the authors claim that tumor involvement of the nipple could be confirmed or excluded through the use of MR imaging. The efficacy of MR imaging compared with that of mammography in the assessment of the retroareolar region remains to be determined.
References
This article has been cited by other articles:
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  D. Da Costa, A. Taddese, M. L. Cure, D. Gerson, R. Poppiti Jr, and L. E. Esserman Common and Unusual Diseases of the Nipple-Areolar Complex RadioGraphics, October 1, 2007; 27(suppl_1): S65 - S77. [Abstract] [Full Text] [PDF]
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