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Webster AJ, Shanno JN, Santa Cruz HS, Kelly BN, Garstka M, Henriquez A, Specht MC, Gadd MA, Verdial FC, Nguyen A, Oseni TO, Coopey SB, Smith BL. Oncologic Safety of Nipple-Sparing Mastectomy for Breast Cancer in BRCA Gene Mutation Carriers: Outcomes at 70 Months Median Follow-Up. Ann Surg Oncol 2023; 30:3215-3222. [PMID: 36604360 DOI: 10.1245/s10434-022-13006-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/04/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Retention of the nipple-areola complex with nipple-sparing mastectomy (NSM) techniques provides a more natural cosmetic result than procedures that sacrifice the nipple. While the oncologic safety of NSM is established by several studies, there is little long-term data on outcomes in BRCA mutation carriers with breast cancer. PATIENTS AND METHODS BRCA1/2 mutation carriers who underwent NSM and immediate reconstruction from 2008 to 2019 were reviewed and patients with breast cancer on biopsy or final pathology were included. Patient demographics and tumor characteristics, as well as treatment, recurrence, and survival data were collected. RESULTS A total of 114 therapeutic NSM were performed in 105 BRCA mutation carriers (56 BRCA1, 47 BRCA2, and two women with both mutations). Median age was 45 years. Cancers were 18% stage 0, 52% stage I, 27% stage II, and 3% stage III. Mean invasive tumor size was 1.6 cm and 33 (35%) invasive tumors were triple negative. There were five (4.4%) positive nipple margins on final pathology; all underwent nipple excision. Most patients (80, 76%) received systemic therapy: 65 (62%) received chemotherapy and 48 (46%) received endocrine therapy. At 70 months median follow-up (range 15-150 months), no patient had developed a recurrence in the retained nipple-areola complex or at the site of a nipple excised for a positive margin. The rate of locoregional recurrence outside the nipple was 2.6%, and the rate of distant recurrence was 3.8%. Overall survival was 96%. CONCLUSIONS NSM is a safe option for BRCA1 and BRCA2 mutation carriers who undergo mastectomy for breast cancer.
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Affiliation(s)
- Alexandra J Webster
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Julia N Shanno
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Heidi S Santa Cruz
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Bridget N Kelly
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Meghan Garstka
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Anthony Henriquez
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michelle C Specht
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michele A Gadd
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Francys C Verdial
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Anvy Nguyen
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Tawakalitu O Oseni
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Suzanne B Coopey
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Barbara L Smith
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA.
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Cavalcante FP, Araújo MMP, Veras IM, Freitas-Junior R. Oncological Outcomes of Nipple-Sparing Mastectomy in an Unselected Population Evaluated in a Single Center. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:1052-1058. [PMID: 36580950 PMCID: PMC9800068 DOI: 10.1055/s-0042-1751286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Nipple-sparing mastectomy (NSM) has been traditionally used in selected cases with tumor-to-nipple distance > 2 cm and negative frozen section of the base of the nipple. Recommending NSM in unselected populations remains controversial. The present study evaluated the oncological outcomes of patients submitted to NSM in an unselected population seen at a single center. METHODS This retrospective cohort study included unselected patients with invasive carcinoma or ductal carcinoma in situ (DCIS) who underwent NSM in 2010 to 2020. The endpoints were locoregional recurrence, disease-free survival (DFS), and overall survival (OS), irrespective of tumor size or tumor-to-nipple distance. RESULTS Seventy-six patients (mean age 46.1 years) (58 invasive carcinomas/18 DCIS) were included. The most invasive carcinomas were hormone-positive (60%) (HER2 overexpression: 24%; triple-negative: 16%), while 39% of DCIS were high-grade. Invasive carcinomas were T2 in 66% of cases, with axillary metastases in 38%. Surgical margins were all negative. All patients with invasive carcinoma received systemic treatment and 38% underwent radiotherapy. After a mean of 34.8 months, 3 patients with invasive carcinoma (5.1%) and 1 with DCIS (5.5%) had local recurrence. Two patients had distant metastasis and died during follow-up. The 5-year OS and DFS rates for invasive carcinoma were 98% and 83%, respectively. CONCLUSION In unselected cases, the 5-year oncological outcomes following NSM were found to be acceptable and comparable to previous reports. Further studies are required.
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Affiliation(s)
- Francisco Pimentel Cavalcante
- Hospital Geral de Fortaleza, Fortaleza, CE, Brazil,Address for correspondence Francisco Pimentel Cavalcante, MD Rua Manuel Jacaré136/1401, Fortaleza 60175-110, CearáBrazil
| | | | | | - Ruffo Freitas-Junior
- Department of Obstetrics and Gynecology, Universidade Federal de Goiás, Goiânia, GO, Brazil
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Kim N, Park W, Cho WK, Kim HY, Choi DH, Nam SJ, Kim SW, Lee JE, Yu J, Chae BJ, Lee SK, Ryu JM, Mun GH, Pyon JK, Jeon BJ. Suggestion for the omission of post-mastectomy chest wall radiation therapy in patients who underwent skin-sparing/nipple-sparing mastectomy. Breast 2022; 66:54-61. [PMID: 36179501 PMCID: PMC9526229 DOI: 10.1016/j.breast.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/24/2022] [Accepted: 09/19/2022] [Indexed: 12/27/2022] Open
Abstract
AIM Both skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) have been widely adopted. Although postmastectomy radiation therapy (PMRT) can improve clinical outcomes, it can worsen cosmesis following reconstruction. Therefore, identifying risk factors of ipsilateral breast tumor recurrence (IBTR) could help de-escalate PMRT after NSM/SSM in patients with pT1-2 disease. METHODS We retrospectively reviewed patients treated with SSM (N = 400) and NSM (N = 156) in patients with pT1-2N0-1 disease between 2009 and 2016. Seventy-four patients received PMRT with 50-50.4 Gy in 25-28 fractions. The Cox proportional hazards model was used to analyze the prognostic factors of IBTR. RESULTS With a median follow-up of 66.2 months, 17 IBTR events were observed, with 5-year IBTR-free rate of 97.2%. Although only one IBTR was observed after PMRT, there was no statistical difference in the 5-year IBTR-free rate (PMRT vs. no PMRT, 98.6% vs. 97.0%, p = 0.360). Multivariable analyses demonstrated that age ≤45 years and lymphovascular invasion (LVI) were adverse features of IBTR. The low-risk group (0 risk factor) showed a better 5-year IBTR-free rate than the high-risk group (≥1 risk factor) (100.0% vs. 95.8%, p = 0.003). In the high-risk group, PMRT slightly improved 5-year IBTR-free rate compared with no PMRT (98.6% vs. 95.2%, p = 0.166). In addition, PMRT increased 5-year cumulative incidence of reconstruction failure (10.0% vs. 2.8%, p = 0.001). CONCLUSION We identified risk factors (age and LVI) related to IBTR following upfront SSM/NSM with pT1-2 disease. As a hypothesis-generating study, de-escalation of PMRT by omitting chest wall irradiation in selective patients could improve reconstruction-related complications without compromising oncologic outcomes.
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Affiliation(s)
- Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea,Corresponding author. Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
| | - Won Kyung Cho
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hae Young Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seok Jin Nam
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seok Won Kim
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Eon Lee
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jonghan Yu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byung Joo Chae
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Se Kyung Lee
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jai Min Ryu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Goo-Hyun Mun
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jai-Kyong Pyon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byung-Joon Jeon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Francis EC, Dimovska EOF, Chou HH, Lin YL, Cheng MH. Nipple-sparing mastectomy with immediate breast reconstruction with a deep inferior epigastric perforator flap without skin paddle using delayed primary retention suture. J Surg Oncol 2022; 125:1202-1210. [PMID: 35298037 DOI: 10.1002/jso.26852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 02/15/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND This study investigated the outcomes of nipple-sparing mastectomy (NSM) with a deep inferior epigastric perforator (DIEP) flap using delayed primary retention suture (DPRS) to achieve superior breast esthetics. METHODS Between December 2010 and March 2021, patients who underwent NSM with DIEP flap were inset with or without a skin paddle (using DPRS) as Group A or B, respectively. Demographics, operative findings, complications, BREAST-Q questionnaire, and Manchester scar scale were compared between two groups. RESULTS Twelve patients underwent 12 unilateral reconstructions in Group A, while 12 patients underwent 13 DIEP flaps in Group B. There was no significant difference in demographics, ischemia time, flap-used weight and percentage, complications of hematoma, infection, re-exploration, partial flap loss, and total flap loss (All p > 0.05, respectively). At a mean 9 months of follow-up, the Breast-Q "Satisfaction with surgeon" domain was significant in Group B (p = 0.04). At a mean 12 months of follow-up, the overall Manchester scar scale of 10.3 in Group B was statistically superior to 12.6 in Group A (p = 0.04). CONCLUSIONS The NSM with a DIEP flap using DPRS is a reliable and straightforward technique. It can provide greater cosmesis of the reconstructed breast mound in a single-stage procedure.
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Affiliation(s)
- Eamon C Francis
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Plastic and Reconstructive Surgery, Royal College of Surgeons in Ireland, Dublin, 2, Ireland
| | - Eleonora O F Dimovska
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Hsu-Huan Chou
- Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yi-Ling Lin
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Center for Lymphedema Microsurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Section of Plastic Surgery, The University of Michigan, Ann Arbor, Michigan, USA
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5
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Hammer J, Servaes M, Berners A, Deconinck C, Pirson G, Fosseprez P. Oncologic Safety of Immediate Breast Reconstruction: A Single-Center Retrospective Review of 138 Patients. Ann Plast Surg 2021; 87:623-627. [PMID: 34818286 DOI: 10.1097/sap.0000000000002869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the oncologic safety of mastectomies associated with immediate breast reconstruction (IBR) in terms of recurrence and survival. METHODS A retrospective review was conducted at a single center (CHU UCL Namur, Belgium). We analyzed the oncologic safety of IBR for patients with invasive and in situ breast cancer who underwent mastectomy associated with IBR. Patients who underwent palliative surgery and those with a diagnosis of breast sarcoma were excluded. RESULTS We retrospectively analyzed 138 patients who underwent mastectomy and IBR between January 2012 and December 2019. Most reconstruction procedures used deep inferior epigastric perforator free flaps (55.1%). The reconstructive failure rate was 8.7%. Among the patients included, 5 cases of local cancer recurrence, 1 case of local cancer recurrence associated with distant metastasis, and 2 cases of systemic recurrence were identified during a mean follow-up of 49.3 months (range, 8-104 months) after surgery. Overall survival was 97.8%, and disease-free survival was 94.2%. CONCLUSIONS Patients had a low incidence of cancer recurrence in this review. Immediate breast reconstruction after mastectomy had no negative impact on recurrence or patient survival, even in patients with advanced disease. The study findings suggest that mastectomy associated with IBR can be a safe surgical option for patients with invasive and noninvasive breast cancers. Longer follow-ups are needed to confirm these preliminary results.
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Affiliation(s)
- Jennifer Hammer
- From the Department of Plastic Surgery, CHU UCL Namur, Namur, Belgium
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Joo JH, Ki Y, Kim W, Nam J, Kim D, Park J, Kim HY, Jung YJ, Choo KS, Nam KJ, Nam SB. Pattern of local recurrence after mastectomy and reconstruction in breast cancer patients: a systematic review. Gland Surg 2021; 10:2037-2046. [PMID: 34268088 DOI: 10.21037/gs-21-15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/14/2021] [Indexed: 12/24/2022]
Abstract
Background This study aimed to describe the locations of local recurrences based on the mastectomy and reconstruction type in breast cancer patients. Methods In November 2020, a systematic literature review was performed through MEDLINE/PubMed and the Cochrane Centre Register of Controlled Trials. Publications that included skin-sparing or nipple-sparing mastectomy followed by breast reconstruction and described the location of local recurrences were analyzed. Exclusion criteria included salvage or prophylactic mastectomy, unclear distinction between local and regional recurrences, rare tumor types. Results From 19 publications, 272 local recurrences lesions were reported in a total of 4,787 patients. After autologous reconstruction (n=2,465), local recurrences were located in the skin in 45 (1.8%) patients, in the chest wall in 18 (0.7%), and in the nipple-areolar complex in 9 (0.4%). After implant reconstruction (n=1,917), local recurrences sites included the skin in 91 (4.7%) patients, chest wall in 8 (0.4%), and nipple-areolar complex in 8 (0.4%). Of the 70 lesions with reported in-breast location, 57 (81.4%) relapsed in the original tumor location. Discussion Although meta-analysis was not conducted, present analysis demonstrated that most local recurrences after skin-sparing or nipple-sparing mastectomy occurred within the skin or subcutaneous tissues. It was found that the original tumor location was the most frequent site of relapse. Therefore, special attention should be paid to the original tumor overlying the skin while planning postmastectomy radiation therapy.
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Affiliation(s)
- Ji Hyeon Joo
- Department of Radiation Oncology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Yongkan Ki
- Department of Radiation Oncology, Pusan National University School of Medicine, Yangsan, Korea
| | - Wontaek Kim
- Department of Radiation Oncology, Pusan National University School of Medicine, Yangsan, Korea
| | - Jiho Nam
- Department of Radiation Oncology, Pusan National University Hospital, Busan, Korea
| | - Donghyun Kim
- Department of Radiation Oncology, Pusan National University School of Medicine, Yangsan, Korea
| | - Jongmoo Park
- Department of Radiation Oncology, Kyungbook National University Chilgok Hospital, Daegu, Korea
| | - Hyun Yul Kim
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Youn Joo Jung
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Ki Seok Choo
- Department of Radiology, Pusan National University School of Medicine, Yangsan, Korea
| | - Kyung Jin Nam
- Department of Radiology, Pusan National University School of Medicine, Yangsan, Korea
| | - Su Bong Nam
- Department of Plastic and Reconstructive Surgery, Pusan National University School of Medicine, Yangsan, Korea
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Eichler C, Stephan S, Thangarajah F, Puppe J, Rahmani N, Kurbacher C, Malter W, Warm M. Intraoperative central nipple biopsy in nipple-sparing mastectomy- A retrospective analysis of 211 patients. Breast J 2021; 27:363-368. [PMID: 33619792 DOI: 10.1111/tbj.14197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/01/2021] [Accepted: 02/01/2021] [Indexed: 11/30/2022]
Abstract
Subcutaneous nipple sparing mastectomies (NSM) are an important tool in modern oncoplastic surgery. Especially when an immediate implant-based reconstruction (IBR) is desired, clean margins are of the utmost importance. Central nipple biopsies during surgery serve two main purposes. Most importantly, it is hypothesized that intraoperative pathological evaluation of this biopsy may increase clean margin resection rates. In addition, a general recurrence risk reduction may occur due to the elimination of glandular and ductal components within the nipple. This analysis is a single center, multi-surgeon, retrospective, head to head analysis. Starting in March 2015, intraoperative central nipple biopsy in NSMs with IBR was introduced at the Municipal Breast Cancer Centre Cologne, Holweide, Germany. This trial retrospectively evaluates global complication rates, clean margin status and local recurrence rates for cohort 1 (NSM/no nipple biopsy, n = 103) vs. cohort 2 (NSM with nipple biopsy, n = 108) Median follow-up was 15 months. All implant-based reconstruction procedures used an epipectoral implant pocket. Cohorts were comparable. Global complication rates slightly favored the nipple biopsy cohort with respects to implant loss rate. An involved central nipple biopsy was found in 4.6% (n = 5/108) of the performed NSM procedures leading to the immediate removal of the nipple areola complex. All positive retro-areolar biopsies correlated with a positive nipple biopsy. However, in n = 1 case we found DCIS discontinual proliferation with an involved nipple biopsy, without a correlating positive retro-areolar biopsy (ie, 1 false-negative case was prevented). For the 15 month follow-up, there was no case of local recurrence within nipple areola complex for both cohorts. With this retrospective head to head analysis of 211 patients, it was shown that the central nipple biopsy correlates well with the retro-areolar biopsy. There may be a reduction in false negative rates. The procedure is safe to use and should be offered to NSM patients.
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Affiliation(s)
- Christian Eichler
- Department of Gynaecology and Obstetrics, Faculty of Medicine University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Sophia Stephan
- Breast Cancer Centre, Municipal Hospital Holweide, Cologne, Germany
| | - Fabinshy Thangarajah
- Department of Gynaecology and Obstetrics, Faculty of Medicine University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Julian Puppe
- Department of Gynaecology and Obstetrics, Faculty of Medicine University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Neda Rahmani
- Department of Gynaecology and Obstetrics, Faculty of Medicine University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christian Kurbacher
- Department of Gynaecology and Obstetrics, Faculty of Medicine University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Wolfram Malter
- Department of Gynaecology and Obstetrics, Faculty of Medicine University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Mathias Warm
- Department of Gynaecology and Obstetrics, Faculty of Medicine University Hospital Cologne, University of Cologne, Cologne, Germany.,Breast Cancer Centre, Municipal Hospital Holweide, Cologne, Germany
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Choi M, Frey JD. Optimizing Aesthetic Outcomes in Breast Reconstruction After Nipple-Sparing Mastectomy. Aesthet Surg J 2020; 40:S13-S21. [PMID: 33202012 DOI: 10.1093/asj/sjaa139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Nipple-sparing mastectomy (NSM) has been associated with improved quality of life and patient satisfaction with similar oncologic outcomes compared with traditional mastectomy techniques. By conserving the nipple-areola complex and the majority of the breast skin envelope, NSM allows for improved aesthetic outcomes after breast reconstruction. However, the technique is also associated with a steep learning curve that must be considered to achieve optimal outcomes. It is important that the plastic surgeon functions in concert with the extirpative breast surgeon to optimize outcomes because the reconstruction is ultimately dependent on the quality of the overlying mastectomy flaps. Various other factors influence the complex interplay between aesthetic and reconstructive outcomes in NSM, including preoperative evaluation, specific implant- and autologous-based considerations, as well as techniques to optimize and correct nipple-areola complex position. Management strategies for complications necessary to salvage a successful reconstruction are also reviewed. Lastly, techniques to expand indications for NSM and maximize nipple viability as well as preshape the breast are discussed. Through thoughtful preoperative planning and intraoperative technique, ideal aesthetic results in NSM may be achieved.
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Affiliation(s)
- Mihye Choi
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | - Jordan D Frey
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
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9
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Putting Together the Pieces: Development and Validation of a Risk-Assessment Model for Nipple-Sparing Mastectomy. Plast Reconstr Surg 2020; 145:273e-283e. [PMID: 31985614 DOI: 10.1097/prs.0000000000006443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Wu ZY, Kim HJ, Lee J, Chung IY, Kim JS, Lee SB, Son BH, Eom JS, Kim SB, Gong GY, Kim HH, Ahn SH, Ko B. Recurrence Outcomes After Nipple-Sparing Mastectomy and Immediate Breast Reconstruction in Patients with Pure Ductal Carcinoma In Situ. Ann Surg Oncol 2020; 27:1627-1635. [PMID: 31912259 DOI: 10.1245/s10434-019-08184-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) has become increasingly prevalent for patients with ductal carcinoma in situ (DCIS) requiring mastectomy. However, few data regarding recurrence outcomes after NSM are available for this patient population. This study evaluated the locoregional recurrence (LRR) rate for patients with pure DCIS who underwent NSM followed by immediate breast reconstruction without adjuvant radiotherapy and investigated potential risk factors for LRR and/or nipple-areola complex recurrence (NR). METHODS A retrospective chart review was performed for 199 consecutive patients with pure DCIS who underwent NSM and immediate breast reconstruction between March 2003 and December 2015. Risk factors for LRR and NR were analyzed using univariate (Chi square test) and multivariate (Cox model) methods. RESULTS The median follow-up duration after surgery was 97 months (range, 39-186 months). At 10 years, the LRR rate was 4.5%, and the NR rate was 3%. The univariate analysis showed that high nuclear grade, negative receptor status, positive human epidermal growth factor receptor 2 (HER2) status, and negative hormone receptor/positive HER2 subtype were associated with increased risk for NR. The multivariate analysis demonstrated that negative progesterone receptor status was an independent risk factor for LRR. However, margin status and tumor-to-nipple distance (TND) were not associated with increased risk for either LRR or NR. CONCLUSIONS The study findings suggest that NSM can be a feasible surgical option even for DCIS with a TND of 1 cm or less if the retroareolar resection margin is negative for malignancy. Determining the molecular subtype of DCIS might be helpful in identifying patients at high risk for recurrence.
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Affiliation(s)
- Zhen Yu Wu
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea.,Department of Breast Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hee-Jeong Kim
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - JongWon Lee
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - Il-Yong Chung
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - Ji-Sun Kim
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - Sae-Byul Lee
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - Byung Ho Son
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - Jin-Sup Eom
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Bae Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Gyung-Yub Gong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hak-Hee Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sei Hyun Ahn
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - BeomSeok Ko
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea.
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12
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Development and Validation of a Nipple-Specific Scale for the BREAST-Q to Assess Patient-Reported Outcomes following Nipple-Sparing Mastectomy. Plast Reconstr Surg 2019; 143:1010-1017. [DOI: 10.1097/prs.0000000000005426] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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13
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14
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Surgical and oncological safety of nipple-sparing mastectomy in an Asian population. Breast Cancer 2018; 26:165-171. [DOI: 10.1007/s12282-018-0908-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 09/05/2018] [Indexed: 01/15/2023]
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15
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Evolution in Monitoring of Free Flap Autologous Breast Reconstruction after Nipple-Sparing Mastectomy. Plast Reconstr Surg 2018; 141:1086-1093. [DOI: 10.1097/prs.0000000000004271] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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17
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Albright EL, Schroeder MC, Foster K, Sugg SL, Erdahl LM, Weigel RJ, Lizarraga IM. Nipple-Sparing Mastectomy is Not Associated with a Delay of Adjuvant Treatment. Ann Surg Oncol 2018; 25:1928-1935. [PMID: 29671138 DOI: 10.1245/s10434-018-6446-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND High-volume single-institution studies support the oncologic safety of nipple sparing mastectomy (NSM). Concerns remain regarding the increased potential for complications, recurrence, and delays to subsequent adjuvant therapy. A national database was used to examine treatment and outcomes for NSM patients. METHODS Women undergoing unilateral NSM or skin sparing mastectomy (SSM) for stage 0-4 breast cancer from 2004 to 2013 were identified from the National Cancer Database. Demographic and oncologic characteristics, short-term outcomes and time to local and systemic treatment were compared. RESULTS NSM was performed on 8173 patients: 8.7% were node positive, and for stage 1-4 disease, 10.6% were triple negative (TN) and 15.3% were HER2-positive. NSM patients were less likely than SSM patients to receive chemotherapy [CT] (37.4 vs. 43.4%) or radiation [PMRT] (15.6 vs. 16.9%), and were also more likely to present with clinically early-stage disease. NSM patients with high-risk features were more likely to receive CT in the neoadjuvant [NCT] than adjuvant setting [AC] (OR 3.76, 1.81, and 1.99 for clinical N2/3, TN, and HER2-positive disease, all p < 0.001). On multivariate analysis, NSM patients had a higher rate of pathologic complete response [pCR] (OR 1.41, p < 0.001). Readmission rate, positive margin rate and time to CT, PMRT or hormonal therapy were not increased for NSM compared to SSM patients. CONCLUSIONS Over one third of NSM patients received chemotherapy and/or radiation. NSM patients with high-risk features were more likely to receive NAC and obtain a pCR. NSM patients did not experience worse outcomes or delayed adjuvant therapy compared to SSM.
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Machida Y, Shimauchi A, Igarashi T, Hoshi K, Fukuma E. Preoperative breast MRI: reproducibility and significance of findings relevant to nipple–areolar complex involvement. Breast Cancer 2018; 25:456-463. [DOI: 10.1007/s12282-018-0845-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 02/07/2018] [Indexed: 02/07/2023]
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Non-BRCA1/2 Breast Cancer Susceptibility Genes: A New Frontier with Clinical Consequences for Plastic Surgeons. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1564. [PMID: 29263966 PMCID: PMC5732672 DOI: 10.1097/gox.0000000000001564] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 09/22/2017] [Indexed: 12/03/2022]
Abstract
Twenty percent of breast cancer cases may be related to a genetic mutation conferring an increased risk of malignancy. The most common and prominent breast cancer susceptibility genes are BRCA1 and BRCA2, found in nearly 40% of such cases. However, continued interest and investigation of cancer genetics has led to the identification of a myriad of different breast cancer susceptibility genes. Additional genes, each with unique significance and associated characteristics, continue to be recognized. Concurrently, advanced genetic testing, while still controversial, has become more accessible and cost-effective. As oncologic and reconstructive advances continue to be made in prophylactic breast reconstructive surgery, patients may present to plastic surgeons with an increasingly more diverse array of genetic diagnoses to discuss breast reconstruction. It is therefore imperative that plastic surgeons be familiar with these breast cancer susceptibility genes and their clinical implications. We, therefore, aim to review the most common non-BRCA1/2 breast cancer susceptibility genetic mutations in an effort to assist plastic surgeons in counseling and managing this unique patient population. Included in this review are syndromic breast cancer susceptibility genes such as TP53, PTEN, CDH1, and STK11, among others. Nonsyndromic breast cancer susceptibility genes herein reviewed include PALB2, CHEK2, and ataxia telangiectasia mutated gene. With this knowledge, plastic surgeons can play a central role in the diagnosis and comprehensive treatment, including successful breast reconstruction, of all patients carrying genetic mutations conferring increased risk for breast malignancies.
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Nipple-Areola Complex Malposition in Nipple-Sparing Mastectomy: A Review of Risk Factors and Corrective Techniques from Greater than 1000 Reconstructions. Plast Reconstr Surg 2017; 140:247e-257e. [PMID: 28369015 DOI: 10.1097/prs.0000000000003507] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Nipple-areola complex malposition after nipple-sparing mastectomy can be a challenging issue to correct. The current literature is largely limited to smaller series and implant-based reconstructions. METHODS A retrospective review of all nipple-sparing mastectomies from 2006 to 2016 at a single institution was performed. Incidence, risk factors, and corrective techniques of nipple-areola complex malposition were analyzed. RESULTS One thousand thirty-seven cases of nipple-sparing mastectomy were identified, of which 77 (7.4 percent) underwent nipple-areola complex repositioning. All were performed in a delayed fashion. The most common techniques included crescentic periareolar excision [n = 25 (32.5 percent)] and directional skin excision [n = 10 (13.0 percent)]. Cases requiring nipple-areola complex repositioning were significantly more likely to have preoperative radiation therapy (p = 0.0008), a vertical or Wise pattern incision (p = 0.0157), autologous reconstruction (p = 0.0219), and minor mastectomy flap necrosis (p = 0.0462). Previous radiation therapy (OR, 3.6827; p = 0.0028), vertical radial mastectomy incisions (OR, 1.8218; p = 0.0202), and autologous reconstruction (OR, 1.77; p = 0.0053) were positive independent predictors of nipple-areola complex repositioning, whereas implant-based reconstruction (OR, 0.5552; p < 0.0001) was a negative independent predictor of repositioning. Body mass index (p = 0.7104) and adjuvant radiation therapy (p = 0.9536), among other variables, were not predictors of nipple-areola complex repositioning. CONCLUSIONS Nipple-areola complex malposition after nipple-sparing mastectomy can be successfully corrected with various techniques. Previous radiation therapy, vertical mastectomy incisions, and autologous reconstruction are independently predictive of nipple-areola complex malposition. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Mastectomy Flap Thickness and Complications in Nipple-Sparing Mastectomy: Objective Evaluation using Magnetic Resonance Imaging. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1439. [PMID: 28894660 PMCID: PMC5585433 DOI: 10.1097/gox.0000000000001439] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/14/2017] [Indexed: 12/11/2022]
Abstract
Background: Ischemic complications after nipple-sparing mastectomy (NSM) have been associated with numerous variables. However, the impact of NSM flap thickness has been incompletely evaluated. Methods: NSM flap thickness was determined for all NSMs from 2006 to 2016 with available pre- or postoperative breast magnetic resonance imaging (MRIs). Demographics and outcomes were stratified by those with and without ischemic complications. Results: Of 1,037 NSM reconstructions, 420 NSMs had MRI data available, which included 379 preoperative MRIs and 60 postoperative MRIs. Average total preoperative skin/subcutaneous tissue NSM flap thickness was 11.4 mm. Average total postoperative NSM flap thickness was 8.7 mm. NSMs with ischemic complications were found to have significantly thinner overall postoperative NSM flap thickness compared with those without ischemic complications (P = 0.0280). Average overall postoperative NSM flap thickness less than 8.0 mm was found to be an independent predictor of ischemic complications (odds ratio, 6.5263; P = 0.026). In NSMs with both pre- and postoperative MRIs, the overall average postoperative NSM flap thickness was 68.2% of preoperative measurements. Average overall postoperative NSM flap thickness was significantly less than average overall preoperative NSM flap thickness (P < 0.0001). NSMs with ischemic complications were found to have a significantly lower ratio of overall postoperative to preoperative flap thickness (52.0% versus 74.0%; P < 0.0001). Conclusions: Ischemic complications after NSM are significantly associated with thinner postoperative NSM flap thickness. Particularly, NSM flap thickness less than 8.0 mm is a positive independent predictor of ischemic complications. The ratio of postoperative to preoperative NSM flap thickness was significantly lower in reconstructions with ischemic complications.
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Accuracy and interobserver agreement of retroareolar frozen sections in nipple-sparing mastectomies. Ann Diagn Pathol 2017; 29:46-51. [DOI: 10.1016/j.anndiagpath.2017.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 05/02/2017] [Indexed: 12/29/2022]
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Comparison of Outcomes with Tissue Expander, Immediate Implant, and Autologous Breast Reconstruction in Greater Than 1000 Nipple-Sparing Mastectomies. Plast Reconstr Surg 2017; 139:1300-1310. [DOI: 10.1097/prs.0000000000003340] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fernando EJ, Eskenazi BR, Djohan RS, Grobmyer SR. A Tumor Ultrasound-guided Incision (TUGI) Approach to Nipple-sparing Mastectomy: Balancing Oncologic Safety and Technical Outcomes. Clin Breast Cancer 2017; 17:572-577. [PMID: 28495572 DOI: 10.1016/j.clbc.2017.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 04/02/2017] [Accepted: 04/04/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) is a prevalent operation for patients with breast cancer. Indications have been limited to tumors accessible via radial, infra-mammary, or periareolar incisions out of concern for oncologic and technical safety. We study an alternative approach to NSM based on tumor ultrasound-guided incisions (TUGI) and report its oncologic and technical outcomes. MATERIALS AND METHODS A retrospective chart review examined patients who underwent TUGI NSM between 2013 and 2016. Operative notes, postoperative notes, pathology reports, and postoperative photography were analyzed. RESULTS Ninety-four patients had mastectomy with reconstruction performed over a 3-year period by the senior authors. Of those, 31 (33%) were NSM and 13 (14%) had the TUGI technique, forming the study group. The median tumor size was 1.5 cm, with a median distance from the nipple areolar complex of 5 cm. Sixty-two percent of the incisions were in the upper quadrants of the breast. Median operative time was 207 minutes. Zero patients had positive margins. One hundred percent of patients underwent immediate tissue expander placement, 46% with acellular dermal matrix. For final reconstruction, 23% had a free flap, 69% implant, and 8% are still pending. Eight percent of patients had wound infection, and 15% of patients had NAC necrosis. No cancer recurrence has been observed at a median follow-up of 17 months. CONCLUSION TUGI offers a valuable, oncologically sound alternative approach to traditional NSM. The technical results and outcomes support its use in selected patients with breast cancer undergoing NSM.
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Affiliation(s)
- Emil J Fernando
- Division of Surgical Oncology, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Risal S Djohan
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
| | - Stephen R Grobmyer
- Division of Surgical Oncology, Department of General Surgery, Cleveland Clinic, Cleveland, OH.
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The Conservative Mastectomy. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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26
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The Effect of Neoadjuvant Chemotherapy Compared to Adjuvant Chemotherapy in Healing after Nipple-Sparing Mastectomy. Plast Reconstr Surg 2017; 139:10e-19e. [DOI: 10.1097/prs.0000000000002841] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Donovan CA, Harit AP, Chung A, Bao J, Giuliano AE, Amersi F. Oncological and Surgical Outcomes After Nipple-Sparing Mastectomy: Do Incisions Matter? Ann Surg Oncol 2016; 23:3226-3231. [DOI: 10.1245/s10434-016-5323-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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28
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Sisco M, Yao KA. Nipple-sparing mastectomy: A contemporary perspective. J Surg Oncol 2016; 113:883-90. [PMID: 26931641 DOI: 10.1002/jso.24209] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 02/10/2016] [Indexed: 01/17/2023]
Abstract
Increasing numbers of women are undergoing nipple-sparing mastectomy, and evidence to support its use for cancer treatment and prophylaxis is expanding. An understanding of technical aspects and pitfalls of the procedure is paramount to ensure that the best results are attained. J. Surg. Oncol. 2016;113:883-890. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Mark Sisco
- Division of Plastic Surgery, Department of Surgery, NorthShore University HealthSystem, Northbrook, Illinois
| | - Katharine A Yao
- Division of Surgical Oncology, Department of Surgery, NorthShore University HealthSystem, Northbrook, Illinois
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