Pre-Operative Breast MRI Can Help Identify Patients Likely to Experience Nipple-Sparing Mastectomy Risks

April 9, 2021
Whitney J. Palmer

Images can pinpoint which women are at risk for ischemia and nipple necrosis.

Using pre-operative MRI can help providers identify which patients could be at increased risk for post-operative ischemic complications following nipple-sparing mastectomy (NSM), according to newly presented research.

During the Society of Breast Imaging/American College of Radiology 2021 Virtual Annual Meeting, Natalie Ultey, a medical student from Georgetown University School of Medicine, shared details of how using these images can help with patient counseling and surgical planning.

For more Society of Breast Imaging conference coverage, click here.

“Nipple sparing mastectomy is a growing surgical option for patients undergoing mastectomy in both the oncologic and prophylactic setting,” she said. “Nipple sparing mastectomy is associated with improved patient satisfaction and has a similar low recurrence rate compared to skin-sparing mastectomy.”

However, between 5.9 percent and 15 percent of patients who undergo NSM experience ischemia and nipple necrosis. To determine whether pre-operative imaging could alert providers to which patients might develop these problems, Utley conducted a retrospective review on women who underwent pre-operative breast MRI and mammography before NSM between 2015 and 2020. Most of the patients included – 68.8 percent – were white, and 16.8 percent were African American.

For the study, she reviewed records from 125 patients who underwent 220 mastectomies – 33.2 percent for invasive cancer, 30 for ductal carcinoma in situ, and 53.2 percent for prophylactic reasons. Within this group, 10 cases of nipple necrosis (4.5 percent) developed in eight patients. In addition, 21 patients experienced 28 cases of post-operative ischemia (12.7 percent) with 19 cases (8.6 percent that occurred in 14 patients being considered major ischemia that required surgical intervention.

Most cases of ischemic complications were identified in patients who had a mild background of parenchymal enhancement (23.9 percent) – and additional 20 percent with minimal background parenchymal enhancement also experienced the complication. Patients with marked background parenchymal enhancement experienced major ischemia. Additionally, 80 percent of nipple necrosis cases occurred in patients with mild background parenchymal enhancement.

Her analysis also showed that all nipple necrosis and major ischemia presented in patients with scattered and hetereogenous fibroglandular tissue. Necrosis cases also developed in patients with minimal and mild nipple enhancement compared to the ipsilateral background parenchymal enhancement of MRI.

The record review also showed that African American women were disproportionately affected by these problems – they accounted for 50 percent of nipple necrosis cases, as well as 36.8 percent of major ischemic complications.

“There is a correlation between the pre-operative breast MRI imaging features of background parenchymal enhancement and the fibroglandular tissue and both post-operative major ischemic changes and nipple necrosis,” Utley concluded.

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