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Shanno JN, Daly AE, Anderman KJ, Santa Cruz HS, Webster AJ, Pride RM, Specht MC, Gadd MA, Oseni TO, Verdial FC, Ozmen T, Kwait R, Colwell AS, Smith BL. Positive Nipple Margins in Nipple-Sparing Mastectomy: Management of Nipples Containing Cancer or Atypia. Ann Surg Oncol 2024; 31:5148-5156. [PMID: 38691238 DOI: 10.1245/s10434-024-15362-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/09/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) is an oncologically safe approach for breast cancer treatment and prevention; however, there are little long-term data to guide management for patients whose nipple margins contain tumor or atypia. METHODS NSM patients with tumor or atypia in their nipple margin were identified from a prospectively maintained, single-institution database of consecutive NSMs. Patient and tumor characteristics, treatment, recurrence, and survival data were assessed. RESULTS A total of 3158 NSMs were performed from June 2007 to August 2019. Nipple margins contained tumor in 117 (3.7%) NSMs and atypia only in 164 (5.2%) NSMs. Among 117 nipple margins that contained tumor, 34 (29%) margins contained invasive cancer, 80 (68%) contained ductal carcinoma in situ only, and 3 (3%) contained lymphatic vessel invasion only. Management included nipple-only excision in 67 (57%) breasts, nipple-areola complex excision in 35 (30%) breasts, and no excision in 15 (13%) breasts. Only 23 (24%) excised nipples contained residual tumor. At 67 months median follow-up, there were 2 (1.8%) recurrences in areolar or peri-areolar skin, both in patients with nipple-only excision. Among 164 nipple margins containing only atypia, 154 (94%) nipples were retained. At 60 months median follow-up, no patient with atypia alone had a nipple or areola recurrence. CONCLUSIONS Nipple excision is effective management for nipple margins containing tumor. No intervention is required for nipple margins containing only atypia. Our results support broad eligibility for NSM with careful nipple margin assessment.
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MESH Headings
- Humans
- Female
- Nipples/surgery
- Nipples/pathology
- Breast Neoplasms/surgery
- Breast Neoplasms/pathology
- Middle Aged
- Margins of Excision
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Neoplasm Recurrence, Local/surgery
- Neoplasm Recurrence, Local/pathology
- Follow-Up Studies
- Adult
- Organ Sparing Treatments/methods
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Ductal, Breast/pathology
- Prognosis
- Survival Rate
- Aged
- Prospective Studies
- Mastectomy, Subcutaneous/methods
- Neoplasm Invasiveness
- Neoplasm, Residual/surgery
- Neoplasm, Residual/pathology
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Affiliation(s)
- Julia N Shanno
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Abigail E Daly
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Kyle J Anderman
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Heidi S Santa Cruz
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Alexandra J Webster
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Robert M Pride
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Michelle C Specht
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Michele A Gadd
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Tawakalitu O Oseni
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Francys C Verdial
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Tolga Ozmen
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Rebecca Kwait
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Amy S Colwell
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Barbara L Smith
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA.
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Wong SM, Apostolova C, Eisenberg E, Foulkes WD. Counselling Framework for Germline BRCA1/2 and PALB2 Carriers Considering Risk-Reducing Mastectomy. Curr Oncol 2024; 31:350-365. [PMID: 38248108 PMCID: PMC10814079 DOI: 10.3390/curroncol31010023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 12/31/2023] [Accepted: 01/05/2024] [Indexed: 01/23/2024] Open
Abstract
Female BRCA1/2 and PALB2 germline pathogenic variant carriers have an increased lifetime risk of breast cancer and may wish to consider risk-reducing mastectomy (RRM) for surgical prevention. Quantifying the residual lifetime risk and absolute benefit from RRM requires careful consideration of a patient's age, pathogenic variant, and their personal history of breast or ovarian cancer. Historically, patients have been counselled that RRM does not necessarily prolong survival relative to high-risk surveillance, although recent studies suggest a possible survival benefit of RRM in BRCA1 carriers. The uptake of RRM has increased dramatically over the last several decades yet varies according to sociodemographic factors and geographic region. The increased adoption of nipple-sparing mastectomy techniques, ability to avoid axillary staging, and availability of reconstructive options for most germline pathogenic variant carriers has helped to minimize the morbidity of RRM. Preoperative discussions should include evidence regarding postmastectomy sensation, the potential for supplemental surgery, pregnancy-related chest wall changes, and the need for continued clinical surveillance. Approaches that include sensation preservation and robotic nipple-sparing mastectomy are an area of evolving research that may be more widely adopted in the future.
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Affiliation(s)
- Stephanie M. Wong
- Department of Surgery, McGill University, Montreal, QC H3G 1A4, Canada
- Stroll Cancer Prevention Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC H3T 1E2, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, QC H4A 3T2, Canada
| | - Carla Apostolova
- Department of Surgery, McGill University, Montreal, QC H3G 1A4, Canada
- Stroll Cancer Prevention Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC H3T 1E2, Canada
| | - Elisheva Eisenberg
- Department of Surgery, McGill University, Montreal, QC H3G 1A4, Canada
- Stroll Cancer Prevention Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC H3T 1E2, Canada
| | - William D. Foulkes
- Stroll Cancer Prevention Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC H3T 1E2, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, QC H4A 3T2, Canada
- Department of Human Genetics, McGill University, Montreal, QC H3A 0C7, Canada
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Yang H, Liang F, Xie Y, Qiu M, Du Z. Single axillary incision reverse-order endoscopic nipple/skin-sparing mastectomy followed by subpectoral implant-based breast reconstruction: Technique, clinical outcomes, and aesthetic results from 88 preliminary procedures. Surgery 2023; 174:464-472. [PMID: 37422354 DOI: 10.1016/j.surg.2023.05.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/18/2023] [Accepted: 05/24/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Single axillary incision reverse-order endoscopic nipple-sparing mastectomy overcomes the limitations of conventional endoscopic nipple-sparing mastectomy application. We introduce this technique and report the preliminary results of this study. METHODS Patients who received single axillary incision reverse-order endoscopic nipple-/skin-sparing mastectomy from May 2020 to May 2022 were enrolled from a single institution. Data were analyzed to evaluate the safety and effectiveness of this technique. Patient-reported and surgeon-reported cosmetic outcomes were collected. RESULTS In total, 68 patients who underwent 88 single axillary incision reverse-order endoscopic nipple-/skin-sparing mastectomy combined with subpectoral implant-based breast reconstruction were enrolled in the current study. The overall complication rate was 10.3%. In total, 2.9% of patients suffered from major complications, and 5 (7.4%) experienced minor complications. Only 1 patient experienced partial nipple-areola complex necrosis. During a median follow-up time of 24 months, the locoregional recurrence and distant metastasis rate was both 1.6%. In the surgeon-reported cosmetic results, 92.1% of patients achieved good or excellent results. The mean SCAR-Q scores were 82.07 ± 8.86, and 85.3% evaluated their breasts as good or excellent. The mean overall cost was 5,670.4 ± 1,351.3 USD. The total mean operation time and maturity-stage mean operation time were 234.3 ± 80.4 and 172.55 ± 41.29 min, respectively. According to cumulative sum plot analysis, approximately 18 cases were needed for surgeons to decrease their operation time significantly and complication rate. CONCLUSION Single axillary incision reverse-order endoscopic nipple-sparing mastectomy is a safe, less expensive, and efficient surgical technique with reliable intermediate-term oncologic safety. For suitable candidates, the technique with subpectoral implant-based breast reconstruction can provide a good cosmetic outcome.
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Affiliation(s)
- Huanzuo Yang
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China; Breast Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Faqing Liang
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China; Breast Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Yanyan Xie
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China; Breast Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Mengxue Qiu
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China; Breast Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Zhenggui Du
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China; Breast Centre, West China Hospital, Sichuan University, Chengdu, China.
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Zhang X, Liu J, Pan L, Zheng W, Chen L, Tang W. Patient satisfaction after nipple-sparing mastectomy with intraoperative radiotherapy and breast reconstruction for breast cancer. Acta Chir Belg 2023; 123:110-117. [PMID: 34236948 DOI: 10.1080/00015458.2021.1952054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The use of nipple-sparing mastectomy (NSM) combined with breast reconstruction is increasing in breast cancer surgeries despite its controversial safety profile. To reduce the recurrence rate of tumors in the nipple-areola complex (NAC), we used intraoperative radiotherapy (IORT). The purpose of this study was to explore patients' feedback on this novel treatment strategy. PATIENTS AND METHODS From January 2014 to May 2018, eligible patients with breast cancer were enrolled in this study and separated into 2 groups. Patients in the NSM group underwent IORT to the NAC flap, and patients in the skin-sparing mastectomy (SSM) group underwent SSM and breast reconstruction. The postoperative satisfaction was collected and assessed using the Breast-Q reconstruction questionnaire and a standardized questionnaire; this was compared between the 2 groups. RESULTS There were 46 patients (52 NSMs) in the NSM group and 20 patients (22 SSMs) in the SSM group. The breast-Q scores were higher in the NSM group than the SSM group, with trends for a 'higher satisfaction with breasts' (67.39 ± 20.59 vs. 55.00 ± 19.33; p = 0.026) and 'higher sexual well-being' (61.74 ± 22.24 vs. 49.50 ± 20.12; p = 0.039). All the patients recognized the importance of nipple preservation. Thirty-seven women (80.40%) were satisfied or very satisfied with the appearance and shape of the NAC in the NSM group, while 38/46 women (82.60%) were very unsatisfied or unsatisfied with the sensitivity of the nipples. CONCLUSIONS The Breast-Q scores showed great satisfaction with breasts and sexual well-being in the NSM group. However, more effort should be made in improving postoperative NAC sensitivity.
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Affiliation(s)
- Xiaoshen Zhang
- Department of Breast Surgery, The First Affiliated Hospital, Guangzhou Medical University, China
| | - Jinhui Liu
- Department of Breast Surgery, The First Affiliated Hospital, Guangzhou Medical University, China
| | - Lingxiao Pan
- Department of Breast Surgery, The First Affiliated Hospital, Guangzhou Medical University, China
| | - Wenbo Zheng
- Department of Breast Surgery, The First Affiliated Hospital, Guangzhou Medical University, China
| | - Lun Chen
- Department of Breast Surgery, The First Affiliated Hospital, Guangzhou Medical University, China
| | - Wei Tang
- Department of Breast Surgery, The First Affiliated Hospital, Guangzhou Medical University, China
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Loreti A, Fanelli B, Abate O, Spallone D, Arelli F, Bruno E, Marcasciano M, La Pinta M, Meli EZ, Fortunato L. Surgical Delay of Nipple Areola Complex: A Powerful Technique to Extend the Indication of Nipple-Sparing Mastectomy. Clin Breast Cancer 2023; 23:255-264. [PMID: 36681577 DOI: 10.1016/j.clbc.2023.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND Surgical delay (SD) techniques, performed before the nipple sparing mastectomy (NSM), are procedures conceived to improve the blood supply to the nipple-areola complex (NAC) in order to overcome the ischemic risk. The aim of the study is reporting our experience with SD of the NAC in the setting of NSM, identify the rate of nipple and skin necrosis and other complications and to evaluate patient satisfaction with cosmetic outcome. PATIENTS AND METHODS A retrospective review of female patients, who underwent NSM and breast reconstruction between the July 2014 and the July 2019, was performed at the Breast Unit of San Giovanni-Addolorata Hospital in Rome. Eighty-nine NSM after SD procedure were performed in 66 patients. In all cases immediate breast reconstruction was performed with a direct to implant technique and polyurethane implants in prepectoral plan were used in all reconstructions. RESULTS We registered only 1 case of total NAC necrosis and 3 skin flap necrosis. Furthermore, patient satisfaction with breast reconstruction resulted excellent or good in 23 cases and good in 36 cases; the external plastic surgeon considered the breast reconstruction excellent or good in 63 cases. CONCLUSION We support the thesis that SD techniques may expand indications for NAC sparing mastectomy and immediate breast reconstruction in women with known risk factors for local complications. Microabstract This is the largest single center series on surgical delay of nipple areola complex providing interesting data on follow-up and complication rates and we support the thesis that surgical delay techniques may expand indications for nipple-areola complex sparing mastectomy and immediate breast reconstruction in women with known risk factors for local complications.
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Affiliation(s)
- Andrea Loreti
- Plastic and Reconstructive Surgery Division, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy.
| | - Benedetta Fanelli
- Department of Surgery ''P.Valdoni'', Unit of Plastic and Reconstructive Surgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Ornella Abate
- Plastic and Reconstructive Surgery Division, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy
| | - Diana Spallone
- Plastic and Reconstructive Surgery Division, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy
| | - Floriana Arelli
- Plastic and Reconstructive Surgery Division, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy
| | - Edoardo Bruno
- Department of Surgery ''P.Valdoni'', Unit of Plastic and Reconstructive Surgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Marco Marcasciano
- Division of Plastic and Reconstructive Surgery, Magna Grecia University of Catanzaro, Viale Europa, Catanzaro, Italy
| | - Massimo La Pinta
- Breast Unit, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy
| | | | - Lucio Fortunato
- Breast Unit, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy
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Acea-Nebril B, García-Novoa A, Díaz MT, Alejandro AB, Carballada CD, Conde Iglesias C, Díaz Martínez I, Martínez Arribas C, Calvo Martínez L, Novoa SA, Santiago Freijanes P, Oses JM. Locoregional relapse after sparing mastectomies and immediate reconstruction in women with breast cancer. Cir Esp 2023; 101:97-106. [PMID: 36064171 DOI: 10.1016/j.cireng.2022.09.007] [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: 12/22/2021] [Accepted: 01/17/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION In recent years, cultural changes in today's society and improved risk assessment have increased the indication for mastectomies in women with breast cancer. Various studies have confirmed the oncological safety of sparing mastectomies and immediate reconstruction. The objective of this study is to analyze the incidence of locoregional relapses of this procedure and its impact on reconstruction and overall survival. PATIENTS AND METHODS Prospective study of patients with breast carcinoma who underwent a sparing mastectomy and immediate reconstruction. Locoregional relapses and their treatment and their impact on survival were analyzed. RESULTS The study group is made up of 271 women with breast carcinoma treated with a skin-sparing mastectomy and immediate reconstruction. The mean follow-up was 7.98 years and during the same 18 locoregional relapses (6.6%) were diagnosed: 72.2% in the mastectomy flap and 27.8% lymph node. There were no significant differences in the pathological characteristics of the primary tumor between patients with and without locoregional relapse, although the percentage of women with hormone-sensitive tumors was higher in the group without relapse. Patients with lymph node relapse had larger tumors (80% T2-T3) and 60% had axillary metastases at diagnosis, compared to 7.7% of women with skin relapse (p = 0.047). All patients operated on for locoregional relapse preserved their reconstruction. The incidence of metastases and deaths was significantly higher in patients with a relapse, causing a non-significant decrease in overall survival. CONCLUSION Locoregional relapses are a rare event in women with a sparing mastectomy and immediate reconstruction. Most patients with locoregional relapse can preserve their initial reconstruction through local resection of the tumor and adjuvant and / or neoadjuvant therapies.
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Affiliation(s)
- Benigno Acea-Nebril
- Servicio de Cirugía General, Unidad de Mama, Hospital Universitario de A Coruña, La Coruña, Spain
| | - Alejandra García-Novoa
- Servicio de Cirugía General, Unidad de Mama, Hospital Universitario de A Coruña, La Coruña, Spain.
| | - Mónica Torres Díaz
- Servicio de Cirugía General, Unidad de Mama, Hospital Universitario de A Coruña, La Coruña, Spain
| | - Alberto Bouzón Alejandro
- Servicio de Cirugía General, Unidad de Mama, Hospital Universitario de A Coruña, La Coruña, Spain
| | - Carlota Díaz Carballada
- Servicio de Ginecología, Unidad de Mama, Hospital Universitario de A Coruña, La Coruña, Spain
| | - Carmen Conde Iglesias
- Servicio de Ginecología, Unidad de Mama, Hospital Universitario de A Coruña, La Coruña, Spain
| | - Inmaculada Díaz Martínez
- Servicio de Oncología Radioterápica, Unidad de Mama, Centro Oncológico de Galicia, La Coruña, Spain
| | - Carme Martínez Arribas
- Servicio de Oncología Radioterápica, Unidad de Mama, Centro Oncológico de Galicia, La Coruña, Spain
| | - Lourdes Calvo Martínez
- Servicio de Oncología Médica, Unidad de Mama, Hospital Universitario de A Coruña, La Coruña, Spain
| | - Silvia Antolin Novoa
- Servicio de Oncología Médica, Unidad de Mama, Hospital Universitario de A Coruña, La Coruña, Spain
| | - Paz Santiago Freijanes
- Servicio de Anatomía Patológica, Unidad de Mama, Hospital Universitario de A Coruña, La Coruña, Spain
| | - Joaquín Mosquera Oses
- Servicio de Radiología, Unidad de Mama, Hospital Universitario de A Coruña, La Coruña, Spain
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Wang ZH, Gao GX, Liu WH, Wu SS, Xie F, Xu W, Ding GQ, Xu YQ, Zhang ZT, Qu X. Single-port nipple-sparing subcutaneous mastectomy with immediate prosthetic breast reconstruction for breast cancer. Surg Endosc 2023; 37:3842-3851. [PMID: 36695902 PMCID: PMC10156621 DOI: 10.1007/s00464-023-09862-6] [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: 09/16/2022] [Accepted: 01/03/2023] [Indexed: 01/26/2023]
Abstract
INTRODUCTION This study compares the perioperative results, aesthetic outcome and oncologic safety of single-port insufflation endoscopic nipple-sparing subcutaneous mastectomy combined with immediate reconstruction using prosthesis implantation (SIE-NSM-IRPI) with those of conventional open-nipple and areola-sparing subcutaneous mastectomy combined with immediate reconstruction using prosthesis implantation (C-NSM-IRPI). METHODS In this retrospective cohort study, 64 early-stage breast cancer patients were divided into SIE-NSM-IRPI (n = 38) and C-NSM-IRPI (n = 26) groups. Perioperative results (operation time, intraoperative blood loss, incision length, drainage duration, and recent complications) were then compared between the two groups. Differences in satisfaction with the breasts, psychosocial well-being, physical well-being (chest) and sexual well-being were analyzed according to the BREAST-Q scale, and survival outcomes were also compared. RESULTS The median follow-up time was 51.5 months. The incision length of SIE-NSM-IRPI was shorter than that of C-NSM-IRPI (P < 0.001). SIE-NSM-IRPI achieved the same detection rate and median number of sentinel lymph nodes as C-NSM-IRPI (3.00vs. 4.00, P = 0.780). The incidence of prosthesis removal due to infection or prosthesis exposure in the SIE-NSM-IRPI group was lower than that in the C-NSM-IRPI group (P = 0.015). Satisfaction with breasts (82.00vs.59.00, P < 0.001), psychosocial well-being (93.00vs.77.00, P = 0.001) and physical well-being (chest) (89.00vs.82.00, P < 0.001) scores were higher in the SIE-NSM-IRPI group. There were no significant differences between the two groups in disease-free survival (hazard ratio = 0.829, 95% confidence interval = 0.182-3.779) and overall survival (hazard ratio = 1.919, 95% confidence interval = 0.169-21.842). CONCLUSION In this selected cohort of patients with early breast cancer, SIE-NSM-IRPI was comparable to C-NSM-IRPI, considering oncologic safety and detection of sentinel lymph nodes. It had a lower incidence of prosthesis removal, shorter incision length, and was associated with better patient satisfaction with the breasts. More random clinical trials of this novel approach in a larger cohort of Chinese patients with an extended follow-up period are needed in the future.
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Affiliation(s)
- Zi-Han Wang
- Department of Breast Disease, Peking University People's Hospital, Beijing, 100044, China
| | - Guo-Xuan Gao
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Wei-Hua Liu
- Surgery Department, Huairou Maternal and Child Health Care Hospital, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 101400, China
| | - Shan-Shan Wu
- Department of Clinical Epidemiology and Evidence-Based Medicine, Beijing Friendship Hospital, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Fang Xie
- Breast Surgery, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, 100010, China
| | - Wei Xu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Guo-Qian Ding
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Ya-Qian Xu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Zhong-Tao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Xiang Qu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China.
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“Hook Shape” Nipple-Sparing Mastectomy and Prepectoral Implant Reconstruction: Technique, Results and Outcomes from a Preliminary Case Series. Aesthetic Plast Surg 2022; 47:546-556. [PMID: 36280606 DOI: 10.1007/s00266-022-03115-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/11/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Nipple-sparing mastectomy (NSM) is a surgical procedure increasingly performed for breast cancer or risk reduction surgeries. The site of skin incision seems to affect not only cosmesis but also technical ease in operating and vascular viability of the nipple. We present a series of patients who underwent a modified vertical surgical approach for NSM, which resulted to be safe, reliable, and with good esthetic results. MATERIALS AND METHODS From December 2016 to February 2019, 27 "Hook Shape" incision NSMs were performed. All patients underwent an immediate subcutaneous muscle-sparing reconstruction with tissue expander covered by a titanium-coated polypropylene mesh, followed by a second surgical step with expander substitution and lipofilling on the definitive implant when indicated. Preoperative and postoperative BREAST-Q patient-reported outcomes measure was performed in all cases. RESULTS Postoperative morbidity was evaluated: One patient developed seroma and another presented a systemic infection that resolved with intravenous infusion of antibiotics. One patient experienced vertical wound dehiscence, recovered after conservative treatment and without implant exposure. No implant loss was observed. Nipple-areola complex necrosis or ischemia rate was 0%. The BREAST-Q outcomes reported significant increases in the overall satisfaction with breast (p < 0.05), psychosocial well-being (p < 0.05), and sexual well-being (p < 0.05) sections. Scores in the physical impact of surgery section appeared to decline from preoperative to postoperative evaluations, with no statistically significant results. CONCLUSION The mastectomy incision pattern can burden the surgical challenge, impact vascular viability of the nipple and significantly affect the aesthetic outcomes in breast reconstruction. We report our experience with an alternative approach for NSM, which appears a safe, practical, and reproducible method for patients with small- to medium-sized breasts and little/medium ptosis (grade I or II). LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
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Satisfaction with Long-Term Aesthetic and 10 Years Oncologic Outcome following Risk-Reducing Mastectomy and Implant-Based Breast Reconstruction with or without Nipple Preservation. Cancers (Basel) 2022; 14:cancers14153607. [PMID: 35892866 PMCID: PMC9331253 DOI: 10.3390/cancers14153607] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/09/2022] [Accepted: 07/16/2022] [Indexed: 11/17/2022] Open
Abstract
Incidence of bilateral risk-reducing mastectomies (RRMs) is increasing. The aim of this study was to compare satisfaction, aesthetic and oncological outcomes in women undergoing RRM with implant-based reconstruction comparing nipple-sparing mastectomy (NSM) with skin-sparing mastectomy (SSM) (sacrificing the nipple +/− nipple reconstruction). Women who had undergone bilateral RRM between 1997 and 2016 were invited. Aesthetic outcome and nipple symmetry were evaluated using standardized anthropometric measurements. The oncological outcome was assessed at last documented follow up. Ninety-three women (186 breasts) participated, 60 (64.5%) had NSM, 33 (35.5%) SSM. Median time between surgery and participation was 98.4 months (IQR: 61.7−133.9). Of the women, 23/33 (69.7%) who had SSM underwent nipple reconstruction. Nipple projection was shorter in the reconstructed SSM group than the maintained NSM group (p < 0.001). There was no significant difference in overall symmetry (p = 0.670), satisfaction regarding nipple preservation (p = 0.257) or overall nipple satisfaction (p = 0.074). There were no diagnoses of breast cancer at a median follow up of 129 months (IQR: 65−160.6). Women who undergo nipple-sparing RRM maintain long-term nipple symmetry. Nipple projection was less maintained after nipple reconstruction. Although satisfaction with the nipples was higher in the NSM group, this did not reach statistical significance. No breast cancers developed after RRM with long-term follow up.
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Magnoni F, Sacchini V, Veronesi P, Bianchi B, Bottazzoli E, Tagliaferri V, Mazzotta E, Castelnovo G, Deguidi G, Rossi EMC, Corso G. Surgical Management of Inherited Breast Cancer: Role of Breast-Conserving Surgery. Cancers (Basel) 2022; 14:3245. [PMID: 35805017 PMCID: PMC9265273 DOI: 10.3390/cancers14133245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 06/26/2022] [Accepted: 06/27/2022] [Indexed: 02/07/2023] Open
Abstract
Recent studies have demonstrated that hereditary breast cancer (BC) has a prevalence of 5-10% among all BC diagnoses. Nowadays, significant technological advances in the identification of an increasingly broad spectrum of genetic mutations allow for the discovery of an ever-growing number of inherited pathogenic (P) or likely pathogenic (LP) variants of breast cancer susceptibility genes. As the management of BC patients carrying mutations in the BRCA1/2 genes or other high-penetrance genes is currently a challenge, extensive research is being carried out and a lively scientific debate has been taking place on what the most appropriate local therapy, especially surgical treatment, of patients with inherited BC should be. In many studies, BC outcomes in BRCA carriers and non-carriers have been compared. A number of them showed that, when compared with mastectomy, breast-conserving surgery in BRCA patients is oncologically safe in terms of overall survival, although an increased risk of ipsilateral recurrence was reported. In these patients, devising a specific therapeutic strategy is an inevitably complex process, as it must take into consideration a series of factors, require a multimodal approach, guarantee personalization, strictly adhere to scientific international guidelines, and consider all available evidence. The present narrative review purposes to identify and illustrate evidence from significant selected studies that discussed those issues, as well as to suggest useful tools to clinicians managing this specific clinical condition in daily clinical practice.
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Affiliation(s)
- Francesca Magnoni
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
| | - Virgilio Sacchini
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA;
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Beatrice Bianchi
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
| | - Elisa Bottazzoli
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
| | - Valentina Tagliaferri
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
| | - Erica Mazzotta
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
| | - Giulia Castelnovo
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
| | - Giulia Deguidi
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
| | - Elisabetta Maria Cristina Rossi
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
| | - Giovanni Corso
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
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11
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Recaídas locorregionales tras mastectomías preservadoras y reconstrucción inmediata en mujeres con cáncer de mama. Cir Esp 2022. [DOI: 10.1016/j.ciresp.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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12
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Esgueva AJ, Noordhoek I, Kranenbarg EMK, Espinosa-Bravo M, Mátrai Z, Zhygulin A, Irmejs A, Mavioso C, Meani F, González E, Özdemir M, Allweis T, Rogowski K, Dos Santos CR, Mora H, Ponzone R, Samorani D, van de Velde C, Audisio RA, Rubio IT. Health-Related Quality of Life After Nipple-Sparing Mastectomy: Results From the INSPIRE Registry. Ann Surg Oncol 2021; 29:1722-1734. [PMID: 34748122 DOI: 10.1245/s10434-021-10930-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/24/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR) is increasingly used for both breast cancer (TNSM) and risk reduction (RRNSM). The aim of the study is to report the results of the INSPIRE registry assessing health-related quality of life (HRQoL) comparing baseline and 1-year follow-up, regarding surgical indications and chemotherapy (CT) received. METHODS INSPIRE is a prospective database including women undergoing NSM and IBR from 18 countries. HRQoL was measured using EORTC QLQC30 and QLQ-BR23 before surgery and after 1 year. RESULTS A total of 677 women were included, of whom 537 (79.3%) underwent TNSM and 140 (21.6%) RRNSM: in total, 806 NSM (556 TNSM and 250 RRNSM). Nipple involvement was present in 7.73% of TNSM and incidental carcinoma in 1.2% of the RRNSM group. Out of the overall 537 patients with systemic treatment, 177 (32.96%) received neoadjuvant chemotherapy (NCT) and 118 (21.92%) adjuvant chemotherapy (CT). A total of 227 patients (28.16%) developed at least one complication postoperatively, 164 (29.5%) in the TNSM group and 63 (25.2%) in the RRNSM group. The TNSM group improved in global health status and emotional functioning after 1 year. No differences were found when comparing HRQoL at 1 year between patients who received NCT and those who received adjuvant CT. The RRNSM group showed improvement in HRQoL, with better emotional functioning and fatigue after 1 year. CONCLUSIONS This registry reports HRQoL findings after NSM. The impact of CT on worse HRQoL is independent from its timing. Patients with RRNSM showed an improved HRQoL at 1-year follow-up. Discussion of HRQoL outcomes with patients will facilitate the informed decision-making when considering NSM.
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Affiliation(s)
- Antonio J Esgueva
- Breast Surgical Oncology Unit, Clinica Universidad de Navarra, Cancer Center Universidad de Navarra, Madrid, Spain
| | - Iris Noordhoek
- Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Zoltán Mátrai
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary
| | - Andrii Zhygulin
- Breast Unit, LISOD, Hospital of Israeli Oncology, Kiev, Ukraine
| | - Arvids Irmejs
- Breast Unit, Pauls Stradins Clinical University Hospital, Institute of Oncology, Riga Stradins University, Riga, Latvia
| | - Carlos Mavioso
- Breast Unit Centro Clínico Champalimaud, Lisboa, Portugal
| | - Francesco Meani
- Centro di Senologia della Svizzera Italiana, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | | | | | | | | | | | - Henrique Mora
- Centro Hospitalar Universitário Sao Joao, Porto, Portugal
| | | | | | | | | | - Isabel T Rubio
- Breast Surgical Oncology Unit, Clinica Universidad de Navarra, Cancer Center Universidad de Navarra, Madrid, Spain.
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13
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Direct-to-implant breast reconstruction following nipple-sparing mastectomy: predictive factors of adverse surgical outcomes in Asian patients. Arch Plast Surg 2021; 48:483-493. [PMID: 34583432 PMCID: PMC8490122 DOI: 10.5999/aps.2021.00374] [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: 02/20/2021] [Accepted: 07/29/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Direct-to-implant (DTI) breast reconstruction after nipple-sparing mastectomy (NSM) with the use of acellular dermal matrix (ADM) provides reliable outcomes; however, the use of ADM is associated with a higher risk of complications. We analyzed our experiences of post-NSM DTI without ADM and identified the predictive factors of adverse surgical outcomes. METHODS Patients who underwent NSM and immediate DTI or two-stage tissue expander (TE) breast reconstruction from 2009 to 2020 were enrolled. Predictors of adverse endpoints were analyzed. RESULTS There were 100 DTI and 29 TE reconstructions. The TE group had a higher rate of postmastectomy radiotherapy (31% vs. 11%; P=0.009), larger specimens (317.37±176.42 g vs. 272.08±126.33 g; P=0.047), larger implants (360.84±85.19 g vs. 298.83±81.13 g; P=0.004) and a higher implant/TE exposure ratio (10.3% vs. 1%; P=0.035). In DTI reconstruction, age over 50 years (odds ratio [OR], 5.43; 95% confidence interval [CI], 1.50-19.74; P=0.010) and a larger mastectomy weight (OR, 1.65; 95% CI, 1.08-2.51; P=0.021) were associated with a higher risk of acute complications. Intraoperative radiotherapy for the nipple-areolar complex increased the risk of acute complications (OR, 4.05; 95% CI, 1.07-15.27; P=0.039) and the likelihood of revision surgery (OR, 5.57; 95% CI, 1.25-24.93; P=0.025). CONCLUSIONS Immediate DTI breast reconstruction following NSM is feasible in Asian patients with smaller breasts.
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Kelly BN, Faulkner HR, Smith BL, Korotkin JE, Lanahan CR, Brown C, Gadd MA, Specht MC, Hughes KS, Oseni TS, Colwell AS, Coopey SB. Nipple-Sparing Mastectomy versus Skin-Sparing Mastectomy: Does Saving the Nipple Impact Short- and Long-Term Patient Satisfaction? Ann Surg Oncol 2021; 29:1033-1040. [PMID: 34498158 DOI: 10.1245/s10434-021-10767-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/15/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) is an oncologically safe alternative to skin-sparing mastectomy (SSM). This study evaluated whether NSM patients were more satisfied than SSM patients in short- and long-term follow-up. METHODS Women who underwent NSM or SSM between 2009 and 2019 completed a postoperative BREAST-Q survey at least 1 year after surgery and patient characteristics were compared. Patient satisfaction at 1-5 years and 6-10 years after NSM and SSM were analyzed. RESULTS Overall, 431 patients were included; 247 had NSM and 184 had SSM 1-10 years prior to BREAST-Q survey completion. SSM patients were older, had higher body mass index (BMI), larger breast weight, and more hypertension than NSM patients, but oncologic treatments were similar between groups. BREAST-Q Psychosocial Well-Being and Sexual Well-Being scores were significantly higher in NSM patients compared with SSM patients in the 1-5 years cohort; however, scores attenuated in the 6-10 years cohort. Satisfaction with breasts was nearly significantly higher in NSM patients compared with SSM patients in the 1-5 years cohort (p = 0.056), but no different in the 6-10 years cohort. Receipt of adjuvant chemotherapy, receipt of postmastectomy radiation therapy, and BMI ≥30 were independent risk factors for dissatisfaction with breasts. CONCLUSIONS Women who are not candidates for NSM should be reassured that long-term qualify of life is not significantly different between SSM and NSM. Dissatisfaction with reconstructed breasts is linked with other factors (besides the nipple), which patients should be made aware of at the time of surgical decision making.
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Affiliation(s)
- Bridget N Kelly
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Heather R Faulkner
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Barbara L Smith
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Jenna E Korotkin
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Conor R Lanahan
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Carson Brown
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Michele A Gadd
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Michelle C Specht
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Kevin S Hughes
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - T Salewa Oseni
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Amy S Colwell
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Suzanne B Coopey
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA.
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Houvenaeghel G, Cohen M, Dammacco MA, D'Halluin F, Regis C, Gutowski M, Acker O, Fournier M, Bannier M, Lusque A, Jouve E. Prophylactic nipple-sparing mastectomy with immediate breast reconstruction: results of a French prospective trial. Br J Surg 2021; 108:296-301. [PMID: 33793719 DOI: 10.1093/bjs/znaa082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 10/14/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR) is used increasingly when performing a prophylactic mastectomy. Few prospective studies have reported on complication rates. This complementary trial to the French prospective multicentre MAPAM trial aimed to evaluate the nipple-areola complex (NAC) necrosis rate in prophylactic NSM with IBR. METHODS Patient characteristics and surgical data were recorded. Morbidity after prophylactic NSM with a focus on NAC necrosis was analysed. RESULTS Among 59 women undergoing prophylactic NSM, 19 (32 per cent) of the incisions were partly on the NAC. Reconstructions were performed with 46 definitive implants and 13 expanders. The crude rate of postoperative complications was 25 per cent (15 patients). Complete NAC necrosis was reported in two women (3 per cent) and partial or total necrosis in nine (15 per cent). No NAC resection was necessary. Median BMI was lower in women with total or partial NAC necrosis compared with the others (20.0 versus 21.3 kg/m2 respectively; P = 0.034). CONCLUSION Results of this prospective study confirm that prophylactic NSM with IBR is associated with a low risk of total NAC necrosis.
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Affiliation(s)
- G Houvenaeghel
- Department of Surgical Oncology, Paoli Calmettes Institute and Centre de Recherche en Cancerérologie de Marseille (CRCM), Aix-Marseille University, Marseille, France
| | - M Cohen
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - M A Dammacco
- Department of Surgical Oncology, Centre Léon Bérard, Lyon, France
| | - F D'Halluin
- Surgery Department, L'Etablissement Rennais du Sein, Centre Hospitalier Privé St Grégoire, St Grégoire, France
| | - C Regis
- Department of Surgical Oncology, Centre Oscar Lambret, Lille, France
| | - M Gutowski
- Department of Surgical Oncology, Institut du Cancer de Montpellier Val d'Aurelle, Montpellier, France
| | - O Acker
- Surgery Department, Pôle Santé Léonard de Vinci, Chambray les Tours, France
| | - M Fournier
- Department of Surgical Oncology, Institut Bergonie, Bordeaux, France
| | - M Bannier
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - A Lusque
- Department of Biostatistics, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
| | - E Jouve
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
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Garstka M, Henriquez A, Kelly BN, Webster A, Khubchandani JA, Hughes K, Nguyen A, Oseni T, Specht M, Coopey SB, Gadd MA, Smith BL. How Protective are Nipple-Sparing Prophylactic Mastectomies in BRCA1 and BRCA2 Mutation Carriers? Ann Surg Oncol 2021; 28:5657-5662. [PMID: 34296361 DOI: 10.1245/s10434-021-10445-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/27/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) is now routinely offered to BRCA mutation carriers for risk reduction. We assessed the rates of ipsilateral cancer events after prophylactic and therapeutic NSM in BRCA1 and BRCA2 mutation carriers. METHODS BRCA1 and BRCA2 mutation carriers undergoing NSM from October 2007 to June 2019 were identified in a single-institution prospective database, with variants of unknown significance being excluded. Patient, tumor, and outcomes data were collected. Follow-up analysis was by cumulative breast-years (total years of follow-up of each breast) and woman-years (total years of follow-up of each woman). RESULTS Overall, 307 BRCA1 and BRCA2 mutation carriers (160 BRCA1, mean age 41.4 years [range 21-65]; and 147 BRCA2, mean age 43.8 years [range 23-65]) underwent 607 NSMs, with a median follow-up of 42 months (range 1-143). 388 bilateral prophylactic NSMs had 744 cumulative woman-years of follow-up, with no new cancers seen (< 0.0013 new cancers per woman-years); 251 BRCA1 prophylactic NSMs had 1034 cumulative breast-years of follow-up, with no new ipsilateral cancers seen (< 0.0010 per breast-year); 66 BRCA1 therapeutic NSMs had 328 cumulative breast-years of follow-up, with one ipsilateral cancer recurrence not directly involving the nipple or areola (0.0030 per breast-year); 237 BRCA2 prophylactic NSMs had 926 cumulative breast-years of follow-up, with no new ipsilateral cancers seen (< 0.0011 per breast-year); and 53 BRCA2 therapeutic NSMs had 239 cumulative breast-years of follow-up, with two ipsilateral recurrent cancers, neither of which directly involved the nipple or areola (0.0084 per breast-year). CONCLUSIONS The risk of new ipsilateral breast cancers is extremely low after NSM in BRCA1 and BRCA2 mutation carriers. NSM is an effective risk-reducing strategy for BRCA gene mutations.
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Affiliation(s)
- Meghan Garstka
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Anthony Henriquez
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Bridget N Kelly
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Alexandra Webster
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Jasmine A Khubchandani
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Kevin Hughes
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Anvy Nguyen
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Tawakalitu Oseni
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Michelle Specht
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Suzanne B Coopey
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Michele A Gadd
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Barbara L Smith
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA.
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Quilichini O, Barrou J, Bannier M, Rua S, Van Troy A, Sabiani L, Lambaudie E, Cohen M, Houvenaeghel G. Mastectomy with immediate breast reconstruction: Results of a mono-centric 4-years cohort. Ann Med Surg (Lond) 2020; 61:172-179. [PMID: 33437474 PMCID: PMC7787913 DOI: 10.1016/j.amsu.2020.12.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/21/2020] [Indexed: 01/31/2023] Open
Abstract
Introduction Oncological safety, quality of life and cosmetic outcomes seems to be similar between breast conserving surgery (BCS) and mastectomy with immediate breast reconstruction (IBR). We report our experience of IBR for consecutive mastectomies realized in a recent period of four years in order to determined immediate surgical results according to type of mastectomy and type of reconstruction, as mains objectives. Methods All mastectomies with IBR during years 2016–2019 were included. A retrospective analysis with prospective data collection was performed. Results We analyzed 748 IBR: 353 nipple-sparing mastectomies (NSM), 391 skin-sparing mastectomies (SSM) and 4 standard mastectomies, 551 with definitive implant or expanders and 196 with latissimus dorsi-flap (LDF). More NSM were performed during the 2 last years and more LDF were performed for high BMI, high breast cup-size, neo-adjuvant chemotherapy and radiotherapy and local recurrence. We realized 111 robotic NSM and 125 robotic LDF. Longer duration of surgery was significantly associated with the robotic procedures. The overall complications crude rate was 31.4% with 9.9% of re-operations and 5.8% of implant loss. Grade 2–3 complications were significantly associated with smoking. Breast complications occurred in 32.9% of mastectomies with principally skin or nipple-areola-complex suffering or necrosis, hematomas and infections. A predictive score was determined to evaluate risk of complications before surgery. Conclusion Mastectomy with IBR seems to be a safe technique with an acceptable complication rate which is increased by tobacco use, high breast cup-size and IBR-type. Mastectomy with immediate breast to determined immediate surgical results. More Nipple Sparing Mastectomy performed during the 2 last years. More Latissimus dorsi-flap performed for high BMI, high breast cup-size, after radiotherapy.
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Affiliation(s)
- Olivia Quilichini
- Department of Surgery, Paoli Calmettes Institute, 232 Bd Ste Marguerite, Marseille, France
| | - Julien Barrou
- Department of Surgery, Paoli Calmettes Institute, 232 Bd Ste Marguerite, Marseille, France
| | - Marie Bannier
- Department of Surgery, Paoli Calmettes Institute, 232 Bd Ste Marguerite, Marseille, France
| | - Sandrine Rua
- Department of Surgery, Paoli Calmettes Institute, 232 Bd Ste Marguerite, Marseille, France
| | - Aurore Van Troy
- Department of Surgery, Paoli Calmettes Institute, 232 Bd Ste Marguerite, Marseille, France
| | - Laura Sabiani
- Department of Surgery, Paoli Calmettes Institute, 232 Bd Ste Marguerite, Marseille, France
| | - Eric Lambaudie
- Department of Surgery, Paoli Calmettes Institute & CRCM & Aix Marseille Univ, 232 Bd Ste Marguerite, Marseille, France
| | - Monique Cohen
- Department of Surgery, Paoli Calmettes Institute, 232 Bd Ste Marguerite, Marseille, France
| | - Gilles Houvenaeghel
- Department of Surgery, Paoli Calmettes Institute & CRCM & Aix Marseille Univ, 232 Bd Ste Marguerite, Marseille, France
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Immediate targeted nipple-areolar complex re-innervation: Improving outcomes in immediate autologous breast reconstruction. J Plast Reconstr Aesthet Surg 2020; 74:1503-1507. [PMID: 33341386 DOI: 10.1016/j.bjps.2020.11.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/13/2020] [Accepted: 11/22/2020] [Indexed: 11/24/2022]
Abstract
Breast reconstruction often renders the chest skin and nipple areolar complex (NAC) insensate. We propose a new technique of preserving the intercostal nerves during mastectomy and using them to reinnervate the NAC following mastectomy and immediate autologous tissue reconstruction. The technique involves preservation of the lateral intercostal nerves during mastectomy, dissection of the lateral intercostal nerves to length, coaptation of the intercostal nerves to a nerve graft which is then tunneled through the free flap and the distal nerve graft is then coapted to the nerve stumps at the base of the NAC. We performed a retrospective analysis of 14 breasts, which underwent nipple reinnervation during immediate autologous breast reconstruction. Mean age was 49 years (range: 32-61 years). Sensory outcomes, as tested with Semmes-Weinstein monofilaments, were compared to a cohort of breasts that underwent nipple sparing mastectomy without neurotization. Compared to control patients, there was no statistically significant difference (p = 0.0969) in sensation between pre-operative and post-operative nipple sensation at final follow-up. This proof-of-concept study suggests that immediate re-innervation of the NAC in the setting of immediate breast reconstruction enhances recovery of the NAC sensation.
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Clinical outcomes of patients after nipple-sparing mastectomy and reconstruction based on the expander/implant technique. Surg Today 2020; 51:862-871. [PMID: 33185799 PMCID: PMC8141482 DOI: 10.1007/s00595-020-02175-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/08/2020] [Indexed: 12/19/2022]
Abstract
Advances in multi-modality treatments incorporating systemic chemotherapy, endocrine therapy, and radiotherapy for the management of breast cancer have resulted in a surgical-management paradigm change toward less-aggressive surgery that combines the use of breast-conserving or -reconstruction therapy as a new standard of care with a higher emphasis on cosmesis. The implementation of skin-sparing and nipple-sparing mastectomies (SSM, NSM) has been shown to be oncologically safe, and breast reconstructive surgery is being performed increasingly for patients with breast cancer. NSM and breast reconstruction can also be performed as prophylactic or risk-reduction surgery for women with BRCA gene mutations. Compared with conventional breast construction followed by total mastectomy (TM), NSM preserving the nipple-areolar complex (NAC) with breast reconstruction provides psychosocial and aesthetic benefits, thereby improving patients' cosmetic appearance and body image. Implant-based breast reconstruction (IBBR) has been used worldwide following mastectomy as a safe and cost-effective method of breast reconstruction. We review the clinical evidence about immediate (one-stage) and delayed (two-stage) IBBR after NSM. Our results suggest that the postoperative complication rate may be higher after NSM followed by IBBR than after TM or SSM followed by IBBR.
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20
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Elmore LC, Dietz JR, Myckatyn TM, Margenthaler JA. The Landmark Series: Mastectomy Trials (Skin-Sparing and Nipple-Sparing and Reconstruction Landmark Trials). Ann Surg Oncol 2020; 28:273-280. [PMID: 32886286 DOI: 10.1245/s10434-020-09052-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/08/2020] [Indexed: 11/18/2022]
Abstract
Despite advances in medical therapy, the foundation of breast cancer treatment is surgery. The landscape of operative intervention for breast cancer has shifted toward less invasive techniques, resulting in improved cosmesis and lower morbidity while maintaining oncologic integrity. In this article, we review the body of literature contributing to landmark advances in mastectomy for the treatment of breast cancer.
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Affiliation(s)
- Leisha C Elmore
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jill R Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Terence M Myckatyn
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Julie A Margenthaler
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.
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21
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Heinzen RN, de Barros ACSD, Carvalho FM, Aguiar FN, Nimir CDCBA, Jacomo AL. Nipple-sparing mastectomy for early breast cancer: the importance of intraoperative evaluation of retroareolar margins and intra-nipple duct removal. Gland Surg 2020; 9:637-646. [PMID: 32775253 DOI: 10.21037/gs-20-405] [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] [Indexed: 11/06/2022]
Abstract
Background Nipple-sparing mastectomy (NSM) is increasingly performed for breast cancer (BC) treatment. To ensure local control with this procedure, it is important to obtain clear surgical margins. Here, we aimed to estimate the confidence in intraoperative evaluation of the retroareolar margin (IERM) and the necessity of removing the intra-nipple ducts. Methods In this retrospective cohort study, we evaluated 224 BC (infiltrating carcinoma 178, ductal carcinoma in situ 46) patients, who underwent NSM. IERM was determined via cytology and frozen sections. Following gland removal, the intra-nipple ducts were excised and embedded in paraffin for analysis. The retroareolar tissue was also paraffin-embedded and reanalyzed for definitive evaluation of retroareolar margins (DERM). The IERM predictive capacity in relation to DERM and the frequency of intra-nipple duct involvement were estimated. Results IERM classified the sub-nipple areolar complex area as cancer-free in 219 cases (97.8%). The condition of clear retroareolar margin was confirmed by DERM in 216 cases (98.6%). The IERM accuracy was estimated as 98.6%. Ductal carcinoma in situ was detected in intra-nipple ducts using paraffin sections in 1.8% of the cases, despite clear IERM (4/219). Conclusions In conclusion, IERM affords high accuracy and its results are suitable to manage the nipple-areolar complex. Nevertheless, some patients may retain residual disease in the intra-nipple ducts; thus, these ducts should ideally be removed during NSM.
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Affiliation(s)
- Rebeca Neves Heinzen
- Discipline of Human Structural Topography, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | | | - Fernando Nalesso Aguiar
- Discipline of Pathologic Anatomy, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Alfredo Luiz Jacomo
- Discipline of Human Structural Topography, University of São Paulo School of Medicine, São Paulo, Brazil
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Barbieri E, Frusone F, Bottini A, Sagona A, Gatzemeier W, Canavese G, Anghelone CAP, De Luca A, Marrazzo E, Amabile MI, Tinterri C. Evolution and time trends of nipple-sparing mastectomy: a single-center experience. Updates Surg 2020; 72:893-899. [PMID: 32449032 DOI: 10.1007/s13304-020-00796-5] [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: 10/29/2019] [Accepted: 05/09/2020] [Indexed: 01/27/2023]
Abstract
Nipple Sparing Mastectomy (NSM) requires the entire breast tissue to be removed, maintaining the nipple-areola complex, and represents nowadays the gold standard of the demolitive breast surgery. Although it represents the evolution of conservative breast surgery, NSM presents some limitations in the selection of women candidates for treatment, and still there are no real guidelines regarding its indications, but simply objective data to address the choice. How the breast surgery approach to demolitive and conservative surgery has changed over time? We evaluated throughout the years (from 2009 up to 2018) the time trend of NSM at our institution and analysed the main differences between patients undergone NSM and other mastectomies and/or breast conserving surgery in terms of cancer size, multicentricity and biological profile. We found 781 NSMs, 1261 other mastectomies and 5621 breast conservative surgeries. Among NSMs, 39.6% were reconstructed with tissue expander and 58.1% with definitive prosthesis. From 2009 to 2018 we found a general increase of NSM rate (from 21.3% of all mastectomies in 2009 to 67.3% in 2018) and a decrease of total mastectomies (from 78.7% of all mastectomies in 2009 to 32.7% in 2018). In line with the literature data, our data confirm that in the recent years NSM represents the gold standard for radical breast surgery. Undisputed in prophylaxis, NSM is continuously acquiring more support in being used as first line treatment for locally advanced disease.
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Affiliation(s)
- Erika Barbieri
- Breast Surgery Department, Humanitas Research Hospital and Cancer Center, Rozzano, Milan, Italy
| | - Federico Frusone
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy.
| | - Alberto Bottini
- Breast Surgery Department, Humanitas Research Hospital and Cancer Center, Rozzano, Milan, Italy
| | - Andrea Sagona
- Breast Surgery Department, Humanitas Research Hospital and Cancer Center, Rozzano, Milan, Italy
| | - Wolfgang Gatzemeier
- Breast Surgery Department, Humanitas Research Hospital and Cancer Center, Rozzano, Milan, Italy
| | - Giuseppe Canavese
- Breast Surgery Department, Humanitas Research Hospital and Cancer Center, Rozzano, Milan, Italy
| | | | - Alessandro De Luca
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Emilia Marrazzo
- Breast Surgery Department, Humanitas Research Hospital and Cancer Center, Rozzano, Milan, Italy
| | - Maria Ida Amabile
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Corrado Tinterri
- Breast Surgery Department, Humanitas Research Hospital and Cancer Center, Rozzano, Milan, Italy
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23
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Valero MG, Moo TA, Muhsen S, Zabor EC, Stempel M, Pusic A, Gemignani ML, Morrow M, Sacchini V. Use of bilateral prophylactic nipple-sparing mastectomy in patients with high risk of breast cancer. Br J Surg 2020; 107:1307-1312. [PMID: 32432359 DOI: 10.1002/bjs.11616] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/02/2019] [Accepted: 03/14/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) is being performed increasingly for risk reduction in high-risk groups. There are limited data regarding complications and oncological outcomes in women undergoing bilateral prophylactic NSM. This study reviewed institutional experience with prophylactic NSM, and examined the indications, rates of postoperative complications, incidence of occult malignant disease and subsequent breast cancer diagnosis. METHODS Women who had bilateral prophylactic NSM between 2000 and 2016 were identified from a prospectively maintained database. Rates of postoperative complications, incidental breast cancer, recurrence and overall survival were evaluated. RESULTS A total of 192 women underwent 384 prophylactic NSMs. Indications included BRCA1 or BRCA2 mutations in 117 patients (60·9 per cent), family history of breast cancer in 35 (18·2 per cent), lobular carcinoma in situ in 29 (15·1 per cent) and other reasons in 11 (5·7 per cent). Immediate breast reconstruction was performed in 191 patients. Of 384 NSMs, 116 breasts (30·2 per cent) had some evidence of skin necrosis at follow-up, which resolved spontaneously in most; only 24 breasts (6·3 per cent) required debridement. Overall, there was at least one complication in 129 breasts (33·6 per cent); 3·6 and 1·6 per cent had incidental findings of ductal carcinoma in situ and invasive breast cancer respectively. The nipple-areola complex was preserved entirely in 378 mastectomies. After a median follow-up of 36·8 months, there had been no deaths and no new breast cancer diagnoses. CONCLUSION These findings support the use of prophylactic NSM in high-risk patients. The nipples could be preserved in the majority of patients, postoperative complication rates were low, and, with limited follow-up, there were no new breast cancers.
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Affiliation(s)
- M G Valero
- Breast Service, Department of Surgery, New York, USA
| | - T-A Moo
- Breast Service, Department of Surgery, New York, USA
| | - S Muhsen
- Breast Service, Department of Surgery, New York, USA
| | - E C Zabor
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - M Stempel
- Breast Service, Department of Surgery, New York, USA
| | - A Pusic
- Division of Plastic Surgery, Brigham and Women's Hospital at Harvard Medical School, Boston, Massachusetts, USA
| | - M L Gemignani
- Breast Service, Department of Surgery, New York, USA
| | - M Morrow
- Breast Service, Department of Surgery, New York, USA
| | - V Sacchini
- Breast Service, Department of Surgery, New York, USA
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24
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Houvenaeghel G, Cohen M, Ribeiro SR, Barrou J, Heinemann M, Frayret C, Lambaudie E, Bannier M. Robotic Nipple-Sparing Mastectomy and Immediate Breast Reconstruction With Robotic Latissimus Dorsi Flap Harvest: Technique and Results. Surg Innov 2020; 27:481-491. [PMID: 32418492 DOI: 10.1177/1553350620917916] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction. Only few cases of robotic latissimus dorsi flap reconstruction (RLDFR) have been reported in indication of reconstruction for breast cancer (BC). We report our experience of combined robotic nipple-sparing mastectomy (R-NSM) and RLDFR, and analyze technique, indications, and reproducibility. Methods. All patients with R-NSM and RLDFR from November 2016 to August 2, 2018, were analyzed, and technics have been described. Complication rate with Clavien-Dindo grading and postoperative hospitalization length (days) are reported. Results. Thirty-five R-NSM with RLDFR were performed in 22 cases for primitive BC and 13 for local recurrence. In 12 patients, another surgical procedure was performed during the same time (axillary lymph node dissection or contralateral breast surgery). R-NSM was realized through a short axillar incision, with inside-only installation for 12 patients (34.3%): 18 nonautologous and 17 autologous RLDFR associated with implant in 9 patients. In logistic regression, mastectomy weight >330 g was significantly associated with the use of implant (odds ratio [OR] = 17, P = .015), and significant factor of the time of anesthesia ≥380 minutes was 2 installations (OR = 10.4, P = .049). The median duration of hospitalization stay was 4 days. Complications rates were 51.4% (18/35; 9 grade-1, 2 grade-2, and 7 grade-3). In logistic regression, associated other surgical procedure was predictive of grade-3 complications (OR = 6.87, P = .053). Conclusion. We confirmed the reproducibility and safety of R-NSM and RLDFR with a decreased complication rate. NSM was performed in 42.8% of our patients after previous radiotherapy. We observed an increase of grade-3 complications when R-NSM and RLDFR was combined to another surgical procedure.
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Affiliation(s)
- Gilles Houvenaeghel
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Monique Cohen
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Sandrine Rua Ribeiro
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Julien Barrou
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Mellie Heinemann
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Christine Frayret
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Eric Lambaudie
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Marie Bannier
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
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25
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Seki H, Sakurai T, Maeda Y, Oki N, Aoyama M, Yamaguchi R, Shimizu K. Utility of the periareolar incision technique for breast reconstructive surgery in patients with breast cancer. Surg Today 2020; 50:1008-1015. [PMID: 32052184 DOI: 10.1007/s00595-020-01975-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/24/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Periareolar incisions for nipple-sparing mastectomy offer the advantages of smaller inconspicuous wounds and easier resection below the nipple-areolar complex. However, they provide a narrow surgical field, which complicates the procedure and carries a risk of nipple necrosis. This study evaluated the clinical outcomes and safety of periareolar incisions for breast reconstructive surgery in patients with breast cancer. METHODS The study included 181 patients with primary operable breast cancer who underwent nipple-sparing mastectomy for reconstructive breast procedures without intraoperative nipple-areolar complex resection. The clinical outcomes and complications were retrospectively evaluated. The recurrence-free survival was compared using Kaplan-Meier curves. RESULTS Nipple-sparing mastectomy was performed via inframammary fold and periareolar incisions in 31 and 150 patients, respectively. There were no significant differences in clinical outcomes related to surgery, frequency of complications, nipple necrosis (inframammary fold incision vs. periareolar incision: 0% vs. 3.3%, P = 0.590), or the recurrence-free survival (P = 0.860) between the 2 groups. CONCLUSION Our results showed that the clinical outcomes and complication rates of periareolar incisions for breast reconstruction were equivalent to those of inframammary fold incisions, suggesting that the periareolar incision technique for breast reconstructive surgery may safely improve cosmetic outcomes if done with adequate care.
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Affiliation(s)
- Hirohito Seki
- Division of Surgery, Saitama Medical Center, 4-9-3 Kitaurawa, Urawa-ku, Saitama city, Saitama, 330-0074, Japan.
| | - Takashi Sakurai
- Division of Surgery, Saitama Medical Center, 4-9-3 Kitaurawa, Urawa-ku, Saitama city, Saitama, 330-0074, Japan
| | - Yuka Maeda
- Division of Surgery, Saitama Medical Center, 4-9-3 Kitaurawa, Urawa-ku, Saitama city, Saitama, 330-0074, Japan
| | - Naohiko Oki
- Division of Surgery, Saitama Medical Center, 4-9-3 Kitaurawa, Urawa-ku, Saitama city, Saitama, 330-0074, Japan
| | - Mina Aoyama
- Division of Surgery, Saitama Medical Center, 4-9-3 Kitaurawa, Urawa-ku, Saitama city, Saitama, 330-0074, Japan
| | - Ryo Yamaguchi
- Division of Surgery, Saitama Medical Center, 4-9-3 Kitaurawa, Urawa-ku, Saitama city, Saitama, 330-0074, Japan
| | - Ken Shimizu
- Division of Pathology, Saitama Medical Center, Saitama, 330-0074, Japan
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Montero A, Ciérvide R, García-Aranda M, Rubio C. Postmastectomy radiation therapy in early breast cancer: Utility or futility? Crit Rev Oncol Hematol 2020; 147:102887. [PMID: 32018127 DOI: 10.1016/j.critrevonc.2020.102887] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/08/2020] [Accepted: 01/27/2020] [Indexed: 01/31/2023] Open
Abstract
Postmastectomy radiation therapy (PMRT) has been shown to reduce the risk of locoregional recurrence (LRR), in patients with locally advanced breast cancer who are considered of high-risk because of large tumors (>5 cm) or presence of axillary lymph-node involvement, as well as to reduce breast cancer mortality. However, controversy still remains with respect to indication of PMRT in case of early-stages invasive tumors. This review aims to analyze the impact that PMRT has on final results in women with breast tumors in different scenarios that would otherwise be considered as early breast cancer, such as extensive DCIS, tumors without axillary lymph-node involvement or with minimal microscopic nodal-involvement. The existence of risk factors including young age, premenopausal status, and presence of lymphovascular invasion (LVI), high grade or tumor size >2 cm has been associated with an increased risk of LRR in these patients at early-stages and advises to consider PMRT in selected cases.
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Affiliation(s)
- Angel Montero
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, Centro Integral Oncológico Clara Campal (CIOCC), Madrid, Spain; Breast Cancer Unit, Hospital Universitario HM Sanchinarro, Madrid, Spain.
| | - Raquel Ciérvide
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, Centro Integral Oncológico Clara Campal (CIOCC), Madrid, Spain; Breast Cancer Unit, Hospital Universitario HM Sanchinarro, Madrid, Spain
| | - Mariola García-Aranda
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, Centro Integral Oncológico Clara Campal (CIOCC), Madrid, Spain; Breast Cancer Unit, Hospital Universitario HM Sanchinarro, Madrid, Spain
| | - Carmen Rubio
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, Centro Integral Oncológico Clara Campal (CIOCC), Madrid, Spain; Breast Cancer Unit, Hospital Universitario HM Sanchinarro, Madrid, Spain
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27
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Tondu T, Hubens G, Tjalma WA, Thiessen FE, Vrints I, Van Thielen J, Verhoeven V. Breast reconstruction after nipple-sparing mastectomy in the large and/or ptotic breast: A systematic review of indications, techniques, and outcomes. J Plast Reconstr Aesthet Surg 2020; 73:469-485. [PMID: 31987776 DOI: 10.1016/j.bjps.2019.11.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 11/22/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Surgeons remain reluctant to perform nipple-sparing mastectomy (NSM) in large breasts due to a higher risk of necrosis. We performed a systematic review of the literature to evaluate indications, techniques, and outcomes in immediate or delayed breast reconstructions in large and/or ptotic breasts. METHODS The following search terms were used for both titles and key words: [NSM AND ("breast ptosis" OR "ptotic breast" OR "large breast" OR "breast hypertrophy" OR "gigantomastia")]. All forms of breast reconstruction in large and/or ptotic breasts from 1990 through September 1st 2018 reporting indications, techniques, and outcomes were included. RESULTS Thirty-one studies met the inclusion criteria, yielding 1128 NSMs (709 immediate and 419 delayed) in 629 patients for analysis. The overall complication rate was 29.08%. The mastectomy flap necrosis rate was 12%, the partial nipple-areola complex (NAC) necrosis 11%, and the complete NAC rate 11%. The overall complication rate in one-stage versus delayed reconstructions was 37.52% versus 14.8%. The incidence of necrosis in one-stage versus delayed reconstructions was 5.36% versus 2.15% for partial, 5.08% versus 0.48% for complete NAC necrosis, and 4.8% versus 1.43% for skin flap necrosis. CONCLUSIONS The majority of studies being small and retrospective as well as the large variation in outcomes indicates that we lack consensus on the timing of reconstruction or ideal technique. A noticeable difference in skin flap and NAC necrosis, however, is seen in the favor of NAC-delayed procedures. Randomized controlled trials are mandatory to prove this difference significantly.
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Affiliation(s)
- Thierry Tondu
- Department of Abdominal, Pediatric and Reconstructive Surgery, Plastic Surgery Unit, Antwerp University Hospital, Antwerp, Belgium; Multidisciplinary Breast Clinic, Unit of Gynecologic Oncology, Antwerp University Hospital, Antwerp, Belgium; Clinic 12B, Plastic Surgery Private Clinic, Antwerp, Belgium.
| | - Guy Hubens
- Department of Abdominal, Pediatric and Reconstructive Surgery, Plastic Surgery Unit, Antwerp University Hospital, Antwerp, Belgium
| | - Wiebren Aa Tjalma
- Clinic 12B, Plastic Surgery Private Clinic, Antwerp, Belgium; Department of Obstetrics and Gynecology, Antwerp University Hospital, Antwerp, Belgium
| | - Filip Ef Thiessen
- Department of Abdominal, Pediatric and Reconstructive Surgery, Plastic Surgery Unit, Antwerp University Hospital, Antwerp, Belgium; Multidisciplinary Breast Clinic, Unit of Gynecologic Oncology, Antwerp University Hospital, Antwerp, Belgium; Clinic 12B, Plastic Surgery Private Clinic, Antwerp, Belgium
| | - Ina Vrints
- Department of Abdominal, Pediatric and Reconstructive Surgery, Plastic Surgery Unit, Antwerp University Hospital, Antwerp, Belgium; Multidisciplinary Breast Clinic, Unit of Gynecologic Oncology, Antwerp University Hospital, Antwerp, Belgium; Clinic 12B, Plastic Surgery Private Clinic, Antwerp, Belgium
| | | | - Veronique Verhoeven
- Department of Primary and Interdisciplinary Care (ELIZA), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Ishibashi N, Nishimaki H, Maebayashi T, Adachi K, Sakurai K, Masuda S, Hata M, Okada M. Partial chest wall radiation therapy for positive or close surgical margins after modified radical mastectomy for breast cancer without lymph node metastasis. Asia Pac J Clin Oncol 2019; 16:28-33. [PMID: 31691502 PMCID: PMC7003910 DOI: 10.1111/ajco.13276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/04/2019] [Indexed: 11/28/2022]
Abstract
Aim Whole‐breast radiation therapy after breast‐conserving surgery can control local recurrence with a long‐term survival rate equivalent to that of radical mastectomy for patients with early breast cancer. However, the significance of radiation therapy for patients with positive/close margins after mastectomy remains controversial. Following radical mastectomy, no residual breast parenchyma remains, and thus radiation therapy of the entire chest wall may represent overtreatment in the patients, especially those without lymph node metastasis (N0). We therefore implemented partial chest wall radiation therapy for patients with N0 breast cancer and positive and/or close margins after mastectomy. Methods A total of 22 patients with N0 status but positive/close margins underwent partial chest wall radiation therapy to irradiate the predetermined clinical target volume, which had margins of at least 2 cm medial, lateral, superior, and inferior to the primary tumor bed. With reference to chest wall thickness, 4‐10‐MV photons or 5‐8‐MeV electrons with/without a bolus were delivered. The total dose was 50‐66 Gy. We compared the results with those from 18 nonradiation therapy patients using Pearson's χ2 test. Results All patients in the partial chest wall radiation therapy group achieved good local control despite having a significantly higher proportion of positive margins (77.3%) compared with the nonradiation therapy group (27.8%) (P = 0.002). Both groups showed 100% recurrence‐ and disease‐free survival. Conclusion Partial chest wall radiation therapy may offer recurrence‐ and disease‐free survival without local recurrence in N0 mastectomy patients with positive/close surgical margins.
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Affiliation(s)
- Naoya Ishibashi
- Department of Radiology, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Haruna Nishimaki
- Department of Pathology, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Toshiya Maebayashi
- Department of Radiology, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Keita Adachi
- Division of Breast and Endocrine Surgery, Department of Surgery, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Kenichi Sakurai
- Division of Breast and Endocrine Surgery, Department of Surgery, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Shinobu Masuda
- Department of Pathology, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Masaharu Hata
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Kanazawa-ku, Yokohama-shi, Kanagawa, Japan
| | - Masahiro Okada
- Department of Radiology, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
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29
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A novel nipple–areola complex involvement predictive index for indicating nipple-sparing mastectomy in breast cancer patients. Breast Cancer 2019; 26:808-816. [DOI: 10.1007/s12282-019-00987-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/02/2019] [Indexed: 10/26/2022]
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30
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Shaffer K, Danko M, DeLaere A, Chant E, Pople B, Grisby S, Dekhne N. Patient satisfaction following nipple-sparing mastectomy and assessment of nipple-areolar sensation. Breast J 2019; 25:542-544. [PMID: 31001911 DOI: 10.1111/tbj.13274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/16/2018] [Accepted: 09/18/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Kristina Shaffer
- Comprehensive Breast Care Center, Beaumont Health, Royal Oak, Michigan
| | - Melissa Danko
- Comprehensive Breast Care Center, Beaumont Health, Royal Oak, Michigan
| | - Angela DeLaere
- Comprehensive Breast Care Center, Beaumont Health, Royal Oak, Michigan
| | - Ericka Chant
- Comprehensive Breast Care Center, Beaumont Health, Royal Oak, Michigan
| | - Blerina Pople
- Comprehensive Breast Care Center, Beaumont Health, Royal Oak, Michigan
| | - Shaunda Grisby
- Comprehensive Breast Care Center, Beaumont Health, Royal Oak, Michigan
| | - Nayana Dekhne
- Comprehensive Breast Care Center, Beaumont Health, Royal Oak, Michigan
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Kim H, Park SJ, Woo KJ, Bang SI. Comparative Study of Nipple-Areola Complex Position and Patient Satisfaction After Unilateral Mastectomy and Immediate Expander-Implant Reconstruction Nipple-Sparing Mastectomy Versus Skin-Sparing Mastectomy. Aesthetic Plast Surg 2019; 43:313-327. [PMID: 30746565 DOI: 10.1007/s00266-018-1217-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 08/16/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Major surgical concerns associated with nipple-sparing mastectomy (NSM) are partial or total nipple-areola complex (NAC) loss, decreased sensation, and nipple malposition. Patient satisfaction and NAC outcomes including malposition in patients who have undergone unilateral expander-implant reconstruction after NSM as compared with skin-sparing mastectomy (SSM) remain unclear. Therefore, the aim of this study was to assess patient satisfaction and NAC outcomes of breast cancer patients who underwent spared or reconstructed NAC after unilateral NSM as compared with unilateral SSM. METHODS Patients who underwent immediate expander-implant breast reconstruction following unilateral NSM or SSM were included. Medical records of patients from April 2010 to February 2014 were retrospectively reviewed. Reconstruction-related complications such as infection, seroma, haematoma, delayed wound healing, and reconstruction failure were recorded. NAC outcome analysis was performed using preoperative and postoperative digital photographs for each patient. Patient satisfaction with the reconstructed breast and NAC was assessed using a study-specific questionnaire. RESULTS Delayed wound healing occurred in 18 of 55 NSM patients and 15 of 85 SSM patients (p = 0.040). Final reconstruction failure occurred in 0 NSM patients and 6 SSM patients (p = 0.043). The mean photography analysis score of total aesthetic outcome was 13.12 ± 2.39 in the NSM group and 14.06 ± 2.75 in the SSM group (p = 0.052). The mean questionnaire score of NAC position was 2.88 ± 0.85 in the NSM group and 3.80 ± 0.84 in the SSM group (p = 0.001). The mean questionnaire score of NAC sensitivity was 2.12 ± 0.58 in the NSM group and 1.84 ± 0.46 in the SSM group (p = 0.003). Satisfaction with the reconstructed breast was similar (p = 0.913) after NSM and SSM. CONCLUSIONS We observed no significant difference in breast reconstruction satisfaction between the NSM and SSM groups. Although overall satisfaction with breast reconstruction is high, patients in the NSM group often report dissatisfaction with nipple position. With a favourable score for NAC position, skin-sparing mastectomy followed by NAC reconstruction can be considered as a balanced alternative to NSM for properly selected patients with breast cancer. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Hyungsuk Kim
- Department of Plastic Surgery, Choonhae Hospital, Busan, South Korea
| | - Sun-June Park
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Kyong-Je Woo
- Department of Plastic Surgery, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Sa Ik Bang
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
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Oncologic outcomes and radiation safety of nipple-sparing mastectomy with intraoperative radiotherapy for breast cancer. Breast Cancer 2019; 26:618-627. [PMID: 30888580 DOI: 10.1007/s12282-019-00962-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 03/11/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy combined with breast reconstruction helps to optimize the contour of the breast after mastectomy. However, the indications for nipple-sparing mastectomy are still controversial. Local radiation to the nipple-areola complex may play some roles in improving the oncological safety of this procedure. METHODS From January 2014 to December 2017, 41 consecutive patients who underwent nipple-sparing mastectomy combined with Intrabeam intraoperative radiotherapy to the nipple-areola complex flap and breast reconstruction were enrolled in this prospective study. The prescribed radiation dose at the surface of the spherical applicator was 16 Gy. RESULTS In eight cases, carcinomas were in the central portion of the breast. Partial necrosis of the nipple-areola complex occurred in three cases. Over 90% of patients reported "no or poor sensation" of the nipple-areola complex postoperatively. With a median follow-up time of 26 months, no recurrences or metastases were identified; however, breast-cancer mortality occurred in one patient. Pathologic evaluation of paraffin-embedded sections showed ductal carcinoma in situ in the remaining tissues deep to the nipple-areola complex flap in two patients. Although no further treatment was administered to the nipple-areola complexes postoperatively, no recurrences or metastases were identified 20 months and 24 months later, respectively. Optical microscopy and transmission electron microscopy revealed changes in some normal tissues immediately after Intrabeam intraoperative radiotherapy. Karyopyknosis were observed in gland tissues, and the collagenous fibers became sparse and arranged chaotically. As assessed by thermoluminescence, radiation doses at different sites in the nipple-areola complex flap varied considerably and were about 10 Gy at the areola surface. No Intrabeam intraoperative radiotherapy-related acute or chronic radiation injuries of the lung, heart or bone marrow were identified. CONCLUSIONS Our findings indicate that Intrabeam intraoperative radiotherapy during nipple-sparing mastectomy combined with breast reconstruction is safe and feasible. TRIAL REGISTRATION The current study was approved by the Ethics Committee of the First Affiliated Hospital of Guangzhou Medical University (registering order 201750). All participants gave their written informed consent.
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Houvenaeghel G, Bannier M, Rua S, Barrou J, Heinemann M, Van Troy A, Lambaudie E, Cohen M. Breast cancer robotic nipple sparing mastectomy: evaluation of several surgical procedures and learning curve. World J Surg Oncol 2019; 17:27. [PMID: 30728011 PMCID: PMC6366058 DOI: 10.1186/s12957-019-1567-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/17/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Few studies of robotic nipple sparing mastectomy (NSM) were reported. We report feasibility of robotic NSM and determine standard surgical procedure and learning curve threefold. METHODS A cohort of patients with robotic NSM for breast cancer was analyzed. Complications and post-operative hospitalization stay were reported. The same technic was used for all patients except for skin and nipple areolar complex (NAC) dissection. Differences between three surgical procedures of NAC dissection were analyzed: group 1, dissection with robotic scissors using coagulation; group 2, dissection with robotic scissors without coagulation; and group 3, dissection with non-robotic scissors and then robotic dissection. We explored possible effect of learning curve among patients from group 1 with the same surgical procedure. RESULTS Twenty-seven NSM with immediate breast reconstruction for breast cancers, 22 invasive and 5 in situ, were performed, with robotic latissimus dorsi-flap (RLDF) only in 17 cases, RLDF and breast implant in 6 cases, and implant alone in 4 cases. Repartition according to 3 surgical procedure groups was 16, 5, and 6 patients. Mean time of surgery and anesthesia decrease according to groups 1 to 3. Among 16 patients from group 1, time of surgery and anesthesia decreased with learning curve. Post-operative hospitalization decreased from group 1 to 3. We reported a total of 11 complications, with significant difference between groups (10 for group 1). Skin complications were higher for group 1 in comparison with groups 2-3 (p = 0.02). CONCLUSION Robotic NSM can be performed with a brief learning. Standardized technique is proposed with non-robotic scissors superficial dissection and then dissection with robot.
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Affiliation(s)
- G Houvenaeghel
- Department of Surgical Oncology, Institut Paoli Calmettes and CRCM and Aix-Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France.
| | - M Bannier
- Department of Surgical Oncology, Institut Paoli Calmettes and CRCM and Aix-Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France
| | - S Rua
- Department of Surgical Oncology, Institut Paoli Calmettes and CRCM and Aix-Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France
| | - J Barrou
- Department of Surgical Oncology, Institut Paoli Calmettes and CRCM and Aix-Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France
| | - M Heinemann
- Department of Surgical Oncology, Institut Paoli Calmettes and CRCM and Aix-Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France
| | - A Van Troy
- Department of Surgical Oncology, Institut Paoli Calmettes and CRCM and Aix-Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France
| | - E Lambaudie
- Department of Surgical Oncology, Institut Paoli Calmettes and CRCM and Aix-Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France
| | - M Cohen
- Department of Surgical Oncology, Institut Paoli Calmettes and CRCM and Aix-Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France
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de Barros ACSD, Carvalho HA, Andrade FEM, Nimir CDCBA, Sampaio MMC, Makdissi FB, Mano MS. Mammary adenectomy followed by immediate reconstruction for treatment of patients with early-infiltrating breast carcinoma: a cohort study. SAO PAULO MED J 2019; 137:336-342. [PMID: 31691766 PMCID: PMC9744021 DOI: 10.1590/1516-3180.2018.0356220719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 07/22/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Use of mammary adenectomy for breast carcinoma treatment remains controversial. OBJECTIVE This study aimed to verify the oncological safety of mammary adenectomy and immediate breast reconstruction for treating selected patients with infiltrating breast carcinoma and to evaluate patients' satisfaction with the reconstructed breasts. DESIGN AND SETTING Cohort study conducted among patients treated at Hospital Sírio-Libanês, São Paulo, Brazil. METHODS This study was based on 152 selected patients (161 operated breasts) with infiltrating breast carcinoma who underwent mammary adenectomy and immediate breast reconstruction. In all patients, the diameter of the largest focus of the tumor was less than 3.0 cm, the imaging tumor-nipple distance was greater than 2.0 cm and the pathological assessment showed clear margins. The cumulative incidence of local recurrence (LR), recurrence-free survival (RFS) and overall survival (OS) curves were estimated using the Kaplan-Meier method. After at least one year of follow-up, 64 patients were asked about their satisfaction with the reconstructed breast(s). RESULTS At a mean follow-up time of 43.5 months, seven cases of LR (4.4%), four distant metastases (2.6%) and five deaths (3.3%) were recorded. The five-year actuarial LR-free survival, RFS and OS were 97.6%, 98.3% and 98.3%, respectively. No cases of nipple-areolar complex recurrence were reported. Forty-one patients (64%) indicated a high level of satisfaction with the reconstructed breasts. CONCLUSIONS Mammary adenectomy is a safe and efficacious procedure for selected patients with early-infiltrating breast carcinoma and results in a high rate of patient satisfaction with the reconstructed breasts.
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Affiliation(s)
| | | | | | | | | | | | - Max Senna Mano
- MD, PhD. Oncologist, Hospital Sírio-Libanês, São Paulo (SP), Brazil.
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Nipple-sparing Mastectomy and Immediate Breast Reconstruction After Recurrence From Previous Breast Conservation Therapy. Ann Plast Surg 2019; 82:S95-S102. [DOI: 10.1097/sap.0000000000001696] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Karanlik H, Igci A. Surgical Approach in Invasive Breast Cancer. Breast Cancer 2019. [DOI: 10.1007/978-3-319-96947-3_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Corso G, De Lorenzi F, Vicini E, Pagani G, Veronesi P, Sargenti M, Magnoni F, Naninato P, Maisonneuve P, Sangalli C, Rietjens M, Galimberti V. Nipple-sparing mastectomy with different approaches: surgical incisions, complications, and cosmetic results. Preliminary results of 100 consecutive patients at a single center. J Plast Reconstr Aesthet Surg 2018; 71:1751-1760. [DOI: 10.1016/j.bjps.2018.07.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 06/04/2018] [Accepted: 07/28/2018] [Indexed: 12/29/2022]
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D'Alonzo M, Pecchio S, Campisi P, De Rosa G, Bounous VE, Villasco A, Balocco P, Biglia N. Nipple-Sparing Mastectomy: Reliability of sub-areolar sampling and frozen section in predicting occult nipple involvement in breast cancer patients. Eur J Surg Oncol 2018; 44:1736-1742. [DOI: 10.1016/j.ejso.2018.07.059] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/16/2018] [Accepted: 07/25/2018] [Indexed: 11/28/2022] Open
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Cavalcante FP, Lima MVA. Nipple-sparing mastectomy with periareolar incision and two-stage reconstruction: Initial analysis of 31 cases. Breast J 2018; 24:940-943. [PMID: 30216598 DOI: 10.1111/tbj.13114] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 10/31/2017] [Accepted: 11/07/2017] [Indexed: 11/29/2022]
Abstract
Surgical treatment of breast cancer has changed considerably over the past four decades, culminating in the substitution of conservative approaches for Halsted's paradigm from 1894. In parallel, many breast reconstruction techniques have been proposed for patients requiring mastectomy with loss of the nipple-areola complex (NAC). Myocutaneous flaps were once the most common form of reconstruction, but recently the use of implants and nipple-sparing mastectomy (NSM) in one or two stages has gained popularity. In this descriptive and cross-sectional study, we evaluated a sample of 31 NSM procedures with periareolar incision and two-stage reconstruction (tissue expander followed by implant) conducted between 2013 and 2017, with emphasis on the rate of complications after at least 3 months of follow-up, local disease control and cosmesis measured on the Harvard scale. Five complications (16%) were observed, all of which related to the first stage: seroma (n = 1; 3.2%), treated with needle aspiration, NAC necrosis (n = 3; 9.6%), one case of which required debridement, and dehiscence (n = 1; 3.2%), treated with resuture. Cosmesis was classified as excellent by the surgeon in 96.8% (n = 27). At the time of writing, no local recurrence had been observed. In conclusion, NSM with periareolar incision and two-stage reconstruction was found to be technically feasible and associated with few complications and satisfactory esthetic outcomes.
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Affiliation(s)
- Francisco Pimentel Cavalcante
- Residency in Mastology, Ceará Cancer Institute (ICC), General Hospital of Fortaleza (HGF), Commission of Examination of Specialists in Mastology (TEMA), Fortaleza, Ceará, Brazil
| | - Marcos Venício Alves Lima
- Mastologist of Ceará Cancer Institute (ICC), Professor of Medical School of Ceará State University (UECE), Fortaleza, Ceará, Brazil
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Giannotti DG, Hanna SA, Cerri GG, Barbosa Bevilacqua JL. Analysis of Skin Flap Thickness and Residual Breast Tissue After Mastectomy. Int J Radiat Oncol Biol Phys 2018; 102:82-91. [DOI: 10.1016/j.ijrobp.2018.05.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 05/01/2018] [Accepted: 05/08/2018] [Indexed: 10/16/2022]
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Affiliation(s)
- Barbara L Smith
- Division of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Suzanne B Coopey
- Division of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Mariscotti G, Durando M, Houssami N, Berzovini C, Esposito F, Fasciano M, Campanino P, Bosco D, Bussone R, Ala A, Castellano I, Sapino A, Bergamasco L, Fonio P, Gandini G. Preoperative MRI evaluation of lesion–nipple distance in breast cancer patients: thresholds for predicting occult nipple–areola complex involvement. Clin Radiol 2018; 73:735-743. [DOI: 10.1016/j.crad.2018.03.008] [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: 03/14/2018] [Indexed: 10/17/2022]
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Nipple-Areola Complex Sensation after Nipple-sparing Mastectomy. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1716. [PMID: 29876167 PMCID: PMC5977969 DOI: 10.1097/gox.0000000000001716] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 01/24/2018] [Indexed: 11/26/2022]
Abstract
Background: Nipple-sparing mastectomy (NSM) has been proven to be oncologically safe for treating breast cancer. This procedure had been developed to optimize the esthetic outcome and reduce feeling mutilation after mastectomy. Risks of necrotic complications and diminishing nipple-areola complex (NAC) sensation are common complications affecting the patient’s satisfaction after the surgery. The evaluation of NAC sensation should be also investigated. Methods: We prospectively analyzed 55 NSMs that were performed on 52 patients for both therapeutic and prophylactic indications in Ramathibodi Hospital from May 2007 to September 2015. Patients’ demographics, operative details, oncologic outcome, and postoperative complications, focusing on NAC sensation and necrotic complications, were analyzed. Results: Forty-seven NSMs (87%) were performed for therapeutic indications, and another 7 NSMs (13%) were risk-reducing operations. Of the 43 patients performing NSM for breast cancer treatment, 33 patients (77%) had invasive cancer and 11 patients (23%) had ductal carcinoma in situ. One subareola base tissue was found an occult cancer, and the NAC was then removed. There were 3 locoregional recurrences after a median follow-up time of 24 months (range, 2–104 months). The NAC sensation was evaluated in a total of 35 patients. Twenty-five patients (46%) underwent serial evaluation after 6 months of operation, and 10 patients were evaluated at more than 1 year after operation. In the first 6 months, 11 patients (44%) showed partial sensation recovery, and 3 more patients had partial recovery after 1-year follow-up. Only 1 patient (2%) had complete sensation recovery in all area of the NAC. In late evaluation group, 7 out of 10 patients had partial recovery. Most pain sensation remained in the lower aspect of the areola away from surgical incision. Conclusions: NSM is technically feasible in selected patients with low rates of NAC removal. Some patients can preserve the NAC sensation. Long-term outcome should receive follow-up.
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Ashikari AY, Kelemen PR, Tastan B, Salzberg CA, Ashikari RH. Nipple sparing mastectomy techniques: a literature review and an inframammary technique. Gland Surg 2018; 7:273-287. [PMID: 29998077 DOI: 10.21037/gs.2017.09.02] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Nipple sparing mastectomy (NSM) has quickly become an accepted technique for patients with selected cancers and for risk reducing surgery. Much of its surgical acceptance over the last decade has been based on the low risk of nipple areolar complex (NAC) occurrence in breast cancer patients. Improved patient satisfaction due to improved cosmetic outcomes with reconstruction have also driven its popularity. We reviewed current English journals to determine the NSM techniques which achieve the lowest complications, best outcomes, and best patient satisfaction. We researched studies showing reductions in complications with improved surgical techniques and patient selection which have been implicated in improved results. In the studies reviewed, incision placement, away from the nipple, resulted in the lowest rates of ischemic nipple complications and the best cosmetic outcomes. The effect of other factors such as surgeon experience and thickness of skin flap development were more difficult to prove. Leaving a 2-3 mm rim of tissue around the nipple bundle was shown to help preserve the nipple vascularity. Lower complication rates with improved outcomes and patient satisfaction were reported in the literature in patients with B or smaller cup sizes, non-smokers, and patients with lower body mass index (BMI). Incision placement, away from the nipple, with preservation of a 2-3 mm rim of tissue around the nipple bundle along with careful patient selection were the most significant variables reviewed which helped to lower complications rates of NSM. Coordinated surgical planning with the breast and plastic surgeons to determine the best surgical approach for each individual patient is necessary to obtain the best results. Although short-term oncologic follow-up seems to be acceptable, longer follow-up will still be needed to define the best breast cancer surgical candidates for the nipple sparing approach.
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Affiliation(s)
- Andrew Y Ashikari
- Ashikari Breast Center, St. John's Riverside Health System, Yonkers, NY, USA.,NYP/Hudson Valley Hospital, Cortlandt Manor, NY, USA.,Department of Surgery, New York Medical College, Valhalla, NY, USA
| | - Pond R Kelemen
- Ashikari Breast Center, St. John's Riverside Health System, Yonkers, NY, USA.,NYP/Hudson Valley Hospital, Cortlandt Manor, NY, USA.,Department of Surgery, New York Medical College, Valhalla, NY, USA
| | - Bahar Tastan
- Ashikari Breast Center, St. John's Riverside Health System, Yonkers, NY, USA.,NYP/Hudson Valley Hospital, Cortlandt Manor, NY, USA
| | - C Andrew Salzberg
- Department of Plastic Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, NY, USA
| | - Roy H Ashikari
- Ashikari Breast Center, St. John's Riverside Health System, Yonkers, NY, USA.,NYP/Hudson Valley Hospital, Cortlandt Manor, NY, USA.,Department of Surgery, New York Medical College, Valhalla, NY, USA
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de Vita R, Buccheri EM. Nipple sparing mastectomy and direct to implant breast reconstruction, validation of the safe procedure through the use of laser assisted indocyanine green fluorescent angiography. Gland Surg 2018; 7:258-266. [PMID: 29998075 DOI: 10.21037/gs.2018.04.03] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Nipple sparing mastectomy (NSM) is a psychologically effective and oncological safe procedure followed by immediate breast reconstruction. Methods Between January 2015 and September 2015 the authors conducted a retrospective review of 40 patients divided into two groups depending on breast volume and weight of mastectomy: group A, 20 patients with small breast; group B, 20 patients with medium breast for nipple sparing mastectomy and direct to implant (DTI) breast reconstruction using strict patient selection and a standardized surgical technique. The nipple areola complex/flap viability were analysed intraoperatively through the use of laser assisted indocyanine green (ICG) fluorescent angiography. Results A total of 44 procedures were followed-up for 24 months. Nineteen patients were assisted in DTI breast reconstruction by acellular dermal matrix (ADM) for inferior/lateral part of the implant coverage. Encouraging results are presented with a unique case of implant failure. Conclusions We report our retrospective experience corroborated by intraoperative laser assisted ICG fluorescent angiography to demonstrate the safety and reliability of the oncoplastic procedure proposed. We also advocate the central role of oncoplastic surgeon as "one man band" to manage breast cancer from the oncological procedure to the breast reconstruction.
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Affiliation(s)
- Roy de Vita
- Department of Plastic Surgery, Regina Elena Cancer Institute of Rome, Rome, Italy
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Jadeja P, Ha R, Rohde C, Ascherman J, Grant R, Chin C, Connolly E, Kalinsky K, Feldman S, Taback B. Expanding the Criteria for Nipple-Sparing Mastectomy in Patients With Poor Prognostic Features. Clin Breast Cancer 2018; 18:229-233. [DOI: 10.1016/j.clbc.2017.08.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 08/17/2017] [Indexed: 12/21/2022]
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Mitchell SD, Willey SC, Beitsch P, Feldman S. Evidence based outcomes of the American Society of Breast Surgeons Nipple Sparing Mastectomy Registry. Gland Surg 2018; 7:247-257. [PMID: 29998074 DOI: 10.21037/gs.2017.09.10] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background The American Society of Breast Surgeons (ASBrS) Nipple Sparing Mastectomy Registry (NSMR) is a prospective, non-randomized, IRB approved, multi-institutional registry. The purpose of this Registry is to provide a large, prospective, non-randomized database of patient characteristics, tumor characteristics, surgical technique, and outcome (both aesthetic and oncologic) of the nipple sparing mastectomy (NSM). Methods Data is entered into the ASBrS NSMR, housed within the Mastery of Surgery Program, after patients consent to participation. Each investigator routinely offers NSM in their practice has obtained IRB approval and completed forms of agreement to participate in the ASBrS NSMR. Results This data set represents a total of 1,935 NSMs performed on 1,170 patients by 98 investigators from 70 institutions/sites. Of the 1,935 NSMs: 833 were performed for an indication of cancer [594 invasive carcinoma and 239 for ductal carcinoma in situ (DCIS)] and 1,102 were prophylactic. Of the 1,170 total patients, 352 underwent a unilateral and 818 underwent a bilateral NSM. Recurrence at a mean follow-up of 31 months/median follow-up of 27 months, with a range of 9.7 to 58.3 months since surgery was 1.4% with no recurrences at the nipple or nipple areola complex (NAC). Cancer occurrence (0.3%) also did not involve the nipple/NAC. Overall patient satisfaction of excellent/good: 94.9% and overall cosmesis (surgeon rated) of excellent/good was 96.4%. Overall infection rates included flap infection of 4.4%, NAC complication rate of 4.5% (defined as necrosis/other or ischemia/epidermolysis requiring surgery), and a 10% rate of NAC epidermolysis with full recovery. Conclusions NSMs were performed on breasts with a variety of sizes and degrees of ptosis, via multiple incisions, dissection and reconstruction techniques with low complication rates and high patient satisfaction and surgeon rated cosmesis.
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Immediate breast reconstruction following nipple-sparing mastectomy in an Asian population: Aesthetic outcomes and mitigating nipple-areolar complex necrosis. Arch Plast Surg 2018; 45:229-238. [PMID: 29788682 PMCID: PMC5968316 DOI: 10.5999/aps.2017.01067] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 01/29/2018] [Accepted: 02/08/2018] [Indexed: 11/08/2022] Open
Abstract
Background Nipple-sparing mastectomies (NSMs) are increasingly performed to obtain the best aesthetic and psychological outcomes in breast cancer treatment. However, merely preserving the nipple-areolar complex (NAC) does not guarantee a good outcome. Darkly pigmented NACs and a tendency for poor scarring outcomes are particular challenges when treating Asian patients. Herein, we review the reconstructive outcomes following NSM at Singapore General Hospital. Methods All breasts reconstructed following NSM over an 11-year period from 2005 to 2015 were reviewed. Information was collected from the patients’ records on mastectomy indications, operative details, and complications. Patient satisfaction, breast sensation, and aesthetic outcomes were evaluated in 15 patients. Sensation was quantified using the Semmes-Weinstein monofilament test. Results A total of 142 NSMs were performed in 133 patients for breast cancer (n=122, 85.9%) or risk reduction (n=20, 14.1%). Of the procedures, 114 (80.2%) were autologous reconstructions, while 27 (19.0%) were reconstructions with implants. Complications occurred in 28 breasts (19.7%), with the most common complication being NAC necrosis, which occurred in 17 breasts (12.0%). Four breasts (2.8%) had total NAC necrosis. The overall mean patient satisfaction score was 3.0 (good). The sensation scores were significantly diminished in the skin envelope, areola, and nipple of breasts that had undergone NSM compared to non-operated breasts (P<0.05). Half of the subset of 15 patients in whom aesthetic outcomes were evaluated had reduced nipple projection. Conclusions Immediate reconstruction after NSM was performed with a low complication rate in this series, predominantly through autologous reconstruction. Patients should be informed of potential drawbacks, including NAC necrosis, reduced nipple projection, and diminished sensation.
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49
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Bernier J. Postoperative radiotherapy after nipple- or skin-sparing mastectomy: a review of recent institutional and pooled data. Ecancermedicalscience 2018; 12:834. [PMID: 29910831 PMCID: PMC5985754 DOI: 10.3332/ecancer.2018.834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Indexed: 11/13/2022] Open
Abstract
The increasing use of nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM) in the treatment of nonmetastatic breast cancer is justified by considerations linked to their therapeutic index. In selected patients, efficacy results tend to be similar to those observed after radical modified mastectomy and at the same time, subcutaneous mastectomies preserve the patient’s body image. Yet the oncologic safety of the two former surgical approaches is still a matter of debate, also in consideration of the almost complete absence of clinical studies directed to prospective, controlled comparisons between subcutaneous and radical modified mastectomies. In addition, no clear statement—and consequently no consensus—emerges from the rather rare reports addressing the issue of whether or not there exist robust algorithms for guiding decision-making in delivering postoperative radiotherapy after NSM or SSM. The objective of the present review article is to revisit the dataset recently provided by the literature, which might help oncology teams optimise local treatment in this patient population.
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Affiliation(s)
- Jacques Bernier
- Genolier Cancer Center, Clinique de Genolier, Genolier 1272, Switzerland
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50
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Lai HW, Lin SL, Chen ST, Kuok KM, Chen SL, Lin YL, Chen DR, Kuo SJ. Single-Axillary-Incision Endoscopic-Assisted Hybrid Technique for Nipple-Sparing Mastectomy: Technique, Preliminary Results, and Patient-Reported Cosmetic Outcome from Preliminary 50 Procedures. Ann Surg Oncol 2018; 25:1340-1349. [DOI: 10.1245/s10434-018-6383-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Indexed: 11/18/2022]
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