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Shanno JN, Daly AE, Anderman KJ, Santa Cruz HS, Webster AJ, Pride RM, Specht MC, Gadd MA, Oseni TO, Verdial FC, Ozmen T, Kwait R, Colwell AS, Smith BL. Positive Nipple Margins in Nipple-Sparing Mastectomy: Management of Nipples Containing Cancer or Atypia. Ann Surg Oncol 2024; 31:5148-5156. [PMID: 38691238 DOI: 10.1245/s10434-024-15362-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/09/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) is an oncologically safe approach for breast cancer treatment and prevention; however, there are little long-term data to guide management for patients whose nipple margins contain tumor or atypia. METHODS NSM patients with tumor or atypia in their nipple margin were identified from a prospectively maintained, single-institution database of consecutive NSMs. Patient and tumor characteristics, treatment, recurrence, and survival data were assessed. RESULTS A total of 3158 NSMs were performed from June 2007 to August 2019. Nipple margins contained tumor in 117 (3.7%) NSMs and atypia only in 164 (5.2%) NSMs. Among 117 nipple margins that contained tumor, 34 (29%) margins contained invasive cancer, 80 (68%) contained ductal carcinoma in situ only, and 3 (3%) contained lymphatic vessel invasion only. Management included nipple-only excision in 67 (57%) breasts, nipple-areola complex excision in 35 (30%) breasts, and no excision in 15 (13%) breasts. Only 23 (24%) excised nipples contained residual tumor. At 67 months median follow-up, there were 2 (1.8%) recurrences in areolar or peri-areolar skin, both in patients with nipple-only excision. Among 164 nipple margins containing only atypia, 154 (94%) nipples were retained. At 60 months median follow-up, no patient with atypia alone had a nipple or areola recurrence. CONCLUSIONS Nipple excision is effective management for nipple margins containing tumor. No intervention is required for nipple margins containing only atypia. Our results support broad eligibility for NSM with careful nipple margin assessment.
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MESH Headings
- Humans
- Female
- Nipples/surgery
- Nipples/pathology
- Breast Neoplasms/surgery
- Breast Neoplasms/pathology
- Middle Aged
- Margins of Excision
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Neoplasm Recurrence, Local/surgery
- Neoplasm Recurrence, Local/pathology
- Follow-Up Studies
- Adult
- Organ Sparing Treatments/methods
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Ductal, Breast/pathology
- Prognosis
- Survival Rate
- Aged
- Prospective Studies
- Mastectomy, Subcutaneous/methods
- Neoplasm Invasiveness
- Neoplasm, Residual/surgery
- Neoplasm, Residual/pathology
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Affiliation(s)
- Julia N Shanno
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Abigail E Daly
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Kyle J Anderman
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Heidi S Santa Cruz
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Alexandra J Webster
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Robert M Pride
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Michelle C Specht
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Michele A Gadd
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Tawakalitu O Oseni
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Francys C Verdial
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Tolga Ozmen
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Rebecca Kwait
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Amy S Colwell
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Barbara L Smith
- Breast Section, Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA.
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Kopicky L, Fan B, Valente SA. Intraoperative evaluation of surgical margins in breast cancer. Semin Diagn Pathol 2024:S0740-2570(24)00065-0. [PMID: 38965021 DOI: 10.1053/j.semdp.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 06/12/2024] [Accepted: 06/20/2024] [Indexed: 07/06/2024]
Abstract
Achieving clear resection margins at the time of lumpectomy is essential for optimal patient outcomes. Margin status is traditionally determined by pathologic evaluation of the specimen and often is difficult or impossible for the surgeon to definitively know at the time of surgery, resulting in the need for re-operation to obtain clear surgical margins. Numerous techniques have been investigated to enhance the accuracy of intraoperative margin and are reviewed in this manuscript.
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Affiliation(s)
- Lauren Kopicky
- Division of Breast Surgical Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Betty Fan
- Department of Breast Surgery, University of Chicago, Chicago, IL, USA
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3
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Serio F, Manna E, La Pinta M, Arienzo F, Costarelli L, Zarba Meli E, Loreti A, Mastropietro T, Broglia L, Ascarelli A, Apicella G, Rossi R, Piccolino G, Fortunato L. Intraoperative Examination of Retro-Areolar Margin is not Routinely Necessary During Nipple-Sparing Mastectomy for Cancer. Ann Surg Oncol 2023; 30:6488-6496. [PMID: 37391672 DOI: 10.1245/s10434-023-13726-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/23/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Intraoperative examination of retro-areolar margin (IERM) often is used during nipple-sparing mastectomy (NSM) for cancer, but there is no robust data regarding its real advantage. METHODS Consecutive patients undergoing NSM for cancer with omission of IERM according to institutional protocols from 2016 to 2021 were retrospectively analyzed. The decision to maintain or remove the Nipple-Areola Complex (NAC) after definitive pathology was taken at the multidisciplinary meeting. RESULTS Among 162 women operated in the study period, the presence of neoplastic cells within 2 mm from the inked retroareolar margin (RAM) was detected at permanent pathology in 17 cases (10.5%). Nipple-Areola-Complex (NAC) was removed postoperatively in five patients (3%) for margins <1 mm, the other 12 were observed, whereas postoperative NAC necrosis required surgical removal in additional five cases (3%). The NAC was thus preserved in 152 of 162 patients (94%). At multivariate analysis, RAM ≤2 mm was associated with radiological tumor-to-nipple distance less than or equal to 1 cm (p = 0.04) and Ki67 label index ≥ 20 (p = 0.04), whereas multifocality/multicentricity showed a trend towards significance (p = 0.07). At a median follow-up of 46 months, five locoregional relapses occurred (3%), only one of them involving the NAC (0, 6%). Locoregional relapse and overall survival for patients with RAM > or < 2 mm were not different. CONCLUSIONS IERM is not routinely necessary during NSM for cancer, because its omission is associated with a very low return to the operating room, it is oncologically safe, and associated pitfalls are avoided. Further studies are necessary to confirm these findings.
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Affiliation(s)
- Francesca Serio
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
- Department of Surgical Science, University of Rome "Tor Vergata", Rome, Italy
| | - Elena Manna
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy.
| | | | | | | | | | - Andrea Loreti
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
| | | | - Laura Broglia
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
| | | | | | - Rosalinda Rossi
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Gianmarco Piccolino
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
- Department of Surgical Sciences, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Lucio Fortunato
- Breast Center, San Giovanni-Addolorata Hospital, Rome, Italy
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4
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Sanchez D, Bloomquist E, Wright H, Barnavon Y. Immediate Nipple Reconstruction With Areolar Flaps After Nipple Excision. Ann Plast Surg 2023; 91:211-214. [PMID: 37489961 DOI: 10.1097/sap.0000000000003570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
ABSTRACT Nipple-sparing mastectomies (NSMs) have become a common surgical approach in the management of invasive breast cancers and ductal carcinoma in situ, and as a risk-reducing approach in genetically predisposed patients. The current standard of care in the management of positive nipple margin after NSM is total excision of the nipple-areola complex. In this article, we aimed to present a case series describing a novel approach to positive nipple margins with nipple-only excision and immediate nipple reconstruction using areolar flaps in patients who underwent NSM for noninvasive tumors. We conducted a retrospective review of patients who underwent NSM and were found to have positive nipple margins and underwent subsequent nipple excision with immediate areolar flap reconstruction. We identified 6 patients who underwent NSM and were found to have nipple margins-5 for ductal carcinoma in situ and 1 for invasive ductal carcinoma. These patients underwent nipple excision with immediate reconstruction using "sickle" flaps. We concluded that if nipple excision and immediate reconstruction with areolar sickle flaps can be performed, it results in good aesthetic outcomes without compromising oncologic results.
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Affiliation(s)
| | | | | | - Yoav Barnavon
- Plastic Surgery, Memorial Healthcare System, Hollywood, FL
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Webster AJ, Shanno JN, Santa Cruz HS, Kelly BN, Garstka M, Henriquez A, Specht MC, Gadd MA, Verdial FC, Nguyen A, Oseni TO, Coopey SB, Smith BL. Oncologic Safety of Nipple-Sparing Mastectomy for Breast Cancer in BRCA Gene Mutation Carriers: Outcomes at 70 Months Median Follow-Up. Ann Surg Oncol 2023; 30:3215-3222. [PMID: 36604360 DOI: 10.1245/s10434-022-13006-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/04/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Retention of the nipple-areola complex with nipple-sparing mastectomy (NSM) techniques provides a more natural cosmetic result than procedures that sacrifice the nipple. While the oncologic safety of NSM is established by several studies, there is little long-term data on outcomes in BRCA mutation carriers with breast cancer. PATIENTS AND METHODS BRCA1/2 mutation carriers who underwent NSM and immediate reconstruction from 2008 to 2019 were reviewed and patients with breast cancer on biopsy or final pathology were included. Patient demographics and tumor characteristics, as well as treatment, recurrence, and survival data were collected. RESULTS A total of 114 therapeutic NSM were performed in 105 BRCA mutation carriers (56 BRCA1, 47 BRCA2, and two women with both mutations). Median age was 45 years. Cancers were 18% stage 0, 52% stage I, 27% stage II, and 3% stage III. Mean invasive tumor size was 1.6 cm and 33 (35%) invasive tumors were triple negative. There were five (4.4%) positive nipple margins on final pathology; all underwent nipple excision. Most patients (80, 76%) received systemic therapy: 65 (62%) received chemotherapy and 48 (46%) received endocrine therapy. At 70 months median follow-up (range 15-150 months), no patient had developed a recurrence in the retained nipple-areola complex or at the site of a nipple excised for a positive margin. The rate of locoregional recurrence outside the nipple was 2.6%, and the rate of distant recurrence was 3.8%. Overall survival was 96%. CONCLUSIONS NSM is a safe option for BRCA1 and BRCA2 mutation carriers who undergo mastectomy for breast cancer.
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Affiliation(s)
- Alexandra J Webster
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Julia N Shanno
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Heidi S Santa Cruz
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Bridget N Kelly
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Meghan Garstka
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Anthony Henriquez
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michelle C Specht
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michele A Gadd
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Francys C Verdial
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Anvy Nguyen
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Tawakalitu O Oseni
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Suzanne B Coopey
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Barbara L Smith
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA.
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6
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Esgueva AJ, Noordhoek I, Kranenbarg EMK, Espinosa-Bravo M, Mátrai Z, Zhygulin A, Irmejs A, Mavioso C, Meani F, González E, Özdemir M, Allweis T, Rogowski K, Dos Santos CR, Mora H, Ponzone R, Samorani D, van de Velde C, Audisio RA, Rubio IT. Health-Related Quality of Life After Nipple-Sparing Mastectomy: Results From the INSPIRE Registry. Ann Surg Oncol 2021; 29:1722-1734. [PMID: 34748122 DOI: 10.1245/s10434-021-10930-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/24/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR) is increasingly used for both breast cancer (TNSM) and risk reduction (RRNSM). The aim of the study is to report the results of the INSPIRE registry assessing health-related quality of life (HRQoL) comparing baseline and 1-year follow-up, regarding surgical indications and chemotherapy (CT) received. METHODS INSPIRE is a prospective database including women undergoing NSM and IBR from 18 countries. HRQoL was measured using EORTC QLQC30 and QLQ-BR23 before surgery and after 1 year. RESULTS A total of 677 women were included, of whom 537 (79.3%) underwent TNSM and 140 (21.6%) RRNSM: in total, 806 NSM (556 TNSM and 250 RRNSM). Nipple involvement was present in 7.73% of TNSM and incidental carcinoma in 1.2% of the RRNSM group. Out of the overall 537 patients with systemic treatment, 177 (32.96%) received neoadjuvant chemotherapy (NCT) and 118 (21.92%) adjuvant chemotherapy (CT). A total of 227 patients (28.16%) developed at least one complication postoperatively, 164 (29.5%) in the TNSM group and 63 (25.2%) in the RRNSM group. The TNSM group improved in global health status and emotional functioning after 1 year. No differences were found when comparing HRQoL at 1 year between patients who received NCT and those who received adjuvant CT. The RRNSM group showed improvement in HRQoL, with better emotional functioning and fatigue after 1 year. CONCLUSIONS This registry reports HRQoL findings after NSM. The impact of CT on worse HRQoL is independent from its timing. Patients with RRNSM showed an improved HRQoL at 1-year follow-up. Discussion of HRQoL outcomes with patients will facilitate the informed decision-making when considering NSM.
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Affiliation(s)
- Antonio J Esgueva
- Breast Surgical Oncology Unit, Clinica Universidad de Navarra, Cancer Center Universidad de Navarra, Madrid, Spain
| | - Iris Noordhoek
- Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Zoltán Mátrai
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary
| | - Andrii Zhygulin
- Breast Unit, LISOD, Hospital of Israeli Oncology, Kiev, Ukraine
| | - Arvids Irmejs
- Breast Unit, Pauls Stradins Clinical University Hospital, Institute of Oncology, Riga Stradins University, Riga, Latvia
| | - Carlos Mavioso
- Breast Unit Centro Clínico Champalimaud, Lisboa, Portugal
| | - Francesco Meani
- Centro di Senologia della Svizzera Italiana, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | | | | | | | | | | | - Henrique Mora
- Centro Hospitalar Universitário Sao Joao, Porto, Portugal
| | | | | | | | | | - Isabel T Rubio
- Breast Surgical Oncology Unit, Clinica Universidad de Navarra, Cancer Center Universidad de Navarra, Madrid, Spain.
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7
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Huang JJ, Chuang EYH, Cheong DCF, Kim BS, Chang FCS, Kuo WL. Robotic-assisted nipple-sparing mastectomy followed by immediate microsurgical free flap reconstruction: Feasibility and aesthetic results - Case series. Int J Surg 2021; 95:106143. [PMID: 34666195 DOI: 10.1016/j.ijsu.2021.106143] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 10/05/2021] [Accepted: 10/07/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The application of robotic-assisted nipple-sparing mastectomy (R-NSM) has allowed mastectomy to be performed via a small incision. Breast reconstruction with free autologous tissue results in the most natural and long-lasting results, however, its application in R-NSM can be difficult via the small incision and haven't been explored in depth. The purpose of the study was to investigate the feasibility and aesthetic outcome of free perforator flap breast reconstruction via small lateral chest wall incision after R-NSM. MATERIALS AND METHODS A retrospective chart review was conducted to identify patients who received R-NSM and free perforator flap reconstruction as the study group and patients who received conventional nipple-sparing mastectomy (C-NSM) and free perforator flap reconstruction as the control group from January 2018 to August 2020 by single reconstructive surgeon. Patient demographic data, complications from both mastectomy and reconstruction, status of resection margin and oncological outcome were reviewed. Aesthetic outcome was evaluated by 9 plastic surgeons. RESULTS A total of 63 patients were included of which 22 (34.9%) received R-NSM and 41 (65.1%) received C-NSM. Their demographic data, reconstruction flaps, overall complication rate and follow up time were similar. Unlike C-NSM, majority of the R-NSM groups used the thoracodorsal or lateral thoracic vessels as the recipient vessels. Patients in the R-NSM group has smaller scar and better aesthetic outcome in the symmetry of breast inframammary fold, scar location and visibility, and overall aesthetic outcome. CONCLUSION Although with difficulty in microvascular anastomosis and flap inset and shaping, R-NSM with perforator flap reconstruction presented with equal surgical and oncological safety with C-NSM and even better aesthetic results.
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Affiliation(s)
- Jung-Ju Huang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan College of Medicine, Chang Gung University, Taoyuan, Taiwan Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan Department of General Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan Division of Breast Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Switzerland Division of Craniofacial Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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8
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Yamashita Y, Tsunoda H, Nagura N, Kajiura Y, Yoshida A, Takei J, Suzuki K, Watanabe T, Iwahira Y, Yamauchi H, Hayashi N. Long-Term Oncologic Safety of Nipple-Sparing Mastectomy With Immediate Reconstruction. Clin Breast Cancer 2021; 21:352-359. [PMID: 33526379 DOI: 10.1016/j.clbc.2021.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/01/2021] [Accepted: 01/03/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND We assessed the long-term oncologic safety of nipple-sparing mastectomy (NSM) compared to skin-sparing mastectomy (SSM) for primary breast cancer patients with immediate reconstruction. PATIENTS AND METHODS Data of stage 0-III primary breast cancer patients undergoing NSM (n = 190) or SSM (n = 729) from June 2006 to December 2012 were retrospectively collected. Nipple-tumor distance (NTD) was measured on pretreatment mammography, magnetic resonance imaging, or ultrasonography findings. NSM patients with NTD < 1 cm were excluded. Locoregional recurrence (LRR) rates were compared between groups. Disease-free survival (DFS) and overall survival (OS) according to surgical procedure were assessed. RESULTS The median (range) follow-up period for NSM and SSM was 71 (10-131) months and 79 (9-140) months, respectively. LRR developed in 11 patients with invasive ductal carcinoma (5.8%) for NSM and 44 (42 in patients with invasive ductal carcinoma and 2 in patients with ductal carcinoma-in-situ) (6.0%) for SSM. Hormone receptor and HER2 status were not associated with LRR in either group. DFS and OS rates did not differ between groups (DFS: 89.3% for NSM, 89.3% for SSM, P = .87; OS: 98.4% for NSM, 94.5% for SSM, P = .43). CONCLUSION NSM with immediate reconstruction was as safe as SSM for primary breast cancer with respect to prognosis and local control, regardless of the presence of invasive carcinoma or breast cancer subtype.
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Affiliation(s)
- Yuji Yamashita
- Department of Breast Surgical Oncology, St Luke's International Hospital, Tokyo, Japan
| | - Hiroko Tsunoda
- Department of Radiology, St Luke's International Hospital, Tokyo, Japan
| | - Naomi Nagura
- Department of Breast Surgical Oncology, St Luke's International Hospital, Tokyo, Japan
| | - Yuka Kajiura
- Department of Breast Surgical Oncology, St Luke's International Hospital, Tokyo, Japan
| | - Atsushi Yoshida
- Department of Breast Surgical Oncology, St Luke's International Hospital, Tokyo, Japan
| | - Junko Takei
- Department of Breast Surgical Oncology, St Luke's International Hospital, Tokyo, Japan
| | - Koyu Suzuki
- Department of Pathology, St Luke's International Hospital, Tokyo, Japan
| | | | - Yoshiko Iwahira
- Department of plastic surgery, Breast Surgery Clinic, Tokyo, Japan
| | - Hideko Yamauchi
- Department of Breast Surgical Oncology, St Luke's International Hospital, Tokyo, Japan
| | - Naoki Hayashi
- Department of Breast Surgical Oncology, St Luke's International Hospital, Tokyo, Japan; Department of Breast Surgery, Watanabe Hospital, Tokyo, Japan.
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9
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Hogan KO, Lai SM, Wagner JL, Fan F. The utility of intraoperative retroareolar margin frozen section assessment and the management of atypical epithelial proliferative lesions at the retroareolar margin in nipple-sparing mastectomies. Ann Diagn Pathol 2021; 51:151697. [PMID: 33444902 DOI: 10.1016/j.anndiagpath.2020.151697] [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: 12/03/2020] [Accepted: 12/21/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Nipple-sparing mastectomy (NSM) has become more frequently utilized due to superior psychological and cosmetic outcomes. The aim of this study was to evaluate the accuracy and utility of intraoperative frozen section evaluation of the retroareolar margin (RAM) in NSM. The management of atypical epithelial proliferative lesions at the RAM was also reviewed and discussed. METHODS A single institution, retrospective analysis was performed on all therapeutic NSM patients with intraoperative evaluation of the RAM from 2014 to 2018. Patient demographics, tumor characteristics, pathologic assessment of the RAM, surgical management, and clinical follow-up were reviewed. RESULTS Seventy-four nipple-sparing mastectomies with intraoperative evaluation of RAMs were identified. Concordance was 95% between frozen and permanent section diagnoses with 4 cases representing false negatives and no false positives. There were no instances of nipple-areolar complex (NAC) recurrence in all cases with preserved NACs (mean follow up: 750 days). In the 9 cases where NACs were excised based on intraoperative RAM evaluation, the findings in the excised NACs were negative in 6 and ductal carcinoma in situ in 3 cases. Postoperative measurement of the tumor to nipple distance was the only statistically significant variable associated with a positive RAM by multivariable logistic regression (OR 0.475; 95% CI 0.238-0.946). CONCLUSIONS Intraoperative RAM evaluation demonstrated high concordance with permanent histology. Negative RAM, including atypical epithelial proliferative lesions, led to NAC preservation without recurrence. Positive RAM alone did not predict NAC involvement, although pagetoid spread of ductal carcinoma in situ along nipple ducts may predict NAC positivity.
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Affiliation(s)
- Keenan O Hogan
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Sue M Lai
- Department of Population Health, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jamie L Wagner
- Department of Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Fang Fan
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS, USA.
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10
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Son JD, Piper M, Hewitt K, Alvarado M, Esserman LJ, Ewing C, Wong JM, Mukhtar RA. Oncological Outcomes of Total Skin-Sparing Mastectomy for Invasive Lobular Carcinoma of the Breast: A 20-Year Institutional Experience. Ann Surg Oncol 2020; 28:2555-2560. [PMID: 33025355 DOI: 10.1245/s10434-020-09042-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 08/03/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Although rates of total skin-sparing (nipple-sparing) mastectomies are increasing, the oncologic safety of this procedure has not been evaluated in invasive lobular carcinoma (ILC). ILC is the second most common type of breast cancer, and its diffuse growth pattern and high positive margin rates potentially increase the risk of poor outcomes from less extensive surgical resection. METHODS We compared time to local recurrence and positive margin rates in a cohort of 300 patients with ILC undergoing either total skin-sparing mastectomy (TSSM), skin-sparing mastectomy, or simple mastectomy between the years 2000-2020. Data were obtained from a prospectively maintained institutional database and were analyzed by using univariate statistics, the log-rank test, and multivariate Cox proportional hazards models. RESULTS Of 300 cases, mastectomy type was TSSM in 119 (39.7%), skin-sparing mastectomy in 52 (17.3%), and simple mastectomy in 129 (43%). The rate of TSSM increased significantly with time (p < 0.001) and was associated with younger age at diagnosis (p = 0.0007). There was no difference in time to local recurrence on univariate and multivariate analysis, nor difference in positive margin rates by mastectomy type. Factors significantly associated with shorter local recurrence-free survival were higher tumor stage and tumor grade. CONCLUSIONS TSSM can be safely offered to patients with ILC, despite the diffuse growth pattern seen in this tumor type.
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Affiliation(s)
- Jennifer D Son
- Division of General Surgery, Department of Surgery, University of California, San Francisco, CA, USA
| | - Merisa Piper
- Division of Plastic Surgery, Department of Surgery, University of California, San Francisco, CA, USA
| | - Kelly Hewitt
- Division of General Surgery, Department of Surgery, University of California, San Francisco, CA, USA
| | - Michael Alvarado
- Division of General Surgery, Department of Surgery, University of California, San Francisco, CA, USA
| | - Laura J Esserman
- Division of General Surgery, Department of Surgery, University of California, San Francisco, CA, USA
| | - Cheryl Ewing
- Division of General Surgery, Department of Surgery, University of California, San Francisco, CA, USA
| | - Jasmine M Wong
- Division of General Surgery, Department of Surgery, University of California, San Francisco, CA, USA
| | - Rita A Mukhtar
- Division of General Surgery, Department of Surgery, University of California, San Francisco, CA, USA.
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Zhu Y, Liu S, Feng C, Liu C, Wang Z, Yu K, Wang J, Zeng X. The Delivery Materials with Chemotherapy Drugs for Treatment of the Positive Margin in Solid Tumors. Tissue Eng Part A 2020; 27:536-548. [PMID: 32762299 DOI: 10.1089/ten.tea.2020.0076] [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: 12/09/2022] Open
Abstract
The positive surgical margins in solid tumors has been a disturbing issue for clinicians. Chemotherapy is an important method to deal with the positive margin. However, systemic chemotherapy is required for long-term administration and has great side effects on health, which cause great pain to the patients. Local administration of slow-release materials provides an opportunity to improve the situation. In this study, we utilized electrospinning technology to create the drug sustained-release materials with nanofibrous structure, which were made from polylactic acid and a certain proportion of chemotherapy drugs (gemcitabine and cisplatin). In vitro release behavior of the drug sustained-release materials were explored by the high-performance liquid chromatography. The antitumor efficacy of the drug sustained-release materials was preliminarily verified in prostate cancer and breast cancer in vitro. Through animal models of breast cancer, the drug sustained-release materials in the treatment of the positive margin has been well documented in vivo, and we also found that the drug sustained-release materials could definitely reduce the liver damage and myelosuppression compared with systemic chemotherapy. In summary, the experimental results showed that the local administration of the drug sustained-release materials could effectively inhibit the growth of the positive incision margins and definitely reduce the partial side effects associated with systemic chemotherapy.
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Affiliation(s)
- Yunpeng Zhu
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiliang Liu
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunxiang Feng
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chang Liu
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhixian Wang
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kai Yu
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Wang
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoyong Zeng
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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12
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Robot-assisted Mastectomy Followed by Immediate Autologous Microsurgical Free Flap Reconstruction: Techniques and Feasibility in Three Different Breast Cancer Surgical Scenarios. Clin Breast Cancer 2019; 20:e1-e8. [PMID: 31780382 DOI: 10.1016/j.clbc.2019.06.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 06/21/2019] [Accepted: 06/23/2019] [Indexed: 11/23/2022]
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13
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Alsharif E, Ryu JM, Choi HJ, Nam SJ, Kim SW, Yu J, Chae BJ, Lee SK, Lee JE. Oncologic Outcomes of Nipple-Sparing Mastectomy with Immediate Breast Reconstruction in Patients with Tumor-Nipple Distance Less than 2.0 cm. J Breast Cancer 2019; 22:613-623. [PMID: 31897334 PMCID: PMC6933026 DOI: 10.4048/jbc.2019.22.e48] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/10/2019] [Indexed: 11/30/2022] Open
Abstract
Purpose Although the indications for nipple-sparing mastectomy (NSM) are expanding, there remains a debate regarding the oncologic outcomes of patients treated with this method, especially those with a short tumor–nipple distance (STND). The aim of this study was to compare the long-term oncologic outcomes between patients with a long tumor–nipple distance (LTND) (≥ 2.0 cm) and those with STND (< 2.0 cm). Methods This was a retrospective study in which 266 patients who underwent NSM with immediate breast reconstruction between January 2008 and December 2014 at a single institution were enrolled. Of these patients, 21 were excluded because of loss to follow-up; thus, 245 patients were finally analyzed. All patients underwent preoperative breast magnetic resonance imaging and intraoperative frozen biopsy. Results The mean age of the patients was 42.4 years. STND was identified in 128 patients, and LTND in 117 patients. The mean follow-up period was 60.5 months. There were no significant differences between the 2 groups with respect to lymphovascular invasion, nuclear grade, nodal status, and subtype (p = 0.339, 0.372, 0.955, and 0.338, respectively). The STND group had significantly smaller tumors than the LTND group (p = 0.005). The median TND in the STND and LTND groups was 0.7 cm and 3.0 cm, respectively. Locoregional recurrence was reported in 4 patients in the STND group (3.1%) and 6 (5.1%) in the LTND group. A total of 3 patients died (1.2%; 2 in the STND group and one in the LTND group). There was no significant difference between the 2 groups with respect to disease-free survival or local recurrence-free survival (p = 0.334 and p = 0.477, respectively). Conclusion The long-term oncologic outcomes of patients treated with NSM did not significantly differ according to TND when the intraoperative frozen biopsy was negative for tumor cells.
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Affiliation(s)
- Emad Alsharif
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Division of Breast and Endocrine Surgery, Specialized Surgical Unit, King Abdullah Medical City, Makkah, Saudi Arabia
| | - Jai Min Ryu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Jun Choi
- Department of Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Seok Jin Nam
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok Won Kim
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jonghan Yu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung Joo Chae
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Se Kyung Lee
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Eon Lee
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Tousimis EA. ASO Author Reflections: Management of the Nipple Margin After Mastectomy: A Trend Toward a more Minimally Invasive Approach. Ann Surg Oncol 2018; 26:537-538. [PMID: 30536127 DOI: 10.1245/s10434-018-7055-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Indexed: 11/18/2022]
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