1
|
Zhu M, Mao J, Fang J, Chen D. Safety of Atypical Ductal Hyperplasia at the Nipple Margin in Nipple-Sparing Mastectomy. J Breast Cancer 2024; 27:260-269. [PMID: 39069781 PMCID: PMC11377941 DOI: 10.4048/jbc.2024.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/16/2024] [Accepted: 07/11/2024] [Indexed: 07/30/2024] Open
Abstract
PURPOSE Controversies persist regarding contraindications for nipple-sparing mastectomy (NSM). This study aimed to assess the accuracy of subareolar frozen section analysis and identify risk factors for nipple-areola complex (NAC) recurrence post NSM. METHODS Consecutive cases of primary invasive breast cancer undergoing NSM at our single center from January 2015 to December 2020 were retrospectively reviewed. RESULTS The nipples were retained in 126 patients (127 breasts), and the areola was retained with nipple excision for five breasts. Frozen section analysis demonstrated a sensitivity of 81.8% and specificity of 95.3%. The NAC recurrence rate was 4.3% over a median follow-up period of 48 (30-105) months. An atypical ductal hyperplasia (ADH) at the margin emerged as an independent factor for NAC recurrence in multivariate Cox regression analysis (hazard ratio, 25.464; 95% confidence interval, 1.841-352.145; p = 0.016). Kaplan-Meier survival analysis revealed no statistically significant reduction in overall survival rates (log-rank test, p = 0.660). CONCLUSION Frozen sections of subareolar tissue are reliable and re-excision may be necessary when ADH is detected at the nipple margin in NSM. The NAC recurrence rate was low, and the outcome was favorable following wide local excision.
Collapse
Affiliation(s)
- Meizhen Zhu
- Department of Breast Surgery, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, China.
| | - Jiefei Mao
- Department of Breast Surgery, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, China
| | - Jun Fang
- Department of Radiation Therapy, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, China
| | - Daobao Chen
- Department of Breast Surgery, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, China
| |
Collapse
|
2
|
Boyd CJ, Ramesh S, Bekisz JM, Guth AA, Axelrod DM, Shapiro RL, Hiotis K, Schnabel FR, Karp NS, Choi M. Low Cancer Occurrence Rate following Prophylactic Nipple-Sparing Mastectomy. Plast Reconstr Surg 2024; 153:37e-43e. [PMID: 36999997 DOI: 10.1097/prs.0000000000010481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) has become widely available for breast cancer prophylaxis. There are limited data on its long-term oncologic safety. The objective of this study was to determine the incidence of breast cancer in patients who underwent prophylactic NSM. METHODS All patients undergoing prophylactic NSM at a single institution from 2006 through 2019 were retrospectively reviewed. Patient demographic factors, genetic predispositions, mastectomy specimen pathology, and oncologic occurrences at follow-up were recorded. Descriptive statistics were performed where necessary to classify demographic factors and oncologic characteristics. RESULTS A total of 871 prophylactic NSMs were performed on 641 patients, with median follow-up of 82.0 months (standard error 1.24). A total of 94.4% of patients ( n = 605) underwent bilateral NSMs, although only the prophylactic mastectomy was considered. The majority of mastectomy specimens (69.6%) had no identifiable pathology. A total of 38 specimens (4.4%) had cancer identified in mastectomy specimens, with ductal carcinoma in situ being the most common (92.1%; n = 35). Multifocal or multicentric disease was observed in seven cases (18.4%) and lymphovascular invasion was identified in two (5.3%). One patient (0.16%), who was a BRCA2 variant carrier, was found to have breast cancer 6.5 years after prophylactic mastectomy. CONCLUSIONS Overall primary oncologic occurrence rates are very low in high-risk patients undergoing prophylactic NSM. In addition to reducing the risk of oncologic occurrence, prophylactic surgery itself may be therapeutic in a small proportion of patients. Continued surveillance for these patients remains important to assess at longer follow-up intervals. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, IV.
Collapse
Affiliation(s)
- Carter J Boyd
- From the Hansjörg Wyss Department of Plastic Surgery
| | - Sruthi Ramesh
- From the Hansjörg Wyss Department of Plastic Surgery
| | | | - Amber A Guth
- Division of Surgical Oncology, Department of Surgery, New York University Langone Health
| | - Deborah M Axelrod
- Division of Surgical Oncology, Department of Surgery, New York University Langone Health
| | - Richard L Shapiro
- Division of Surgical Oncology, Department of Surgery, New York University Langone Health
| | - Karen Hiotis
- Division of Surgical Oncology, Department of Surgery, New York University Langone Health
| | - Freya R Schnabel
- Division of Surgical Oncology, Department of Surgery, New York University Langone Health
| | - Nolan S Karp
- From the Hansjörg Wyss Department of Plastic Surgery
| | - Mihye Choi
- From the Hansjörg Wyss Department of Plastic Surgery
| |
Collapse
|
3
|
Youn S, Lee E, Peiris L, Olson D, Lesniak D, Rajaee N. Spare the Nipple: A Systematic Review of Tumor Nipple-Distance and Oncologic Outcomes in Nipple-Sparing Mastectomy. Ann Surg Oncol 2023; 30:8381-8388. [PMID: 37620525 DOI: 10.1245/s10434-023-14143-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 07/24/2023] [Indexed: 08/26/2023]
Abstract
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.
Collapse
Affiliation(s)
- Susie Youn
- Department of Surgery, University of Alberta Hospital, Edmonton, AB, Canada.
| | - Esther Lee
- Department of Surgery, University of Alberta Hospital, Edmonton, AB, Canada
| | - Lashan Peiris
- Department of Surgery, University of Alberta Hospital, Edmonton, AB, Canada
| | - David Olson
- Department of Surgery, University of Alberta Hospital, Edmonton, AB, Canada
| | - David Lesniak
- Department of Surgery, University of Alberta Hospital, Edmonton, AB, Canada
| | - Nikoo Rajaee
- Department of Surgery, University of Alberta Hospital, Edmonton, AB, Canada
| |
Collapse
|
4
|
Ugurlu MU, Bugdayci O, Akmercan A, Kaya H, Akin Telli T, Akoglu H, Gulluoglu BM. Prediction of nipple involvement in breast cancer after neoadjuvant chemotherapy: Should we rely on breast MRI to preserve the nipple? Breast Cancer Res Treat 2023; 201:417-424. [PMID: 37490171 DOI: 10.1007/s10549-023-07041-8] [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: 05/24/2023] [Accepted: 07/05/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Indications for nipple sparing mastectomy (NSM) is extending to post-neoadjuvant chemotherapy (NAC) setting. Eligibility for NSM with an optimum tumor-nipple distance (TND) after NAC is unclear. We examined predictive factors for nipple tumor involvement in patients undergoing total mastectomy following NAC. METHODS Clinical and pathological data from prospectively collected medical records of women with invasive breast carcinoma, who were undergone NAC and total mastectomy with sentinel lymph node biopsy and/or axillary lymph node dissection were analyzed. PreNAC and postNAC magnetic resonance imaging (MRI) views were examined and a cut-off TND value for predicting the negative nipple tumor status was determined. RESULTS Among 180 women, the final mastectomy specimen analysis revealed that 12 (7%) had nipple involvement as invasive carcinoma. Patients with nipple involvement had more postNAC multifocal/multicentric tumors (p: 0.03), larger tumors on preNAC and postNAC images (p: 0.002 and p < 0.001), shorter median TNDs on preNAC and postNAC images (7 mm-IQR 1.5-14, p: 0.005 and 8.5 mm-IQR 3-15.5, p < 0.001, respectively), more nipple retraction on preNAC and postNAC images (p: 0.007 and p: 0.006) and more nipple areola complex skin thickening (> 2mm) on preNAC and postNAC images (p < 0.001 and p: 0.01). The best likelihood ratios (LR) belonged to the postNAC positivity of the < 20 mm TND, with a + LR of 3.40, and - LR of 0.11 for nipple involvement. PreNAC positivity of the < 20 mm TND also had a similar - LR of 0.14. CONCLUSION A TND-cut-off ≥ 2 cm on preNAC and postNAC MRI was shown to be highly predictive of negative nipple tumor involvement.
Collapse
Affiliation(s)
- M Umit Ugurlu
- Department of General Surgery, Breast and Endocrine Surgery Unit, Marmara University School of Medicine, Istanbul, Turkey.
| | - Onur Bugdayci
- Department of Radiology, Marmara University School of Medicine, Istanbul, Turkey
| | - Ahmet Akmercan
- Department of General Surgery, Breast and Endocrine Surgery Unit, Marmara University School of Medicine, Istanbul, Turkey
| | - Handan Kaya
- Department of Pathology, Marmara University School of Medicine, Istanbul, Turkey
| | - Tugba Akin Telli
- Department of Medical Oncology, Marmara University School of Medicine, Istanbul, Turkey
| | - Haldun Akoglu
- Department of Emergency Medicine, Marmara University School of Medicine, Istanbul, Turkey
| | - Bahadir M Gulluoglu
- Department of General Surgery, Breast and Endocrine Surgery Unit, Marmara University School of Medicine, Istanbul, Turkey
| |
Collapse
|
5
|
Byon JH, Hwang S, Choi H, Choi EJ. Diagnostic Accuracy of Magnetic Resonance Imaging Features and Tumor-to-Nipple Distance for the Nipple-Areolar Complex Involvement of Breast Cancer: A Systematic Review and Meta-Analysis. Korean J Radiol 2023; 24:739-751. [PMID: 37500575 PMCID: PMC10400374 DOI: 10.3348/kjr.2022.0846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 05/02/2023] [Accepted: 05/19/2023] [Indexed: 07/29/2023] Open
Abstract
OBJECTIVE This systematic review and meta-analysis evaluated the accuracy of preoperative breast magnetic resonance imaging (MRI) features and tumor-to-nipple distance (TND) for diagnosing occult nipple-areolar complex (NAC) involvement in breast cancer. MATERIALS AND METHODS The MEDLINE, Embase, and Cochrane databases were searched for articles published until March 20, 2022, excluding studies of patients with clinically evident NAC involvement or those treated with neoadjuvant chemotherapy. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Two reviewers independently evaluated studies that reported the diagnostic performance of MRI imaging features such as continuity to the NAC, unilateral NAC enhancement, non-mass enhancement (NME) type, mass size (> 20 mm), and TND. Summary estimates of the sensitivity and specificity curves and the summary receiver operating characteristic (SROC) curve of the MRI features for NAC involvement were calculated using random-effects models. We also calculated the TND cutoffs required to achieve predetermined specificity values. RESULTS Fifteen studies (n = 4002 breast lesions) were analyzed. The pooled sensitivity and specificity (with 95% confidence intervals) for NAC involvement diagnosis were 71% (58-81) and 94% (91-96), respectively, for continuity to the NAC; 58% (45-70) and 97% (95-99), respectively, for unilateral NAC enhancement; 55% (46-64) and 83% (75-88), respectively, for NME type; and 88% (68-96) and 58% (40-75), respectively, for mass size (> 20 mm). TND had an area under the SROC curve of 0.799 for NAC involvement. A TND of 11.5 mm achieved a predetermined specificity of 85% with a sensitivity of 64%, and a TND of 12.3 mm yielded a predetermined specificity of 83% with a sensitivity of 65%. CONCLUSION Continuity to the NAC and unilateral NAC enhancement may help predict occult NAC involvement in breast cancer. To achieve the desired diagnostic performance with TND, a suitable cutoff value should be considered.
Collapse
Affiliation(s)
- Jung Hee Byon
- Department of Radiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Seungyong Hwang
- Department of Genetics, Stanford University, Stanford, CA, USA
| | - Hyemi Choi
- Department of Statistics and Institute of Applied Statistics, Jeonbuk National University, Jeonju, Republic of Korea.
| | - Eun Jung Choi
- Department of Radiology, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Republic of Korea.
| |
Collapse
|
6
|
Muradali D, Fletcher GG, Cordeiro E, Fienberg S, George R, Kulkarni S, Seely JM, Shaheen R, Eisen A. Preoperative Breast Magnetic Resonance Imaging: An Ontario Health (Cancer Care Ontario) Clinical Practice Guideline. Curr Oncol 2023; 30:6255-6270. [PMID: 37504323 PMCID: PMC10378361 DOI: 10.3390/curroncol30070463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/23/2023] [Accepted: 06/28/2023] [Indexed: 07/29/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Derek Muradali
- Department of Medical Imaging, University of Toronto, Toronto, ON M5T 1W7, Canada
| | - Glenn G Fletcher
- Program in Evidence-Based Care, Department of Oncology, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Erin Cordeiro
- Department of Surgery, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | | | - Ralph George
- Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Supriya Kulkarni
- Department of Medical Imaging, University of Toronto, Toronto, ON M5T 1W7, Canada
| | - Jean M Seely
- Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Rola Shaheen
- Department of Radiology, Queen's University, Kingston, ON K7L 3N6, Canada
- Diagnostic Imaging, Peterborough Regional Health Centre, Peterborough, ON K9J 7C6, Canada
| | - Andrea Eisen
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
| |
Collapse
|
7
|
Shinzaki W, Manabe H, Kubota M, Inui H, Hojo T, Ito T, Itani Y, Komoike Y. Breast cancer local recurrence after mastectomy with immediate latissimus dorsi myocutaneous flap reconstruction: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231177510. [PMID: 37325163 PMCID: PMC10265333 DOI: 10.1177/2050313x231177510] [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: 12/17/2022] [Accepted: 05/02/2023] [Indexed: 06/17/2023] Open
Abstract
Even though most local recurrences after autologous breast reconstruction occur in superficial tissue, they also occur in deep tissue in the reconstructed breast. A 49-year-old woman presented with a bloody discharge from the right nipple. Ultrasonography revealed a hypoechoic area in her right breast, which was diagnosed as ductal carcinoma in situ on histopathology. We performed nipple-sparing mastectomy and immediate reconstruction of the breast with a latissimus dorsi myocutaneous flap. At 6 years postoperatively, the patient presented with a palpable mass. Ultrasonography revealed a solid mass lesion subcutaneously in the right breast. Computed tomography revealed multiple enhanced solid mass lesions in the subcutaneous and deep tissues of the reconstructed breast. The mass in the deep tissue of the reconstructed breast was diagnosed as an invasive micropapillary carcinoma by biopsy. For local recurrence, we performed wide excision of the reconstructed breast. The masses in the subcutaneous and deep tissues of the reconstructed breast were diagnosed as invasive micropapillary carcinoma. Superficial recurrence was first detected by physical examination, and deep recurrence was later detected with further imaging. We present a case of local recurrences that occurred in the deep tissue, in addition to superficial tissue of the reconstructed breast.
Collapse
Affiliation(s)
- Wataru Shinzaki
- Division of Breast and Endocrine Surgery, Department of Surgery, Faculty of Medicine, Kindai University, Osakasayama City, Japan
| | - Hironobu Manabe
- Division of Breast and Endocrine Surgery, Department of Surgery, Faculty of Medicine, Kindai University, Osakasayama City, Japan
| | - Michiyo Kubota
- Division of Breast and Endocrine Surgery, Department of Surgery, Faculty of Medicine, Kindai University, Osakasayama City, Japan
| | - Hiroki Inui
- Division of Breast and Endocrine Surgery, Department of Surgery, Faculty of Medicine, Kindai University, Osakasayama City, Japan
| | - Toshiya Hojo
- Division of Breast and Endocrine Surgery, Department of Surgery, Faculty of Medicine, Kindai University, Osakasayama City, Japan
| | - Toshikazu Ito
- Division of Breast and Endocrine Surgery, Department of Surgery, Faculty of Medicine, Kindai University, Osakasayama City, Japan
| | - Yoshihito Itani
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Kindai University, Osakasayama City, Japan
| | - Yoshifumi Komoike
- Division of Breast and Endocrine Surgery, Department of Surgery, Faculty of Medicine, Kindai University, Osakasayama City, Japan
| |
Collapse
|
8
|
Boyd CJ, Bekisz JM, Ramesh S, Hemal K, Guth AA, Axelrod DM, Shapiro RL, Hiotis K, Schnabel FR, Choi M, Karp NS. No Cancer Occurrences in 10-year Follow-up after Prophylactic Nipple-sparing Mastectomy. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5087. [PMID: 37325374 PMCID: PMC10266511 DOI: 10.1097/gox.0000000000005087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/05/2023] [Indexed: 06/17/2023]
Abstract
Prophylactic nipple-sparing mastectomies (NSM) have become increasingly common, although there is little long-term data on its efficacy in prevention of breast cancer. The objective of this study was to assess the incidence of breast cancer in a cohort of patients undergoing prophylactic NSM with a median follow-up of 10 years. Methods Patients receiving prophylactic NSM at a single institution from 2006 to 2019 were included in a retrospective nature. Patient demographics, genetic mutations, operative details, and specimen pathology were recorded, and all postoperative patient visits and documentation were screened for cancer occurrence. Descriptive statics were performed where appropriate. Results Two hundred eighty-four prophylactic NSMs were performed on 228 patients with a median follow-up of 120.5 ± 15.7 months. Roughly, a third of patients had a known genetic mutation, with 21% BRCA1 and 12% BRCA2. The majority (73%) of prophylactic specimens had no abnormal pathology. The most commonly observed pathologies were atypical lobular hyperplasia (10%) and ductal carcinoma in situ (7%). Cancer was identified in 10% of specimens, with only one case of lymphovascular invasion. Thus far, there have been no incidences of locoregional breast cancer occurrence in this cohort. Conclusions The long-term breast cancer occurrence rate in this cohort of prophylactic NSM patients at the time of this study is negligible. Despite this, continued surveillance of these patients is necessary until lifetime risk of occurrence following NSM has been established.
Collapse
Affiliation(s)
- Carter J. Boyd
- From the Hansjörg Wyss Department of Plastic Surgery, NYU Langone, New York, N.Y
| | - Jonathan M. Bekisz
- From the Hansjörg Wyss Department of Plastic Surgery, NYU Langone, New York, N.Y
| | - Sruthi Ramesh
- From the Hansjörg Wyss Department of Plastic Surgery, NYU Langone, New York, N.Y
| | - Kshipra Hemal
- From the Hansjörg Wyss Department of Plastic Surgery, NYU Langone, New York, N.Y
| | - Amber A. Guth
- Division of Surgical Oncology, Department of Surgery, NYU Langone, New York, N.Y
| | - Deborah M. Axelrod
- Division of Surgical Oncology, Department of Surgery, NYU Langone, New York, N.Y
| | - Richard L. Shapiro
- Division of Surgical Oncology, Department of Surgery, NYU Langone, New York, N.Y
| | - Karen Hiotis
- Division of Surgical Oncology, Department of Surgery, NYU Langone, New York, N.Y
| | - Freya R. Schnabel
- Division of Surgical Oncology, Department of Surgery, NYU Langone, New York, N.Y
| | - Mihye Choi
- From the Hansjörg Wyss Department of Plastic Surgery, NYU Langone, New York, N.Y
| | - Nolan S. Karp
- From the Hansjörg Wyss Department of Plastic Surgery, NYU Langone, New York, N.Y
| |
Collapse
|
9
|
Modern Approaches to Implant-Based Breast Reconstruction. Clin Plast Surg 2023; 50:223-234. [PMID: 36813400 DOI: 10.1016/j.cps.2022.09.003] [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: 01/03/2023]
Abstract
The modern approach to implant-based breast reconstruction encompasses an evolution in surgical techniques, patient selection, implant technology, and use of support materials. Successful outcomes are defined by teamwork throughout the ablative and reconstructive processes as well as appropriate and evidence-based utilization of modern material technologies. Patient education, focus on patient-reported outcomes, and informed and shared decision-making are the key to all steps of these procedures.
Collapse
|
10
|
Long-Term Cancer Recurrence Rates Following Nipple-Sparing Mastectomy: A 10-year Follow-up Study. Plast Reconstr Surg 2022; 150:13S-19S. [PMID: 35943969 DOI: 10.1097/prs.0000000000009495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
Collapse
|
11
|
Lee SC, Mendez-Broomberg K, Eacobacci K, Vincoff NS, Gupta E, McElligott SE. Nipple-sparing Mastectomy: What the Radiologist Should Know. Radiographics 2022; 42:321-339. [PMID: 35179983 DOI: 10.1148/rg.210136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Nipple-sparing mastectomy (NSM) is increasingly offered to patients undergoing treatment of breast cancer and prophylaxis treatment for reduction of breast cancer risk. NSM is considered oncologically safe for appropriately selected patients and is associated with improved cosmetic outcomes and quality of life. Accepted indications for NSM have expanded in recent years, and currently only inflammatory breast cancer or malignancy involving the nipple is considered an absolute contraindication. Neoplasms close to and involving the nipple areolar complex are common, and cancer of the lactiferous ducts can spread to the nipple. Therefore, accurate determination of nipple involvement at imaging examinations is critical to identifying appropriate candidates for NSM and preventing local recurrence. Multiple imaging features have been described as predictors of nipple involvement, with tumor to nipple distance, enhancement between the index malignancy and the nipple, and nipple retraction demonstrating the highest predictive values. These features can be assessed at multimodality breast imaging, particularly at breast MRI, which demonstrates high specificity and negative predictive value for determining nipple involvement in malignancy. Online supplemental material is available for this article. ©RSNA, 2022.
Collapse
Affiliation(s)
- Samantha C Lee
- From the Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra University/Northwell Health System, 300 Community Dr, Manhasset, NY 11030
| | - Karen Mendez-Broomberg
- From the Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra University/Northwell Health System, 300 Community Dr, Manhasset, NY 11030
| | - Katherine Eacobacci
- From the Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra University/Northwell Health System, 300 Community Dr, Manhasset, NY 11030
| | - Nina S Vincoff
- From the Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra University/Northwell Health System, 300 Community Dr, Manhasset, NY 11030
| | - Ekta Gupta
- From the Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra University/Northwell Health System, 300 Community Dr, Manhasset, NY 11030
| | - Suzanne E McElligott
- From the Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra University/Northwell Health System, 300 Community Dr, Manhasset, NY 11030
| |
Collapse
|
12
|
Gender-affirming Mastectomy with Concurrent Oncologic Mastectomy. PLASTIC AND RECONSTRUCTIVE SURGERY - GLOBAL OPEN 2022; 10:e4092. [PMID: 35169524 PMCID: PMC8830861 DOI: 10.1097/gox.0000000000004092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/06/2021] [Indexed: 11/26/2022]
Abstract
Transmasculine individuals may not have undergone gender-affirming mastectomy and retain natal breast tissue. Our center offers simultaneous oncologic mastectomy with gender-affirming reconstruction to patients who are diagnosed with breast cancer. This study is the first reported series of concurrent gender-affirming and oncologic mastectomies.
Collapse
|
13
|
Nakagawa T, Oda G, Mori H, Uemura N, Onishi I, Sagawa N, Fujioka T, Mori M, Kubota K, Ishikawa T, Okamoto K, Uetake H. Prognosis of Subcutaneous Mastectomy for Special Types of Breast Cancer. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58010112. [PMID: 35056420 PMCID: PMC8780999 DOI: 10.3390/medicina58010112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 11/16/2022]
Abstract
Background and objectives: In the treatment of the special type of breast cancer (STBC), the choice of chemotherapeutic agents is often based on the characteristic features of the histological type. On the other hand, the surgical strategy is usually determined by the tumor size and presence of lymph node metastasis, and the indication for immediate reconstruction is rarely discussed based on the histological type. The prognoses of STBC and invasive ductal carcinoma of the breast (IDC) patients who underwent subcutaneous mastectomy (SCM) with immediate reconstruction at our institution were compared. Materials and Methods: A total of 254 patients with SCM with immediate reconstruction from 1998 to 2018 were included; their tumor diameter or induration was less than 25 mm, and it was not in close proximity to the skin. Preoperative chemotherapy and non-invasive cancer cases were excluded. Results: The number of patients was 166 for skin-sparing mastectomy (SSM) and 88 for nipple-sparing mastectomy (NSM). The reconstructive techniques were deep inferior epigastric artery perforator flap (DIEP) reconstruction in 43 cases, latissimus dorsi flap reconstruction (LDflap) in 63 cases, tissue expander (TE) in 117 cases, and transverse rectus abdominis myocutaneous flap/vertical rectus abdominis myocutaneous flap (TRAM/VRAM) reconstruction in 31 cases. The histological types of breast cancer were 211 IDC and 43 STBC; 17 were mucinous carcinoma (MUC), 17 were invasive lobular carcinoma (ILC), 6 were apocrine carcinoma, 1 was tubular carcinoma, and 2 were invasive micropapillary carcinoma. There was no difference in local recurrence or disease-free survival (LRFS, DFS) between IDC and STBC, and overall survival (OS) was significantly longer in STBC. OS was better in the STBC group because SCM with immediate reconstruction was performed for STBC, which is a histological type with a relatively good prognosis. Highly malignant histological types, such as squamous cell carcinoma or metaplastic carcinoma, were totally absent in this study. Conclusions: The indications for SCM with immediate reconstruction for relatively common STBCs such as MUC and ILC can be the same as for IDC.
Collapse
Affiliation(s)
- Tsuyoshi Nakagawa
- Department of Breast Surgery, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (G.O.); (N.S.)
- Correspondence: ; Tel.: +81-3-5803-5261
| | - Goshi Oda
- Department of Breast Surgery, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (G.O.); (N.S.)
| | - Hiroki Mori
- Department of Plastic Surgery, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (H.M.); (N.U.)
| | - Noriko Uemura
- Department of Plastic Surgery, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (H.M.); (N.U.)
| | - Iichiro Onishi
- Department of Pathology, Tokyo Medical and Dental University, Tokyo 1138519, Japan;
| | - Noriko Sagawa
- Department of Breast Surgery, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (G.O.); (N.S.)
| | - Tomoyuki Fujioka
- Department of Radiology, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (T.F.); (M.M.); (K.K.)
| | - Mio Mori
- Department of Radiology, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (T.F.); (M.M.); (K.K.)
| | - Kazunori Kubota
- Department of Radiology, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (T.F.); (M.M.); (K.K.)
| | - Toshiaki Ishikawa
- Department of Specialized Surgeries, Graduated School, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (T.I.); (K.O.); (H.U.)
| | - Kentaro Okamoto
- Department of Specialized Surgeries, Graduated School, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (T.I.); (K.O.); (H.U.)
| | - Hiroyuki Uetake
- Department of Specialized Surgeries, Graduated School, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (T.I.); (K.O.); (H.U.)
| |
Collapse
|
14
|
Comparing Incision Choices in Immediate Microvascular Breast Reconstruction after Nipple-Sparing Mastectomy: Unique Considerations to Optimize Outcomes. Plast Reconstr Surg 2021; 148:1173-1185. [PMID: 34644280 DOI: 10.1097/prs.0000000000008282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Incision planning is a critical factor in nipple-sparing mastectomy outcomes. Evidence on optimal incision patterns in patients undergoing nipple-sparing mastectomy and immediate microvascular breast reconstruction is lacking in the literature. METHODS A single-institution retrospective review was performed of consecutive patients undergoing nipple-sparing mastectomy and immediate microvascular autologous reconstruction from 2007 to 2019. Outcomes-including major mastectomy flap necrosis, full nipple-areola complex necrosis, and any major ischemic complication of the skin envelope-were compared among incision types. Multivariable logistic regression identified factors associated with major ischemic complication. RESULTS Two hundred seventy-nine reconstructions (163 patients) were identified, primarily using internal mammary recipient vessels (98.9 percent). Vertical incisions were used in 139 cases; inframammary, in 53; lateral radial, in 51; and inverted-T, in 35. Thirty-two cases (11.5 percent) had major mastectomy flap necrosis, 11 (3.9 percent) had full nipple-areola complex necrosis, and 38 (13.6 percent) had any major ischemic complication. Inframammary incisions had higher rates of major ischemic complication (25 percent) than vertical (5.8 percent; p < 0.001) and lateral radial (7.8 percent; p = 0.032) incisions. Inverted-T incisions also had higher rates of major ischemic complication (36.1 percent) than both vertical (p < 0.001) and lateral radial (p = 0.002) incisions. Inframammary incisions (OR, 4.382; p = 0.002), inverted-T incisions (OR, 3.952; p = 0.011), and mastectomy weight (OR, 1.003; p < 0.001) were independently associated with an increased risk of major ischemic complication. Inframammary incisions with major ischemic complication demonstrated significantly higher body mass index, mastectomy weight, and flap weight compared to those without. CONCLUSIONS Inframammary and inverted-T incisions are associated with a higher risk of major ischemic skin envelope complications after nipple-sparing mastectomy and immediate microvascular breast reconstruction. Radial incisions can be considered to optimize recipient vessel exposure without compromising perfusion. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
Collapse
|
15
|
|
16
|
Bae SJ, Cha YJ, Eun NL, Ji JH, Kim D, Lee J, Ahn SG, Son EJ, Jeong J. Diagnostic Accuracy of Nonmass Enhancement at Breast MRI in Predicting Tumor Involvement of the Nipple: A Prospective Study in a Single Institution. Radiology 2021; 301:47-56. [PMID: 34254854 DOI: 10.1148/radiol.2021204136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Although nonmass enhancement (NME) extension to the nipple at preoperative MRI frequently leads to sacrifice of the nipple-areolar complex (NAC), its correlation with pathologically confirmed NAC involvement is unclear. Purpose To evaluate the diagnostic accuracy of using NME extension to the subareolar region at breast MRI to predict pathologic nipple involvement and the eligibility for nipple-sparing mastectomy. Materials and Methods From November 2017 to November 2019, the authors prospectively enrolled participants with breast cancer and NME within 2 cm of the nipple at breast MRI who underwent surgery that included removal of the NAC. The authors evaluated NME extensions that were ipsilateral and contiguous with the biopsy-proven tumor lesions on images acquired during the early contrast phases. Pathologic nipple involvement and the distance from the nipple to the nearest cancer cell were evaluated by using serial vertical sectioning of the area extending from the entire NAC to the tumor. The primary end point was the positive predictive value (PPV) of NME, which was calculated as follows: (number with pathologic nipple invasion and NME extension to the nipple at breast MRI/number with NME extension to the nipple at breast MRI) × 100. Results Of 64 women (mean age, 52 years ± 9.8 [standard deviation]), 49 (77%) had NME extension to the nipple at breast MRI. The PPV of NME extension to the nipple was 86% (42 of 49 women; 95% CI: 73, 94). Among the 15 participants without NME extension to the nipple, only one (7%) had pathologic nipple involvement. The diagnostic accuracy of using NME extension to the nipple was 88% (56 of 64 women; 95% CI: 77, 95). The radiologic distance correlated well with the pathologic distance (Spearman correlation coefficient = 0.71, P = .003). Conclusion Nonmass enhancement extension to the nipple base at preoperative MRI has a high positive predictive value for identifying tumor involvement of the nipple, a contraindication to nipple-sparing mastectomy. © RSNA, 2021 Online supplemental material is available for this article.
Collapse
Affiliation(s)
- Soong June Bae
- From the Departments of Surgery (S.J.B., J.H.J., D.K., J.L., S.G.A., J.J.), Pathology (Y.J.C.), and Radiology (N.L.E., E.J.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Yoon Jin Cha
- From the Departments of Surgery (S.J.B., J.H.J., D.K., J.L., S.G.A., J.J.), Pathology (Y.J.C.), and Radiology (N.L.E., E.J.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Na Lae Eun
- From the Departments of Surgery (S.J.B., J.H.J., D.K., J.L., S.G.A., J.J.), Pathology (Y.J.C.), and Radiology (N.L.E., E.J.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Jung Hwan Ji
- From the Departments of Surgery (S.J.B., J.H.J., D.K., J.L., S.G.A., J.J.), Pathology (Y.J.C.), and Radiology (N.L.E., E.J.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Dooreh Kim
- From the Departments of Surgery (S.J.B., J.H.J., D.K., J.L., S.G.A., J.J.), Pathology (Y.J.C.), and Radiology (N.L.E., E.J.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Janghee Lee
- From the Departments of Surgery (S.J.B., J.H.J., D.K., J.L., S.G.A., J.J.), Pathology (Y.J.C.), and Radiology (N.L.E., E.J.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Sung Gwe Ahn
- From the Departments of Surgery (S.J.B., J.H.J., D.K., J.L., S.G.A., J.J.), Pathology (Y.J.C.), and Radiology (N.L.E., E.J.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Eon Ju Son
- From the Departments of Surgery (S.J.B., J.H.J., D.K., J.L., S.G.A., J.J.), Pathology (Y.J.C.), and Radiology (N.L.E., E.J.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Joon Jeong
- From the Departments of Surgery (S.J.B., J.H.J., D.K., J.L., S.G.A., J.J.), Pathology (Y.J.C.), and Radiology (N.L.E., E.J.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| |
Collapse
|
17
|
Corey B, Smania MA, Spotts H, Andersen M. Young Women With Breast Cancer: Treatment, Care, and Nursing Implications. Clin J Oncol Nurs 2021; 24:139-147. [PMID: 32196004 DOI: 10.1188/20.cjon.139-147] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Young women with breast cancer (YWBC) are more likely to have aggressive disease, carry mutations for hereditary cancer genes, and experience higher mortality. They also may face reduced fertility because of the toxicity of chemotherapy. OBJECTIVES This article aims to present a review of YWBC treatments, sequelae of treatment, and psychosocial challenges. METHODS The authors performed a review of guideline-supported treatment options, patient resources, and nursing implications. FINDINGS Because of high-risk cancers and a lack of specific treatment guidelines, healthcare providers may consider aggressive treatments for younger patients. However, studies indicate that the foundation for treatment decisions for YWBC are best based on disease stage and National Comprehensive Cancer Network guidelines.
Collapse
|
18
|
Pestana IA, Jones VM, Velazquez C. Breast Reconstruction and Nipple-Sparing Mastectomy: Technical Modifications and Their Outcomes Over Time at an Academic Breast Center. Ann Plast Surg 2021; 86:S521-S525. [PMID: 34100809 DOI: 10.1097/sap.0000000000002701] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Superior aesthetic outcomes can be achieved with mastectomy techniques that maximize breast envelope preservation and maintain the nipple-areolar complex. This is the impetus for the popularization of the nipple-sparing mastectomy (NSM). Nipple-sparing mastectomy is a challenging procedure due to potential ischemia of the mastectomy flap (which includes the nipple-areolar complex) and the risk of incomplete oncologic resection. We review our experience with NSM, identify technique modifications used over time, and evaluate reconstructive outcomes of NSM and its modifications. METHODS A retrospective review of consecutive patients with NSM and breast reconstruction over an 8-year period was completed. RESULTS Fifty-five patients underwent 95 NSMs. Indications included invasive and in situ cancer, atypical ductal hyperplasia, and risk reduction. In the first 4 years of experience, the most frequently used NSM incision was radial (lateral) whereas use of a variety of incision patterns was noted in the second 4 years. Overall NSM and breast reconstruction complication rate for the entire study period was 50.9% and included a full-thickness mastectomy skin flap necrosis/nipple necrosis rate of 8.4%. In situ cancer of the nipple was identified in 3.2% of the patients, and 1 patient had locoregional recurrence. Overall complication rate was lower in the second 4 years of experience with NSM and reconstruction. One third of the patients underwent intraoperative fluorescent angiography (FA) to assess mastectomy skin perfusion before reconstruction start. Of the patients who had FA due to perfusion concerns, more than 70% of studies demonstrated poor perfusion and 83.3% of these patients had reconstruction delayed based on these results. Immediate, implant-based reconstruction was performed most commonly. An average of 2.66 procedures were required to achieve reconstruction completion, and 92.4% of the patients who sought reconstruction achieved completion. CONCLUSIONS At our institution, NSM use is increasing, NSM incision pattern types used are expanding, and complication rates are decreasing. Immediate, implant-based reconstruction is most commonly used in combination with NSM at our institution. Fluorescent angiography is used to assess mastectomy skin perfusion and likely limits mastectomy complication effects on reconstruction. Despite the occurrence of complications, most patients will complete the breast reconstruction process.
Collapse
Affiliation(s)
- Ivo A Pestana
- From the Departments of Plastic & Reconstructive Surgery
| | - V Morgan Jones
- General Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | | |
Collapse
|
19
|
Wang D, Xiong S, Ai T, Zeng N, Ren Y, Wu M, Wu Y. The Use of DCE-MRI to Evaluate the Blood Supply to the Nipple-Areola Complex: A Study in 245 Asian Women. Aesthet Surg J 2021; 41:NP346-NP354. [PMID: 34002211 DOI: 10.1093/asj/sjaa406] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Understanding the main blood supply to the nipple-areola complex (NAC) is important for breast plastic surgery. However, previous reports have involved studies of cadavers and small sample sizes. OBJECTIVES This study aimed to identify and classify the in vivo blood supply to the NAC based on dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). METHODS DCE-MRI images of 393 breasts in 245 Asian women obtained from March 2012 to October 2019 were included retrospectively. Axial, coronal, and sagittal maximum-intensity projection images were evaluated to identify all vessels supplying the NAC. Blood supply to the NAC was classified into 9 anatomic zones: superomedial (Ia), medial (Ib), inferomedial (Ic), superolateral (IIa), lateral (IIb), inferolateral (IIc), central (III), inferior (IV), and superior (V). RESULTS A total of 637 source vessels were identified in 393 breasts. Of the 393 breasts, 211 (53.7%) were supplied by a single zone, 132 (33.6%) by 2 zones, 38 (9.7%) by 3 zones, and 12 (3.1%) by 4 zones. Of the 637 vessels, 269 (42.2%) vessels were in zone Ia, 180 (28.3%) vessels were in zone IIa, and <10% of vessels were in the other zones. The number of NAC perfusion zones (P = 0.093) and the distribution of source vessels (P = 0.602) did not differ significantly between the left and right breasts. CONCLUSIONS DCE-MRI provides a clear indication of the blood supply to the NAC. Blood vessels from the superomedial and superolateral zones were the predominant sources of blood supplying the NAC.
Collapse
Affiliation(s)
- Dawei Wang
- Department of Plastic Surgery, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Shixuan Xiong
- Department of Plastic Surgery, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Tao Ai
- Department of Radiology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Ning Zeng
- Department of Plastic Surgery, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Yuping Ren
- Department of Plastic Surgery, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Min Wu
- Department of Plastic Surgery, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Yiping Wu
- Department of Plastic Surgery, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
20
|
Eichler C, Stephan S, Thangarajah F, Puppe J, Rahmani N, Kurbacher C, Malter W, Warm M. Intraoperative central nipple biopsy in nipple-sparing mastectomy- A retrospective analysis of 211 patients. Breast J 2021; 27:363-368. [PMID: 33619792 DOI: 10.1111/tbj.14197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/01/2021] [Accepted: 02/01/2021] [Indexed: 11/30/2022]
Abstract
Subcutaneous nipple sparing mastectomies (NSM) are an important tool in modern oncoplastic surgery. Especially when an immediate implant-based reconstruction (IBR) is desired, clean margins are of the utmost importance. Central nipple biopsies during surgery serve two main purposes. Most importantly, it is hypothesized that intraoperative pathological evaluation of this biopsy may increase clean margin resection rates. In addition, a general recurrence risk reduction may occur due to the elimination of glandular and ductal components within the nipple. This analysis is a single center, multi-surgeon, retrospective, head to head analysis. Starting in March 2015, intraoperative central nipple biopsy in NSMs with IBR was introduced at the Municipal Breast Cancer Centre Cologne, Holweide, Germany. This trial retrospectively evaluates global complication rates, clean margin status and local recurrence rates for cohort 1 (NSM/no nipple biopsy, n = 103) vs. cohort 2 (NSM with nipple biopsy, n = 108) Median follow-up was 15 months. All implant-based reconstruction procedures used an epipectoral implant pocket. Cohorts were comparable. Global complication rates slightly favored the nipple biopsy cohort with respects to implant loss rate. An involved central nipple biopsy was found in 4.6% (n = 5/108) of the performed NSM procedures leading to the immediate removal of the nipple areola complex. All positive retro-areolar biopsies correlated with a positive nipple biopsy. However, in n = 1 case we found DCIS discontinual proliferation with an involved nipple biopsy, without a correlating positive retro-areolar biopsy (ie, 1 false-negative case was prevented). For the 15 month follow-up, there was no case of local recurrence within nipple areola complex for both cohorts. With this retrospective head to head analysis of 211 patients, it was shown that the central nipple biopsy correlates well with the retro-areolar biopsy. There may be a reduction in false negative rates. The procedure is safe to use and should be offered to NSM patients.
Collapse
Affiliation(s)
- Christian Eichler
- Department of Gynaecology and Obstetrics, Faculty of Medicine University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Sophia Stephan
- Breast Cancer Centre, Municipal Hospital Holweide, Cologne, Germany
| | - Fabinshy Thangarajah
- Department of Gynaecology and Obstetrics, Faculty of Medicine University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Julian Puppe
- Department of Gynaecology and Obstetrics, Faculty of Medicine University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Neda Rahmani
- Department of Gynaecology and Obstetrics, Faculty of Medicine University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christian Kurbacher
- Department of Gynaecology and Obstetrics, Faculty of Medicine University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Wolfram Malter
- Department of Gynaecology and Obstetrics, Faculty of Medicine University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Mathias Warm
- Department of Gynaecology and Obstetrics, Faculty of Medicine University Hospital Cologne, University of Cologne, Cologne, Germany.,Breast Cancer Centre, Municipal Hospital Holweide, Cologne, Germany
| |
Collapse
|
21
|
Oncologic Safety of Nipple-Sparing Mastectomy for Patients with Breast Cancer. CURRENT BREAST CANCER REPORTS 2021. [DOI: 10.1007/s12609-020-00399-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
22
|
Wu ZY, Kim HJ, Lee J, Chung IY, Kim J, Lee SB, Son BH, Han J, Han HH, Eom JS, Kim SB, Jung KH, Gong G, Kim HH, Ahn SH, Ko B. Oncologic Safety of Nipple-Sparing Mastectomy in Patients with Breast Cancer and Tumor-to-Nipple Distance ≤ 1 cm: A Matched Cohort Study. Ann Surg Oncol 2021; 28:4284-4291. [PMID: 33423119 DOI: 10.1245/s10434-020-09427-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/12/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND A short tumor-to-nipple distance (TND) is reported as a strong predictor of nipple-areola complex (NAC) involvement. Eligibility for nipple-sparing mastectomy (NSM) remains controversial, especially regarding TND. In this study, we compared long-term oncologic outcomes after NSM between patients with a TND ≤ 1 cm and those with a TND > 1 cm. METHODS Overall, 1369 patients with primary breast cancer who underwent NSM with immediate reconstruction from March 2003 to December 2015 were included for analysis. After propensity score matching, 495 patients with a TND ≤ 1 cm (group A) and 495 patients with a TND > 1 cm (group B) on imaging were selected to compare long-term oncologic outcomes. RESULTS After matching, the median follow-up periods for surviving patients were 109 months and 112 months for groups A and B, respectively. There were no significant differences between groups with respect to the 5-year cumulative local recurrence (8.1% vs. 6.3%; p = 0.268), NAC recurrence (5.1% vs. 2.8%; p = 0.072), regional recurrence (2.0% vs. 3.6%; p = 0.125), or distant recurrence (5.9% vs. 4.8%; p = 0.480) rates. Furthermore, no significant differences were observed between the groups with respect to the 10-year local recurrence-free survival (87.1% vs. 90.7%; p = 0.164) or disease-free survival (77.9% vs. 81.6%; p = 0.222) rates. CONCLUSIONS A preoperative TND ≤ 1 cm on imaging should not be contraindicated to NSM as long as there is no involvement of NAC clinically or on imaging and if retroareolar margins are confirmed to be negative for tumor cells.
Collapse
Affiliation(s)
- Zhen-Yu Wu
- Department of Breast Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China.,Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hee Jeong Kim
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jongwon Lee
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Il Yong Chung
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jisun Kim
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sae-Byul Lee
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Byung-Ho Son
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jing Han
- Department of Breast Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hyun Ho Han
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin-Sup Eom
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Bae Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyung Hae Jung
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Gyungyub Gong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hak Hee Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sei-Hyun Ahn
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - BeomSeok Ko
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
23
|
Choi M, Frey JD. Optimizing Aesthetic Outcomes in Breast Reconstruction After Nipple-Sparing Mastectomy. Aesthet Surg J 2020; 40:S13-S21. [PMID: 33202012 DOI: 10.1093/asj/sjaa139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Nipple-sparing mastectomy (NSM) has been associated with improved quality of life and patient satisfaction with similar oncologic outcomes compared with traditional mastectomy techniques. By conserving the nipple-areola complex and the majority of the breast skin envelope, NSM allows for improved aesthetic outcomes after breast reconstruction. However, the technique is also associated with a steep learning curve that must be considered to achieve optimal outcomes. It is important that the plastic surgeon functions in concert with the extirpative breast surgeon to optimize outcomes because the reconstruction is ultimately dependent on the quality of the overlying mastectomy flaps. Various other factors influence the complex interplay between aesthetic and reconstructive outcomes in NSM, including preoperative evaluation, specific implant- and autologous-based considerations, as well as techniques to optimize and correct nipple-areola complex position. Management strategies for complications necessary to salvage a successful reconstruction are also reviewed. Lastly, techniques to expand indications for NSM and maximize nipple viability as well as preshape the breast are discussed. Through thoughtful preoperative planning and intraoperative technique, ideal aesthetic results in NSM may be achieved.
Collapse
Affiliation(s)
- Mihye Choi
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | - Jordan D Frey
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| |
Collapse
|
24
|
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.
Collapse
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
| |
Collapse
|
25
|
Park S, Yoon C, Bae SJ, Cha C, Kim D, Lee J, Ahn SG, Roh TS, Kim YS, Jeong J. Comparison of complications according to incision types in nipple-sparing mastectomy and immediate reconstruction. Breast 2020; 53:85-91. [PMID: 32653836 PMCID: PMC7375566 DOI: 10.1016/j.breast.2020.06.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/15/2020] [Accepted: 06/28/2020] [Indexed: 02/06/2023] Open
Abstract
Background Nipple-sparing mastectomy (NSM), followed by immediate reconstruction (IR) of the breast, has become a preferred surgical procedure with good cosmesis results and patient satisfaction. However, nipple-areolar complex (NAC) ischemia and necrosis remain major problems after NSM and IR. Methods We retrospectively analyzed patients who underwent NSM and IR at Gangnam Severance Hospital from January 2009 to June 2018. We compared the patient characteristics and complication rate among three different incisions (inframammary fold [IMF], radial, periareolar). Additionally, we identified the risk factors of NAC necrosis. Results Data from 290 eligible breasts in 275 patients were analyzed. Patients with IMF incision had relatively lower breast weights. The overall complication rate was the highest with periareolar incision and the lowest with IMF incision (42.6% vs. 18.8%, p < 0.001). The rate of NAC ischemia or necrosis was significantly different among the three incisions (9.7%, 17.0%, and 31.1% in IMF, radial, and periareolar, respectively; p < 0.001). Moreover, surgical treatments were more frequently needed in patients with periareolar incision. Periareolar incision, short distance from the tumor to the nipple base, and large breast weight were independent risk factors of NAC ischemia or necrosis in multivariable analysis. Conclusions Compared with IMF incision, periareolar incision was associated with higher incidences of surgical complications and NAC necrosis. Careful consideration is needed when planning NSM in patients with a large breast volume or a tumor close to the nipple. Periareolar incision shows higher complication rate in nipple-sparing mastectomy. Periareolar incision is a risk factor for nipple-areolar complex necrosis. Other risk factors include tumor-nipple distance and breast weight.
Collapse
Affiliation(s)
- Soeun Park
- Department of Breast Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea; Department of Surgery, CHA Ilsan Medical Center, CHA University, Goyang, South Korea
| | - Changik Yoon
- Department of Breast Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Soong June Bae
- Department of Breast Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Chihwan Cha
- Department of Breast Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Dooreh Kim
- Department of Breast Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Janghee Lee
- Department of Breast Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung Gwe Ahn
- Department of Breast Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Tai Suk Roh
- Department of Plastic and Reconstructive Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Seok Kim
- Department of Plastic and Reconstructive Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Joon Jeong
- Department of Breast Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
| |
Collapse
|
26
|
Outcomes of Volume Replacement Oncoplastic Breast-Conserving Surgery Using Chest Wall Perforator Flaps: Comparison with Volume Displacement Oncoplastic Surgery and Total Breast Reconstruction. Plast Reconstr Surg 2020; 146:14-27. [DOI: 10.1097/prs.0000000000006911] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
27
|
Kopkash K, Sisco M, Poli E, Seth A, Pesce C. The modern approach to the nipple‐sparing mastectomy. J Surg Oncol 2020; 122:29-35. [DOI: 10.1002/jso.25909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/13/2020] [Indexed: 01/04/2023]
Affiliation(s)
- Katherine Kopkash
- Department of SurgeryNorthShore University HealthSystem Evanston Illinois
| | - Mark Sisco
- Division of Plastic SurgeryNorthShore University HealthSystem Evanston Illinois
| | - Elizabeth Poli
- Department of SurgeryUniversity of Chicago Chicago Illinois
| | - Akhil Seth
- Division of Plastic SurgeryNorthShore University HealthSystem Evanston Illinois
| | - Catherine Pesce
- Department of SurgeryNorthShore University HealthSystem Evanston Illinois
| |
Collapse
|
28
|
Jun S, Bae SJ, Cha YJ, Cha C, Park S, Kim D, Lee J, Ahn SG, Son EJ, Jeong J. Significance of Non-Mass Enhancement in the Subareolar Region on Preoperative Breast Magnetic Resonance Imaging for Nipple-Sparing Mastectomy. Clin Breast Cancer 2020; 20:e458-e468. [PMID: 32201166 DOI: 10.1016/j.clbc.2020.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 02/13/2020] [Accepted: 02/15/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The eligibility for nipple-sparing mastectomy (NSM) regarding subareolar non-mass enhancement (NME) on breast magnetic resonance imaging (MRI) was not clear. This study aimed to evaluate the eligibility for NSM according to the NME-to-nipple distance on preoperative breast MRI. METHODS We identified patients with breast cancer who underwent mastectomy with NME suspected of malignancy in the subareolar region on preoperative breast MRI. The incidence of nipple invasion was pathologically evaluated according to the NME-to-nipple distance on breast MRI, and the clinicopathologic factors related to pathologic nipple invasion were analyzed. RESULTS Of 137 patients, 55 (40.1%) had NME extension to the nipple, 53 (38.7%) had radiologic distance less than 2 cm, and 29 (21.2%) had radiologic distance of 2 cm or more. The rate of pathologic nipple invasion was 52.7% (29 of 55) in patients with NME extension to nipple, 7.5% (4 of 53) in patients with NME-to-nipple distance less than 2 cm, and 3.4% (1 of 29) in patients with NME-to-nipple distance of 2 cm or more (P < .001). NME extension to the nipple was an independent risk factor for pathologic nipple invasion (odds ratio 21.702; 95% confidence interval, 2.613-180.225; P = .004). The survival outcome was not different between NSM and conventional total mastectomy/skin-sparing mastectomy in patients with radiologic distance less than 2 cm, but without NME extension to the nipple. CONCLUSIONS NSM is an acceptable procedure in patients with breast cancer with a low incidence of pathologic nipple invasion when there is no evidence of NME extension to the nipple on preoperative breast MRI.
Collapse
Affiliation(s)
- Shiyeol Jun
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Soong June Bae
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Jin Cha
- Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chihwan Cha
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Soeun Park
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dooreh Kim
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Janghee Lee
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Gwe Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Eon Ju Son
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
29
|
|
30
|
Ischemic Complications after Nipple-sparing Mastectomy: Predictors of Reconstructive Failure in Implant-based Reconstruction and Implications for Decision-making. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2280. [PMID: 31333984 PMCID: PMC6571321 DOI: 10.1097/gox.0000000000002280] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 04/09/2019] [Indexed: 12/15/2022]
Abstract
Background: Mastectomy flap and nipple–areola complex (NAC) ischemia can be devastating complications after nipple-sparing mastectomy (NSM). Predictors of reconstructive failure with major skin envelope ischemia and implications for decision-making remain to be fully elucidated. Methods: All cases of implant-based reconstruction after NSM from 2006 to June 2018 with mastectomy flap necrosis or NAC necrosis requiring debridement were reviewed. Data on patient demographics, operative characteristics, additional complications, and the nature and management of ischemic complications were collected and analyzed. Results: Out of 1045 NSMs, 70 cases (6.7%) had major ischemic complications. Fifty-two cases (74.3% of major ischemic complications) had isolated major mastectomy flap necrosis, 7 (10%) had full NAC necrosis and 11 (15.7%) had both. Five cases (7.1%) underwent implant exchange at the time of debridement and 15 cases (21.4%) required explantation. Explanted cases had significantly lower body mass index (22.3 versus 24.7, P = 0.013) and larger debridement size (49.5 cm2 versus 17.6 cm2, P = 0.0168). Additionally, explanted cases had a higher rate of acellular dermal matrix/mesh (100% versus 45.5%, P < 0.0001), prior radiation (20.0% versus 0%, P = 0.0083), immediate implants (46.7% versus 20.0%, P = 0.0491), major infection (30.0% versus 1.8%, P = 0.028), and both major mastectomy flap/NAC necrosis (33.3% versus 10.9%, P = 0.0494). Conclusions: NSM cases with major ischemia requiring explantation had a lower body mass index and significantly higher rate of preoperative radiation, immediate implant placement, use of acellular dermal matrix/mesh, and concomitant major infection. These variables should be taken into account when discussing risks with patients preoperatively and assessing the quality of mastectomy flaps and subsequent reconstructive choices intraoperatively.
Collapse
|