Preoperative Ultrasound-guided Sub-areolar Biopsy in Predicting Occult Nipple Involvement in Breast Cancer Patients: Proposal for a Methodological Approach

Background/Aim: The prediction of a sub-areolar tissue infiltration in breast cancer (BC) patients could be helpful in selecting the best functional outcome according to several reconstructive oncoplastic or radical techniques. This study aims to evaluate the diagnostic performance of preoperative ultrasound (US) guided sub-areolar biopsy (SAB) in detecting occult nipple involvement, in comparison with the definitive pathological examination of tissue after surgery. Patients and Methods: We prospectively recorded clinical and pathological data of 46 consecutive patients scheduled for breast conserving surgery or nipple-areola sparing mastectomy. All cases underwent preoperative SAB and the results were compared with the histopathology of the dissected tumors and their biological characteristics. All parameters were correlated with nipple involvement by univariate and multivariate analysis. Results: The sensitivity, specificity, overall accuracy, positive predictive value, and negative predictive value of the SAB examination for nipple staging were 60%, 97.5%, 75% and 95.2%, respectively. According to the clinicopathological features, the bivariate analysis did not show a significant interaction between patient age, tumor size or type, lymph node status, lymphatic vascular invasion, histologic grade, ER, PR, Ki-67 status, HER2 amplification, multifocal or multicentric disease and positive NAC assessment (p>0.05). Conclusion: A preoperative sample of retroareolar tissue obtained by US guided biopsy could be considered a reproducible, mini invasive diagnostic procedure useful to facilitate immediate breast reconstruction with implants or through conservative oncoplastic approaches, thereby guiding clinical practice.