When mastectomy becomes inevitable: The nipple-sparing approach

Trans-axillary single port insufflation technique-assisted endoscopic surgery for breast diseases: Clinic experience, cosmetic outcome and oncologic result

Purpose

With an increasing demand for postoperative cosmetic effects in breast diseases, the single port by trans-axillary incision and air-inflation system, which provided better space and spared the assistant the effort of retraction, is widely used in clinic surgical treatment for multiple breast diseases.

Methods

According to inclusion and exclusion criteria, patients who underwent trans-axillary single-incision surgery at Tianjin Medical University Cancer Hospital between December 2020 and July 2022 were included in the study. We collected and analyzed data on age, fertility history, ultrasound grade, clinical stage, pathological results, oncological prognosis, patient-centered cosmetic outcome, etc.

Results

A total of 115 cases were included, of which 33 patients with benign disease underwent mass resection, 68 patients with malignant tumors underwent mastectomy. 10 patients had a special type of breast lesion. A mastectomy was performed in 4 patients with male mammary gland development. Of the 115 cases, the maximum mass diameter was 3.00 ± 1.644 (0.6–8.5) cm. Blood loss during surgery was 85.77 ± 50.342 (10-200) ml. The surgery took 131.84 ± 59.332 (30-280) minutes to complete. The patient spent a total of 5.05 ± 2.305 (2-18) days in the hospital. And the length of surgical incision in all patients was 3.83 ± 0.884 (3-8) cm. All patients were very satisfied with the appearance of their breasts after dressing. 94.78% of patients were satisfied with the position of the incision.

Conclusion

Through this study, we believe that in benign breast diseases and malignant breast tumors, trans-axillary single port insufflation technique-assisted endoscopic surgery has oncological safety and an aesthetic effect for most people with breast diseases.

Minimal Access (Endoscopic and Robotic) Breast Surgery in the Surgical Treatment of Early Breast Cancer-Trend and Clinical Outcome From a Single-Surgeon Experience Over 10 Years

Objective

Endoscopic assisted breast surgery (EABS) or robotic assisted breast surgery (RABS) performed through minimal axillary and/or peri-areolar incisions has become the representative of minimal access breast surgery (MABS). We report the trend and clinical outcome of MABS for treatment of breast cancer.

Methods

Information on patients who underwent breast cancer operation by the principal investigator during the period of 2011 to 2020 was collected from a single institute for analysis. The clinical outcome, trend, and cost of MABS were analyzed and compared with conventional breast surgery (CBS).

Results

A total of 824 breast cancer patients operated by a single surgeon were enrolled in this study: 254 received CBS and 570 received MABS, namely, 476 EABS and 94 RABS. From 2011 to 2020, the number of MABS performed annually has shown an increasing trend. Compared with CBS, MABS such as breast conserving surgery and nipple sparing mastectomy (NSM) have effectively reduced wound scar length. Since the sequential uprise from conventional NSM (C-NSM), dual-axillary-areolar-incision two dimensional (2D) endoscopic assisted NSM (E-NSM), single-axillary-incision E-NSM, robotic assisted NSM (R-NSM), and single-port 3D E-NSM, the development of minimal access mastectomies increasingly paralleled with NSM. The operation time of various MABS decreased significantly and showed no statistical difference compared with CBS. R-NSM was associated with highest cost, followed by 3D E-NSM, E-NSM, and C-NSM. The positive surgical margin rate and local recurrence rate of MABS and CBS were not statistically different.

Conclusion

MABS showed comparable clinical outcome and preliminary oncologic safety as CBS and has been increasingly performed as the surgical treatment of breast cancer, especially minimal access NSM.

Endoscopy-Assisted Total Mastectomy with and without Immediate Reconstruction: An Extended Follow-Up, Multicenter Study

BACKGROUND

Endoscopy-assisted total mastectomy has been used for surgical intervention of breast cancer patients; however, large cohort studies with long-term follow-up data are lacking.

METHODS

Breast cancer patients who underwent endoscopy-assisted total mastectomy from May of 2009 to March of 2018 were collected prospectively from multiple centers. Clinical outcome, impact of different phases, oncologic results, and patient-reported aesthetic outcomes of endoscopy-assisted total mastectomy were reported.

RESULTS

A total of 436 endoscopy-assisted total mastectomy procedures were performed; 355 (81.4 percent) were nipple-sparing mastectomy, and 81 (18.6 percent) were skin-sparing mastectomy. Three hundred fourteen (75.4 percent) of the procedures were associated with immediate breast reconstruction; 255 were prosthesis based and 59 were associated with autologous flaps. The positive surgical margin rate for endoscopy-assisted total mastectomy was 2.1 percent. In morbidity evaluation, there were 19 cases (5.4 percent) with partial nipple necrosis, two cases (0.6 percent) with total nipple necrosis, and three cases (0.7 percent) with implant loss. Compared with the early phase, surgeons operating on patients in the middle or late phase had significantly decreased operation time and blood loss. With regard to patient-reported cosmetic outcomes, approximately 94.4 percent were satisfied with the aesthetic results. Patients who underwent breast reconstruction with preservation of the nipple had higher satisfaction rates. Over a median follow-up of 54.1 ± 22.4 months, there were 14 cases of locoregional recurrence (3.2 percent), three distant metastases (0.7 percent), and one mortality (0.2 percent).

CONCLUSION

This multicenter study showed that endoscopy-assisted total mastectomy is a reliable surgical intervention for early breast cancer, with high patient satisfaction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Single-Port Three-Dimensional (3D) Videoscope-Assisted Endoscopic Nipple-Sparing Mastectomy in the Management of Breast Cancer: Technique, Clinical Outcomes, Medical Cost, Learning Curve, and Patient-Reported Aesthetic Results from 80 Preliminary Procedures

BACKGROUND

The preliminary results of an innovative surgical technique, which incorporated single-port three-dimensional (3D) videoscope and instruments for endoscopic nipple-sparing mastectomy (E-NSM), were reported.

METHODS

The medical records of patients who underwent single-port 3D E-NSM for breast cancer from August 2018 to September 2020 were analyzed, and the preliminary outcome of this procedure as well as the patient-reported aesthetic results are described in this article.

RESULTS

The study enrolled 70 patients who received 80 procedures of single-port 3D E-NSM. The mean operation time was 158 ± 36 min, and the mean blood loss was 41 ± 26 ml. Three procedures (3.8 %) associated with delayed axillary wound-healing, eight cases of transient nipple ischemia (10 %), three cases of partial nipple ischemia/necrosis (3.7 %), and one case of total nipple-areolar complex (NAC) necrosis (1.3 %) were observed. No patient had margin involvement. Satisfaction rates of approximately 90 % were observed in terms of postoperative scar appearance, location, and length. Most of the patients (87.8 %) reported that they would choose the same operation again if given the chance to do so. The overall cost of a single-port 3D E-NSM was 7522 ± 470 U.S. dollars. According to cumulative sum (CUSUM) plot analysis, about 14 cases were needed for surgeons to familiarize themselves with single-port 3D E-NSM and immediate gel implant reconstruction and to decrease their operation time significantly in the initial learning phase.

CONCLUSION

Single-port 3D E-NSM, a safe, efficient, lower-cost procedure, is associated with a good aesthetic result. It is a promising new technique for breast cancer patients indicated for mastectomy, but long-term oncologic safety follow-up evaluation still is needed.

A novel MRI-based predictive index can identify patients suitable for preservation of the nipple-areola complex in breast reconstructive surgery

INTRODUCTION

Accurately predicting nipple-areola complex (NAC) involvement in breast cancer is necessary for identifying patients who may be candidates for a nipple-sparing mastectomy. Although multiple risk factors are indicated in the guidelines, it is difficult to predict NAC involvement (NAC-i) preoperatively even if these factors are evaluated individually. This study aimed to develop a more accurate and practical preoperative NAC-i prediction model using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

All tumors in 252 patients were evaluated using postcontrast T1-weighted subtraction on MRI.

RESULTS

The receiver operating characteristic curves identified cut-off values for tumor size and tumor-to-nipple distance (TND) as 4 cm and 1.2 cm, respectively. Multivariate analysis demonstrated that TND (p < 0.001), ductal enhancement extending to the nipple (DEEN) (p < 0.001), and nipple enhancement (NE) (p = 0.005) were independent clinical risk factors for pathological NAC-i. A formula was constructed using odds ratios for these three independent preoperative risk factors in multivariate analysis: the MRI-based NAC-i predictive index (mNACPI) = TND × 4 + DEEN × 3 + NE × 1. A total score of ≤4 points was defined as low risk and ≥5 points as high risk. NAC-i rates were 2.4% in the low-risk group and 89.4% in the high-risk group; a significant correlation was observed between the risk group and permanent pathological NAC-i (p < 0.001). Assuming that the NAC was preserved in low-risk patients and resected in high-risk patients, NAC-i was verified using the mNACPI.

CONCLUSION

mNACPI may contribute greatly to the improvement of selecting suitable patients for NAC preservation in breast reconstructive surgery while maintaining oncological safety.

Robotic versus conventional nipple sparing mastectomy and immediate gel implant breast reconstruction in the management of breast cancer- A case control comparison study with analysis of clinical outcome, medical cost, and patient-reported cosmetic results

BACKGROUND

Robotic nipple sparing mastectomy (R-NSM), which uses the da Vinci surgical platform, could perform NSM and immediate breast reconstruction through a small and inconspicuous extra-mammary axillary or lateral chest incision. R-NSM was reported with extremely low nipple areolar complex (NAC) necrosis rate, good cosmetic results, and high patient satisfaction. However, there was little evidence available comparing the effectiveness and safety of R-NSM and conventional NSM (C-NSM) in the management of breast cancer.

METHODS

A case control comparison study was conducted for patients with breast cancer who underwent R-NSM or C-NSM with immediate gel implant breast reconstruction (IGBR) from July 2011 to September 2019 at a single institution to compare the clinical outcomes, patient-reported esthetic results, and medical cost.

RESULTS

According to the study design, 54 procedures of R-NSM were compared with 62 procedures of C-NSM in the surgical management of breast cancer combined with IGBR. Compared with C-NSM, R-NSM was associated with higher overall satisfaction (92% excellent and 8% good versus 75.6% excellent and 24.4% good, P = 0.046), and wound/scar related outcome in patient-reported esthetic results. The NAC ischemia/necrosis risk, overall complication rate, and blood loss were not significantly different between R-NSM and C-NSM groups. However, longer operation time and higher overall medical cost (10,877 ± 796 versus 5,702 ± 661 US Dollars, P<0.01) was observed in R-NSM group.

CONCLUSION

Compared with C-NSM, R-NSM showed comparable clinical outcomes and favorable patients' satisfaction with the esthetic results, but at the price of longer operation time and higher cost.

Utility of the periareolar incision technique for breast reconstructive surgery in patients with breast cancer

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.

Nipple viability after nipple-sparing mastectomy in patients with prior circum-areolar incisions

Nipple-areola-sparing mastectomy (NSM) is becoming more commonplace as it offers a more esthetic breast appearance while still appropriately treating malignancy. However, patients with prior circum-areolar incisions are often considered at risk for nipple viability. The authors present a case series of all patients undergoing NSM at their institution between 2012 and 2016. Eighteen consecutive female nonsmoking patients underwent 32 NSMs. None of the patients had reconstructive failures including those relating to the nipple-areola complex (NAC), such as nipple necrosis. NSM is therefore feasible in cases with prior circum-areolar incisions. These patients can be safely reconstructed with both prosthetic devices and autologous tissue.

Skin-reducing oncoplasty: A new concept and classification in breast cancer surgery

BACKGROUND AND OBJECTIVES

Breast-conserving surgery and skin-sparing mastectomy are nowadays widely accepted as the standard of care in selected patients with early breast cancer. After an accurate review of the literature, it appeared that no ordered list of the numerous techniques described for conservative breast surgery has been established so far. The aim of this study was to develop a simple classification of the different skin incision patterns that may be used in breast surgery.

METHODS

A systematic review of the English literature was conducted using the PubMed database to identify all the articles reporting breast-conserving surgery and skin-sparring mastectomy techniques up to the 31st of December 2016.

RESULTS

Among the 1426 titles identified, 230 were selected for review. Based on the reviewed papers, the skin-reducing oncoplasty incision pattern (SROIP) classification was elaborated.

CONCLUSIONS

Breast cancer surgery should nowadays optimise aesthetic outcomes by improving the final breast shape, volume and scar location. This may be achieved using different procedures that we grouped together under the term skin-reducing oncoplasty (SRO). Depending on the breast cancer location, the SROIP classification helps in the choice of the best technique to be used.

Role of breast magnetic resonance imaging in predicting malignant invasion of the nipple-areolar complex: Potential predictors and reliability between inter-observers

In this study, we assessed the diagnostic accuracy of breast magnetic resonance imaging (MRI) for evaluation of malignant invasion of the nipple-areolar complex (NAC).Patients with primary operable breast cancer who underwent preoperative breast MRI and received surgery during January 2011 to December 2013 were collected. The accuracy and potential factors of MRI in predicting nipple invasion were evaluated by comparing preoperative MRI with postoperative histopathologic findings. The consistency of interobservers' variances across different radiologists was also compared.Totally, 704 patients were enrolled in this study, and 56 (8%) patients have pathologic NAC invasion. Several MRI factors were potential predictors of nipple invasion. Only unilateral nipple enhancement on MRI was the most significant independent predictor of NAC involvement in multivariate analysis. The statistical measures, such as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the accuracy of breast MRI were 71.4%, 81.6%, 25.2%, 97.1%, and 80.8%, respectively, in one investigator and 78.6%, 88.1%, 36.4%, 97.9%, and 87.4%, respectively, in the other investigator.MR images showed acceptable accuracy and impressive NPV, but low PPV in evaluation of malignant NAC invasion preoperatively. MRI finding of unilateral nipple enhancement was the most significant predictor of NAC involvement.

Small refinements in breast reconstruction: a technique for inframammary fold creation

BACKGROUND

In breast reconstructive surgery, the inframammary fold (IMF) is an essential component of breast identity. The lack of the IMF following previous mastectomy requires restoration. We have developed a new IMF reconstruction technique using the posterior sheet (PS) of the expander capsule. This article presents our 10-year experience of performing this original technique during two-stage breast reconstruction.

METHODS

Preoperatively, the midline, lateral, and medial borders (MBs) of the implant pocket and the new IMF line were marked. After extracting the expander, the anterior sheet of the expander capsule was removed with the exception of its lowest 2-cm portion. Two needles were placed at the intersection of the new IMF line with the lateral border (LB) of the implant pocket and its MB. Within the pocket, horizontal dissection of the PS of the capsule was performed from one needle to another, after which the sheet was mobilized downward. The mobilized free border of the PS was pulled upward until the inframammary crease was at the new marked location, and then fixed with non-absorbable interrupted sutures to the underlying tissues. An implant was placed over this layer. The covering tissues were then closed.

RESULTS

A total of 321 patients were included. The median age was 38 years (range, 18-58 years). No serious wound complications were observed. Breast-thoracic angle decreased in 21 patients (6.5%), and the distance from the IMF to the lower border of breast segment III was greater than that of the contralateral breast in 14 patients (4.4%).

CONCLUSION

This technique provides a well-defined IMF without indentations or retraction. The results are stable on long-term follow-up and provide a sharp breast-thoracic angle, which is crucial in creating natural-looking ptosis of the reconstructed breast.

Nipple Reconstruction After Autologous or Expander Breast Reconstruction: A Multimodal and 3-Dimensional Analysis

BACKGROUND

Little is known about the influence of the underlying tissue as donor for nipple-areola complex (NAC) reconstruction. Also, there is a complete lack of knowledge about the fate of nipple volume.

OBJECTIVES

The goal of this retrospective, single-institution study was to analyze a case series after nipple reconstruction using a multimodal evaluation including 3-dimensional (3D) laser scanner analyses.

METHODS

Unilateral mastectomy patients after either expander-based or autologous breast reconstruction using the skate flap were included. NAC caliper measurement of nipple and areola size was performed. 3D laser scanner analysis (Minolta Vivid 900) was used to calculate nipple volume, measurement of nipple, and areolar projection and diameter. Sensitivity was evaluated using the Semmes Weinstein test and patient satisfaction by a visual analog scale (VAS 1-10).

RESULTS

A total of 10 patients were included in the expander group and 12 patients were included in the flap group. After a median follow-up period of 32 months in the expander group and 34 months in the flap group, non-contact 3D laser surface scanning revealed a difference in projection of 55 to 60% compared to the contralateral side. The contraction in all 3 dimensions led to a dramatic difference in nipple volume with 12 ± 8% (flap reconstructions) and 12 ± 7% (expander reconstructions). Sensitivity of the areola showed better values after expander-based reconstruction. Despite the significant discrepancy in nipple volume and projection as well as areolar diameter, overall patient satisfaction was acceptable (VAS 4.1 ± 3.5).

CONCLUSIONS

Volume assessment revealed a massive asymmetry to the intact nipple but not between expander and flap reconstructions. Although asymmetry of the areola and nipple remains, patient satisfaction is acceptable. LEVEL OF EVIDENCE 4.

Nipple-sparing mastectomy using a hemi-periareolar incision with or without minimal medial-lateral extensions; clinical outcome and patient satisfaction: A single centre prospective observational study

BACKGROUND

Nipple-sparing mastectomy (NSM) is becoming a viable oncoplastic option. There is debate regarding the best approach that balances oncological safety with aesthetics. In this study, we describe an approach involving a hemi-periareolar incision and evaluate its safety and outcomes.

METHODS

Patients treated at single center between 2012 and 2015 were observed prospectively. After a histologically negative subareolar biopsy, immediate reconstruction with implant and acellular dermal matrix was performed after NSM. Primary end points were wound complications and explantation. Secondary end points included local recurrence, quality of life, patient satisfaction, and esthetic outcome.

RESULTS

Sixty-three patients were included with 92 procedures. Twenty-seven percent received chemotherapy and 12.7% received radiotherapy. Mean follow-up was 27.6 months. There were only 2 wound complications, and no recurrences. Mean outcome scores were promising (Breast Q = 88%, subjective esthetic = 9.2, objective esthetic = 9.3, hardening = 2.6).

CONCLUSIONS

NSM via a hemi-periareolar incision is oncologically safe with a low-complication rate and high patients' satisfaction.

Does Breast Magnetic Resonance Imaging Combined With Conventional Imaging Modalities Decrease the Rates of Surgical Margin Involvement and Reoperation?: A Case-Control Comparative Analysis

The objective of this study was to assess whether preoperative breast magnetic resonance imaging (MRI) combined with conventional breast imaging techniques decreases the rates of margin involvement and reexcision.Data on patients who underwent surgery for primary operable breast cancer were obtained from the Changhua Christian Hospital (CCH) breast cancer database. The rate of surgical margin involvement and the rate of reoperation were compared between patients who underwent conventional breast imaging modalities (Group A: mammography and sonography) and those who received breast MRI in addition to conventional imaging (Group B: mammography, sonography, and MRI).A total of 1468 patients were enrolled in this study. Among the 733 patients in Group A, 377 (51.4%) received breast-conserving surgery (BCS) and 356 (48.6%) received mastectomy. Among the 735 patients in Group B, 348 (47.3%) received BCS and 387 (52.7%) received mastectomy. There were no significant differences in operative method between patients who received conventional imaging alone and those that received MRI and conventional imaging (P = 0.13). The rate of detection of pathological multifocal/multicentric breast cancer was markedly higher in patients who received preoperative MRI than in those who underwent conventional imaging alone (14.3% vs 8.6%, P < 0.01). The overall rate of surgical margin involvement was significantly lower in patients who received MRI (5.0%) than in those who received conventional imaging alone (9.0%) (P < 0.01). However, a significant reduction in rate of surgical margin positivity was only observed in patients who received BCS (Group A, 14.6%; Group B, 6.6%, P < 0.01). The overall BCS reoperation rates were 11.7% in the conventional imaging group and 3.2% in the combined MRI group (P < 0.01). There were no significant differences in rate of residual cancer in specimens obtained during reoperation between the 2 preoperative imaging groups (Group A, 50%; Group B, 81.8%, P = 0.09). In multivariate analysis, multifocal/multicentric breast cancer (odds ratio = 2.38, P = 0.02) and without MRI use (odds ratio = 2.35, P < 0.01) were the major predisposing factors to margin involvement in patients received BCS.Preoperative breast MRI combined with conventional breast imaging results in a lower rate of surgical margin involvement and reoperations in patients who receive BCS.

Current Trends in the Oncologic and Surgical Managements of Breast Cancer in Women with Implants: Incidence, Diagnosis, and Treatment

Breast augmentation is the most common cosmetic surgery in the United States, and thousands of augmented patients develop breast cancer each year. The possible effects of implants on cancer incidence, diagnosis, and treatment usually generate a disarming confusion. The present paper represents an update of the more recent oncologic and surgical strategies, aiming to support plastic and general surgeons in such challenging aspects. Several aspects of breast cancer management in augmented women are investigated, including (1) risk estimation and cancer characteristics, stage at diagnosis, and prognosis; (2) cancer diagnosis with clinical examination, mammography, ultrasound, and magnetic resonance imaging; (3) cancer treatment including breast conservation, intraoperative radiotherapy, sentinel node biopsy and mastectomy, and reconstruction. A brief resume of recommendations and conclusions is suggested, elucidating correct trends in the oncologic management of augmented patients and refusing well-established misconceptions: (1) breast augmentation does not increase the risk of breast cancer incidence, and it does not influence the prognosis; (2) possible risks exist in cancer detection due to technical difficulties; (3) sentinel lymph node detection is feasible; (4) intraoperative radiotherapy represents a good chance for conserving treatment; (5) immediate reconstruction with submuscular-subfascial implants is the most common procedure after mastectomy, and biological substitutes could support this procedure. Breast clinicians should be alerted because of high expectations of this subgroup of patients, accustomed to emphasize the aesthetic result.

LEVEL OF EVIDENCE V

This journal requires that the 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.

Nipple Sparing Mastectomy in Patients With Prior Breast Scars: Is It Safe?

BACKGROUND

Nipple-sparing mastectomy (NSM) preserves the native skin envelope, including the nipple-areolar skin, and has significant benefits including improved aesthetic outcome and psychosocial well-being. Patients with prior breast scars undergoing NSM are thought to be at increased risk for postoperative complications, such as skin and/or nipple necrosis. This study describes our experience performing NSM in patients who have had prior breast surgery and aims to identify potential risk factors in this subset of patients.

METHODS

A retrospective review of all patients undergoing nipple sparing mastectomy at The University of Utah from 2005 to 2011 was performed. Fifty-two patients had prior breast scars, for a total of 65 breasts. Scars were categorized into 4 groups depending on scar location: inframammary fold, outer quadrant, periareolar, and circumareolar. Information regarding patient demographics, social and medical history, treatment intent, and postoperative complications were collected and analyzed.

RESULTS

Eight of the 65 breasts (12%) developed a postoperative infection requiring antibiotic treatment. Tobacco use was associated with an increased risk of infection in patients with prior breast scars (odds ratio [OR], 7.95; 95% confidence interval [CI], 1.37-46.00; P = 0.0206). There was a 13.8% rate of combined nipple and skin flap necrosis and receipt of chemotherapy (OR, 5.00; CI, 1.11-22.46; P = 0.0357) and prior BCT (OR, 12.5; CI, 2.2-71.0; P = 0.004) were found to be associated with skin flap or NAC necrosis.

CONCLUSIONS

Nipple-sparing mastectomy is a safe and viable option for patients with a prior breast scar. Our results are comparable to the published data in patients without a prior scar. Caution should be exercised with patients who have a history of tobacco use or those requiring chemotherapy because these patients are at increased risk for infection and NAC/skin flap necrosis, respectively, when undergoing NSM in the setting of a prior breast scar.

Current Trends in and Indications for Endoscopy-Assisted Breast Surgery for Breast Cancer: Results from a Six-Year Study Conducted by the Taiwan Endoscopic Breast Surgery Cooperative Group

Background

Endoscopy-assisted breast surgery (EABS) performed through minimal axillary and/or periareolar incisions is a possible alternative to open surgery for certain patients with breast cancer. In this study, we report the early results of an EABS program in Taiwan.

Methods

The medical records of patients who underwent EABS for breast cancer during the period May 2009 to December 2014 were collected from the Taiwan Endoscopic Breast Surgery Cooperative Group database. Data on clinicopathologic characteristics, type of surgery, method of breast reconstruction, complications and recurrence were analyzed to determine the effectiveness and oncologic safety of EABS in Taiwan.

Results

A total of 315 EABS procedures were performed in 292 patients with breast cancer, including 23 (7.8%) patients with bilateral disease. The number of breast cancer patients who underwent EABS increased initially from 2009 to 2012 and then stabilized during the period 2012–2014. The most commonly performed EABS was endoscopy-assisted total mastectomy (EATM) (85.4%) followed by endoscopy-assisted partial mastectomy (EAPM) (14.6%). Approximately 74% of the EATM procedures involved breast reconstruction, with the most common types of reconstruction being implant insertion and autologous pedicled TRAM flap surgery. During the six-year study period, there was an increasing trend in the performance of EABS for the management of breast cancer when total mastectomy was indicated. The positive surgical margin rate was 1.9%. Overall, the rate of complications associated with EABS was 15.2% and all were minor and wound-related. During a median follow-up of 26.8 (3.3–68.6) months, there were 3 (1%) cases of local recurrence, 1 (0.3%) case of distant metastasis and 1 (0.3%) death.

Conclusion

The preliminary results from the EABS program in Taiwan show that EABS is a safe procedure and results in acceptable cosmetic outcome. These findings could help to promote this under-used surgical technique in the field of breast cancer.

Oncological safety and outcomes of nipple-sparing mastectomy with breast reconstruction: a single-centered experience in Taiwan

INTRODUCTION

Nipple-sparing mastectomy has become a contemporary surgical treatment that achieves improved cosmetic outcomes for patients with breast cancer in Western countries. We examined oncological and cosmetic outcomes in Asian women who underwent nipple-sparing mastectomy in Taiwan.

METHODS

Between 2006 and 2011, 42 patients with breast cancer who underwent 44 nipple-sparing mastectomy operations with immediate reconstruction at the Tri-Service General Hospital were reviewed. The cancer type, tumor stage, reconstruction method, presence of local recurrence, presence of distant metastasis, mortality, and complications were assessed and documented. Questionnaires were used to assess and rate patients' satisfaction with regard to appearance, sensation, symmetry, color, arousal, and texture.

RESULTS

The mean follow-up period was 40.9 months (median, 45.5 months; range, 13-72 months). Among the 42 cases, only one case (2.4%) of local recurrence was observed and treated by nipple-areola complex resection. The overall complication rate was 25%, with nipple necrosis comprising 13.6%.

CONCLUSION

Nipple-sparing mastectomy is a safe procedure in properly selected patients with breast cancer. This procedure yields similar oncological safety and cosmetic outcomes among Asians and women from Western countries.

Nipple sparing mastectomy: does breast morphological factor related to necrotic complications?

BACKGROUND

Nipple sparing mastectomy (NSM) can be performed for prophylactic mastectomy and the treatment of selected breast cancer with oncologic safety. The risk of skin and nipple necrosis is a frequent complication of NSM procedure, and it is usually related to surgical technique. However, the role of the breast morphology should be also investigated.

METHOD

We prospectively performed an analysis of 124 NSM from September 2012 to January 2013 at the European Institute of Oncology, Milan, Italy, focusing on necrotic complications. We analyzed the association between the risks of skin necrosis and the breast morphology of the patients.

RESULTS

Among 124 NSM in 113 patients, NSM procedures were associated with necrosis in 22 mastectomies (17.7%) among which included partial necrosis of nipple-areolar complex (NAC) in 15 of 124 NSM (12.1%) and total necrosis in 4 cases (3.5%). The NAC was removed in 5 NSM cases (4%). The volume of breast removed was the only significant factor increasing the risk of skin necrosis. The degree of ptosis was not significantly related to the necrosis risk.

CONCLUSIONS

Large glandular specimen increases the risk of NAC necrosis. The degree of ptosis and the distance between the sternal notch and the NAC have no significant impact on necrotic complications in NSM. To reduce the necrotic complications in large breast after NSM, reconstruction should better be performed with autologous flap or slow skin expansion using the expander technique.

Buried flap reconstruction after nipple-sparing mastectomy: advancing toward single-stage breast reconstruction

BACKGROUND

Recent evolutions of oncologic breast surgery and reconstruction now allow surgeons to offer the appropriate patients a single-stage, autologous tissue reconstruction with the least donor-site morbidity. The authors present their series of buried free flaps in nipple-sparing mastectomies as proof of concept, and to explore indications, techniques, and early outcomes from their series.

METHODS

From 2001 to 2011, a total of 2262 perforator-based free flaps for breast reconstruction were reviewed from the authors' prospectively maintained database.

RESULTS

There were 338 free flaps performed on 215 patients following nipple-sparing mastectomy, including 84 patients who underwent breast reconstruction with 134 buried free flaps. Ductal carcinoma in situ and BRCA-positive were the most common diagnoses, in 26 patients (30.9 percent) each. The most common flaps used were the deep inferior epigastric perforator (77.6 percent), transverse upper gracilis (7.5 percent), profunda artery perforator (7.5 percent), and superficial inferior epigastric artery flaps (3.7 percent). An implantable Cook-Swartz Doppler was used to monitor all buried flaps. Fat necrosis requiring excision was present in 5.2 percent of breast reconstructions, and there were three flap losses (2.2 percent). Seventy-eight flaps (58.2 percent) underwent minor revision for improved cosmesis; 56 (41.8 percent) needed no further surgery.

CONCLUSIONS

Nipple-sparing mastectomy with immediate autologous breast reconstruction can successfully and safely be performed in a single stage; however, the authors are not yet ready to offer this as their standard of care.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Nipple-sparing mastectomy in modern breast practice

Breast cancer management has evolved from the conventional radical Halsted to a fully integrated multidisciplinary approach. Nipple sparing mastectomy (NSM) is an innovative technique that preserves native breast envelope without mutilation of nipple-areola complex (NAC), thus providing a reasonable alternative for early cancers without NAC involvement and prophylactic high risk patients and avoids multiple surgical procedures required for reconstruction. This article aims to critically review indications, intra-operative protocols, radiotherapy planning and limitations of NSM. Patient selection should be based on study of breast duct anatomy by Magnetic Resonance Imaging, mammographic tumor-nipple distance and obligatory intra-operative frozen section from retro-areolar tissue. Tumor size, axillary lymph node status, lymphovascular invasion and/or degree of intraductal component are factors used to include NSM candidates based on institutional practice. Given the heterogeneity of patients and lack of standardization of preoperative investigations, surgical technique and pathologic sampling of retro-areola tissue so far, mandates a multi-institutional prospective study to define and validate a role for NSM in invasive breast cancer and DCIS. Nipple necrosis is an important NSM complication which can be greatly reduced using alternative skin incisions. Even if the nipple survives, an insensate nipple and lack of sexual function is common and requires preoperative counseling and discussion. Finally the relation and timing of intra-operative versus adjuvant breast radiation and tailoring of dosage and delivery methods has not been fully explored. Although NSM reduces psychological trauma associated with nipple loss, the oncologic safety as well as functional and aesthetic outcomes needs additional investigation.

A formula for implant volume choice in breast reconstruction after nipple sparing mastectomy

Implant choice after Nipple Sparing Mastectomy (NSM) is a problematic perioperative issue. In this retrospective study, the authors searched for a correlation between mastectomy weight and implant volume choice after NSM. A mathematical expression of this correlation was found that might help surgeons decide implant volume after NSM.

Update on breast reconstruction techniques and indications

Breast reconstruction is considered as part of the breast cancer treatment when a mastectomy is required. Implants or expanders are the most frequent techniques used for the reconstructions. Expander provides usually a better symmetry. A contralateral mastoplasty often is required to improve the symmetry. The nipple areola complex, which can be preserved in certain conditions, is usually removed and can be reconstructed in a second stage under local anesthesia. In case of radical mastectomy and/or radiotherapy, a musculocutaneous flap, such as rectus abdominis or latissimus dorsi autologous flaps, is required. When microsurgical facilities are available, free or perforator flaps respecting the muscle are preferred to decrease the donor site complications. In situ carcinomas or prophylactic mastectomy can be reconstructed immediately as well as invasive carcinoma according to the recent literature. Locally advanced breast cancer can be reconstructed after complete oncologic treatment. Radiotherapy of the thoracic wall is proposed in case of lymph node metastases, raising the discussion about the technique choice and the timing of the reconstruction. Plastic surgery procedures can improve the cosmetic results of the conservative surgery, also extending its indications and reducing both mastectomy and reexcision rates. Oncoplasty techniques are becoming more and more sophisticated, requiring the skill of trained plastic surgeons. Numerous publications confirm the psychosocial benefit resulting from the breast reconstruction.

Risk factors associated with recurrence after nipple-sparing mastectomy for invasive and intraepithelial neoplasia

BACKGROUND

To identify risk factors of recurrence in a large series of patients with breast cancer who underwent a nipple-sparing mastectomy (NSM).

PATIENTS AND METHODS

Breast-related recurrences and local recurrences (LR) in the breast and the nipple areola complex (NAC) were studied. Cumulative incidences of events were estimated through competing risk analysis. Multivariate Cox regression models were also applied.

RESULTS

We identified 934 consecutive NSM patients during 2002-2007. Median follow-up was 50 months. In 772 invasive carcinoma patients, the rate of LR in the breast and in the NAC was 3.6% and 0.8%, respectively. In the 162 patients with intraepithelial neoplasia, the rate of LR in the breast and in the NAC was 4.9% and 2.9%, respectively. The significant risk factors of LR in the breast for the group A were grade, overexpression/amplification of HER2/neu and breast cancer molecular subtype Luminal B. In group B, the risk factors of LR in the breast and in the NAC were age (<45 years), absence of estrogen receptors, grade, HER2/neu overexpression and high Ki-67.

CONCLUSIONS

The LR rate after NSM in our series was low. Biological features of disease and young age should be taken into account when considering NSM in breast cancer patients.

Nipple sparing mastectomy: can we predict the factors predisposing to necrosis?

BACKGROUND

Nipple sparing mastectomy (NSM) is an accepted surgical approach in selected breast cancer and prophylactic mastectomy, nevertheless post-mastectomy skin necrosis is one of the frequent complications. This study aimed to analyze the factors that may lead to skin necrosis after NSM.

PATIENTS AND METHODS

From May 2010 to July 2010, we prospectively registered 50 consecutive NSM from 45 patients. There were 40 mastectomies for cancer, and 10 prophylactic mastectomies. The various patient's and surgical factors were registered during pre-, intra- and postoperative period.

RESULTS

No total necrosis of the nipple areola complex (NAC) was observed. There were thirteen cases with partial necrosis (26.0%) of the areola or the adjacent skin. All these necrosis were partial both for the surface and the thickness. Surgical debridement was performed in 9 (18.0%) cases. The significant risk factors are smoking, young age, type of incision and NAC involvement with areola flap thickness less than 5 mm.

CONCLUSION

NSM should be done with high caution in smokers. Young patients, periareolar incision and superior circumareolar incision have also a higher risk of necrosis. We recommend keeping areolar flap thickness more than 5 mm in areola region.

Nipple-sparing mastectomy--is it worth the risk?

Nipple-sparing mastectomy (NSM) is a surgical protocol designed to reduce the disabling psychological effects of radical or skin-sparing mastectomy. The preservation of the nipple-areola complex produces a more-natural result of the breast reconstruction, but this preservation is suspected of increasing tumor local recurrence. To reduce this risk, different approaches have been proposed: restrict the inclusion criteria and/or add localized radiation therapy. The local recurrence rate in recent series of patients receiving NSM is comparable with the local recurrence rate in modified radical or skin-sparing mastectomies. Today, the quality of the subcutaneous mastectomy technique allows for a more radical glandular removal, especially in the retroareolar area; therefore, local recurrence is observed in 3-6% of patients at 5 years, consistent with traditional mastectomy.

The Changing Face of Mastectomy (from Mutilation to Aid to Breast Reconstruction)

Breast cancer is the most common cancer in women. Primary treatment is surgery, with mastectomy as the main treatment for most of the twentieth century. However, over that time, the extent of the procedure varied, and less extensive mastectomies are employed today compared to those used in the past, as excessively mutilating procedures did not improve survival. Today, many women receive breast-conserving surgery, usually with radiotherapy to the residual breast, instead of mastectomy, as it has been shown to be as effective as mastectomy in early disease. The relatively new skin-sparing mastectomy, often with immediate breast reconstruction, improves aesthetic outcomes and is oncologically safe. Nipple-sparing mastectomy is newer and used increasingly, with better acceptance by patients, and again appears to be oncologically safe. Breast reconstruction is an important adjunct to mastectomy, as it has a positive psychological impact on the patient, contributing to improved quality of life.

Advances in nipple-sparing mastectomy: oncological safety and incision selection

BACKGROUND

With the evolution of breast reconstruction and oncoplastic techniques, more aesthetic mastectomies are being offered to patients. Nipple-sparing mastectomy (NSM) has been controversial, but an expanding body of published experience has allowed this concept to gain momentum.

OBJECTIVES

The authors review their experience with NSM.

METHODS

From 2007 to 2009, 112 consecutive patients (204 breasts) who were candidates for NSM presented to one of two private plastic surgery practices. All patients underwent preoperative magnetic resonance imaging to assess the size of the tumor, its distance from the nipple, and any additional disease within the ipsilateral/contralateral breast or axillae. Exclusion criteria included tumors larger than 3 cm, clinical invasion of the nipple-areolar complex, tumors within 2 cm of the nipple, evidence of multicentric disease, a positive intraoperative retroareolar frozen section, or nodal disease (excluding isolated immunohistochemistry positivity). Fourteen patients were excluded from the study for one of these reasons, leaving a total of 98 patients (186 breasts) who underwent NSM.

RESULTS

Risk-reducing mastectomies were performed on 45 patients. Therapeutic mastectomies were performed for Stage 0 cancer (ductal carcinoma in situ) in 26 patients, for Stage 1A in 24 patients, and for Stage 1B in three patients. Disease-free survival was calculated from the date of surgery to any local, regional, or distant relapse (whichever occurred first). As of the writing of this article, follow-up ranged from nine months to three years, and there has been no local or regional recurrence in any patient.

CONCLUSIONS

NSM is evolving and should be considered a good treatment option in carefully-selected patients. These findings add to the growing body of evidence showing that, with proper patient selection and operative technique, NSM is a safe and effective intervention for patients requiring therapeutic or prophylactic mastectomy.

Patient satisfaction following nipple-sparing mastectomy and immediate breast reconstruction: an 8-year outcome study

BACKGROUND

Nipple-sparing mastectomy has become an accepted treatment for appropriately selected breast cancers. No reports have correlated patient satisfaction following nipple-sparing mastectomy with objective observer assessments.

METHODS

From 2001 to 2008, nipple-sparing mastectomy and immediate reconstruction were performed on 141 patients. After institutional review board approval, patients completed questionnaires rating their satisfaction with various aspects of their nipple-areola complex using a Likert-type scale. Three independent observers then reviewed the nipple-areola complex in 34 patients and rated the outcome using the same scale.

RESULTS

The survey completion rate was 53 percent and the mean follow-up was 50.4 months (range, 9 to 100 months). A majority of patients rated appearance, symmetry, color, position, and texture as good or excellent. A majority of patients rated sensation and arousal as fair or poor. Fifty-seven patients (73.1 percent) stated they would definitely undergo nipple-sparing mastectomy again. Patients with larger volumes of breast tissue removed (p = 0.010), larger preoperative body mass index (p = 0.034), or larger tissue expander volumes (p = 0.007) reported lower satisfaction. Patient assessments for appearance, color, symmetry, and position correlated with those of objective observers.

CONCLUSIONS

The authors' study is the largest series to address patient satisfaction with the nipple-areola complex following nipple-sparing mastectomy and the only one to correlate patient self-assessment with assessment by independent observers. Overall, patients were very satisfied with appearance of the nipple-areola complex and most would choose nipple-sparing mastectomy again. A majority of patients rated sensation as fair or poor, with sensation constituting the most frequent aspect of the nipple-areola complex that patients would change. Larger body mass index, expander volumes, and volume of breast tissue removed may predict dissatisfaction postoperatively.

Clinical and pathological characteristics of Chinese patients with BRCA related breast cancer

Breast cancers related to BRCA mutations are associated with particular biological features. Here we report the clinical and pathological characteristics of breast cancer in Chinese women with and without BRCA mutations and of carriers of BRCA1 mutations compared to BRCA2 mutations. Two hundred and 26 high-risk Hong Kong Chinese women were tested for BRCA mutations, medical information was obtained from medical records, and risk and demographic information was obtained from personal interviews. In this cohort, 28 (12.4%) women were BRCA mutation carriers and among these carriers, 39.3% were BRCA1 and 60.7% were BRCA2 mutations. Mutation carriers were more likely to have a familial history of breast and ovarian cancer, high-grade cancers, and triple negative (TN) cancers. Prevalence of TN was 48.3% in BRCA carriers and 25.6% in non-carriers and was 67.7% in BRCA1 and 35.3% in BRCA2 carriers. Estrogen receptor (ER) negative cancer was significantly associated with BRCA1 mutations, especially in those under 40 years of age. BRCA-related breast cancer in this Chinese population is associated with family history and adverse pathological/prognostic features, with BRCA2 mutations being more prevalent but BRCA1 carriers having more aggressive and TN cancers. Compared to Caucasian populations, prevalence of BRCA2 mutations and TN cancer in BRCA2 mutation carriers in Chinese population are elevated.

Recent advances in the surgical care of breast cancer patients

A tremendous improvement in every aspect of breast cancer management has occurred in the last two decades. Surgeons, once solely interested in the extipartion of the primary tumor, are now faced with the need to incorporate a great deal of information, and to manage increasingly complex tasks.

As a comprehensive assessment of all aspects of breast cancer care is beyond the scope of the present paper, the current review will point out some of these innovations, evidence some controversies, and stress the need for the surgeon to specialize in the various aspects of treatment and to be integrated into the multisciplinary breast unit team.

Nipple-sparing mastectomy and immediate tissue expander/implant breast reconstruction

BACKGROUND

The nipple is an uncommon site for breast cancer development, but the nipple-areola complex is routinely excised in breast cancer treatment. The authors evaluated the risks and benefits of nipple- or areola-sparing mastectomy with breast reconstruction.

METHODS

The authors analyzed data on 115 consecutive nipple- or areola-sparing mastectomies with immediate tissue expander breast reconstruction performed in 66 patients from 1998 to 2008 at a single tertiary-care cancer center. Nipple-sparing mastectomies were performed for prophylaxis (n = 75) or treatment of disease (n = 40).

RESULTS

Mean patient age was 45 years (range, 24 to 61 years) and mean follow-up time was 22 months (range, 2 weeks to 91 months). There were 115 nipple- or areola-sparing mastectomies (48 bilateral and 19 unilateral), including 111 nipple-sparing and four areola-sparing mastectomies. On pathologic review, 20 breasts had ductal carcinoma in situ, 20 breasts had invasive cancer, 11 breasts had lobular carcinoma in situ, one breast had phyllodes tumor, one breast had mucinous carcinoma, and 62 breasts were cancer-free. Incision placement was periareolar and radial (n = 61), inframammary (n = 25), omega type (n = 14), customized to include a previous scar (n = 10), or transareolar (n = 5). Of all 115 nipple- or areola-sparing mastectomies, six nipples were lost because of occult disease (5.2 percent), and four nipples were lost because of wound-healing problems (3.5 percent).

CONCLUSIONS

In the authors' series of nipple- and areola-sparing mastectomies performed for risk reduction or breast cancer, there was a low incidence of occult disease (5.2 percent). Nipple- and areola-sparing mastectomy may be feasible in selected patients and should be the subject of additional investigation.