Long-Term Oncologic Safety of Nipple-Sparing Mastectomy With Immediate Reconstruction

Comparison of Clinical Breast Exam to Breast MRI Surveillance in Patients Following Nipple-Sparing Mastectomy

BACKGROUND

Nipple sparing mastectomy (NSM) is increasingly being performed for patients with breast cancer. However, optimal postoperative surveillance has not been defined.

METHODS

A prospectively maintained database identified patients with in-situ and invasive cancer who underwent NSM between 2007-2021. Clinical data on postoperative breast surveillance and interventions were collected. Patients who had MRI surveillance versus clinical breast exam (CBE) alone were compared with respect to tumor characteristics, recurrence, and survival.

RESULTS

A total of 483 NSMs were performed on 399 patients. 255 (63.9%) patients had invasive ductal carcinoma, 31 (7.8%) invasive lobular carcinoma, 92 (23.1%) DCIS, 6 (1.5%) mixed ductal and lobular carcinoma, 9 (2.3%) others, and 6 (1.5%) unknown. Postoperatively, 265 (66.4%) patients were followed with CBE alone and 134 (33.6%) had surveillance MRIs. At a median follow-up of 33 months, 20 patients (5.0%) developed in-breast recurrence, 6 patients had (1.5%) an axillary recurrence, and 28 with (7.0%) distant recurrence. 14 (53.8%) LRR were detected in the CBE group and 12 (46.2%) were detected in the MRI group (P = .16). Overall survival (OS) was 99%, with no difference in OS between patients who had CBE alone versus MRI (P = .46). MRI was associated with higher biopsy rates compared to CBE alone (15.8% vs. 7.8%, P = .01).

CONCLUSIONS

Compared to CBE alone, the use of screening MRI following NSM results in higher rate of biopsy and no difference in overall survival.

Minimizing Nipple-Areolar Complex Complications in Prepectoral Breast Reconstruction After Nipple-Sparing Mastectomy

PURPOSE

Nipple-areolar complex (NAC) viability remains a significant concern following prepectoral tissue expander (TE) reconstruction after nipple-sparing mastectomy (NSM). This study assesses the impact of intraoperative TE fill on NAC necrosis and identifies strategies for mitigating this risk.

METHODS

A chart review of all consecutive, prepectoral TEs placed immediately after NSM was performed between March 2017 and December 2022 at a single center. Demographics, mastectomy weight, intraoperative TE fill, and complications were extracted for all patients. Partial NAC necrosis was defined as any thickness of skin loss including part of the NAC, whereas total NAC necrosis was defined as full-thickness skin loss involving the entirety of the NAC. P < 0.05 was considered statistically significant.

RESULTS

Forty-six patients (83 breasts) with an average follow-up of 22 months were included. Women were on average 46 years old, nonsmoker (98%), and nondiabetic (100%) and had a body mass index of 23 kg/m2. All reconstructions were performed immediately following prophylactic mastectomies in 49% and therapeutic mastectomies in 51% of cases. Three breasts (4%) were radiated, and 15 patients (33%) received chemotherapy. Mean mastectomy weight was 346 ± 274 g, median intraoperative TE fill was 150 ± 225 mL, and median final TE fill was 350 ± 170 mL. Partial NAC necrosis occurred in 7 breasts (8%), and there were zero instances of complete NAC necrosis. On univariate analysis, partial NAC necrosis was not associated with any patient demographic or operative characteristics, including intraoperative TE fill. In multivariable models controlling for age, body mass index, mastectomy weight, prior breast surgery, and intraoperative TE fill, partial NAC necrosis was associated with lower body mass index (odds ratio, 0.53; confidence interval [CI], 0.29-0.98; P < 0.05) and higher mastectomy weight (odds ratio, 1.1; CI, 1.01-1.20; P < 0.05). Prior breast surgery approached significance, as those breasts had a 19.4 times higher odds of partial NAC necrosis (95% CI, 0.88-427.6; P = 0.06).

CONCLUSIONS

Nipple-areolar complex necrosis following prepectoral TE reconstruction is a rare but serious complication. In this study of 83 breasts, 7 (8%) developed partial NAC necrosis, and all but one were able to be salvaged.

Areolar reconstruction: MICAP flap as a skin paddle donor site in skin sparing mastectomy and implant-based reconstruction

The main advantage of preserving the nipple-areola complex (NAC) in small to moderate size breasts reconstruction is that the main diameters of the breast mound remain unaltered. When for oncological reason the NAC must be excised, a paddle of skin needs to be borrowed from a donor site and transferred into the surgical defect to maintain the breast contour. While this is easily achievable with the majority of autologous reconstructions, it is very challenging in the context of implant-based reconstructions, where the primary closure of the defect leads to a flattened breast mound and suboptimal cosmetic results. In our experience, the medial intercostal artery perforator flap enables the safe resection of the NAC with concurrent reconstruction of the defect, allowing a satisfactory cosmetic result in terms of contour and projection even in the setting of implant-based reconstruction.

Spare the Nipple: A Systematic Review of Tumor Nipple-Distance and Oncologic Outcomes in Nipple-Sparing Mastectomy

BACKGROUND

Preserving the nipple-areolar complex (NAC) in breast cancer surgery improves patient satisfaction and quality of life. The oncologic safety of NSM in tumors < 2 cm from the nipple remains in question. We conducted a systematic review to determine whether TND < 2 cm was associated with increased risk of LRR in patients undergoing NSM.

METHODS

We included studies of invasive or in situ breast cancer < 2 cm from NAC undergoing NSM which reported LRR rates. LRR rates were stratified by TND and culminated across studies. Cohort study quality was assessed using Newcastle-Ottawa Criteria. Meta-analysis was not possible due to heterogeneity in reporting survival outcomes.

RESULTS

We identified seven retrospective cohort studies with 2295 patients and 18 case series with 3507 patients. Direct tumor involvement of NAC was considered an absolute contraindication to NSM in all studies. In cohort studies, median follow-up was 31-112 (range 14-204) months. Cohorts with TND < 2 cm did not have a significantly higher rate of LRR. Amongst case series, 275 patients had TND < 2 cm. Combined LRR in case series was 2.6%, with median follow-up 10.4-71 (range 0-158) months.

CONCLUSIONS

Our systematic review did not identify TND < 2 cm as a significant risk factor for LRR. NSM appears oncologically safe in select patients with TND < 2 cm. Given the improved quality of life associated with NSM compared to skin-sparing mastectomy, we suggest NSM as the procedure of choice in appropriately selected patients.

Long-Term Outcomes of Breast Cancer Patients with Local Recurrence After Mastectomy Undergoing Immediate Breast Reconstruction: A Retrospective Multi-institutional Study of 4153 Cases

BACKGROUND

The number of breast cancer patients in Japan undergoing immediate breast reconstruction (IBR) has increased and the postoperative follow-up period has been extended. This study was conducted to clarify the clinical aspects of, and factors associated with, local recurrence (LR) after IBR.

METHODS

This was a multicenter study which included 4153 early breast cancer patients who underwent IBR. Clinicopathological characteristics were examined and factors potentially contributing to LR were analyzed. Risk factors for LR were examined separately for non-invasive and invasive breast cancers.

RESULTS

The median follow-up period was 75 months. The 7-year LR rates were 2.1% and 4.3% for non-invasive and invasive cancers, respectively (p < 0.001). The proportions of LR detected by palpation, subjective symptoms, and ultrasonography were 40.0%, 27.3%, and 25.9%, respectively. Overall, 75.7% of LR were solitary, and 92.7% of these cases had no further recurrences during the observational period. Multivariate analysis of LR for invasive cancer showed that skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM), the presence of lymphovascular invasion, cancer at the surgical margin, and not receiving radiation therapy were factors related to LR. The 7-year overall survival rates of the patients with LR and non-LR of invasive cancers were 92.5% and 97.3%, respectively, (p = 0.002).

CONCLUSIONS

The rate of LR after IBR was acceptably low and IBR can thus be performed safely for early breast cancer patients. Invasive cancer, SSM/NSM, lymphovascular invasion, and/or cancer at the surgical margin should prompt awareness of the possibility of LR.

Preoperative Breast Magnetic Resonance Imaging: An Ontario Health (Cancer Care Ontario) Clinical Practice Guideline

BACKGROUND

The use of preoperative breast magnetic resonance imaging (MRI) after the diagnosis of breast cancer by mammography and/or ultrasound is inconsistent.

METHODS

After conducting a systematic review and meta-analysis comparing preoperative breast MRI versus no MRI, we reconvened to prepare a clinical practice guideline on this topic.

RESULTS

Based on the evidence that MRI improved recurrence, decreased the rates of reoperations (re-excisions or conversion mastectomy), and increased detection of synchronous contralateral breast cancer, we recommend that preoperative breast MRI should be considered on a case-by-case basis in patients diagnosed with breast cancer for whom additional information about disease extent could influence treatment. Based on stronger evidence, preoperative breast MRI is recommended in patients diagnosed with invasive lobular carcinoma for whom additional information about disease extent could influence treatment. For both recommendations, the decision to proceed with MRI would be conditional on shared decision-making between care providers and the patient, taking into account the benefits and risks of MRI as well as patient preferences. Based on the opinion of the Working Group, preoperative breast MRI is also recommended in the following more specific situations: (a) to aid in surgical planning of breast conserving surgery in patients with suspected or known multicentric or multifocal disease; (b) to identify additional lesions in patients with dense breasts; (c) to determine the presence of pectoralis major muscle/chest wall invasion in patients with posteriorly located tumours or when invasion of the pectoralis major muscle or chest wall is suspected; (d) to aid in surgical planning for skin/nipple-sparing mastectomies, autologous reconstruction, oncoplastic surgery, and breast conserving surgery with suspected nipple/areolar involvement; and (e) in patients with familial/hereditary breast cancer but who have not had recent breast MRI as part of screening or diagnosis.

Hyperbaric Oxygen Therapy for Threatened Nipple-Sparing Mastectomy Flaps: An Adjunct for Flap Salvage

BACKGROUND

Nipple-sparing mastectomy (NSM) is emerging as the standard of care for treatment of breast cancer because of its oncologic safety and superior aesthetic outcomes. However, ischemia or necrosis of the skin flap and/or nipple-areola complex remain frequent complications. Hyperbaric oxygen therapy (HBOT) has emerged as a potential adjunct for flap salvage, although it is not currently a widely accepted practice. Here we review our institution's experience using a protocol of HBOT in patients with signs of flap ischemia or necrosis after NSM.

METHODS

Retrospective review identified all patients treated with HBOT at our institution's hyperbaric and wound care center because of signs of ischemia after NSM. Treatment parameters consisted of 90-minute dives at 2.0 atmosphere once or twice daily. Patients unable to tolerate dives were considered a treatment failure, whereas those lost to follow-up were excluded from analysis. Patient demographics, surgical characteristics, and treatment indications were recorded. Primary outcomes assessed were flap salvage (no operative revision), need for revision procedures, and treatment complications.

RESULTS

A total of 17 patients and 25 breasts met the inclusion criteria. The mean ± SD time to initiation of HBOT was 9.47 ± 12.7 days. The mean ± SD age was 46.7 ± 10.4 years, and mean ± SD follow-up time was 36.5 ± 25.6 days. Indications for NSM included invasive cancer (41.2%), carcinoma in situ (29.4%), and breast cancer prophylaxis (29.4%). Initial reconstruction included tissue-expander placement (47.1%), autologous reconstruction with deep inferior epigastric flaps (29.4%), and direct-to-implant reconstruction (23.5%). Hyperbaric oxygen therapy indications included ischemia or venous congestion for 15 breasts (60.0%) and partial thickness necrosis for 10 breasts (40.0%). Flap salvage was achieved in 22 of 25 breasts (88.0%). Reoperation was required for 3 breasts (12.0%). Hyperbaric oxygen therapy-related complications were observed in 4 patients (23.5%), which included 3 patients with mild ear pain and 1 patient with severe sinus pressure leading to treatment abortion.

CONCLUSIONS

Nipple-sparing mastectomy is an invaluable tool for breast and plastic surgeons to achieve oncologic and cosmetic goals. However, ischemia or necrosis of the nipple-areola complex or mastectomy skin flap remains frequent complications. Hyperbaric oxygen therapy has emerged as a possible intervention for threatened flaps. Our results demonstrate the utility of HBOT in this population to achieve excellent NSM flap salvage rates.

A systematic review of oncological outcomes after nipple-sparing mastectomy for breast cancer

Nipple-sparing mastectomy is an alternative to skin-sparing mastectomy in select patients. Increasing evidence supports its use in the setting of breast cancer, however concerns still exist regarding oncological safety. The aim of this systematic review was to evaluate long-term oncological outcomes of patients who underwent nipple-sparing mastectomy for breast cancer. A systematic review of the literature was performed to evaluate oncological outcomes in patients with breast cancer who underwent nipple-sparing mastectomy. Five major databases (PubMed, Embase, Scopus, Web of Science and Cochrane) were searched. The review included all original articles published in English reporting long-term oncological outcomes. 2334 studies were identified. After applying inclusion and exclusion criteria, 17 retrospective studies involving 7107 patients were included. The indication for nipple-sparing mastectomy was invasive carcinoma in 6069 patients (85.4%) and in situ disease in 1038 (14.6%). Median follow up was 48 months (range 25-94). The weighted mean rates of local recurrence and recurrence involving the nipple-areola complex were 5.4% (0.9-11.9) and 1.3% (0-4.9), respectively. The weighted mean distant failure rate was 4.8% (1.5-23.0). Therapeutic nipple-sparing mastectomy is oncologically safe in select patients with breast cancer.

Long-Term Cancer Recurrence Rates Following Nipple-Sparing Mastectomy: A 10-year Follow-up Study

BACKGROUND

Despite the increased utilization of nipple-sparing mastectomies (NSM), there is limited data examining long-term cancer recurrence rates in these patients. The objective of this study was to analyze breast cancer recurrence in patients who received therapeutic NSM with a median of 10 years of follow-up.

METHODS

All patients undergoing NSM at a single institution were retrospectively reviewed temporally to obtain a median of 10-years of follow up. Patient demographic factors, mastectomy specimen pathology, and oncologic outcomes were analyzed. Univariate analysis was performed to identify independent risk factors for locoregional recurrence.

RESULTS

126 therapeutic NSM were performed on 120 patients. The most frequently observed tumor histology included invasive ductal carcinoma (48.4%) and ductal carcinoma in situ (38.1%). Mean tumor size was 1.62 cm. Multifocal or multicentric disease and lymphovascular invasion were present in 31.0% and 10.3% of NSM specimens, respectively. Sentinel lymph node biopsy was performed in 84.9% of NSM and 17.8% were positive. The rate of positive frozen subareolar biopsy was 7.3% (n=82) and permanent subareolar pathology was 9.5% (n=126). The most frequently observed pathologic tumor stages was stage I (44.6%) and stage 0 (33.9%). Incidence of recurrent disease was 3.17% per mastectomy and 3.33% per patient. Upon univariate analysis, no demographic, operative, or tumor-specific variables were independent risk factors for locoregional recurrence.

CONCLUSIONS

Overall recurrence rates are low in patients undergoing NSM at a median follow-up of 10-years. Close surveillance should remain a goal for patients and their providers to promptly identify potential recurrence.