Prevalence of Terminal Duct Lobular Units in Nipple to Assess the Safety of Nipple Sparing Mastectomy

  • Asha Peedikayil Punnoose Department of Pathology, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
  • Deepti Ramakrishnan Department of Pathology, Amala Institute of Medical Sciences, Thrissur, Kerala, India.
  • Kripa Susan Thomas Tricare Diagnostics, Thiruvalla, Kerala, India.
Keywords: terminal duct lobular units, breast cancer, nipple, mastectomy

Abstract

Background: Nipple sparing mastectomy is widely used for both treatment and risk reduction of breast cancer. Terminal duct lobular units (TDLU) are considered as the basic reacting unit in all neoplastic lesions arising from the breast. TDLU is the basic anatomic unit of breast parenchyma, studies revealed that it also exists in the nipple whose frequency is not widely researched. Our objective is to study the frequency of TDLUs in nipple along with its location, number and association with age and laterality of breast.   Methods: The descriptive study involved entire submission of nipples from 191 consecutive therapeutic mastectomy specimens from a reputed cancer institute in India between January 2015 and June 2016. The nipple is divided into two parts, nipple papilla and nipple base and presence of TDLU were recorded separately.   Result:  From the specimens submitted, 38% were observed to have TDLU in the nipple. While 45.2% were in the papillae and 26% in the base the remaining 28.8% were in both the papillae and base with maximum number of TDLU counted at 5 and mean age of subjects at 53.56 years, 57.5% from the left and 42.4% from the right breast respectively. There was no significant association between age (p= 0.59), laterality of breast (p = 0.37) with presence of TDLU whereas a significant negative linear correlation observed between age and number of TDLUs (r =-0.237, p=0.043).   Conclusion: Nipples show a high frequency of TDLU and is observed more in papilla than in the base.  

References

1. Cady B, Stone MD, Wayne J. New therapeutic possibilities in primary invasive breast cancer. Ann Surg. 1993; 218(3):338–347.
2. Cady B. Traditional and future management of nonpalpable breast cancer. Am Surg. 1997; 63(1):55–58.
3. Jabor MA, Shayani P, Collins DR Jr, Karas T, Cohen BE. Nipple – areola reconstruction: satisfaction and clinical determinants. Plastic Reconstr Surg 2002; 110:457 – 463.
4. Carlson GW, Styblo TM, Lyles RH, Bostwick J, et al. Local recurrence after skin-sparing mastectomy: tumour biology or surgical conservatism? Ann Surg Oncol 2003; 10:108–12.
5. Newman LA, Kuerer HM, Hunt KK, Kroll SS, et al. Presentation, treatment, and outcome of local recurrence after skin sparing mastectomy and immediate breast reconstruction. Ann Surg Oncol 1998; 5:620–6.
6. Medina-Franco H, Vasconez LO, Fix RJ, Heslin MF, et al. Factors associated with local recurrence after skin-sparing mastectomy and immediate breast reconstruction for invasive breast cancer. Ann Surg 2002; 235:814–9.
7. Foster RD, Esserman LJ, Anthony JP, Hwang ES, et al. Skin sparing mastectomy and immediate breast reconstruction: a prospective cohort study for the treatment of advanced stages of breast carcinoma. Ann Surg Oncol 2002; 9:462–66.
8. Stanec Z, Zic R, Stanec S, Budi S. Skin-sparing mastectomy with nipple-areola conservation. Plast Reconstr Surg 2003; 111:496–8.
9. Crowe JP, Kim JA, Yetman R, Banbury J, et al. Nipple sparing mastectomy: technique and results of 54 procedures. Arch Surg 2004; 139:148–50.
10. Gerber B, Krause A, Reimer T, Muller H, et al. Skin-sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction is an oncologically safe procedure. Ann Surg 2003; 238:120–7.
11. Sacchini V, Pinotti JA, Barros AC, Luini A, et al. Nipple sparing mastectomy for breast cancer and risk reduction: oncologic or technical problem? J Am Coll Surg 2006; 203:704– 14.
12. Paepke S, Schmid R, Fleckner S, et al. Subcutaneous mastectomy with conservation of the nipple-areola skin: broadening the indications. Ann Surg. 2009; 250(2):288–292.
13. Rusby JE, Smith BL, Gui GP. Nipple-sparing mastectomy. Br J Surg. 2010; 97(3):305–316.
14. Wellings SR, Jensen HM. On the origin and progression of ductal carcinoma in the human breast. J Natl Cancer Inst 1973; 50:1111-8.
15. Wellings SR. A hypothesis on the origin of human breast cancer from the terminal duct lobular unit. Pathol Res Pract 1980; 166:515-35.
16. Schnitt SJ, Collins LC. Breast. In: Mills SE, ed. Histology for Pathologists. Philadelphia, PA: LWW; 2007:57–75.)
17. Gulben K, Yildirim E, Berberoglu U. Prediction of occult nipple-areola complex involvement in breast cancer patients. Neoplasm. 2009; 56(1):72–75.
18. Luttges J, Kalbfleisch H, Prinz P. Nipple involvement and multicentricity in breast cancer: a study on whole organ sections. J Cancer Res Clin Oncol. 1987; 113(5):481–487.
19. Voltura AM, Tsangaris TN, Rosson GD, et al. Nipple-sparing mastectomy: critical assessment of 51 procedures and implications for selection criteria. Ann Surg Oncol. 2008; 15(12):3396–3401.
20. Rosen PP, Tench W. Lobules in the nipple: frequency and significance for breast cancer treatment. Pathol Annu. 1985; 20(pt 2):317–322.
21. Stolier AJ, Wang J. Terminal duct lobular units are scarce in the nipple: implications for prophylactic nipple-sparing mastectomy: terminal duct lobular units in the nipple. Ann Surg Oncol. 2008; 15(2):438–442.
22. Reynolds C, Davidson JA, Lindor NM, et al. Prophylactic and therapeutic mastectomy in BRCA mutation carriers: can the nipple be preserved? Ann Surg Oncol. 2011; 18(11):3102–3109.
23. Brachtel EF, Rusby JE, Michaelson JS, et al. Occult nipple involvement in breast cancer: clinicopathologic findings in 316 consecutive mastectomy specimens. J Clin Oncol. 2009; 27(30):4948–4954.
24. Menon RS, van Geel AN. Cancer of the breast with nipple involvement. Br J Cancer. 1989; 59(1):81–84.
25. Oleksandr N. Kryvenko, Ji Yoon, Dhananjay A. Chitale, Min W. Lee. Prevalence of Terminal Duct Lobular Units and Frequency of Neoplastic Involvement of the Nipple in Mastectomy. Arch Pathol Lab Med 2013; 137: 955- 960.

26. Paepke S, Schmid R, Fleckner S, et al. Subcutaneous mastectomy with conservation of the nipple-areola skin: broadening the indications. Ann Surg. 2009; 250(2):288–29.

27. Randall P, Dabb R, Loc N. ‘‘Apple coring’’ the nipple in subcutaneous mastectomy. Plast Reconstr Surg. 1979; 64(6):800–803.

28. Petit JY, Veronesi U, Orecchia R, et al. Nipple-sparing mastectomy in association with intra operative radiotherapy (ELIOT): a new type of mastectomy for breast cancer treatment. Br Breast Cancer Res Treat. 2006; 96(1):47–51.

29. Petit JY, Veronesi U, Orecchia R, et al. Nipple sparing mastectomy with nipple areola intraoperative radiotherapy: one thousand and one cases of a five years experience at the European institute of oncology of Milan (EIO). Breast Cancer Res Treat. 2009; 117(2):333–338.
Published
2020-09-25
Section
Original Article