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Ray HR, Doren EL, Adamson K, Kong AL, Cortina CS. Risk Factors for Skin Flap and Nipple-Areolar Necrosis in Patients Undergoing Nipple-Sparing Mastectomy With Deep Inferior Epigastric Perforator Flap Reconstruction. Am Surg 2024; 90:2769-2779. [PMID: 38671547 DOI: 10.1177/00031348241250039] [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] [Indexed: 04/28/2024]
Abstract
INTRODUCTION Nipple-sparing mastectomy (NSM) with deep inferior epigastric perforator (DIEP) flap reconstruction is a surgical option for select patients with or at risk of breast cancer. However, post-operative skin flap and nipple-areolar complex (NAC) necrosis remain common complications. This study aimed to identify factors associated with necrosis in patients undergoing NSM with DIEP reconstruction. METHODS A retrospective cohort study was performed from 2015 to 2023. 74 variables were analyzed in patients undergoing NSM with DIEP. Patients were stratified into 3 groups based on post-operative skin/NAC necrosis: none, partial thickness, and full thickness. Comparative and descriptive statistics were performed via t-tests, ANOVA, and chi-squared tests. RESULTS 34 women with 31 breast cancers met inclusion. 44% experienced necrosis: 15% partial thickness and 29% full thickness. The majority were white (85.3%) with mean age of 50 years (SD = 9.11). In patients with immediate DIEP reconstruction, hypoperfused areas identified by SPY angiography increased risk of necrosis (P = .012). Approximately 50% of both partial thickness and full thickness necrosis patients had concerns on SPY angiography. Former smokers in the full thickness necrosis group had more pack years than those without necrosis (9 vs .65 pack years, P = .035). CONCLUSION In patients receiving NSM with DIEP flap reconstruction, those with hypoperfusion on SPY angiography and longer smoking history had higher necrosis rates. This supports the continued used of SPY angiography and the role of pre-operative counseling in former smokers with increased pack years on their risk of necrosis and the role of preventative measures in the perioperative setting.
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Affiliation(s)
- Hannah R Ray
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Erin L Doren
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Karri Adamson
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Amanda L Kong
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA
| | - Chandler S Cortina
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA
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Song R, Lee D, Jung S, Lee S, Kang H, Han J, Woo J, Lee E. Unveiling the Clinical Path of Microinvasive Breast Cancer: A Comparative Study With Tis-T1 Breast Cancer. Cancer Med 2024; 13:e70297. [PMID: 39382213 PMCID: PMC11462587 DOI: 10.1002/cam4.70297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 08/31/2024] [Accepted: 09/22/2024] [Indexed: 10/10/2024] Open
Abstract
PURPOSE The prognosis of microinvasive breast cancer (MIBC) is controversial, with a high reported rate of local recurrence (LR). This study aimed to evaluate the characteristics, treatments, and prognosis of patients with MIBC compared to those with carcinoma in situ (CIS) or early invasive cancer. METHODS Patients who diagnosed with CIS or stage I breast cancer were retrospectively enrolled. Using the Kaplan-Meier method, local recurrence-free survival (LRFS), systemic recurrence-free survival (SRFS), and cancer-specific survival (CSS) were compared according to T stage. The prognostic factors associated with LRFS were identified using the Cox proportional hazards model. RESULTS According to T stage, 517 (21.6%), 200 (8.4%), 207 (8.7%), 363 (15.2%), and 1101 (46.1%) patients had Tis, T1mi, T1a, T1b, and T1c tumors, respectively. The proportion of human epidermal growth factor receptor 2-positive tumors was significantly higher in patients with MIBC (p < 0.0001). The administered adjuvant treatments also showed differences according to T stage (p < 0.0001). During the 73-month median follow-up period, patients with MIBC showed significantly worse LRFS than those with T1a or T1c tumors (p = 0.002). There was no significant difference in SRFS and CSS. In the Cox regression analysis, tumor multiplicity (p = 0.017), Ki-67 (p = 0.025), cancer subtype (p = 0.034), adjuvant endocrine therapy (p = 0.003), and adjuvant radiation therapy (p < 0.0001) were significant prognostic factors associated with LRFS. CONCLUSION The risk of LR was higher in patients with MIBC than in those with small invasive breast cancer. Therefore, if indicated, adjuvant endocrine and radiation therapies should be administered to prevent undertreatment in patients with MIBC.
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Affiliation(s)
- Ran Song
- Department of SurgeryKonyang University Hospital, Konyang University College of MedicineDaejeonRepublic of Korea
| | - Dong‐Eun Lee
- Biostatistics Collaboration Team, Research Core CenterResearch Institute of National Cancer CenterGoyangRepublic of Korea
| | - So‐Youn Jung
- Department of Surgery, Center of Breast CancerNational Cancer CenterGoyangRepublic of Korea
| | - Seeyoun Lee
- Department of Surgery, Center of Breast CancerNational Cancer CenterGoyangRepublic of Korea
| | - Han‐Sung Kang
- Department of Surgery, Center of Breast CancerNational Cancer CenterGoyangRepublic of Korea
| | - Jai Hong Han
- Department of Surgery, Center of Breast CancerNational Cancer CenterGoyangRepublic of Korea
| | - Jaeyeon Woo
- Department of Surgery, Center of Breast CancerNational Cancer CenterGoyangRepublic of Korea
| | - Eun‐Gyeong Lee
- Department of Surgery, Center of Breast CancerNational Cancer CenterGoyangRepublic of Korea
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3
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Kim JH, Ryu JM, Bae SJ, Ko BS, Choi JE, Kim KS, Cha C, Choi YJ, Lee HY, Nam SE, Kim Z, Kang YJ, Lee MH, Lee JE, Park E, Shin HJ, Kim MK, Choi HJ, Kwon SU, Son NH, Park HS, Lee J. Minimal Access vs Conventional Nipple-Sparing Mastectomy. JAMA Surg 2024; 159:1177-1186. [PMID: 39141399 PMCID: PMC11325243 DOI: 10.1001/jamasurg.2024.2977] [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: 03/18/2024] [Accepted: 05/18/2024] [Indexed: 08/15/2024]
Abstract
Importance While nipple-sparing mastectomy (NSM) for breast cancer was only performed using the open method in the past, its frequency using endoscopic and robotic surgical instruments has been increasing rapidly. However, there are limited studies regarding postoperative complications and the benefits and drawbacks of minimal access NSM (M-NSM) compared with conventional NSM (C-NSM). Objective To examine the differences in postoperative complications between C-NSM and M-NSM. Design, Setting, Participants This was a retrospective multicenter cohort study enrolling 1583 female patients aged 19 years and older with breast cancer who underwent NSM at 21 university hospitals in Korea between January 2018 and December 2020. Those with mastectomy without preserving the nipple-areolar complex (NAC), clinical or pathological malignancy in the NAC, inflammatory breast cancer, breast cancer infiltrating the chest wall or skin, metastatic breast cancer, or insufficient medical records were excluded. Data were analyzed from November 2021 to March 2024. Exposures M-NSM or C-NSM. Main Outcomes and Measures Clinicopathological factors and postoperative complications within 3 months of surgery were assessed. Statistical analyses, including logistic regression, were used to identify the factors associated with complications. Results There were 1356 individuals (mean [SD] age, 45.47 [8.56] years) undergoing C-NSM and 227 (mean [SD] age, 45.41 [7.99] years) undergoing M-NSM (35 endoscopy assisted and 192 robot assisted). There was no significant difference between the 2 groups regarding short- and long-term postoperative complications (<30 days: C-NSM, 465 of 1356 [34.29%] vs M-NSM, 73 of 227 [32.16%]; P = .53; <90 days: C-NSM, 525 of 1356 [38.72%] vs M-NSM, 73 of 227 [32.16%]; P = .06). Nipple-areolar complex necrosis was more common in the long term after C-NSM than M-NSM (C-NSM, 91 of 1356 [6.71%] vs M-NSM, 5 of 227 [2.20%]; P = .04). Wound infection occurred more frequently after M-NSM (C-NSM, 58 of 1356 [4.28%] vs M-NSM, 18 of 227 [7.93%]; P = .03). Postoperative seroma occurred more frequently after C-NSM (C-NSM, 193 of 1356 [14.23%] vs M-NSM, 21 of 227 [9.25%]; P = .04). Mild or severe breast ptosis was a significant risk factor for nipple or areolar necrosis (odds ratio [OR], 4.75; 95% CI, 1.66-13.60; P = .004 and OR, 8.78; 95% CI, 1.88-41.02; P = .006, respectively). Conversely, use of a midaxillary, anterior axillary, or axillary incision was associated with a lower risk of necrosis (OR for other incisions, 32.72; 95% CI, 2.11-508.36; P = .01). Necrosis occurred significantly less often in direct-to-implant breast reconstruction compared to other breast reconstructions (OR, 2.85; 95% CI, 1.11-7.34; P = .03). Conclusions and Relevance The similar complication rates between C-NSM and M-NSM demonstrates that both methods were equally safe, allowing the choice to be guided by patient preferences and specific needs.
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Affiliation(s)
- Joo Heung Kim
- Department of Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Jai Min Ryu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soong June Bae
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Beom Seok Ko
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Eun Choi
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - Ku Sang Kim
- Department of Surgery, Kosin University College of Medicine, Gospel Hospital, Busan, Korea
| | - Chihwan Cha
- Department of Surgery, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Korea
| | - Young Jin Choi
- Department of Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Hye Yoon Lee
- Department of Surgery, Korea University Ansan Hospital, Ansan, Korea
| | - Sang Eun Nam
- Department of Surgery, Konkuk University School of Medicine, Seoul, Korea
| | - Zisun Kim
- Department of Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Young-Joon Kang
- Department of Surgery, Incheon St. Mary’s Hospital, The Catholic University of Korea, Incheon, Korea
| | - Moo Hyun Lee
- Department of Surgery, Keimyung University School of Medicine, Daegu, Korea
| | - Jong Eun Lee
- Department of Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Eunhwa Park
- Department of Surgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Hyuk Jai Shin
- Department of Surgery, Myongji Hospital, Hanyang University Medical Center, Goyang, Korea
| | - Min Kyoon Kim
- Department of Surgery, Chung-Ang University Hospital, Seoul, Korea
| | - Hee Jun Choi
- Department of Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Seong Uk Kwon
- Department of Surgery, Konyang University Hospital, Daejeon, Korea
| | - Nak-Hoon Son
- Department of Statistics, Keimyung University, Daegu, Korea
| | - Hyung Seok Park
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jeeyeon Lee
- Department of Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
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Yao R, Du F, Liu R, Tan L, Lian J, Gao L, Zhang H, Huang L, Pan B, Zhou Y, Sun Q, Zhao J, Long X. Breast Modular Resection (BMR) in Nipple-Sparing Mastectomy (NSM) With Intraoperative Laser Speckle Contrast Imaging (LSCI) Monitoring Improved Surgical Training Outcome Among Fellows. Clin Breast Cancer 2024:S1526-8209(24)00223-4. [PMID: 39289111 DOI: 10.1016/j.clbc.2024.08.011] [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: 06/09/2024] [Revised: 08/14/2024] [Accepted: 08/16/2024] [Indexed: 09/19/2024]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM) are challenging for surgical training among fellow trainees. We developed a surgical training course with novel concept of breast modular resection (BMR) for NSM/SSM procedure, and performed this study to investigate whether BMR could improve surgical outcomes compared to classical procedure resection (CPR). METHODS The records of 105 breast cancer patients undergoing NSM/SSM with immediate reconstruction performed by fellow trainees were reviewed. Clinicopathological characteristics and surgical outcomes were compared between 2 groups. Laser speckle contrast imaging (LSCI) was performed to intraoperatively evaluate the blood supply of the NAC, and the absolute perfusion unit (PU) values and relative perfusion unit (rPU) values were further compared. RESULTS Surgical training outcomes of BMR group (N = 52) were insignificantly improved compared to CPR group (N = 53). The rates of NAC necrosis, flap necrosis and implant removal all reduced respectively. Among the 60 NSM patients, the blood loss (P = .011) and surgery time (P < .001) was significantly reduced in BMR group (N = 30) and all the other outcomes were insignificantly improved. Both the absolute PU values and rPU values were significantly higher among patients without NAC necrosis (P < .001). The absolute PU values were significantly higher in BMR group (P = .002). CONCLUSION Compared to CPR, the BMR-based surgical training course for NSM demonstrated the reduction in complications and operating time, offering a potential streamlined, efficient, and safe method for NSM procedure. LSCI was effective for intraoperative visualized evaluation of NAC blood supply and could provide effective real-time feedback for fellow trainees.
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Affiliation(s)
- Ru Yao
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Fengzhou Du
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Runzhu Liu
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Linjuan Tan
- Department of Anesthesia and Operating Room, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jie Lian
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Lu Gao
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Hailin Zhang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Li Huang
- Department of Education, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Bo Pan
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.
| | - Yidong Zhou
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.
| | - Qiang Sun
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jun Zhao
- Department of Education, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China; Institute of Clinical Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao Long
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.
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5
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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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Golijanin D, Radovanović Z, Radovanović D, Đermanović A, Starčević S, Đermanović M. Molecular subtype and risk of local recurrence after nipple‑sparing mastectomy for breast cancer. Oncol Lett 2024; 28:389. [PMID: 38966584 PMCID: PMC11223028 DOI: 10.3892/ol.2024.14522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 06/03/2024] [Indexed: 07/06/2024] Open
Abstract
The present study aimed to investigate whether local recurrence (LR) after nipple-sparing mastectomy (NSM) and reconstruction was associated with i) Ki67 values and molecular subtypes of the initial lesions, and ii) the size of the initial tumor and the size of the implant. A total of 156 patients with breast cancer with a mean age of 51.58 years (age range, 26-75 years) who underwent NSM with primary implant breast reconstruction were analyzed. After surgery, the mean follow-up time was 59.26 months (range, 17-85 months). Molecular subtypes, Ki67 values, estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status were recorded for each patient. Additionally, information regarding the size of the implant and the initial tumor size were collected. The information was used to assess LR. For univariate analyses of risk factors, χ2 test, Fisher's exact test, Mann-Whitney U test and Student's t-test for independent samples were used. For multivariate analyses, a Cox proportional-hazards model was used. NSM was the primary treatment for breast cancer in 34/156 patients (21.8%), while 122/156 (78.2%) of patients received neoadjuvant chemotherapy followed by surgery. Luminal B was the most frequent molecular subtype, detected in 82/156 patients (52.6%), whereas the luminal A subtype was detected in 37 patients (23.7%) and the HER2-enriched subtype was detected in 17/156 patients (10.9%). Ki67 expression was low in 13/156 patients (8.3%), while medium expression was detected in 78/156 patients (50.0%) and high expression was present in 58/156 patients (37.2%). LR was noted in 17/156 patients (10.9%). As determined by univariate analysis, lower ER (P=0.010) and PR (P=0.008) expression were indicated to be significant risk factors for LR. In conclusion, in the present patient cohort, low ER and PR expression were risk factors for LR of breast cancer, whereas Ki67 status and molecular subtype were not statistically significant risk factors for LR. Additionally, the size of the initial tumor and the size of the implant were not risk factors for LR. These findings are consistent with the current literature, and should be utilized when discussing treatment options and potential clinical outcomes with patients prior to surgical management.
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Affiliation(s)
- Danica Golijanin
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Republic of Serbia
- Clinic for Surgical Oncology, Oncology Institute of Vojvodina, 21204 Sremska Kamenica, Republic of Serbia
| | - Zoran Radovanović
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Republic of Serbia
- Clinic for Surgical Oncology, Oncology Institute of Vojvodina, 21204 Sremska Kamenica, Republic of Serbia
| | - Dragana Radovanović
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Republic of Serbia
- Department for Anesthesiology with Reanimatology, Oncology Institute of Vojvodina, 21204 Sremska Kamenica, Republic of Serbia
| | - Aleksandar Đermanović
- Clinic for Surgical Oncology, Oncology Institute of Vojvodina, 21204 Sremska Kamenica, Republic of Serbia
| | - Sanja Starčević
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Republic of Serbia
- Department for Anesthesiology with Reanimatology, Oncology Institute of Vojvodina, 21204 Sremska Kamenica, Republic of Serbia
| | - Marija Đermanović
- Department for Neonatology, Institute for Child and Youth Health Care of Vojvodina, 21000 Novi Sad, Republic of Serbia
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Doll A, Kopkash K, Baker J. Emerging Role of Robotic Surgery in the Breast. Clin Breast Cancer 2024; 24:286-291. [PMID: 38220537 DOI: 10.1016/j.clbc.2023.12.009] [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: 11/03/2023] [Revised: 12/04/2023] [Accepted: 12/22/2023] [Indexed: 01/16/2024]
Abstract
In recent years, there has been increased adoption of robotic technology in oncologic breast surgery, particularly with the use of robotic nipple sparing mastectomy (r-NSM). Here we review the emergence of robotic-assisted surgery in breast procedures, and discuss the safety, limited oncologic outcomes, apparent advantages, and potential limitations of r-NSM compared to conventional open-NSM (c-NSM). Limited data suggests that robotic-assisted surgery offers smaller incisions and potential for improved cosmesis and ergonomic advantage when compared to c-NSM. Similar periprocedural complication rates are seen with r-NSM compared with c-NSM. Short-term oncologic follow-up is reassuring however, but remains early and continues to be investigated. The increased cost of r-NSM compared to open surgery and feasibility of widespread adoption of the procedure are important considerations that need to be evaluated. Randomized trials are currently ongoing to address the apparent advantages, oncologic outcomes, and cost/feasibility of robotic breast surgery.
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Affiliation(s)
- Alissa Doll
- Department of Surgery, Division of Surgical Oncology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Katherine Kopkash
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL; University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Jennifer Baker
- Department of Surgery, Division of Surgical Oncology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA.
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8
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Gabriel A, Chan V. Outcomes of Mastectomy and Immediate Reconstruction Managed with Closed-incision Negative Pressure Therapy Applied Over the Whole Breast. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5809. [PMID: 38818231 PMCID: PMC11139461 DOI: 10.1097/gox.0000000000005809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 03/22/2024] [Indexed: 06/01/2024]
Abstract
Background Incision healing after mastectomy and immediate reconstruction can be supported with closed-incision negative pressure therapy (ciNPT). Studies have reported patients receiving postoperative care with ciNPT after breast surgery exhibited lower rates of dehiscence, infection, necrosis, and seroma, compared with standard dressings. A recent approach to ciNPT involves the application of negative pressure to the incision and a wider area of surrounding tissue. In this retrospective review, we investigated the outcomes of ciNPT using full-coverage dressings over the entire breast after mastectomy and reconstruction. Methods Patients underwent mastectomies and immediate prepectoral breast reconstruction with an implant or tissue expander. After surgery, patients received oral antibiotics and ciNPT with full-coverage foam dressings at -125 mm Hg. Results All 54 patients (N = 105 incisions) were women, with a mean age of 53.5 years and 29.1 kg per m2 body mass index. Common comorbidities included prior chemotherapy (31.3%) or radiation (21.6%), hypertension (14.8%), and diabetes (5.6%). Procedures included skin-reducing (34.3%), skin-sparing (7.6%), and nipple-sparing (58.1%) mastectomies. Lymph nodes were removed in 38 (36.2%) incisions. All patients were discharged home with ciNPT on postoperative day (POD) 1, and ciNPT was discontinued on POD 5-7. At POD 30, three patients developed seromas, requiring revision. Of these, one required removal of the left tissue expander. The remaining 102 incisions (97.1%) healed without complication. Conclusions Among this cohort, the use of ciNPT with full-dressing coverage of the breast incisions and surrounding soft tissue was effective in supporting incisional healing after mastectomy and immediate reconstruction.
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Affiliation(s)
- Allen Gabriel
- From the Department of Plastic Surgery, Loma Linda University Medical Center, Lomo Linda, Calif
- AG Aesthetic Center, Vancouver, Wash
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9
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Antoniazzi E, De Grazia A, Dell'Antonia F, Pasquali S, Burelli P, Rizzetto C, Berna G. Immediate prepectoral breast reconstruction in nipple-sparing mastectomy with Wise-pattern incision in large and ptotic breasts: Our experience and short-term results. J Plast Reconstr Aesthet Surg 2024; 91:154-163. [PMID: 38412604 DOI: 10.1016/j.bjps.2024.01.042] [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: 09/18/2023] [Revised: 01/17/2024] [Accepted: 01/29/2024] [Indexed: 02/29/2024]
Abstract
INTRODUCTION Current breast cancer treatment trends advocate nipple-sparing mastectomy (NSM) as the preferred technique for selected patients. A considerable and ptotic breast is often considered a relative contraindication for NSM due to the increased risk of skin and nipple necrosis. METHODS A retrospective review was performed for patients who underwent immediate prepectoral breast reconstruction (PPBR) after NSM with Wise-pattern incision between February 2020 and February 2023 at our institution. This procedure was offered to patients with grade II or III ptosis or large breasts eligible for NSM for therapeutic or prophylactic purpose. Exclusion criteria comprised a preoperative nipple-sternal notch distance greater than 30 cm, previous radiotherapy, pinch test <1 cm, body mass index (BMI) greater than 34 and active smoke. We present our short-term results with this technique. RESULTS During the study period, 62 patients (76 breasts) had NSM with Wise-pattern incision. Patients had immediate PPBR with implant or tissue expander, both entirely wrapped with ADM. The median age of the patients was 57.0 years [The Interquartile Range (IQR 50.0-68.6)] with a median BMI of 25.5 (IQR 23.3-28.4). The median mastectomy specimen weight was 472 g (341-578). Median implant volume was 465 g (IQR 370-515). Major complications occurred in 8 patients (10.5%). Three patients experienced total nipple-areolar complex (NAC) necrosis (3.9%), and partial NAC necrosis occurred in 2 patients (2.6%). Two patients developed implant infection (2.6%). Univariate analysis showed a statistically significant correlation between major complications and the mastectomy specimen weight (p = 0.003). CONCLUSION If oncologically indicated, NSM with Wise-pattern incision and immediate PPBR can safely be performed in selected patients with large and ptotic breasts.
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Affiliation(s)
- E Antoniazzi
- Plastic Surgery Unit, "Ca' Foncello" Regional Hospital, 31100 Treviso, Italy.
| | - A De Grazia
- Plastic Surgery Unit, "Ca' Foncello" Regional Hospital, 31100 Treviso, Italy
| | - F Dell'Antonia
- Plastic Surgery Unit, "Ca' Foncello" Regional Hospital, 31100 Treviso, Italy
| | - S Pasquali
- Plastic and Reconstructive Surgery Unit, Cattinara Hospital-Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - P Burelli
- Breast Surgery Unit, "Ca' Foncello" Regional Hospital, 31100 Treviso, Italy
| | - C Rizzetto
- Breast Surgery Unit, "Ca' Foncello" Regional Hospital, 31100 Treviso, Italy
| | - G Berna
- Plastic Surgery Unit, "Ca' Foncello" Regional Hospital, 31100 Treviso, Italy
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Perez-Otero S, Hemal K, Boyd CJ, Kabir R, Sorenson TJ, Jacobson A, Thanik VD, Levine JP, Cohen OD, Karp NS, Choi M. Minimizing Nipple-Areolar Complex Complications in Prepectoral Breast Reconstruction After Nipple-Sparing Mastectomy. Ann Plast Surg 2024; 92:S179-S184. [PMID: 38556670 DOI: 10.1097/sap.0000000000003906] [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: 04/02/2024]
Abstract
PURPOSE Nipple-areolar complex (NAC) viability remains a significant concern following prepectoral tissue expander (TE) reconstruction after nipple-sparing mastectomy (NSM). This study assesses the impact of intraoperative TE fill on NAC necrosis and identifies strategies for mitigating this risk. METHODS A chart review of all consecutive, prepectoral TEs placed immediately after NSM was performed between March 2017 and December 2022 at a single center. Demographics, mastectomy weight, intraoperative TE fill, and complications were extracted for all patients. Partial NAC necrosis was defined as any thickness of skin loss including part of the NAC, whereas total NAC necrosis was defined as full-thickness skin loss involving the entirety of the NAC. P < 0.05 was considered statistically significant. RESULTS Forty-six patients (83 breasts) with an average follow-up of 22 months were included. Women were on average 46 years old, nonsmoker (98%), and nondiabetic (100%) and had a body mass index of 23 kg/m2. All reconstructions were performed immediately following prophylactic mastectomies in 49% and therapeutic mastectomies in 51% of cases. Three breasts (4%) were radiated, and 15 patients (33%) received chemotherapy. Mean mastectomy weight was 346 ± 274 g, median intraoperative TE fill was 150 ± 225 mL, and median final TE fill was 350 ± 170 mL. Partial NAC necrosis occurred in 7 breasts (8%), and there were zero instances of complete NAC necrosis. On univariate analysis, partial NAC necrosis was not associated with any patient demographic or operative characteristics, including intraoperative TE fill. In multivariable models controlling for age, body mass index, mastectomy weight, prior breast surgery, and intraoperative TE fill, partial NAC necrosis was associated with lower body mass index (odds ratio, 0.53; confidence interval [CI], 0.29-0.98; P < 0.05) and higher mastectomy weight (odds ratio, 1.1; CI, 1.01-1.20; P < 0.05). Prior breast surgery approached significance, as those breasts had a 19.4 times higher odds of partial NAC necrosis (95% CI, 0.88-427.6; P = 0.06). CONCLUSIONS Nipple-areolar complex necrosis following prepectoral TE reconstruction is a rare but serious complication. In this study of 83 breasts, 7 (8%) developed partial NAC necrosis, and all but one were able to be salvaged.
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Affiliation(s)
| | - Kshipra Hemal
- Hansjorg Wyss Department of Plastic Surgery, New York University-Langone Health, New York, NY
| | - Carter J Boyd
- Hansjorg Wyss Department of Plastic Surgery, New York University-Langone Health, New York, NY
| | - Raeesa Kabir
- University of Minnesota Medical School, Minneapolis, MN
| | - Thomas J Sorenson
- Hansjorg Wyss Department of Plastic Surgery, New York University-Langone Health, New York, NY
| | | | - Vishal D Thanik
- Hansjorg Wyss Department of Plastic Surgery, New York University-Langone Health, New York, NY
| | - Jamie P Levine
- Hansjorg Wyss Department of Plastic Surgery, New York University-Langone Health, New York, NY
| | - Oriana D Cohen
- Hansjorg Wyss Department of Plastic Surgery, New York University-Langone Health, New York, NY
| | - Nolan S Karp
- Hansjorg Wyss Department of Plastic Surgery, New York University-Langone Health, New York, NY
| | - Mihye Choi
- Hansjorg Wyss Department of Plastic Surgery, New York University-Langone Health, New York, NY
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11
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Creasy H, Citron I, Davis TP, Cooper L, Din AH, Rose V. Buried Autologous Breast Reconstruction: Outcomes and Technical Considerations. J Clin Med 2024; 13:1463. [PMID: 38592319 PMCID: PMC10935370 DOI: 10.3390/jcm13051463] [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: 12/13/2023] [Revised: 02/17/2024] [Accepted: 02/27/2024] [Indexed: 04/10/2024] Open
Abstract
The purpose of this study is to compare outcomes in patients undergoing buried and non-buried free flaps for breast reconstruction, in addition to evaluating the safety and reliability of venous flow couplers. A retrospective review was performed of all patients undergoing free flap breast reconstruction between 2013 and 2023. The primary outcomes were free flap failure, complications and the number of procedures required to complete the reconstructive journey. A total of 322 flaps were performed in 254 consecutive patients, with 47.5% (n = 153) being buried and 52.0% (n = 169) being non-buried reconstructions. The most common flap of choice being deep inferior epigastric artery perforator flaps (81.9%) followed by profunda artery perforator flaps (14.3%). There was no significant difference between the two groups in complications, including flap failure (buried 2.0% vs. non-buried 1.8% p = 0.902). There was a significant reduction in the number of procedures required to complete the reconstructive journey, with 52.2% (n = 59) of patients undergoing single-stage breast reconstruction in the buried group compared with only 25.5% (n = 36) in the non-buried group (p < 0.001). Two (0.6%) patients experienced a false negative in which the signal of the flow coupler was lost but the flap was perfused during re-exploration. No flap losses occurred without being identified in advance by a loss of audible venous flow signal. Buried free flap breast reconstruction is safe and requires fewer operations to complete patients' reconstructive journey. Flow couplers are a safe and effective method of monitoring buried free flaps in breast reconstruction.
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Affiliation(s)
- Henrietta Creasy
- Plastic Surgery Department, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK (T.P.D.)
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12
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Farr DE, Haddock NT, Tellez J, Radi I, Alterio R, Sayers B, Zeh H. Safety and Feasibility of Single-Port Robotic-Assisted Nipple-Sparing Mastectomy. JAMA Surg 2024; 159:269-276. [PMID: 38231502 PMCID: PMC10794977 DOI: 10.1001/jamasurg.2023.6999] [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: 05/14/2023] [Accepted: 09/23/2023] [Indexed: 01/18/2024]
Abstract
Importance Robotic-assisted nipple-sparing mastectomies with multiport robots have been described in the US since 2015; however, significant hurdles to multiport robotic surgery exist in breast surgery. Objective To demonstrate that the single-port da Vinci SP (Intuitive Surgical) robotic system is feasible in patients undergoing robotic nipple-sparing mastectomy (rNSM). Design, Setting, and Participants An initial case series of 20 patients at a large university hospital underwent bilateral single-port robotic nipple-sparing mastectomies (SPrNSM) with tissue expander reconstruction from February 1, 2020, through January 4, 2023. Participants included women who met surgical criteria for nipple-sparing mastectomies, per standard of care. Intervention Surgery using a single-port robot and the surgical technique of the authors. Main Outcomes and Measures Age, indication, body mass index, breast size, operative time, conversion to open surgery, systemic complications, postoperative skin necrosis, and reported skin and nipple areolar complex (NAC) sensation. Results Twenty women aged 29 to 63 years (median, 40 years) underwent bilateral SPrNSM. Eleven patients completed prophylactic surgery due to a high risk for breast cancer (more than 20% lifetime risk) and 9 patients had breast cancer. Breast size ranged from A through D cup with median B cup and a body mass index range of 19.7 through 27.8 (median 24.4). The total duration of the procedure from incision to skin closure for both sides ranged from 205 minutes to 351 minutes (median, 277). The median robotic time for bilateral SPrNSM was 116 minutes and varied by cup size (A cup, 95 minutes; B cup, 140 minutes; C cup, 118 minutes; D cup, 114 minutes) with no inflection point in learning curve. No cases were converted to open and no immediate complications, such as hematoma, positive margins, or recurrence, were seen. In the first 10 patients prior to routine sensation testing, 20 resected breasts had measurable NAC sensation at a range from 4 to 36 months post-index resection (65%). In the second 10 patients of the cohort, measurable NAC was preserved in 13 of 20 resected breasts 2 weeks following the index operation (65%). Conclusion and Relevance In this case series, SPrNSM with immediate reconstruction was feasible and performed safely by an experienced breast surgeon with limited previous robotic training. Further studies confirming the preliminary data demonstrating improved NAC and skin sensation following SPrNSM are warranted. Trial Registration ClinicalTrials.gov Identifier: NCT05245812.
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Affiliation(s)
- Deborah E. Farr
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nicholas T. Haddock
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Juan Tellez
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Imad Radi
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rodrigo Alterio
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Brendan Sayers
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Herbert Zeh
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
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13
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Hastings-Robinson A, Chung M, Hayward JH, Ray KM, Price ER, Navarro R, Joe BN, Lee AY. The role of digital mammographic surveillance for detection of asymptomatic recurrence in autologous flap reconstructions. Clin Imaging 2024; 106:110062. [PMID: 38128403 DOI: 10.1016/j.clinimag.2023.110062] [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: 10/06/2023] [Revised: 11/21/2023] [Accepted: 12/09/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To evaluate the utility of digital mammography in detecting asymptomatic malignancy in autologous flap reconstructions after mastectomy. METHODS A retrospective database review identified all mammograms performed on asymptomatic patients with flap reconstructions over a 9-year period (1/1/2009 to 12/31/2017). A negative examination was defined as BI-RADS 1 or 2 and a positive examination was defined as BI-RADS 0, 4, or 5 assigned to the mastectomy side. Malignant outcomes were determined by pathology results. Interval cancers, or false negatives, were defined as locoregional malignant diagnosis within one year of a negative mammogram. Sensitivity, specificity, predictive values, abnormal interpretation rate, and cancer detection rate were calculated. RESULTS 626 mammograms of asymptomatic flap reconstructions were performed in 183 patients. The most common flap type was TRAM (83.5 %, 523/626) and DIEP (13.4 %, 84/626). Most exams (98.2 %, 615/626) were negative, assessed as BI-RADS 1 or 2, with no interval cancers at follow-up. Eleven exams (1.8 %, 11/626) were positive, assessed as BI-RADS 0, 4, or 5. After diagnostic work-up of all BI-RADS 0 exams, 9 cases had a final recommendation for biopsy of which 3 were malignant. Mammography yielded a cancer detection rate of 0.5 % (3/626), abnormal interpretation rate of 1.8 % (11/626), NPV of 100 % (615/615), overall PPV of 27.3 % (3/11), PPV2 (positive predictive value of a biopsy recommendation) of 33.3 % (3/9), sensitivity of 100 % (3/3), and specificity of 98.7 % (615/623). CONCLUSION Digital mammography of asymptomatic autologous flap reconstructions after mastectomy demonstrated high sensitivity and low abnormal interpretation rate. Cancer detection rate was comparable to current national benchmarks for mammographic screening in the general U.S. population without mastectomy.
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Affiliation(s)
| | - Maggie Chung
- University of California, San Francisco, Department of Radiology and Biomedical Imaging, USA
| | - Jessica H Hayward
- University of California, San Francisco, Department of Radiology and Biomedical Imaging, USA
| | - Kimberly M Ray
- University of California, San Francisco, Department of Radiology and Biomedical Imaging, USA
| | - Elissa R Price
- University of California, San Francisco, Department of Radiology and Biomedical Imaging, USA
| | - Ryan Navarro
- University of California, San Francisco, Department of Radiology and Biomedical Imaging, USA
| | - Bonnie N Joe
- University of California, San Francisco, Department of Radiology and Biomedical Imaging, USA
| | - Amie Y Lee
- University of California, San Francisco, Department of Radiology and Biomedical Imaging, USA.
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Lai HW, Chen DR, Liu LC, Chen ST, Kuo YL, Lin SL, Wu YC, Huang TC, Hung CS, Lin YJ, Tseng HS, Mok CW, Cheng FTF. Robotic Versus Conventional or Endoscopic-assisted Nipple-sparing Mastectomy and Immediate Prosthesis Breast Reconstruction in the Management of Breast Cancer: A Prospectively Designed Multicenter Trial Comparing Clinical Outcomes, Medical Cost, and Patient-reported Outcomes (RCENSM-P). Ann Surg 2024; 279:138-146. [PMID: 37226826 PMCID: PMC10727200 DOI: 10.1097/sla.0000000000005924] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To compare the clinical and patient-reported outcomes of minimal access and conventional nipple-sparing mastectomy (C-NSM). The secondary outcomes investigated included medical costs and oncological safety. BACKGROUND Minimal-access NSM has been increasingly applied in the treatment of patients with breast cancer. However, prospective multicenter trials comparing robotic-assisted NSM (R-NSM) versus C-NSM or endoscopic-assisted NSM (E-NSM) are lacking. METHODS A prospectively designed 3-arm multicenter, nonrandomized trial (NCT04037852) was conducted from October 1, 2019 to December 31, 2021, to compare R-NSM with C-NSM or E-NSM. RESULTS A total of 73 R-NSM, 74 C-NSM, and 84 E-NSM procedures were enrolled. The median wound length and operation time of C-NSM was (9 cm, 175 minutes), (4 cm, and 195 minutes) in R-NSM, and (4 cm and 222 minutes) in E-NSM. Complications were comparable among the groups. Better wound healing was observed in the minimal-access NSM group. The R-NSM procedure was 4000 and 2600 United States Dollars more expensive than C-NSM and E-NSM, respectively. Wound/scar and postoperative acute pain evaluation favored the use of minimal access NSM over C-NSM. Quality of life in terms of chronic breast/chest pain, mobility, and range of motion of the upper extremity showed no significant differences. The preliminary oncologic results showed no differences among the 3 groups. CONCLUSIONS R-NSM or E-NSM is a safe alternative if compared with C-NSM in terms of perioperative morbidities, especially with better wound healing. The advantage of minimal access groups was higher wound-related satisfaction. Higher costs remain one of the major limiting factors in the widespread adoption of R-NSM.
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Affiliation(s)
- Hung-Wen Lai
- Department of Surgery, Endoscopic & Oncoplastic Breast Surgery Center, Changhua Christian Hospital, Changhua, Taiwan
- Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Department of Surgery, Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
- Department of Surgery, Minimal invasive surgery research center, Changhua Christian Hospital, Changhua, Taiwan
- Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Breast Surgery, Department of Surgery, Yuanlin Christian Hospital, Yuanlin, Taiwan
- Division of Surgery, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Division of Breast Surgery, Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Dar-Ren Chen
- Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Department of Surgery, Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Liang-Chih Liu
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
- Department of Surgery, Breast Medical Center, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Shou-Tung Chen
- Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Department of Surgery, Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Yao-Lung Kuo
- Breast Medical Center, National Cheng Kung University Hospital, Tainan, Taiwan
- Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
- Department of Surgery, College of Medicine, National Cheng Kung University and National Cheng Kung University Hospital, Tainan, Taiwan
| | - Shih-Lung Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Yao-Chung Wu
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Tsung-Chun Huang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Chin-Sheng Hung
- Division of Breast Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Surgery, College of Medicine, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ying-Jen Lin
- Division of Breast Surgery, Department of Surgery, Changi General Hospital, Singapore
| | - Hsin-Shun Tseng
- Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Department of Surgery, Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Chi Wei Mok
- Division of Breast Surgery, Department of Surgery, Changi General Hospital, Singapore
- Division of General Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Fiona Tsui-Fen Cheng
- Division of General Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
- College of Medicine, Fu Jen Catholic University, Taipei, Taiwan
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15
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Daly L, Tsai J, Stone K, Wapnir I, Karin M, Wan D, Momeni A. Nipple-areola-complex preservation and obesity-Successful in stages. Microsurgery 2024; 44:e31043. [PMID: 37013250 DOI: 10.1002/micr.31043] [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: 06/21/2022] [Revised: 01/12/2023] [Accepted: 03/09/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND The superiority of nipple-sparing mastectomy (NSM) on breast aesthetics and patient-reported outcomes has previously been demonstrated. Despite 42.4% of adults in the United States being considered obese, obesity has been considered a contraindication to NSM due to concerns for nipple areolar complex (NAC) malposition or ischemic complications. This report investigates the feasibility and safety of a staged surgical approach to NSM with immediate microsurgical breast reconstruction in the high-risk obese population. METHODS Only patients with a body mass index (BMI) of >30 kg/m2 who underwent bilateral mastopexy or breast reduction for correction of ptosis or macromastia (stage 1), respectively, followed by bilateral prophylactic NSM with immediate microsurgical breast reconstruction with free abdominal flaps (stage 2) were included in the analysis. Patient demographics and surgical outcomes were analyzed. RESULTS Fifteen patients with high-risk genetic mutations for breast cancer with a mean age and BMI of 41.3 years and 35.0 kg/m2 , respectively, underwent bilateral staged NSM with immediate microsurgical breast reconstruction (30 breast reconstructions). At a mean follow-up of 15.7 months, complications were encountered following stage 2 only and included mastectomy skin necrosis (5 breasts [16.7%]), NAC necrosis (2 breasts [6.7%]), and abdominal seroma (1 patient [6.7%]) all of which were considered minor and neither required surgical intervention nor admission. CONCLUSIONS Implementation of a staged approach permits NAC preservation in obese patients who present for prophylactic mastectomy and immediate microsurgical reconstruction.
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Affiliation(s)
- Lauren Daly
- Division of Plastic and Reconstructive Surgery Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jacqueline Tsai
- Division of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Kim Stone
- Division of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Irene Wapnir
- Division of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Mardi Karin
- Division of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Derrick Wan
- Division of Plastic and Reconstructive Surgery Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery Medicine, Stanford University School of Medicine, Palo Alto, California, USA
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16
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Parmeshwar N, Dugan CL, Barnes LL, Cheng JK, Patterson AK, Miller A, Mukhtar R, Piper M. Nipple-Sparing Mastectomies in Patients over the Age of 60 Years: Factors Associated with Surgical Outcomes. Ann Surg Oncol 2023; 30:8428-8435. [PMID: 37700172 DOI: 10.1245/s10434-023-14278-6] [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: 06/09/2023] [Accepted: 08/24/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) outcomes in the elderly have not been well characterized. The goal of this study was to evaluate NSM outcomes in patients over age 60. PATIENTS AND METHODS A single-institution retrospective cohort study was performed for NSM patients over the age of 60 from January 2004 to January 2022. Demographic, intraoperative, and postoperative variables were collected. RESULTS We identified 136 women who underwent a total of 200 NSMs at a mean age 65.2 years and with mean body mass index of 25. Most (56%) had invasive breast cancer, requiring neoadjuvant chemotherapy in 15%, and 17.5% had radiation prior to NSM. A total of 91% had immediate tissue expander placement. The infection rate was 19%, with 11.5% requiring expander explantation in the follow-up period. In binomial logistic regression analysis, prior radiation increased the odds of any complication by 2.9 (OR 2.93, CI 1.30-6.58, p = 0.009) and increased the odds of infection by 5.7 (OR 5.70, CI 1.95-16.66, p = 0.001), but no associations were seen for other covariates including age, comorbidities, prior chemotherapy, or presence of invasive disease. Diabetes increased the odds of wound breakdown specifically by 9.0 (OR 8.97, CI 2.01-39.92, p = 0.004). Local recurrence was 3% in mean 3.4-year follow-up. CONCLUSIONS Our data support NSM in patients over the age of 60 years with acceptable outcomes within the standard of care. Locoregional recurrence was within the cited range of 0-5%, and only diabetes and prior radiation were associated with reconstructive complications. NSM should thus be offered when appropriate regardless of increased age to achieve oncologic and reconstructive goals.
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Affiliation(s)
- Nisha Parmeshwar
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
| | - Catherine L Dugan
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Laura L Barnes
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Justin K Cheng
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Anne K Patterson
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Amanda Miller
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Rita Mukhtar
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Merisa Piper
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
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17
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King CA, Bartholomew AJ, Dabic S, Sogunro O, Perez-Alvarez IM, Welschmeyer AF, Sosin M, Thibodeau RM, Fan KL, Song DH, Greenwalt IT, Tousimis EA. Nipple-Sparing Mastectomy With Immediate Reconstruction After Breast-Conserving Therapy and Radiation: Complications and Oncologic Safety. Ann Plast Surg 2023; 91:709-714. [PMID: 37830503 DOI: 10.1097/sap.0000000000003692] [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: 10/14/2023]
Abstract
INTRODUCTION Nipple-sparing mastectomy (NSM) offers improved, patient-centered outcomes with demonstrated oncologic safety ( Ann Surg Oncol 2020;27:344-351). Indications for NSM continue to expand to patients outside of the traditional eligibility criteria, including those with prior breast-conserving therapy (BCT) with radiotherapy. Currently, limited data exist evaluating both short- and long-term outcomes in patients proceeding to NSM after prior BCT. METHODS All patients undergoing bilateral NSM in a single institution from 2002 through 2017 with history of prior BCT were included in the final cohort, without exclusions. A retrospective chart review was performed to identify patient demographics, operative details, and complications. Outcomes assessed included early complications (<30 days from NSM), late complications (>30 days), rates of prosthetic failure, unplanned reoperations, and reconstructive failures, as well as oncologic safety. Student t , χ 2 , and Fisher exact tests were used to analyze outcomes of paired (BCT vs non-BCT) breasts within each patient. RESULTS A total of 17 patients undergoing 34 NSMs were included. Each had a history of BCT and either ipsilateral breast recurrence (64.7%), risk-reducing NSM (23.5%), or a new contralateral primary cancer (11.8%). The cohort had a mean age of 51.1 years. With regard to acute complications (ischemia, infection, nipple-areolar complex or flap ischemia or necrosis, and wound dehiscence), there was no significant difference noted between breasts with prior BCT versus no prior BCT overall (41.2% vs 35.3%, respectively; P = 0.724). Complications occurring after 30 days postoperatively (capsular contracture, contour abnormality, animation deformity, bottoming out, rotation, and rippling) in prior BCT breasts versus no prior BCT had no significant differences overall (58.8% vs 41.2% respectively; P = 0.303). The mean follow-up was 5.5 years, during which no patients had a reported locoregional or distant recurrence in either breast. CONCLUSIONS No significant differences in early or late complications were identified between breasts in patients undergoing bilateral NSM with a history of unilateral BCT and XRT. In the 5.5 years of follow-up, there were no recurrences, lending support to NSM for management of recurrent disease in addition to National Comprehensive Cancer Network-recommended total mastectomy. We propose that NSM should not be contraindicated in patients exposed to radiation with BCT.
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Affiliation(s)
- Caroline A King
- From the Division of Breast Surgery, Department of Surgery, MedStar Georgetown University Hospital, Washington, DC
| | | | - Stefan Dabic
- From the Division of Breast Surgery, Department of Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Olutayo Sogunro
- From the Division of Breast Surgery, Department of Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Idanis M Perez-Alvarez
- Department of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL
| | - Alexandra F Welschmeyer
- From the Division of Breast Surgery, Department of Surgery, MedStar Georgetown University Hospital, Washington, DC
| | | | - Renee M Thibodeau
- Department of Breast Surgery, Central Maine Medical Center, Lewiston, ME
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - David H Song
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Ian T Greenwalt
- From the Division of Breast Surgery, Department of Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Eleni A Tousimis
- Department of Breast Surgical Oncology, Scully-Welsh Cancer Center, Cleveland Clinic Indian River Hospital, Vero Beach, FL
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Cho JH, Park JM, Park HS, Kim HJ, Shin DM, Kim JY, Park S, Kim SI, Park BW. Oncologic Outcomes in Nipple-sparing Mastectomy with Immediate Reconstruction and Total Mastectomy with Immediate Reconstruction in Women with Breast Cancer: A Machine-Learning Analysis. Ann Surg Oncol 2023; 30:7281-7290. [PMID: 37587360 DOI: 10.1245/s10434-023-13963-w] [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: 02/14/2023] [Accepted: 07/03/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND This study used a single-institution cohort, the Severance dataset, validated the results by using the surveillance, epidemiology, and end results (SEER) database, adjusted with propensity-score matching (PSM), and analyzed by using a machine learning method. To determine whether the 5-year, disease-free survival (DFS) and overall survival (OS) of patients undergoing nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR) are not inferior to those of women treated with total mastectomy/skin-sparing mastectomy (TM/SSM). METHODS The Severance dataset enrolled 611 patients with early, invasive breast cancer from 2010 to 2017. The SEER dataset contained data for 485,245 patients undergoing TM and 14,770 patients undergoing NSM between 2000 and 2018. All patients underwent mastectomy and IBR. Intraoperative, frozen-section biopsy for the retro-areolar tissue was performed in the NSM group. The SEER dataset was extracted by using operation types, including TM/SSM and NSM. The primary outcome was DFS for the Severance dataset and OS for the SEER dataset. PSM analysis was applied. Survival outcomes were analyzed by using the Kaplan-Meier method and Cox proportional hazard (Cox PH) regression model. We implemented XGBSE to predict mortality with high accuracy and evaluated model prediction performance using a concordance index. The final model inspected the impact of relevant predictors on the model output using shapley additive explanation (SHAP) values. RESULTS In the Severance dataset, 151 patients underwent NSM with IBR and 460 patients underwent TM/SSM with IBR. No significant differences were found between the groups. In multivariate analysis, NSM was not associated with reduced oncologic outcomes. The same results were observed in PSM analysis. In the SEER dataset, according to the SHAP values, the individual feature contribution suggested that AJCC stage ranks first. Analyses from the two datasets confirmed no impact on survival outcomes from the two surgical methods. CONCLUSIONS NSM with IBR is a safe and feasible procedure in terms of oncologic outcomes. Analysis using machine learning methods can be successfully applied to identify significant risk factors for oncologic outcomes.
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Affiliation(s)
- Jun-Ho Cho
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Mi Park
- Department of Biostatistics and Computing, Graduate School, Yonsei University, Seoul, Korea
| | - Hyung Seok Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Hye Jin Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong-Min Shin
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jee Ye Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seho Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byeong-Woo Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
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Kim JH, Kang J, Najmiddinov B, Kim EK, Myung Y, Heo CY. Nipple Projection Change in Immediate Breast Reconstruction and Use of an Acellular Dermal Matrix Strut for Maintaining Nipple Projection. Plast Reconstr Surg 2023; 152:949-957. [PMID: 36877621 DOI: 10.1097/prs.0000000000010355] [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: 03/07/2023]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) has gained popularity as more studies have supported its oncologic safety. Although there have been some studies reporting complications including mastectomy flap and nipple necrosis, there have been few reports discussing the change in nipple projection following NSM. This study aimed to analyze the change in nipple projection after NSM and identify risk factors for nipple depression. In addition, the authors present a new method for maintaining nipple projection. METHODS Patients who underwent NSM between March of 2017 and December of 2020 at the authors' institute were included in this study. The authors measured the preoperative and postoperative nipple projection height and used a nipple projection ratio (NPR) to compare the change in height. Univariate and multivariate analyses were performed to examine the correlation of variables with the NPR. RESULTS A total of 307 patients and 330 breasts were included in this study. There were 13 cases of nipple necrosis. The postoperative nipple height was decreased by 32.8%, which was statistically significant. In multiple linear regression analysis, the use of an acellular dermal matrix strut was positively correlated with the NPR and implant-based reconstruction and postmastectomy radiation therapy were negatively correlated with the NPR. CONCLUSIONS The results of this study demonstrated that the reduction in nipple height after NSM was statistically significant. Surgeons need to be aware of these changes following NSM and explain this possibility to patients who have risk factors. The application of an acellular dermal matrix strut should be considered for the prevention of nipple reduction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Jong-Ho Kim
- From the Departments of Plastic and Reconstructive Surgery
| | - Jiwon Kang
- From the Departments of Plastic and Reconstructive Surgery
| | | | - Eun-Kyu Kim
- General Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital
| | - Yujin Myung
- From the Departments of Plastic and Reconstructive Surgery
| | - Chan Yeong Heo
- From the Departments of Plastic and Reconstructive Surgery
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Hung YC, McCarthy JT, Park BC, Chaker SC, Saad M, Braun SA, Perdikis G, Higdon K. Comparison of Complication Rates Between Subpectoral vs Prepectoral Techniques in Prosthetic Breast Reconstruction. Aesthet Surg J 2023; 43:1285-1292. [PMID: 37184120 DOI: 10.1093/asj/sjad145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND The location of tissue expanders in implant-based breast reconstruction remains controversial due to variation in surgical techniques and devices. OBJECTIVES The aim of this study was to provide a comprehensive assessment of early and late complication rates between prepectoral and subpectoral placement of tissue expanders. METHODS A retrospective cohort study was conducted of all adult female patients who had undergone 2-stage implant-based breast reconstruction between 2013 and 2019 in our institution. Early complication was defined as complications that occurred within 30 days after surgery. Time-to-event analyses were performed and Cox proportional hazard models were used to adjust for confounders. RESULTS In total, 854 patients were included; 76% of patients underwent a subpectoral tissue expander placement. After the first-stage procedure, the early complication rate was 34% and the late complication rate was 36.4%. After the second-stage procedure, the early complication rate was 16.3% and the late complication rate was 16.1%. Location of the tissue expander did not predict either overall early or late complication rates, regardless of the stages of reconstruction, after adjusting for confounders. Tissue expanders placed in prepectoral plane were associated with a higher hazard ratio (HR) for developing early and late infection after the first stage of reconstruction (HR, 2.1 and 2.4, respectively) as well as late infection after the second stage of reconstruction (HR, 5.3; all P < .05). CONCLUSIONS Location of tissue expanders did not predict risk of complication. However, the prepectoral group was associated with an increased risk of developing infection. LEVEL OF EVIDENCE: 4
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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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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.
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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
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Yang H, Liang F, Xie Y, Qiu M, Du Z. Single axillary incision reverse-order endoscopic nipple/skin-sparing mastectomy followed by subpectoral implant-based breast reconstruction: Technique, clinical outcomes, and aesthetic results from 88 preliminary procedures. Surgery 2023; 174:464-472. [PMID: 37422354 DOI: 10.1016/j.surg.2023.05.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/18/2023] [Accepted: 05/24/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Single axillary incision reverse-order endoscopic nipple-sparing mastectomy overcomes the limitations of conventional endoscopic nipple-sparing mastectomy application. We introduce this technique and report the preliminary results of this study. METHODS Patients who received single axillary incision reverse-order endoscopic nipple-/skin-sparing mastectomy from May 2020 to May 2022 were enrolled from a single institution. Data were analyzed to evaluate the safety and effectiveness of this technique. Patient-reported and surgeon-reported cosmetic outcomes were collected. RESULTS In total, 68 patients who underwent 88 single axillary incision reverse-order endoscopic nipple-/skin-sparing mastectomy combined with subpectoral implant-based breast reconstruction were enrolled in the current study. The overall complication rate was 10.3%. In total, 2.9% of patients suffered from major complications, and 5 (7.4%) experienced minor complications. Only 1 patient experienced partial nipple-areola complex necrosis. During a median follow-up time of 24 months, the locoregional recurrence and distant metastasis rate was both 1.6%. In the surgeon-reported cosmetic results, 92.1% of patients achieved good or excellent results. The mean SCAR-Q scores were 82.07 ± 8.86, and 85.3% evaluated their breasts as good or excellent. The mean overall cost was 5,670.4 ± 1,351.3 USD. The total mean operation time and maturity-stage mean operation time were 234.3 ± 80.4 and 172.55 ± 41.29 min, respectively. According to cumulative sum plot analysis, approximately 18 cases were needed for surgeons to decrease their operation time significantly and complication rate. CONCLUSION Single axillary incision reverse-order endoscopic nipple-sparing mastectomy is a safe, less expensive, and efficient surgical technique with reliable intermediate-term oncologic safety. For suitable candidates, the technique with subpectoral implant-based breast reconstruction can provide a good cosmetic outcome.
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Affiliation(s)
- Huanzuo Yang
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China; Breast Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Faqing Liang
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China; Breast Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Yanyan Xie
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China; Breast Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Mengxue Qiu
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China; Breast Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Zhenggui Du
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China; Breast Centre, West China Hospital, Sichuan University, Chengdu, China.
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Aschen SZ, Paik KC, Swistel AS, Talmor M. Pregnancy-Associated Breast Changes after Nipple-Sparing Mastectomy. Plast Reconstr Surg 2023; 152:492-500. [PMID: 36727812 DOI: 10.1097/prs.0000000000010199] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Women of reproductive age are chronically underrepresented in breast cancer studies. Recent studies suggest that almost 40% of patients diagnosed with breast cancer who are of reproductive age want to have children after completing treatment. In this study, the authors evaluated patients of reproductive age who had undergone nipple-sparing mastectomy (NSM) and implant-based reconstruction. The authors compared those who became pregnant with those who did not with respect to clinical and radiologic changes that are reported at follow-up. METHODS Any patient 45 years of age or younger at the time of NSM was determined to be of reproductive age, selected for evaluation, and followed prospectively. The presence or absence of breast examination changes in the setting of pregnancy after NSM was recorded. RESULTS A total of 36 patients became pregnant after NSM, and 158 patients did not become pregnant after NSM. Of those who became pregnant, nearly half reported some clinical change just before or immediately after delivery. These changes included color change and discharge at the residual nipple-areola complex and palpable nodularity elsewhere. For those with palpable changes, an ultrasound was performed and hypoechoic lesions with variable vascularity were identified. For those who went on to excision, lactational hyperplasia was the most common diagnosis. CONCLUSIONS Ultrasound is an appropriate first-line investigation of breast changes, which can include hyperplasia of remaining ductal and glandular tissue. Patients who became pregnant after NSM commonly had clinical breast examination changes, but the majority of these changes were found to be benign on further evaluation. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Affiliation(s)
- Seth Z Aschen
- From the Divisions of Plastic and Reconstructive Surgery
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Lai HW, Chang YL, Chandrachamnong K, See MH, Huang HI, Lin SL, Fang DY, Chen ST, Chen DR, Mok CW, Cheng FTF. Factors associated with alteration of nipple or skin sensation and impact of duration of time following nipple-sparing mastectomy (NSM): an analysis of 460 cases with comparison of conventional versus endoscopic- or robotic-assisted NSM. World J Surg Oncol 2023; 21:222. [PMID: 37491239 PMCID: PMC10369824 DOI: 10.1186/s12957-023-03107-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/12/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND The current study aims to evaluate the nipple and skin sensation following nipple-sparing mastectomy (NSM) and identify patient-, surgical-, or treatment-related factors affecting nipple or skin sensation in this cohort. METHODS Patients who received NSM with postoperative nipple and skin sensation test evaluation at a single institution over the past 10 years were retrospectively retrieved from a prospectively collected breast cancer surgery database. RESULTS A total of 460 NSM procedures were included in this current study, with the mean age of 48.3 ± 9.1. Three-hundred eighty-three (83.3%) patients had breast reconstructions. One-hundred seventy-four (37.8%) received conventional NSM (C-NSM), 195 (42.4%) endoscopic-assisted NSM (E-NSM), and 91 (19.8%) robotic-assisted NSM (R-NSM) procedures. For nipple sensation assessment, 15 (3.3%) were grade 0, 83 (18.2%) grade I, 229 (49.7%) grade II, and 133 (28.9%) grade III (normal sensation), respectively, with mean grade score of 2.1 ± 0.7. The preserved (grade III) nipple sensation rate was 36.2% (63/174) in the C-NSM group, 26.7% (52/195) in the E-NSM group, and 19.7% (18/91) in the R-NSM group (P = 0.06). The "time since surgery to last evaluation" was significantly longer in the C-NSM group (45.6 ± 34 months) or E-NSM group (44.7 ± 35.8 months) as compared to R-NSM group (31.8 ± 16 months, P < 0.01). In multivariate analysis, peri-areolar incision showed higher grade of nipple sensation (OR: 2.1, P = 0.02) compared to upper outer quadrant incision, and longer follow-up time post-NSM showed significant improvement of nipple or skin sensation (> 60 months vs. ≦ 12 months: nipple odds ratio (OR) = 5.75, P < 0.01; skin, OR = 1.97, P < 0.05). CONCLUSION Our current analysis showed some factors to be related to postoperative nipple or skin sensation, and longer "time after surgery" was associated with significant improvement of nipple and skin sensation in patients who received NSM, regardless of the surgical approaches. SYNOPSIS Our current analysis showed a significant portion of patients with decrease or loss of nipple or skin sensation after nipple-sparing mastectomy (NSM). Several factors associated with preserved nipple or skin sensation were identified, including age, surgical methods, surgical wound location, and association of time from surgery showing that improvement of partial nipple or skin sensation was evident after a longer follow-up.
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Affiliation(s)
- Hung-Wen Lai
- Endoscopic & Oncoplastic Breast Surgery Center, Changhua Christian Hospital, Changhua, Taiwan
- Department of Surgery, Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
- Minimal Invasive Surgery Research Center, Changhua Christian Hospital, Changhua, Taiwan
- Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Breast Surgery, Yuanlin Christian Hospital, Yuanlin, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Lin Chang
- Department of Surgery, Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Korawan Chandrachamnong
- Department of Surgery, Division of Breast Surgery, Police General Hospital, Bangkok, Thailand
| | - Mee-Hoong See
- Department of Surgery, Faculty of Medicine, Breast Oncoplastic Surgery Unit, University Malaya, Kuala Lumpur, Malaysia
| | - Hsin-I Huang
- Department of Information Management, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Wesing Breast Hospital, Kaohsiung, Taiwan
| | - Shih-Lung Lin
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Dar-Yuan Fang
- Department of Surgery, Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Shou-Tung Chen
- Department of Surgery, Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Dar-Ren Chen
- Department of Surgery, Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Chi Wei Mok
- Department of Surgery, Division of Breast Surgery, Changi General Hospital, Singapore, Singapore
- SingHealth Duke-NUS Breast Centre, Singapore, Singapore
| | - Fiona Tsui-Fen Cheng
- Department of Surgery, Division of General Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.
- School of Medicine, College of Medicine, Fu Jen Catholic University, Taipei, Taiwan.
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Kawai K, Fujiwara T, Nishimoto S, Ishise H, Saito T, Nakajima K, Kubo T, Kakibuchi M. Surgical Correction of Nipple Hypertrophy after Nipple-sparing Mastectomy with Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5134. [PMID: 37465282 PMCID: PMC10351939 DOI: 10.1097/gox.0000000000005134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 06/07/2023] [Indexed: 07/20/2023]
Abstract
Nipple hypertrophy is a relatively common phenomenon, particularly in the Asian patient population. The incidence and prevalence or cause of nipple hypertrophy are not well defined in the literature. As survival rates for breast cancer patients continue to improve, there is an increasing emphasis on enhancing their quality of life. Treatment options, such as lumpectomy and radiation therapy or mastectomy, now prioritize preservation of the nipple-areolar complex (NAC) through techniques like nipple-sparing mastectomy (NSM). This approach has been shown to improve patient satisfaction and quality of life. However, it is important to note that NSM is associated with certain complications, including NAC necrosis, malposition, and local recurrence of the tumor. Among those complications, nipple hypertrophy is quite rare. In this report, we present a case of nipple hypertrophy that developed after breast reconstruction, using autologous tissue. The patient, a 48-year-old woman, underwent NSM for breast cancer, and had a tissue expander placed simultaneously. Following tissue expansion, breast reconstruction with a deep inferior epigastric perforator (DIEP) flap was performed. However, during the tissue expansion phase, the patient's nipple gradually enlarged, and the protrusion became more pronounced after the DIEP flap transfer. Nipple reduction surgery was subsequently performed for both diagnostic and cosmetic purposes. We present this case along with a review of relevant literature.
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Affiliation(s)
- Kenichiro Kawai
- From the Department of Plastic Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Toshihiro Fujiwara
- From the Department of Plastic Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Soh Nishimoto
- From the Department of Plastic Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Hisako Ishise
- From the Department of Plastic Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Takuya Saito
- From the Department of Plastic Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Koyo Nakajima
- From the Department of Plastic Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Tateki Kubo
- Department of Plastic Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masao Kakibuchi
- From the Department of Plastic Surgery, Hyogo Medical University, Nishinomiya, Japan
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Ryu JM, Lee J, Lee J, Ko B, Kim JH, Shin H, Park HS. Mastectomy with Reconstruction Including Robotic Endoscopic Surgery (MARRES): a prospective cohort study of the Korea Robot-Endoscopy Minimal Access Breast Surgery Study Group (KoREa-BSG) and Korean Breast Cancer Study Group (KBCSG). BMC Cancer 2023; 23:571. [PMID: 37344780 DOI: 10.1186/s12885-023-10978-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/17/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Robotic nipple-sparing mastectomy (RNSM) has emerged as a new treatment option for breast cancer and risk-reducing mastectomy (RRM) for women who have a high risk of pathogenic variants. Even though several studies have reported that RNSM is a feasible procedure, some argue that it should only be performed by specialized surgeons, and data on oncologic outcomes and patient-reported outcomes (PROs) are limited. Recently, the United States Food and Drug Administration and several surgeons warned that robotic breast surgery should be performed only by specialized surgeons and recommended that the benefits, risks, and alternatives of all available treatment options be discussed with patients so they can make informed treatment decisions. The Korea Robot-Endoscopy Minimal Access Breast Surgery Study Group (KoREa-BSG) has been established to evaluate, standardize, and teach this state-of-the-art procedure. We have designed a multicenter prospective cohort study entitled Mastectomy with Reconstruction Including Robot Endoscopic Surgery (MARRES) to report surgical, PRO, and oncologic outcomes. METHODS MARRES is a multi-institution cohort study prospectively collecting data from patients undergoing mastectomy and reconstruction. The patient inclusion criteria are adult women older than 19 with breast cancer or a high risk of breast cancer (patients with BRCA1/2, TP53, PALB2 mutations, etc.), who have scheduled therapeutic or RRM and want immediate reconstruction. Surgical outcomes, including pre- and postoperative photos, oncologic outcomes, cost-effectiveness, and PRO, are collected. The primary endpoints are postoperative complication rates within 30 postoperative days and the Clavien-Dindo grade of postoperative complications within 180 postoperative days. The secondary endpoints are 5-year postoperative recurrence-free survival and cancer incidence rate (for those who underwent RRM), patient satisfaction with reconstruction expectations preoperative (baseline) and results within 6 to 12 postoperative months, surgeon satisfaction with postoperative results in 6 postoperative months, and cost-effectiveness of the definitive surgery. Patient recruitment will be completed in April 2025, and the target number of enrolled patients is 2000. DISCUSSION This study will provide evidence about the surgical outcomes, oncologic outcomes, and patient satisfaction with RNSM and endoscopic nipple-sparing mastectomy (NSM), compared with conventional NSM. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT04585074. Registered April 8, 2020.
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Affiliation(s)
- Jai Min Ryu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeea Lee
- Department of Surgery, Uijeongbu Eulji Medical Center, Eulji University, Gyeonggi-Do, Korea
- Department of Surgery, Graduate School of Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jeeyeon Lee
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - BeomSeok Ko
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Joo Heung Kim
- Department of Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi, Korea
| | - Hyukjai Shin
- Department of Surgery, Myongji Hospital, Hanyang University Medical Center, Goyang, Korea
| | - Hyung Seok Park
- Department of Surgery, Yonsei University College of Medicine, 50-1, Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea.
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Zarba Meli E, De Santis A, Cortese G, Manna E, Mastropietro T, La Pinta M, Loreti A, Arelli F, Scavina P, Minelli M, Andrulli AD, Costarelli L, Broglia L, Ponzani T, Fortunato L. Nipple-Sparing Mastectomy After Neoadjuvant Chemotherapy: Definitive Results with a Long-Term Follow-Up Evaluation. Ann Surg Oncol 2023; 30:2163-2172. [PMID: 36598627 DOI: 10.1245/s10434-022-13035-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/15/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) is increasingly used for women with breast cancer who are not candidates for conservative surgery. The authors previously reported satisfying results with NSM after neoadjuvant chemotherapy (NACT). METHODS From 2010 to 2020, 1072 women underwent mastectomy at the authors' institution. In this group, 433 NSMs were performed (40%). The only contraindications to NSM were close proximity to the nipple-areola complex (NAC), bloody discharge, and Paget disease. RESULTS In 112 cases involving 111 women, NSM followed NACT (group 1), whereas it was performed as primary surgery in 321 instances involving 306 women (group 2). At 5 years, local relapse was 7% in group 1 and 2% in group 2, although in the multivariate analysis, locoregional relapses (LRRs) did not differ between the two groups. An increased incidence of local relapse was associated with higher tumor stage (stage III; p = 0.046) and age younger than 51 years (p = 0.038). For 34 (30.3%) of the 111 women in group 1 with a pathologic complete response (pCR), no LRRs were recorded. Only one NAC recurrence was observed. Overall survival with each tumor stage did not differ between the two groups. No differences in complications were observed. Cosmetic results were satisfying in 83.8% of the cases and did not get worse after NACT. CONCLUSIONS The study data definitively confirm that NSM is safe even after NACT, with good cosmetic results and complications comparable with those in the primary surgery setting. Tumor stage and age were the only independent factors for local relapse. Patients with pCR enjoyed optimal locoregional control.
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Affiliation(s)
| | - Anna De Santis
- Breast Center San Giovanni-Addolorata Hospital, Rome, Italy
| | - Giuliana Cortese
- Department of Statistical Sciences, University of Padova, Padua, Italy
| | - Elena Manna
- Breast Center San Giovanni-Addolorata Hospital, Rome, Italy
| | | | | | - Andrea Loreti
- Plastic and Reconstructive Surgery, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Floriana Arelli
- Plastic and Reconstructive Surgery, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Paola Scavina
- Medical Oncology, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Mauro Minelli
- Medical Oncology, San Giovanni-Addolorata Hospital, Rome, Italy
| | | | | | - Laura Broglia
- Breast Radiology, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Tatiana Ponzani
- Breast Radiology, San Giovanni-Addolorata Hospital, Rome, Italy
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29
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Lee AY. Nipple-sparing Mastectomy in the Era of Neoadjuvant Systemic Therapy: The Accuracy of Preoperative MRI. Radiology 2023; 307:e223297. [PMID: 36749217 DOI: 10.1148/radiol.223297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Amie Y Lee
- From the Department of Radiology and Biomedical Imaging, University of California, San Francisco, 1825 4th St, Room L3185, San Francisco, CA 94107
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30
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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.
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Basso RB, Rodriguez BG, Palacios Huatuco RM, Coloccini A, Ramírez MF, Mayer HF. Usefulness of Glucose Measurement To Assess Tissue Perfusion of the Nipple-Areola Complex in Conservative Mastectomy: A Prospective Cohort Study Protocol. Int J Surg Protoc 2022; 26:68-72. [PMID: 35978840 PMCID: PMC9354559 DOI: 10.29337/ijsp.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/02/2022] [Indexed: 12/02/2022] Open
Abstract
In recent decades, the mastectomy technique has undergone progressive adaptations in order to preserve the integrity of the breast structure and the nipple-areola complex (NAC), allowing reconstruction to be performed immediately after ablation. However, mastectomy flap necrosis or NAC has become a common complication, with an incidence between 2% and 22.3%. Blood glucose measurement to monitor microsurgical flaps has been reported as a simple method for the early detection of venous compromise. In this scenario, we propose the need to use an alternative, cost-effective method to assess the vitality of NAC in conservative oncological mastectomies. This protocol describes a prospective cohort study and was approved by the Research Protocols Ethics Committee of our institution. Patients will be included after signing informed consent. The anonymity and confidentiality of the information collected will be respected according to the Declaration of Helsinki and according to local and national guidelines.
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Affiliation(s)
- Robertino B. Basso
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires School of Medicine, Hospital Italiano de Buenos Aires University Institute, Buenos Aires, Argentina
| | - Breyner Garcia Rodriguez
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires School of Medicine, Hospital Italiano de Buenos Aires University Institute, Buenos Aires, Argentina
| | - René M. Palacios Huatuco
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires School of Medicine, Hospital Italiano de Buenos Aires University Institute, Buenos Aires, Argentina
| | - Alejandro Coloccini
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires School of Medicine, Hospital Italiano de Buenos Aires University Institute, Buenos Aires, Argentina
| | - Mariano F. Ramírez
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires School of Medicine, Hospital Italiano de Buenos Aires University Institute, Buenos Aires, Argentina
| | - Horacio F. Mayer
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires School of Medicine, Hospital Italiano de Buenos Aires University Institute, Buenos Aires, Argentina
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Magnoni F, Sacchini V, Veronesi P, Bianchi B, Bottazzoli E, Tagliaferri V, Mazzotta E, Castelnovo G, Deguidi G, Rossi EMC, Corso G. Surgical Management of Inherited Breast Cancer: Role of Breast-Conserving Surgery. Cancers (Basel) 2022; 14:3245. [PMID: 35805017 PMCID: PMC9265273 DOI: 10.3390/cancers14133245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 06/26/2022] [Accepted: 06/27/2022] [Indexed: 02/07/2023] Open
Abstract
Recent studies have demonstrated that hereditary breast cancer (BC) has a prevalence of 5-10% among all BC diagnoses. Nowadays, significant technological advances in the identification of an increasingly broad spectrum of genetic mutations allow for the discovery of an ever-growing number of inherited pathogenic (P) or likely pathogenic (LP) variants of breast cancer susceptibility genes. As the management of BC patients carrying mutations in the BRCA1/2 genes or other high-penetrance genes is currently a challenge, extensive research is being carried out and a lively scientific debate has been taking place on what the most appropriate local therapy, especially surgical treatment, of patients with inherited BC should be. In many studies, BC outcomes in BRCA carriers and non-carriers have been compared. A number of them showed that, when compared with mastectomy, breast-conserving surgery in BRCA patients is oncologically safe in terms of overall survival, although an increased risk of ipsilateral recurrence was reported. In these patients, devising a specific therapeutic strategy is an inevitably complex process, as it must take into consideration a series of factors, require a multimodal approach, guarantee personalization, strictly adhere to scientific international guidelines, and consider all available evidence. The present narrative review purposes to identify and illustrate evidence from significant selected studies that discussed those issues, as well as to suggest useful tools to clinicians managing this specific clinical condition in daily clinical practice.
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Affiliation(s)
- Francesca Magnoni
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
| | - Virgilio Sacchini
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA;
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Beatrice Bianchi
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
| | - Elisa Bottazzoli
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
| | - Valentina Tagliaferri
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
| | - Erica Mazzotta
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
| | - Giulia Castelnovo
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
| | - Giulia Deguidi
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
| | - Elisabetta Maria Cristina Rossi
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
| | - Giovanni Corso
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20041 Milan, Italy; (P.V.); (B.B.); (E.B.); (V.T.); (E.M.); (G.C.); (G.D.); (E.M.C.R.); (G.C.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
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Hunt KK. Editorial on Toesca et al's "A Randomized Trial of Robotic Mastectomy Versus Open Surgery in Women With Breast Cancer or BRCA Mutation". Ann Surg 2022; 276:20-21. [PMID: 35703454 DOI: 10.1097/sla.0000000000005485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Kelly K Hunt
- Olla Stribling Distinguished Chair for Cancer Research, Chair, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1434, Houston, TX
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Frasson AL, Falcone AB, Miranda I, Souza ABAD, Vollbrecht B, Barbosa F, Frasson MARM, Lichtenfels M. Nipple-sparing Mastectomy with Immediate Implant-based Reconstruction for Patients with Pure Ductal Carcinoma in Situ. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:376-384. [PMID: 35623619 PMCID: PMC9948099 DOI: 10.1055/s-0042-1742315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The presence of an extensive intraductal component is associated to an increasing risk of relapse in the nipple-areola complex. The aim of the present study was to evaluate the outcomes of patients diagnosed with ductal carcinoma in situ (DCIS) who underwent nipple-sparing mastectomy (NSM) with immediate breast reconstruction using silicone implants. METHODS We retrospectively analyzed the postoperative complications and oncological safety of 67 breast cancer patients diagnosed with pure DCIS who underwent NSM with immediate breast reconstruction using silicone implants between 2004 and 2018. RESULTS Among the 127 NSM procedures performed, 2 hematomas (1.5%) and 1 partial nipple necrosis (0.7%) were observed. After a mean follow-up of 60 months, the local recurrence rate was of 8.9%, the disease-free survival rate was of 90%, and 1 of the patients died. CONCLUSION Despite the local recurrence rate, we showed that NSM with immediate breast reconstruction using silicone implants is a feasible surgical approach, with a low rate of complications and high survival rates for patients with a diagnosis of pure DCIS when breast-conserving surgery is not an option.
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Affiliation(s)
- Antônio Luiz Frasson
- Mastology Service, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Ana Beatriz Falcone
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.,Mastology Service, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Isabela Miranda
- Mastology Service, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Betina Vollbrecht
- Mastology Service, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | | | - Martina Lichtenfels
- Mastology Service, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Bilateral Prophylactic Nipple-Sparing Mastectomy: Analysis of the Risk-Reducing Effect in BRCA1/2 Mutation Carriers. Aesthetic Plast Surg 2022; 46:706-711. [PMID: 34342702 DOI: 10.1007/s00266-021-02506-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/24/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Mutations in the BRCA1 or BRCA2 genes increase the lifetime risk of developing breast cancer to 68-72% by the age of 80. One of the modalities to manage the risk is a prophylactic mastectomy. Bilateral nipple-sparing mastectomy specifically offers the most favorable esthetic outcomes but the evidence for its oncological safety remains limited. Thus, we aimed to compare the occurrence of breast cancer between nipple-sparing mastectomy and surveillance groups of BRCA1 or BRCA 2 mutations carriers. MATERIALS AND METHODS BRCA1 or BRCA2-positive patients undergoing bilateral prophylactic nipple-sparing mastectomy at our department were identified. Only those unaffected by breast cancer were eligible. Each patient was pair-matched with a BRCA1 or BRCA2-positive patient of equal age from the surveillance group. Breast cancer incidence in both groups was recorded and the results were compared. RESULTS None of 105 patients who underwent NSM between 2009 and 2019 at a single institution with a mean follow-up time of 50 months developed breast cancer over this time period. One patient in this group died of an unrelated cause. Nine patients from 105 in the match-paired surveillance group were diagnosed with breast cancer during a mean follow-up time of 58.3 months, however, none of them died. CONCLUSION To the best of our knowledge, this is the largest single-center study of risk-reducing bilateral NSM in healthy BRCA1 or BRCA2 mutation carriers. Based on our results and those of other series, we conclude that NSM in its current form appears to be at least equally as safe as other types of mastectomy for preventing breast cancer in BRCA1 or BRCA2 mutation carriers. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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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: 4] [Impact Index Per Article: 2.0] [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.
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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
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Mathelin C, Barranger E, Boisserie-Lacroix M, Boutet G, Brousse S, Chabbert-Buffet N, Coutant C, Daraï E, Delpech Y, Duraes M, Espié M, Golfier F, Hamy AS, Kermarrec E, Lavoué V, Lodi M, Luporsi É, Maugard C, Molière S, Seror JY, Taris N, Uzan C, Vaysse C, Fritel X. [Techniques and complications of non-genetic risk reducing mastectomies: Guidelines of the National College of French Gynecologists and Obstetricians (CNGOF)]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:121-129. [PMID: 34922037 DOI: 10.1016/j.gofs.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Based on an updated review of the international literature covering the different surgical techniques and complications of risk reducing mastectomies (RRM) in non-genetic context, the Commission of Senology (CS) of the College National des Gynécologues Obstétriciens Français (CNGOF) aimed to establish recommendations on the techniques to be chosen and their implementation. DESIGN The CNGOF CS, composed of 24 experts, developed these recommendations. A policy of declaration and monitoring of links of interest was applied throughout the process of making the recommendations. Similarly, the development of these recommendations did not benefit from any funding from a company marketing a health product. The CS adhered to and followed the AGREE II (Advancing guideline development, reporting and evaluation in healthcare) criteria and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making recommendations in the presence of poor quality or insufficient evidence were highlighted. METHODS The CS considered 6 questions in 4 thematic areas, focusing on oncologic safety, risk of complications, aesthetic satisfaction and psychological impact, and preoperative modalities. RESULTS The application of the GRADE method resulted in 7 recommendations, 6 with a high level of evidence (GRADE 1±) and 1 with a low level of evidence (GRADE 2±). CONCLUSION There was significant agreement among the CS members on recommendations for preferred surgical techniques and practical implementation.
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Affiliation(s)
- C Mathelin
- CHRU, avenue Molière, 67200 Strasbourg, France; ICANS, 17, rue Albert-Calmette, 67033 Strasbourg cedex, France.
| | - E Barranger
- Centre Antoine-Lacassagne, 36, avenue de Valombrose, 06189 Nice, France
| | | | - G Boutet
- AGREGA, service de chirurgie gynécologique et médecine de la reproduction, centre Aliénor d'Aquitaine, centre hospitalier universitaire de Bordeaux, groupe hospitalier Pellegrin, place Amélie-Raba-Léon, 33 000 Bordeaux, France
| | - S Brousse
- CHU de Rennes, 2, rue Henri-le-Guilloux, 35033 Rennes cedex 9, France
| | | | - C Coutant
- Département d'oncologie chirurgicale, centre Georges-François-Leclerc, 1, rue du Pr Marion, 21079 Dijon cedex, France
| | - E Daraï
- Hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - Y Delpech
- Centre Antoine Lacassagne, 33, avenue de Valombrose, 06189 Nice, France
| | - M Duraes
- CHU de Montpellier, 191, avenue du Doyen-Giraud, 34295 Montpellier cedex, France
| | - M Espié
- Hôpital St Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - F Golfier
- Centre hospitalier Lyon Sud, bâtiment 3B, 165, chemin du Grand-Revoyet, 69495 Pierre Benite, France
| | - A S Hamy
- Institut Curie, 26, rue d'Ulm, 75248 Paris, France
| | - E Kermarrec
- Service de radiologie, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - V Lavoué
- Service de gynécologie, CHU, 16, boulevard de Bulgarie, 35200 Rennes, France
| | - M Lodi
- CHU, avenue Molière, 67200 Strasbourg, France
| | - É Luporsi
- Oncologie médicale et oncogénétique, hôpital de Mercy, CHR Metz-Thionville, 1, allée du Château, 57085 Metz, France
| | - C Maugard
- Service de génétique oncologique clinique et unité de génétique oncologique moléculaire, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg
| | - S Molière
- Imagerie du sein, CHRU, avenue Molière 67200 Strasbourg, France
| | - J-Y Seror
- Cabinet privé, 9 ter boulevard Montparnasse, 75006 Paris, France
| | - N Taris
- Oncogénétique, ICANS, 17, rue Albert Calmette, 67033 Strasbourg, France
| | - C Uzan
- Hôpital Pitié-Salpetrière, 47, boulevard de l'Hôpital, 75013 Paris, France
| | - C Vaysse
- Service de chirurgie oncologique, CHU de Toulouse, institut universitaire du cancer de Toulouse-Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse, France
| | - X Fritel
- Centre hospitalo-universitaire de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France
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Progress in breast cancer surgical management. Eur J Cancer Prev 2022; 31:551-553. [DOI: 10.1097/cej.0000000000000741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Costeira B, da Silva FB, Oom R, Costa C, Moniz JV, Abecasis N, Santos CR. Locoregional recurrence in skin-sparing and nipple-sparing mastectomies. J Surg Oncol 2021; 125:352-360. [PMID: 34687468 DOI: 10.1002/jso.26725] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/06/2021] [Accepted: 10/10/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Skin- and nipple-sparing mastectomies (SSMs/NSMs) present as an alternative for patients requiring mastectomy, with better aesthetic results. We aimed to evaluate the locoregional recurrence (LRR) rate and its predictive factors. METHODS Retrospective analysis of all consecutive cases of SSM and NSM for a primary diagnosis of in situ or invasive breast cancer, at a national cancer center, from January 1st, 2013 to May 31st, 2019. The primary outcome was LRR. Secondary outcomes included LRR predictive factors, overall survival (OS), and disease-free survival (DFS). RESULTS There were included 461 patients; 402 (87%) with invasive carcinoma. The median age was 46 (interquartile range [IQR]: 40-53) years. Ninety (20%) patients had locally advanced disease. LRR rate was 3.0%, with a median follow-up time of 39 (IQR: 21-59) months. The median time to recurrence was 22 (IQR: 10-45) months. Factors independently associated with LRR were high histological grade, negative estrogen receptor status, and high Ki67 (p < 0.05). OS was 94.8% and DFS was 92.8%. LRR was associated with decreased OS. DISCUSSION SSM and NSM present as a safe approach to breast cancer requiring mastectomy, including selected patients with a locally advanced tumor. The associated LRR rate is 3.0%, with risk factors being high grade, negative estrogen receptor status, and high Ki67.
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Affiliation(s)
- Beatriz Costeira
- Breast Surgery Unit, Department of General Surgery, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - Francisca B da Silva
- Breast Surgery Unit, Department of General Surgery, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - Rodrigo Oom
- Breast Surgery Unit, Department of General Surgery, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - Cristina Costa
- Breast Surgery Unit, Department of General Surgery, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - João V Moniz
- Breast Surgery Unit, Department of General Surgery, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - Nuno Abecasis
- Breast Surgery Unit, Department of General Surgery, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - Catarina R Santos
- Breast Surgery Unit, Department of General Surgery, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal.,Deparment of Surgery, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
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Magnoni F, Alessandrini S, Alberti L, Polizzi A, Rotili A, Veronesi P, Corso G. Breast Cancer Surgery: New Issues. Curr Oncol 2021; 28:4053-4066. [PMID: 34677262 PMCID: PMC8534635 DOI: 10.3390/curroncol28050344] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 12/24/2022] Open
Abstract
Since ancient times, breast cancer treatment has crucially relied on surgeons and clinicians making great efforts to find increasingly conservative approaches to cure the tumor. In the Halstedian era (mid-late 19th century), the predominant practice consisted of the radical and disfiguring removal of the breast, much to the detriment of women's psycho-physical well-being. Thanks to enlightened scientists such as Professor Umberto Veronesi, breast cancer surgery has since impressively progressed and adopted a much more conservative approach. Over the last three decades, a better understanding of tumor biology and of its significant biomarkers has made the assessment of genetic and molecular profiles increasingly important. At the same time, neo-adjuvant treatments have been introduced, and great improvements in genetics, imaging technologies and in both oncological and reconstructive surgical techniques have been made. The future of breast cancer management must now rest on an ever more precise and targeted type of surgery that, through an increasingly multidisciplinary and personalized approach, can ensure oncological radicality while offering the best possible quality of life.
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Affiliation(s)
- Francesca Magnoni
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (S.A.); (L.A.); (A.P.); (P.V.); (G.C.)
| | - Sofia Alessandrini
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (S.A.); (L.A.); (A.P.); (P.V.); (G.C.)
| | - Luca Alberti
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (S.A.); (L.A.); (A.P.); (P.V.); (G.C.)
| | - Andrea Polizzi
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (S.A.); (L.A.); (A.P.); (P.V.); (G.C.)
| | - Anna Rotili
- Division of Breast Radiology, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy;
| | - Paolo Veronesi
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (S.A.); (L.A.); (A.P.); (P.V.); (G.C.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Giovanni Corso
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (S.A.); (L.A.); (A.P.); (P.V.); (G.C.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
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Comparing Nipple-sparing Mastectomy to Secondary Nipple Reconstruction: A Multi-institutional Study. Ann Surg 2021; 274:390-395. [PMID: 31469747 DOI: 10.1097/sla.0000000000003577] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The primary aim of this study was to compare patient-reported outcomes (PROs) of women who underwent immediate implant-based breast reconstruction (IBBR) after receiving either: (1) nipple-sparing mastectomy (NSM) or (2) simple mastectomy with subsequent nipple reconstruction (SNR). BACKGROUND The goal of post-mastectomy breast reconstruction is to restore body image and quality-of-life after mastectomy, but removal of the nipple-areolar complex may have its own negative psychosocial consequences. NSM may have increased in popularity due to its perceived oncologic safety in many women and to reports of superior aesthetic results with this technique. Despite the increased utilization of NSM, few studies have evaluated the impact of NSM on PROs and complications in women undergoing immediate IBBR. METHODS We performed a secondary analysis of the Mastectomy Reconstruction Outcomes Consortium study, a multicenter, prospective cohort study that recruited patients between February 2012 and July 2015. The primary aim of this study was to compare PROs as measured by BREAST-Q scores between women who underwent IBBR after NSM versus SNR. The secondary aim was to compare complication rates. Mixed-effects regression models controlled for demographic and clinical covariates. RESULTS Of the 600 women in the study, 286 (47.7%) underwent NSM. After controlling for baseline patient characteristics, we found no significant differences in satisfaction with breast, psychosocial well-being, physical well-being or sexual well-being between women undergoing NSM versus SNR. Mastectomy type was not a significant predictor of complications or reconstructive failure. CONCLUSIONS Despite reports of superior aesthetics for NSM over simple mastectomy with nipple reconstruction in immediate IBBR, we found no significant differences at 2 years after reconstruction in patient satisfaction, quality-of-life, or complication rates.
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Factors Associated With Increased Complications in Patients With BRCA Gene Mutations Undergoing Reconstructive Breast Surgery. Plast Surg Nurs 2021; 41:43-50. [PMID: 33626564 DOI: 10.1097/psn.0000000000000331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Reconstructive breast surgery after bilateral prophylactic mastectomy in patients who carry a mutation of the breast cancer (BRCA) gene has been increasing. Undergoing risk-reducing breast surgery can be of great benefit to young patients who have a high risk of developing breast cancer. There is little available evidence about the rate of complications in these patients and which factors are related to increased complications. The objective of this study was to identify predictors of complications in BRCA gene mutation carriers who underwent reconstructive breast surgery. A single-center, retrospective cohort study was conducted that included all patients with a mutation of the BRCA gene who underwent a breast reconstructive procedure, either immediate or delayed, between January 2013 and March 2019 and received a minimum of 6 months' follow-up. The results of our study showed that smoking is the most important modifiable risk factor associated with an increased complication rate for reconstructive breast surgery in patients with BRCA gene mutation. Smoking cessation will reduce the patient's risk for postoperative complications by 50%; therefore, it should be encouraged in all surgical patients and enforced in patients undergoing prophylactic procedures.
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Houvenaeghel G, Cohen M, Dammacco MA, D'Halluin F, Regis C, Gutowski M, Acker O, Fournier M, Bannier M, Lusque A, Jouve E. Prophylactic nipple-sparing mastectomy with immediate breast reconstruction: results of a French prospective trial. Br J Surg 2021; 108:296-301. [PMID: 33793719 DOI: 10.1093/bjs/znaa082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 10/14/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR) is used increasingly when performing a prophylactic mastectomy. Few prospective studies have reported on complication rates. This complementary trial to the French prospective multicentre MAPAM trial aimed to evaluate the nipple-areola complex (NAC) necrosis rate in prophylactic NSM with IBR. METHODS Patient characteristics and surgical data were recorded. Morbidity after prophylactic NSM with a focus on NAC necrosis was analysed. RESULTS Among 59 women undergoing prophylactic NSM, 19 (32 per cent) of the incisions were partly on the NAC. Reconstructions were performed with 46 definitive implants and 13 expanders. The crude rate of postoperative complications was 25 per cent (15 patients). Complete NAC necrosis was reported in two women (3 per cent) and partial or total necrosis in nine (15 per cent). No NAC resection was necessary. Median BMI was lower in women with total or partial NAC necrosis compared with the others (20.0 versus 21.3 kg/m2 respectively; P = 0.034). CONCLUSION Results of this prospective study confirm that prophylactic NSM with IBR is associated with a low risk of total NAC necrosis.
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Affiliation(s)
- G Houvenaeghel
- Department of Surgical Oncology, Paoli Calmettes Institute and Centre de Recherche en Cancerérologie de Marseille (CRCM), Aix-Marseille University, Marseille, France
| | - M Cohen
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - M A Dammacco
- Department of Surgical Oncology, Centre Léon Bérard, Lyon, France
| | - F D'Halluin
- Surgery Department, L'Etablissement Rennais du Sein, Centre Hospitalier Privé St Grégoire, St Grégoire, France
| | - C Regis
- Department of Surgical Oncology, Centre Oscar Lambret, Lille, France
| | - M Gutowski
- Department of Surgical Oncology, Institut du Cancer de Montpellier Val d'Aurelle, Montpellier, France
| | - O Acker
- Surgery Department, Pôle Santé Léonard de Vinci, Chambray les Tours, France
| | - M Fournier
- Department of Surgical Oncology, Institut Bergonie, Bordeaux, France
| | - M Bannier
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - A Lusque
- Department of Biostatistics, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
| | - E Jouve
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
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Comparison of Immediate Breast Reconstruction Outcomes in Patients With and Without Prior Cosmetic Breast Surgery. Clin Breast Cancer 2021; 22:136-142. [PMID: 34481753 DOI: 10.1016/j.clbc.2021.07.016] [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: 06/07/2021] [Revised: 07/29/2021] [Accepted: 07/31/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Skin-sparing (SSM) and nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR) have significantly increased. There is limited information on complications of IBR in patients with prior cosmetic breast surgery (CBS). We compare IBR outcomes in patients undergoing SSM and/or NSM with and without prior CBS. MATERIALS AND METHODS Patients undergoing mastectomy from January 1, 2017 to December 31, 2019 were selected. Patient characteristics, surgical approach, and complications were compared between mastectomy and IBR cases for breasts with and without prior CBS. Binary logistic regression analysis was performed to identify predictors of complications and reconstruction loss. RESULTS 956 mastectomies were performed in 697 patients, with IBR performed for 545 mastectomies in 356 patients. Median age was 51 (range 19-83), 45.8% of patients were age < 50, 62.6% of mastectomies were performed for breast cancer. 95 mastectomies (17.4%) were performed in breasts with prior CBS and 450 (82.6%) without. NSM was more frequently utilized for breasts with prior CBS (P < .001). Complications occurred in 80 mastectomies (14.7%); reconstruction loss in 30 (5.5%). On multivariable analysis, age ≥ 50 (OR 1.76, 95%CI 1.01-3.09, P = .047) and NSM (OR 2.11, 95%CI 1.17-3.79, P = .013) were associated with an increased risk of any complication. Prior CBS was not associated with an increased risk of complications (OR 1.11, 95%CI 0.58-2.14, P = .743) or reconstruction loss (OR 1.32, 95%CI 0.51-3.38, P = .567). CONCLUSION In this analysis of mastectomy and IBR, prior CBS was not associated with an increased risk of complications or reconstruction loss. In patients with prior CBS undergoing mastectomy, IBR may be safely performed.
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Ju T, Chandler J, Momeni A, Gurtner G, Tsai J, Nguyen D, Wapnir I. Two-Stage Versus One-Stage Nipple-Sparing Mastectomy: Timing of Surgery Prevents Nipple Loss. Ann Surg Oncol 2021; 28:5707-5715. [PMID: 34291379 DOI: 10.1245/s10434-021-10456-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/21/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Devascularization of the nipple-areola complex (NAC) before nipple-sparing mastectomy (NSM) enhances blood flow to the skin. This study analyzed the effect of the interval between stages in two-stage (2S) operations and compared the ischemic events with those of one-stage (1S) NSM. METHODS Ischemic complications were defined as partial/reversible (PR) or full-thickness/irreversible (FI) skin necrosis of the NAC or flap. The latter encompassed limited areas of the NAC, resulting in loss of nipple height or areolar circumference without affecting the integrity or appearance of the NAC. Outcomes between the two groups were compared using chi-square and both uni- and multivariate analyses. RESULTS From 2015 to 2019, 109 breasts underwent 2S NSM and 103 breasts underwent 1S NSM. Grade 2 or 3 breast ptosis was more common in the 2S group than in the 1S group (60.5% vs 30.5%; p < 0.01). The median time between devascularization and NSM was 30 days (range, 11-415 days). After devascularization, ischemic events occurred in 25.7% of the breasts. Nipple loss occurred in 7.8% of the 1S group and 0% of the 2S group. Both PR and FI NAC ischemic events were observed in 66.7% of the breasts when NSM took place fewer than 20 days (n = 9) after devascularization versus 15% when NSM took place 20 days or longer afterward (n = 100). Overall, NAC, flap ischemic complications, or both occurred in 35.9% of the 1S group versus 20.2% of the 2S group (p < 0.05). In the multivariate analysis, the odds ratio of ischemic complications in the 2S versus the 1S group was 0.38 (range, 0.19-0.75). CONCLUSIONS Fewer ischemic complications and no nipple loss occurred in 2S NSM. Ischemic events are fewer when the interval between devascularization and NSM is 20 days or longer.
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Affiliation(s)
- Tammy Ju
- Section of Surgical Oncology, Department of Surgery, Stanford University School of Medicine Stanford, Stanford, CA, USA
| | - Julia Chandler
- Section of Surgical Oncology, Department of Surgery, Stanford University School of Medicine Stanford, Stanford, CA, USA
| | - Arash Momeni
- Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine Stanford, Stanford, CA, USA
| | - Geoffrey Gurtner
- Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine Stanford, Stanford, CA, USA
| | - Jacqueline Tsai
- Section of Surgical Oncology, Department of Surgery, Stanford University School of Medicine Stanford, Stanford, CA, USA
| | - Dung Nguyen
- Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine Stanford, Stanford, CA, USA
| | - Irene Wapnir
- Section of Surgical Oncology, Department of Surgery, Stanford University School of Medicine Stanford, Stanford, CA, USA.
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Is Nipple-Sparing Mastectomy Indicated after Previous Breast Surgery? A Series of 387 Institutional Cases. Plast Reconstr Surg 2021; 148:21-30. [PMID: 34181601 DOI: 10.1097/prs.0000000000008097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Previous breast surgery does not represent an absolute contraindication for nipple-sparing mastectomy, although it may negatively interfere with surgical outcomes. The aim of the authors' study was to confirm the feasibility of nipple-sparing mastectomy after previous breast surgery, focusing on skin incisions and risk factors, complications, and oncologic outcomes. METHODS The authors retrospectively identified 368 patients who underwent 387 nipple-sparing mastectomies and reconstruction after previous surgery (quadrantectomy, breast resection, augmentation and reduction mammaplasty, mastopexy) at the European Institute of Oncology from January of 2003 to November of 2017. Patterns of skin incisions (i.e., radial, hemiperiareolar, periareolar, vertical pattern, inframammary fold, Wise-pattern, and round-block) for primary surgery and for mastectomy, type of reconstruction, and radiotherapy have been recorded. The authors collected data regarding early and late complications and further operations (implant change, fat grafting) performed within 2 years to improve cosmetic outcomes. Oncologic follow-up has been reported for in-breast recurrences. RESULTS Complete and partial nipple-areola complex necrosis occurred, respectively, in 2.8 percent and in 5.4 percent of cases. The authors recorded 5.4 percent failures resulting in implant removal. The analysis of risk factors for complications or for the need for further operations showed no significant association with skin incision for first surgery and mastectomy, use of the same skin incision, previous radiotherapy, or type of primary surgery. Five-year overall survival and disease-free survival were 99.1 and 93.8 percent, respectively. No nipple recurrence was recorded. CONCLUSIONS The authors' results confirm that nipple-sparing mastectomy can be a safe surgical procedure after previous breast surgery. Surgical planning should be tailored to each patient. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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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.
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A Randomized Trial of Robotic Mastectomy versus Open Surgery in Women With Breast Cancer or BRCA Mutation. Ann Surg 2021; 276:11-19. [PMID: 34597010 DOI: 10.1097/sla.0000000000004969] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective To compare robotic mastectomy with open classical technique outcomes in breast cancer patients. Summary Background Data As the use of robotic nipple sparing mastectomy continues to rise, improved understanding of the surgical, oncologic and quality of life outcomes is imperative for appropriate patient selection as well as to better understand indications, limits, advantages and dangers. Methods In a phase III, open label, single center, randomized controlled trial involving 80 women with breast cancer (69) or with BRCA mutation (11), we compared the outcome of robotic and open nipple sparing mastectomy. Primary outcomes were surgical complications and quality of life using specific validated questionnaires. Secondary objective included oncologic outcomes. Results Robotic procedure was 1 hour and 18 minutes longer than open (P < 0.001). No differences in the number or type of complications (P = 0.11) were observed. Breast-Q scores in satisfaction with breasts, psychosocial, physical and sexual well-being were significantly higher after robotic mastectomy vs open procedure. Respect to baseline, physical and sexual well-being domains remained stable after robotic mastectomy while they significantly decreased after open procedure (P<= 0.02). The overall Body Image Scale questionnaire score was 20.7 +/- 13.8 vs. 9.9 +/- 5.1 in the robotic vs open groups respectively, P < 0.0001. At median follow-up 28.6 months (range 3.7-43.3), no local events were observed. Conclusions Complications were similar among groups upholding the robotic technique to be safe. Quality of life was maintained after robotic mastectomy while significantly decrease after open surgery. Early follow up confirm no premature local failure. ClinicalTrials.gov NCT03440398.
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Yazar S, Bengur FB, Altinkaya A, Kara H, Uras C. Nipple-Sparing Mastectomy and Immediate Implant-Based Reconstruction with or Without Skin Reduction in Patients with Large Ptotic Breasts: A Case-Matched Analysis. Aesthetic Plast Surg 2021; 45:956-967. [PMID: 33095302 DOI: 10.1007/s00266-020-02000-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/29/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) and implant-based immediate breast reconstruction are becoming preferred options with improved outcomes. However, reconstruction in patients with large and ptotic breasts is challenging. When mastectomy and skin reduction are combined in a single-staged procedure, the vasculature of the skin is disturbed leading to increased complication rates. This paper aims to compare complication rates of NSM and immediate implant-based reconstruction with or without reduction to determine the safety of reduction in this patient group. METHODS Breast cancer patients that underwent NSM and implant-based immediate breast reconstruction between November 2010 and 2018 were analyzed. All implants were placed submuscularly. Patients with skin reduction and nipple-areolar complex transposition were matched in a 1:1 fashion with patients without reduction. RESULTS There were 50 patients (72 procedures) in each group. Demographics of the groups were similar as a part of matching process. Mean implant volume in the reduction group was higher (399.93 ± 97.54 vs. 360.21 ± 82.54, p = 0.009). Full thickness skin necrosis rate was higher in the reduction group [12/72 (%17) vs. 2/72 (3%), p = 0.009], and the most common site was over the suture line [6/12 (50%)]. Complications in the reduction group were more common in reconstructions with implant volumes greater than 500 cc (p = 0.008). CONCLUSIONS When compared with no reduction, the skin necrosis rate of NSM and immediate implant-based reconstruction with skin reduction is higher. The described technique can only be considered in patients with moderate breast volumes, grade II-III ptosis, and when the planned implant volume is low (< 500 cc). LEVEL OF EVIDENCE IV. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Sukru Yazar
- Department of Plastic Reconstructive and Aesthetic Surgery, Acibadem Mehmet Ali Aydinlar University School of Medicine, Kayisdagi Caddesi, No:32 Atasehir, 34752, Istanbul, Turkey.
| | - Fuat Baris Bengur
- Department of Plastic Reconstructive and Aesthetic Surgery, Acibadem Mehmet Ali Aydinlar University School of Medicine, Kayisdagi Caddesi, No:32 Atasehir, 34752, Istanbul, Turkey
| | - Altug Altinkaya
- Department of Plastic Reconstructive and Aesthetic Surgery, Acibadem Mehmet Ali Aydinlar University School of Medicine, Kayisdagi Caddesi, No:32 Atasehir, 34752, Istanbul, Turkey
| | - Halil Kara
- Department of General Surgery, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Cihan Uras
- Department of General Surgery, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
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Blanckaert M, Vranckx J. Oncological safety of therapeutic 'nipple-sparing mastectomy' followed by reconstruction: a systematic review. Acta Chir Belg 2021; 121:155-163. [PMID: 33929924 DOI: 10.1080/00015458.2021.1922829] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Breast cancer (BC) treatment traditionally consisted of radical and often mutilating surgery. Advances in the field of BC have led to new remedies, enabling the paradigm shift from radical to conservative surgery. New treatments such as nipple-sparing mastectomy (NSM) are becoming more popular, aiming to improve both oncological and aesthetic outcomes. However, evidence confirming the oncological safety of NSM is currently lacking, hindering its application. This systematic review sought to analyze NSM's oncological safety as an alternative to conventional mastectomy (CM). PATIENTS AND METHODS A systematic review was performed, respecting the PRISMA guidelines. Pubmed, Embase, and Web of Science databases were consulted and searched for keywords: 'nipple-sparing mastectomy' and 'mammaplasty', or combinations of synonyms. Only original studies published between 2000 and 2020 reporting tumor recurrence and/or survival rates with a minimum of 5-year follow-up were included. RESULTS From the 1675 unique records found, 14 studies were included, amounting to 5980 female BC patients who underwent NSM plus reconstruction. Included studies described either only ductal carcinoma in situ (DCIS, n = 1), only invasive BC (n = 3) or DCIS and invasive BC (n = 10). The most recurrent oncological metrics were 5-year local recurrence (0-10%), locoregional recurrence (0-7.4%), distant recurrence (1.6-15.6%), and overall survival rate (93.1-100%). CONCLUSION Based on long-term low BC recurrences and high survival rates, NSM is perceived to be non-inferior to CM from an oncological perspective. This identifies NSM plus reconstruction to be a safe curative treatment. Further studies should aim to elicit clear and applicable selection criteria in order to maximize NSM's potential.
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Affiliation(s)
- Maxim Blanckaert
- Department of Plastic and Reconstructive Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jan Vranckx
- Department of Plastic and Reconstructive Surgery, University Hospitals Leuven, Leuven, Belgium
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