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Nipple-sparing Mastectomy And Subareolar Biopsy: To Freeze Or Not To Freeze? An Updated Experience On The Use Of Subareolar Intraoperative Frozen Section
Michael Alperovich, MD1, Mihye Choi, MD1, Nolan S. Karp, MD1, Keith M. Blechman, MD2, Fares Samra, MD3, Jamie P. Levine, MD1, Daniel F. Roses, MD1, Freya R. Schnabel, MD1, Deborah M. Axelrod, MD1, Richard L. Shapiro, MD1, Amber A. Guth, MD1.
1New York University Medical Center, New York, NY, USA, 2MD Anderson Cancer Center, Houston, TX, USA, 3Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

PURPOSE: Use of nipple-sparing mastectomy for risk-reduction and therapeutic breast cancer resection is growing. The role for intraoperative frozen section of the nipple-areolar complex remains controversial.
METHODS: Records of patients undergoing nipple-sparing mastectomy at our institution from 2006-2012 were reviewed retrospectively. The use of intraoperative subareolar frozen section was at the breast surgeon’s discretion.
RESULTS: Records from a total of 277 nipple-sparing mastectomies were reviewed (162 prophylactic, 115 therapeutic). Subareolar biopsy was not utilized in 7 breasts. Of the remaining 270 breasts, 219 had subareolar intraoperative frozen sections and 51 were evaluated with permanent paraffin section only. Among the 219 intraoperative frozen sections, 13 biopsies were positive on permanent paraffin section (5.9%). Of the 13 positive permanent biopsies, 9 were false negatives and the remaining 4 concordant intraoperatively. The overall positive permanent paraffin section rate for subareolar biopsy in 270 breasts was 5.2% (14/270).
Positive subareolar biopsies consisted of DCIS in 71% (10 of 14), atypical ductal hyperplasia (2/14), invasive ductal carcinoma (1/14) and invasive lobular carcinoma (1/14). The majority of the NAC were resected following the mastectomy (8/14) while the rest were resected either intraoperatively (4/14) or during second stage breast reconstruction (2/14). Interestingly, only 36% (5/14) of NAC had abnormal residual pathology in the resected specimen. There has been no local recurrence in these patients to date.
CONCLUSION: Intraoperative frozen section does not detect the majority of positive subareolar biopsies in NSM. Its limited utility in our large series of NSM patients raises questions about its future role.
Table I: Subareolar biopsy results for detection of occult cancer in the nipple-areolar complex
Classification of Positive Subareolar BiopsiesPercentage (Proportion)
Total Positive Subareolar Biopsies5.2% (14/270)
Sensitivity of Intraoperative Subareolar Frozen Sections31% (4/13)
Type of Positive Subareolar Biopsy in Final Pathology:
DCIS71% (10/14)
Atypical Ductal Hyperplasia14% (2/14)
Invasive Lobular Carcinoma7% (1/14)
Invasive Ductal Carcinoma7% (1/14)
Abnormal Pathology in NAC Resected Following Positive Subareolar Biopsy36% (5/14)


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