JSUR Journal

Discussion

This study presents the first multi-institutional case series of NSM and ASM in men, with description of clinical and pathologic features and outcome data. There were no locoregional recurrences or distant metastasis at a mean follow up of 68 (range 18-156) months and one contralateral breast cancer. This demonstrates the oncologic safety of NSM and ASM for male breast cancer. For men with breast cancer who are not candidates for NSM due to proximity or involvement of the nipple, ASM was performed with clear margins and no evidence of recurrence at mean follow up of 41.6 (range 7-83) months.

We have formulated a current algorithm of indications for male NSM and ASM (Figure 1) with our proposed surgical management of male breast cancer patients which was previously published in a smaller single-institution case series [28]. Similar to women with breast cancer, men with breast cancer may be candidates for BCT if tumor to breast size ratio can accommodate a lumpectomy usually combined with RT. As in women, breast conserving surgery in men is associated with similar oncologic outcomes compared to mastectomy, with reported locoregional recurrence rates of 0-17.4% [7,14-17,30,31] though there are no randomized clinical trials directly comparing BCT and mastectomy for men. This study, with no locoregional recurrences, demonstrates that NSM and ASM for male breast cancer are oncologically safe alternatives, and comparing favorably to TM and BCT.

Men with a relatively large cancer to breast size ratio, or those who are interested in potentially avoiding adjuvant Radiation Therapy (RT), may be better candidates for mastectomy than BCT, and now can be offered NSM or ASM for improved appearance compared to TM. Moreover, some have questioned the benefit/cost ratio of BCT in men, given minimal glandular tissue to preserve, added resources required for RT, and difficulty of obtaining necessary future mammograms to screen for recurrence [32]. BCT may also be a less desirable option for some men due to RT-associated alopecia, which can be managed with laser hair removal on the contralateral side, however in men with significant chest hair that that might not be desirable. Furthermore, male chest hair can conceal the scar well from NSM and result in a better appearance, a factor that is not a consideration in women selecting for BCT or NSM (Figure 3). Due to these factors, and the typically small contralateral breast in men, the authors have observed that NSM or ASM, provide reasonable symmetry and significantly improved appearance and patient satisfaction compared to TM. Based on these multiple considerations and excellent oncologic outcomes in this study, NSM or ASM are demonstrated to be good options for surgical treatment of males with breast cancer, provided patients meet selection criteria as outlined in Figure 1.

Extrapolating from studies of female breast cancer patients [3337] we would expect a higher rate of locoregional recurrence with lumpectomy in the absence of RT, although ongoing clinical trials such as NRG-BR007 [38] may show that omission of RT is safe in certain low-risk patients; this trial is open to both women and men with breast cancer. These results may impact the surgical decision making for men with breast cancer in the future. Nevertheless, at present it appears that most male breast cancer patients, for various reasons, undergo mastectomy rather than BCT [17,19]. Thus, it is important to offer men the modern mastectomy options of NSM or ASM for improved appearance, either without reconstruction or with fat grafting for improved chest contour.

The concept of NSM in women was first introduced in 1962 [39] and its practice has gained popularity over the subsequent decades. Main concerns for the preservation of the Nipple-Areola Complex (NAC) include increased risk of local recurrence and risk of ischemia/necrosis of the NAC [20,40-42]. In the last 2 decades several large meta-analyses [20-22,24] have reported on the oncologic safety of NSM and ASM in women with breast cancer and the inclusion criteria for women who are candidates for NSM has widely expanded [43]. Currently, NSM is considered a safe option for most women whose tumors do not directly involve the NAC [23,44]. The absolute contraindication for NSM is direct tumor invasion of the nipple, or a positive sub-nipple biopsy margin [45-47]. We propose that these same criteria be applied to men, so that men would similarly be candidates for possible NSM or ASM.

Data for male breast cancer patients are currently lacking due to both rarity of the disease and the fact that breast cancer in men has traditionally been treated with TM without significant consideration of alternatives [19]. Like their female counterparts, selection criteria for NSM in male breast cancer patients should include no involvement of the nipple clinically on physical examination or imaging, negative sub-nipple biopsy, and clear microscopic tumor margins (no tumor on ink) [23,47]. NSM in males is performed in the same manner as females, with removal of all of the breast tissue from under the dermis of the nipple and removing the tissue directly under the nipple for a sub-nipple biopsy [41,42,47], in contrast to subcutaneous mastectomy for men with gynecomastia which leaves breast tissue under nipple. Male breast cancer patients can be candidates for ASM if the tumor is close to or involving the nipple, provided at least a portion of the areola is disease free and can be preserved for improved cosmesis and symmetry, and the surgical technique in males developed by the senior author (MK) was previously described in detail [28]. Figure 2 shows preoperative, intraoperative, and postoperative photographs of male ASM with partial areolar sparing, which is an option if unable to undergo NSM for breast cancer due to proximity to nipple or involvement of the nipple. This ASM technique with partial areolar sparing and areola closure to reconstruct the appearance of a nipple avoids a scar on the medial breast, and usually provides improved aesthetics compared to TM (Figure 1, Figure 3).

Figure 3: Appearance of TM, ASM, or NSM surgical treatment for male breast cancer. A: Typical appearance following left total mastectomy; B: Bilateral ASM, for initial left breast cancer, then subsequent right breast cancer (following technique of ASM with partial areolar sparing and closure described in Figure 2); C: Right NSM frontal view of preserved nipple with arm raised, and radial scar barely visible with chest hair (white arrow). D: Right NSM bilateral frontal view with comparison to normal left breast (same patient as c).

A sub-nipple biopsy is recommended in men undergoing planned NSM, due to the common subareolar location and relative smaller breast size compared to women. Similarly, sub-nipple biopsy is commonly performed to determine eligibility for NSM in women [23]. For NSM in men, sending the sub-nipple biopsy to pathology for evaluation during surgery is recommended to provide important information intraoperatively to assess for NSM, which resulted in one conversion to ASM in this series. Patients should be counseled for the possibility of conversion to ASM or TM in the case of positive sub-nipple biopsy. This series contains the first report in the literature to our knowledge of bilateral ASM for bilateral male breast cancer involving the nipple (Figure 3).

There is a significant body of literature regarding the psychologic impact of a breast cancer diagnosis and particularly of mastectomy in women. While there is much less written about male psychologic stress related to breast cancer diagnosis and treatment, certain studies have demonstrated high levels of cancer-specific distress in men with breast cancer [48], and when compared to agematched controls, poorer life satisfaction [49] and major deficits in emotional functioning [50]. The emotional impact of being diagnosed with cancer and with being diagnosed with a disease traditionally associated with women may be compounded by the physical and psychological changes associated with treatment of the disease, leading to altered body image and feelings of isolation and stigma [51-53]. Men who experience shame associated with post-surgical appearance may seek to conceal their scars or be hesitant to engage in activities such as swimming where scars may be conspicuous [48,54,55]. Concerns about masculinity may further hinder emotional expression and discourage patients from seeking support [53]. A study of 161 male breast cancer patients showed that 23% of participants reported cancer-related distress with depressive symptoms being associated with altered body image [48]. Similarly, in 2022 the Male WhySurg national survey of patient reported outcomes in 63 men undergoing breast cancer surgery, reported 98.6% had their nipple removed during surgery and 33% reported feeling uncomfortable with their postoperative appearance related to feelings of imbalance or asymmetry, scar, lack of nipple, or lack of hair on the surgical side [19].

Despite these psychological and aesthetic concerns, postmastectomy reconstruction is rarely considered or discussed with male breast cancer patients [19,56]. Unlike women with breast cancer, who are routinely offered plastic surgery referrals, men with breast cancer are seldom provided the same opportunity. This practice likely stems from the misconception that men with breast cancer are less likely to be impacted by the cosmetic outcome of breast surgery [57]. In the Male Breast Cancer WhySurg study with 485 surgeons responding to the survey about surgical options offered to men with breast cancer, only 34% would offer NSM regardless of reconstruction and 20.8% routinely offered reconstruction, most commonly fat grafting, while 36.6% do not even consider it in their surgical planning [19]. Consequently, men with breast cancer often endure distorted chest appearance without being offered the option of reconstruction, possibly further exacerbating the psychologic burden already being suffered.

A systematic review of breast reconstruction following male mastectomies in 2022 by Deldar, et al, identified five studies and 29 males undergoing breast reconstruction [56]. Mastectomy type reported was radical mastectomy in 34.5%, modified radical mastectomy in 17.2% and not reported in the remainder, however, no NSM or ASM were reported. Breast reconstruction consisted of flap reconstruction in 89% (n=26) including latissimus flap, Transverse Rectus Abdominus Muscle (TRAM), or local flap, and the remainder had fat grafting (n=1), implant (n=1), or wound closure with subsequent Nipple Areolar Complex (NAC) reconstruction (n=1); patient satisfaction was recorded and although numbers are small, all patients who underwent reconstruction reported satisfaction with postoperative appearance [57-61]. Interestingly, the patient who underwent fat grafting had it performed at the time of mastectomy under the pectoralis fascia, then repeat delayed fat grafting and NAC reconstruction from groin skin [58]. Also described following mastectomy in men, is contralateral liposuction, for symmetry, instead of filling in the mastectomy site, combined with NAC reconstruction with a skin graft from the groin or scrotum after TM [56,60]. The magnitude of the reconstruction performed, and nipple-areolar reconstruction described with skin graft, was likely reflective of men previously commonly undergoing much more extensive surgery without any nipple or areolar preservation.

Integrating plastic and reconstructive surgery consultations is an option for men with breast cancer and could potentially offer a more comprehensive and supportive care model. Notably, however, insurance companies in the United States are mandated to cover reconstructive procedures for women undergoing breast cancer surgery, yet breast reconstruction is not regularly provided to men with breast cancer [19]. In this series, for the men that had satisfaction recorded, they reported following NSM or ASM being satisfied with their appearance and comfortable without a shirt in appropriate sports, swimming, and other settings. Furthermore, all ASM patients were offered additional nipple reconstruction or breast reconstruction such as fat grafting, for symmetry and all declined reconstruction being satisfied with appearance. Delayed fat-grafting after male NSM was done in 2 men (14%) following NSM, and the surgeon (S.W.) noted excellent appearance after. Therefore, it appears that if men desire further reconstruction after NSM or ASM, much less extensive procedures such as fat-grafting, or contralateral liposuction for symmetry, can successfully provide excellent aesthetic appearance, compared to the type of reconstruction previously described following total mastectomies. The authors have observed significantly improved appearance with male NSM or ASM compared to TM in men (Figure 3).

Post-mastectomy complication rates are rare in the male population. A retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program Database (NSQIP) that examined treatment and outcomes of male breast cancer patients between 2008 and 2016 showed overall morbidity of 4.6% of which most were wound healing complications (overall rate of 3.2%) [62]. In the current series we show that NSM and ASM are both oncologically safe options with few minor surgical complications of seromas, without any major complications and no locoregional recurrence was noted, even in the presence of node-positive disease. In contrast to reported rates of 4.1-35.9% for Nipple Areolar Complex (NAC) or mastectomy flap ischemic complications in female NSM [63,64], none of our male NSM patients experienced either NAC or mastectomy flap ischemia.

Regarding guidelines for screening of men at increased risk for breast cancer, the National Comprehensive Cancer Network (NCCN) recommends annual clinical breast exam as well as monthly self-examination in men with pathologic or likelypathologic BRCA 1 or 2 mutations starting at age 35 [65]. However, even in men with BRCA mutations, routine imaging screening is not recommended by NCCN 2024 guidelines. In men with a history of breast cancer treated with lumpectomy, the American Society of Clinical Oncology (ASCO) recommends offering annual ipsilateral mammogram; in men with a history of breast cancer AND a high-risk genetic mutation, ASCO recommends offering annual contralateral mammogram [66]. Screening breast Magnetic Resonance Imaging (MRI) is not routinely recommended in men with a history of breast cancer [67]. Men with known BRCA gene mutations, particularly BRCA2 mutations, have a lifetime risk of breast cancer as high as 8%, approaching the lifetime average risk for women of 12%, thus some have proposed these men undergo screening mammograms to detect breast cancer at earlier stages [68]. We support incorporating the ASCO guidelines for contralateral screening mammogram in men with BRCA mutations following unilateral mastectomy for breast cancer. Perhaps screening mammography should be considered in asymptomatic male BRCA genetic mutation carriers, to identify cancer at an earlier stage and more likely allow for treatment with NSM or ASM.

In contrast to female BRCA mutation carriers, prophylactic bilateral mastectomies in male BRCA mutation carriers are not routinely recommended [69], due to the lifetime risk of breast cancer as stated above of approximately 8%, which is similar to average risk women [68]. In addition, while Contralateral Prophylactic Mastectomy (CPM) is often done for women with breast cancer, with or without a high-risk genetic mutation, the same is not true of men with breast cancer due to this low risk of future contralateral breast cancer. Thus, for men with a high-risk genetic mutation, mammogram screening is reasonable to assess the contralateral breast, but CPM is not usually recommended.

The strengths of this study are the multi-institutional dataset assessing long term outcomes for male NSM or ASM, a topic rarely discussed in the literature, and presenting selection criteria that can be applied to men with breast cancer. The weaknesses of this study are that it is retrospective, and did not include formal patient reported outcomes of aesthetic appearances with NSM or ASM compared to TM. Future studies of male breast cancer surgical options, including NSM, ASM, TM, and BCT, with patient reported outcomes to evaluate surgical appearance, and RT side effects with BCT such as alopecia or muscle tightness, in addition to oncologic outcomes, would provide further information for surgical decision making for male breast cancer patients

Conclusions

This is the first multi-institutional case series of NSM and ASM in men with breast cancer, demonstrating the oncologic safety and improved appearance compared to TM. Similar surgical oncological principals for female breast cancer should be applied to men, and NSM and ASM should be considered acceptable surgical options in select male breast cancer patients based on the surgical treatment algorithm presented. Nipple and/or areolar preservation not only improve the aesthetic appearance compared to TM but may also decrease psychologic distress.

Conflict of Interest: The authors do not have any conflict of interest.

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