Neoadjuvant chemotherapy is not a contraindication for nipple sparing mastectomy

Oncologic Outcomes of Immediate Breast Reconstruction in the Setting of Neoadjuvant Chemotherapy: A Long-term Follow-up Study of a Matched Cohort

PURPOSE

Despite the increasing use of immediate breast reconstruction (IBR), its oncologic safety in the setting of neoadjuvant chemotherapy (NACT) needs to be comprehensively clarified in breast cancer management. The objective of the present study was to analyze the oncologic safety of IBR following NACT.

METHODS

In total, 587 patients with breast cancer who underwent a total mastectomy (TM) with IBR after NACT between 2008 and 2017 at a single institution were retrospectively reviewed. The reviewed patients with IBR following skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM) were matched 1:3 to patients who underwent TM alone after NACT. Matching variables included age, clinical T and N stages before NACT, response to NACT, pathologic T and N stages, and molecular subtypes.

RESULTS

After propensity score matching, 95 patients who underwent IBR following SSM/NSM after NACT (IBR group) and 228 patients who underwent TM alone after NACT (TM group) were selected. The median follow-up period was 73 (range, 5-181) months after matching. After matching, there were no significant differences between the two groups in 5-year locoregional recurrence-free survival (88.8% vs. 91.2%, p = 0.516), disease-free survival (67.3% vs. 76.6%, p = 0.099), distant metastasis-free survival (71.9% vs. 81.9%, p = 0.057), or overall survival (84.1% vs. 91.5, p = 0.061) rates. In multivariate analyses, conducting IBR was not associated with increased risks for locoregional recurrence, any recurrence, distant metastasis, or overall death.

CONCLUSION

Our findings suggest that IBR following SSM/NSM elicits comparable long-term oncologic outcomes to those of TM alone in the setting of NACT.

Low Cancer Occurrence Rate following Prophylactic Nipple-Sparing Mastectomy

BACKGROUND

Nipple-sparing mastectomy (NSM) has become widely available for breast cancer prophylaxis. There are limited data on its long-term oncologic safety. The objective of this study was to determine the incidence of breast cancer in patients who underwent prophylactic NSM.

METHODS

All patients undergoing prophylactic NSM at a single institution from 2006 through 2019 were retrospectively reviewed. Patient demographic factors, genetic predispositions, mastectomy specimen pathology, and oncologic occurrences at follow-up were recorded. Descriptive statistics were performed where necessary to classify demographic factors and oncologic characteristics.

RESULTS

A total of 871 prophylactic NSMs were performed on 641 patients, with median follow-up of 82.0 months (standard error 1.24). A total of 94.4% of patients ( n = 605) underwent bilateral NSMs, although only the prophylactic mastectomy was considered. The majority of mastectomy specimens (69.6%) had no identifiable pathology. A total of 38 specimens (4.4%) had cancer identified in mastectomy specimens, with ductal carcinoma in situ being the most common (92.1%; n = 35). Multifocal or multicentric disease was observed in seven cases (18.4%) and lymphovascular invasion was identified in two (5.3%). One patient (0.16%), who was a BRCA2 variant carrier, was found to have breast cancer 6.5 years after prophylactic mastectomy.

CONCLUSIONS

Overall primary oncologic occurrence rates are very low in high-risk patients undergoing prophylactic NSM. In addition to reducing the risk of oncologic occurrence, prophylactic surgery itself may be therapeutic in a small proportion of patients. Continued surveillance for these patients remains important to assess at longer follow-up intervals.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, IV.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prediction of nipple involvement in breast cancer after neoadjuvant chemotherapy: Should we rely on breast MRI to preserve the nipple?

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.

Oncological safety of nipple-sparing mastectomy after neoadjuvant chemotherapy: a systematic review

BACKGROUND

the use of nipple-sparing mastectomy (NSM) in local advanced breast cancer after neoadjuvant chemotherapy (NQT) is increasing, despite few studies on the subject. The aim of this systematic review was to determine the safety of NSM after neoadjuvant chemotherapy.

METHODS

for this systematic review we searched MEDLINE; Cochrane; Scientific Electronic Library Online (SciELO); Embase and Scopus. A literature search of all original studies including randomized controlled trials, cohort studies and case-control studies comparing women undergoing NSM after neoadjuvant chemotherapy for breast cancer was undertaken. Outcomes were locoregional recurrence (LRR), nipple recurrence and distant recurrence (DR). Data analysis was undertaken to explore the safety of NSM after NQT. The quality of the evidence was assessed with the Cochrane risk of bias tool. This study is registered on PROSPERO, number CRD42021276778.

FINDINGS

a total of 437 articles were identified. Four articles were included with 1466 patients all of which had a high to serious risk of overall bias. Local recurrence in the NSM after the NQT group ranged from zero to 9.8%. Nippleareolar complex (NAC) recurrence ranged from zero to 2.1%. The distant recurrence rate ranged from 6.5% to 16%. Due to the lack of pattern among the control groups, it was not possible to perform a meta-analysis.

INTERPRETATION

this review provides information for decision making in performing NSM after NQT. Despite the low rates of local recurrence and patients should be counseled about limited oncological information.

Nipple-Sparing Mastectomy After Neoadjuvant Chemotherapy: Definitive Results with a Long-Term Follow-Up Evaluation

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.

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

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

Nipple-sparing Mastectomy: What the Radiologist Should Know

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.

Innovative Standards in Surgery of the Breast after Neoadjuvant Systemic Therapy

BACKGROUND

The goal of neoadjuvant systemic therapy (NST) in breast cancer is to downstage tumors and downgrade treatment. Indications are constantly evolving. These changes raise practical questions for planning of surgery after NST.

SUMMARY

In this review we discuss current evolving aspects of surgery of the breast after NST. Breast-conserving surgery (BCS) eligibility increases after NST - both neoadjuvant chemotherapy (NAC) and neoadjuvant endocrine therapy. Adequate margin width in NST and upfront surgery are similar - "no tumor on ink" for invasive cancer. Oncoplastic breast surgery after NST is feasible - both for BCS and mastectomy with reconstruction. There is increasing interest in the possibility of omitting surgery in patients with a complete response to NAC. Several trials are being conducted in aim of achieving acceptable prediction of pathological complete response, by combination of imaging and percutaneous biopsy of the tumor bed, as well as assessing the safety of such an approach.

KEY MESSAGES

Surgery of the breast after NST should be determined not only according to biologic and anatomic parameters at diagnosis, but is dynamic, and must be tailored according to the response to therapy. The omission of surgery in exceptional responders after NAC is being explored.

Factors Predicting Locoregional Recurrence After Neoadjuvant Chemotherapy and Nipple-Sparing/Skin-Sparing Mastectomy With Immediate Breast Reconstruction

Background

Few data are available on the risk factors of locoregional recurrence (LRR) after neoadjuvant chemotherapy (NACT) and immediate breast reconstruction (IBR) in breast cancer. Herein, we evaluated the factors predicting LRR in a large series of patients who underwent either nipple- (NSM) or skin-sparing mastectomy (SSM) with IBR after NACT.

Methods

We retrospectively analyzed 609 breast cancer patients who underwent NACT and NSM/SSM with IBR between February 2010 and June 2017. Factors associated with an increased risk of LRR were analyzed by univariate (chi-square or Fisher's exact test) and multivariate (Cox proportional hazard regression model) analyses.

Results

During a median follow-up of 63 months, LRR as the first event occurred in 73 patients, and the 5-year cumulative LRR rate was 10.8%. Multivariate analysis revealed post-NACT Ki67 ≥ 10% [hazard ratio (HR), 2.208; 95% confidence interval (CI), 1.295-3.765; P = 0.004], high tumor grade (HR, 1.738; 95% CI, 1.038-2.908; P = 0.035), and presence of lymphovascular invasion (LVI) (HR, 1.725; 95% CI, 1.039-2.864; P = 0.035) as independently associated with increased LRR risk. The 10-year LRR rate was 8.5% for patients with none of the three associated risk factors, 11.6% with one factor, 25.1% with two factors, and 33.7% with all three factors (P < 0.001).

Conclusions

Post-NACT Ki67 ≥ 10%, high tumor grade, and presence of LVI are independently associated with an increased risk of developing LRR after NACT and NSM/SSM with IBR. Future prospective trials are warranted to decrease the risk of LRR in patients with associated risk factors.

Prepectoral Breast Reconstruction in Nipple-Sparing Mastectomy With Immediate Mastopexy

BACKGROUND

Nipple-areola preservation positively impacts quality of life of the patients and helps them to achieve a better psychological and sexual well-being, as well as higher satisfaction with their reconstruction. Patients with large or ptotic breasts, however, represent a technical challenge to surgeons, and nipple-areola preservation may be deferred in this clinical scenario. The aim of this study is to report our experience in patients with large or ptotic breasts who underwent nipple-sparing mastectomy (NSM) and prepectoral implant-based breast reconstruction with immediate mastopexy.

METHODS

A single-institution retrospective chart review was performed in all consecutive patients who underwent NSM and prepectoral implant-based breast reconstruction, simultaneously with mastopexy. This procedure was offered preoperatively to patients who had ptotic or large breasts, which could benefit from mastopexy to obtain a better result. Aesthetic outcomes were evaluated using a modified 5-point Likert scale, and satisfaction and quality of life were evaluated using the reconstruction module of the BREAST-Q questionnaire.

RESULTS

Seventeen NSMs with simultaneous mastopexy were performed on 9 patients. All completed reconstruction successfully, and there were no cases of nipple ischemia or necrosis. Global aesthetic evaluation score was 3.77 (±0.95). The Q-scores were as follows: satisfaction with breast was 90, psychosocial well-being was 95, sexual well-being was 80, and physical well-being with chest was 86.

CONCLUSIONS

In patients with large and/or ptotic breasts, NSM with prepectoral breast reconstruction and immediate mastopexy showed promising results. However, adequate preoperative planning and intraoperative flap assessment are necessary in order to minimize complications.

Reconstructive outcome analysis of the impact of neoadjuvant chemotherapy on immediate breast reconstruction: a retrospective cross-sectional study

BACKGROUND

Neoadjuvant chemotherapy (NACT) was initially applied to locally advanced breast cancer to convert advanced lesions to an operable status. Currently, its application has been expanded to enhance overall oncological results, especially in patients with triple-negative or HER-2-positive breast cancer. With more NACT being applied, the role and impact of this approach on breast reconstruction needs to be determined. This study aimed to perform a complete reconstructive outcome analysis of patients receiving NACT who underwent immediate breast reconstruction.

METHODS

A retrospective review of a single reconstructive surgeon's immediate breast reconstructions performed from July 2008 to December 2018 was undertaken. The results were stratified by the use of NACT. Patient demographics, delivery of NACT, adjuvant treatment, incidence of surgical complications, and postoperative photographs were analyzed.

RESULTS

A total of 269 patients were included. The mean follow-up was 46.3 months. Forty-six out of 269 patients received NACT and were included in the NACT group. The other patients were included in the non-NACT group. When implant-based reconstruction was planned, the NACT group had a higher rate of two-stage tissue expander-implant reconstruction than direct-to-implant reconstruction (p < 0.001). The requirement for postmastectomy radiotherapy was higher in the NACT group (p < 0.001). The surgical complication rates were similar between groups after adjusting for confounding factors. The objective aesthetic outcomes assessed by 6 plastic surgeons were also similar between groups.

CONCLUSIONS

Immediate breast reconstruction is a safe and reliable procedure, with an acceptable reconstructive complication rate and satisfactory aesthetic outcomes, for patients treated with NACT.

First Surgical National Consensus Conference of the Italian Breast Surgeons association (ANISC) on breast cancer management in neoadjuvant setting: Results and summary

RATIONALE

On October 15th, 2020, the first Surgical National Consensus Conference on neoadjuvant chemotherapy (NACT) was promoted by the Italian Association of Breast Surgeons (ANISC).

METHOD

The Consensus Conference was entirely held online due to anti-Covid-19 restrictions and after an introductory four lectures held by national and international experts in the field, a total of nine questions were presented and a digital "real-time" voting system was obtained. A consensus was reached if 75% or more of all panelists agreed on a given question.

RESULTS

A total of 202 physicians, from 76 different Italian Breast Centers homogeneously distributed throughout the Italian country, participated to the Conference. Most participants were surgeons (75%). Consensus was reached for seven out of the nine considered topics, including management of margins and lymph nodes at surgery, and there was good correspondence between the 32 "Expert Panelists" and the "Participants" to the Conference. Consensus was not achieved regarding the indications to NACT for high-grade luminal-like breast tumors, and the need to perform an axillary lymph node dissection in case of micrometastases in the sentinel lymph node after NACT.

CONCLUSIONS

NACT is a topic of major interest among surgeons, and there is need to develop shared guidelines. While a Consensus was obtained for most issues presented at this Conference, controversies still exist regarding indications to NACT in luminal B-like tumors and management of lymph node micrometastases. There is need for clinical studies and analysis of large databases to improve our knowledge on this subject.

Tumor-Nipple Distance of ≥ 1 cm Predicts Negative Nipple Pathology After Neoadjuvant Chemotherapy

BACKGROUND

As neoadjuvant chemotherapy (NAC) for breast cancer has become more widely used, so has nipple-sparing mastectomy. A common criterion for eligibility is a 1 cm tumor-to-nipple distance (TND), but its suitability after NAC is unclear. In this study, we examined factors predictive of negative nipple pathologic status (NS-) in women undergoing total mastectomy after NAC.

METHODS

Women with invasive breast cancer treated with NAC and total mastectomy from August 2014 to April 2018 at our institution were retrospectively identified. Following review of pre- and post-NAC magnetic resonance imaging (MRI) and mammograms, the association of clinicopathologic and imaging variables with NS- was examined and the accuracy of 1 cm TND on imaging for predicting NS- was determined.

RESULTS

Among 175 women undergoing 179 mastectomies, 74% of tumors were cT1-T2 and 67% were cN+ on pre-NAC staging; 10% (18/179) had invasive or in situ carcinoma in the nipple on final pathology. On multivariable analysis, after adjusting for age, grade, and tumor stage, three factors, namely number of positive nodes, pre-NAC nipple-areolar complex retraction, and decreasing TND, were significant predictors of nipple involvement (p < 0.05). The likelihood of NS- was higher with increasing TND on pre- and post-NAC imaging (p < 0.05). TND ≥ 1 cm predicted NS- in 97% and 95% of breasts on pre- and post-NAC imaging, respectively.

CONCLUSIONS

Increasing TND was associated with a higher likelihood of NS-. A TND ≥ 1 cm on pre- or post-NAC imaging is highly predictive of NS- and could be used to determine eligibility for nipple-sparing mastectomy after NAC.

Long-term Oncologic Outcomes of Immediate Breast Reconstruction vs Conventional Mastectomy Alone for Breast Cancer in the Setting of Neoadjuvant Chemotherapy

Importance

An increasing number of patients with breast cancer receiving neoadjuvant chemotherapy (NACT) undergo immediate breast reconstruction (IBR) with nipple-sparing mastectomy (NSM) or skin-sparing mastectomy (SSM) as surgical treatment. However, the oncologic efficacy and safety of this treatment sequencing strategy is unclear.

Objective

To compare the long-term oncologic outcomes of IBR with NSM/SSM and conventional mastectomy (CM) alone for breast cancer in the NACT setting.

Design, Setting, and Participants

A retrospective, propensity score-matched case-control study was conducted at Asan Medical Center, Seoul, Korea. A total of 1266 patients with breast cancer who underwent NACT followed by mastectomy with or without breast reconstruction between January 1, 2010, and November 30, 2016, were included. Data analysis was performed from July 1, 2019, to January 24, 2020. After propensity score matching, 323 patients who underwent IBR with NSM/SSM and 323 who underwent CM alone were selected for comparison of long-term oncologic outcomes.

Main Outcomes and Measures

The 5-year local recurrence-free survival, disease-free survival, distant metastasis-free survival, and overall survival rates were calculated using the Kaplan-Meier method and compared using log-rank tests. Hazard ratios (HRs) and 95% CIs were estimated using the Cox proportional hazards regression model.

Results

After matching, the median follow-up periods were 67 (range, 17-125) months for the IBR group and 68 (range, 17-126) months for the CM-alone group. Median age of the women in the IBR group was 42 (range, 23-72) years; median age of those in the CM-alone group was 46 (range, 30-75) years. No significant differences were observed between the IBR and CM-alone groups in local recurrence (3.7% vs 3.4%; P = .83), regional recurrence (7.1% vs 5.3%; P = .33), or distant metastasis (17.3% vs 18.6%; P = .68) rates. There was also no significant difference between the IBR and CM-alone groups in 5-year local recurrence-free survival (95.6% vs 96.7%; HR, 1.124; 95% CI, 0.495-2.549; P = .78), disease-free survival (76.5% vs 79.9%; HR, 1.089; 95% CI, 0.790-1.500; P = .60), distant metastasis-free survival (82.5% vs 82.5%; HR, 0.941; 95% CI, 0.654-1.355; P = .74), or overall survival (92.0% vs 89.3%; HR, 0.847; 95% CI, 0.530-1.353; P = .49) rates.

Conclusions and Relevance

The long-term oncologic outcomes of IBR with NSM/SSM for breast cancer in this study appeared to be comparable to those of CM alone after NACT, suggesting the feasibility of IBR with NSM/SSM in the NACT setting.

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

BACKGROUND

We assessed the long-term oncologic safety of nipple-sparing mastectomy (NSM) compared to skin-sparing mastectomy (SSM) for primary breast cancer patients with immediate reconstruction.

PATIENTS AND METHODS

Data of stage 0-III primary breast cancer patients undergoing NSM (n = 190) or SSM (n = 729) from June 2006 to December 2012 were retrospectively collected. Nipple-tumor distance (NTD) was measured on pretreatment mammography, magnetic resonance imaging, or ultrasonography findings. NSM patients with NTD < 1 cm were excluded. Locoregional recurrence (LRR) rates were compared between groups. Disease-free survival (DFS) and overall survival (OS) according to surgical procedure were assessed.

RESULTS

The median (range) follow-up period for NSM and SSM was 71 (10-131) months and 79 (9-140) months, respectively. LRR developed in 11 patients with invasive ductal carcinoma (5.8%) for NSM and 44 (42 in patients with invasive ductal carcinoma and 2 in patients with ductal carcinoma-in-situ) (6.0%) for SSM. Hormone receptor and HER2 status were not associated with LRR in either group. DFS and OS rates did not differ between groups (DFS: 89.3% for NSM, 89.3% for SSM, P = .87; OS: 98.4% for NSM, 94.5% for SSM, P = .43).

CONCLUSION

NSM with immediate reconstruction was as safe as SSM for primary breast cancer with respect to prognosis and local control, regardless of the presence of invasive carcinoma or breast cancer subtype.

A Propensity Score-matched Analysis of Long-term Oncologic Outcomes After Nipple-sparing Versus Conventional Mastectomy for Locally Advanced Breast Cancer

OBJECTIVES

To compare the long-term oncologic outcomes of nipple-sparing mastectomy (NSM) with those of conventional mastectomy (CM) in patients with locally advanced breast cancer (LABC) receiving neoadjuvant chemotherapy (NACT).

SUMMARY OF BACKGROUND DATA

NSM has been increasingly implemented in patients with breast cancer. However, oncologic efficacy of NSM in patients with LABC has not been sufficiently demonstrated.

METHODS

The study group comprised 850 patients with clinical stage IIB to IIIC breast cancer who underwent NACT followed by either NSM and immediate breast reconstruction or CM alone. After propensity score-matching, 418 patients were included in the analysis. Local recurrence-free survival, disease-free survival (DFS), distant metastasis-free survival, and overall survival (OS) rates were calculated using the Kaplan-Meier method and compared using log-rank tests between the NSM and CM groups.

RESULTS

After matching, the mean follow-up period was 70 ± 25 months for the NSM group and 74 ± 27 months for the CM group (P = 0.181). There were no significant differences between the groups in terms of 6-year local recurrence-free survival (91.6% vs. 95.8%; P = 0.239), DFS (70.5% vs. 73.4%; P = 0.583), distant metastasis-free survival (79.8% vs. 77.4%; P = 0.320), or OS (87.6% vs. 84.8%; P = 0.465) rates. Additionally, we identified 30 patients in the NSM group who initially presented with tumor extension in the subareolar area; the nipple-areola complex was successfully preserved after NACT, and no recurrence at the nipple was observed in these patients.

CONCLUSIONS

In this matched control study, we demonstrated comparable long-term oncologic outcomes between NSM with immediate reconstruction and CM alone after NACT for LABC. In patients who had tumors extending to the subareolar area before NACT, NSM can be tried if tumor involvement of the nipple-areola complex appears resolved on imaging studies after chemotherapy.

Modern surgical treatment of breast cancer

Breast cancer is the most frequent cancer in women all over the world. The prognosis is generally good, with a five-year overall survival rate above 90% for all stages. It is still the second leading cause of cancer-related death among women. Surgical treatment of breast cancer has changed dramatically over the years. Initially, treatment involved major surgery with long hospitalization, but it is now mostly accomplished as an outpatient procedure with a quick recovery. Thanks to well-designed retrospective and randomly controlled prospective studies, guidelines are continually changing. We are presently in an era where safely de-escalating surgery is increasingly emphasized. Breast cancer is a heterogenous disease, where a "one-size-fits-all" treatment approach is not appropriate. There is often more than one surgical solution carrying equal oncological safety for an individual patient. In these situations, it is important to include the patient in the treatment decision-making process through well informed consent. For this to be optimal, the physician must be fully updated on the surgical options. A consequence of an improved prognosis is more breast cancer survivors, and therefore physical appearance and quality of life is more in focus. Modern breast cancer treatment is increasingly personalized from a surgical point of view but is dependent on a multidisciplinary approach. Detailed algorithms for surgery of the breast and the axilla are required for optimal treatment and quality control. This review illustrates how breast cancer treatment has changed over the years and how the current standard is based on high quality scientific research.

Can I Keep My Nipple? Factors Influencing the Surgical Decision between Skin-Sparing and Nipple-Sparing Mastectomy

Both skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) are well accepted in the management of breast cancer. Factors that influence the decision of choosing one of these techniques over the other, however, remain to be well elucidated. From January 2010 to December 2017, 734 patients at our institution underwent one of these two procedures. Factors differentiating these patient cohorts were compared. In this study, 196 (26.7%) underwent NSM and 538 (73.3%) underwent SSM. The median age of patients at the time of surgery was 50 years (range, 22–78 years). On multivariate analysis, younger patient age, insurance type, BRCA1 mutation status, smaller breast size (by weight), and those who did not undergo neoadjuvant chemotherapy were more likely to undergo NSM. Surgeon also was an independent predictor of whether patients had NSM or SSM. There may be many factors that play into the decision to pursue NSM versus SSM, but younger patient age, BRCA mutation status, breast size, and whether the patient had neoadjuvant chemotherapy may be key among them. Insurance status may also be a factor for some patients. Aside from these factors, some surgeons may be more or less inclined to perform NSM.

Oncologic Outcomes of Nipple-sparing Mastectomy and Immediate Reconstruction After Neoadjuvant Chemotherapy for Breast Cancer

OBJECTIVES

To evaluate the oncologic outcomes and risk factors for locoregional recurrence (LRR) and nipple-areola complex recurrence (NR) in a large series of breast cancer patients who underwent nipple-sparing mastectomy (NSM) and immediate reconstruction after neoadjuvant chemotherapy (NACT).

SUMMARY OF BACKGROUND DATA

The use of NSM and immediate reconstruction in breast cancer patients receiving NACT is increasing. However, the oncologic safety of this approach is unclear.

PATIENTS AND METHODS

A total of 310 breast cancer patients (319 breasts) who underwent NACT and NSM between February 2010 and November 2016 were retrospectively analyzed. Clinical and pathologic factors associated with increased risks of LRR and NR were analyzed using univariate (Chi-square or Fisher exact test) and multivariate (Cox proportional hazard regression model) analyses.

RESULTS

During a mean follow-up of 63 ± 22 months, 38 cases had LRR as the first event, including 6 cases of NR as the first event. The 5-year cumulative LRR and NR rates were 11.0% and 1.9%, respectively. In univariate analysis, clinical T stage, pathologic nodal status, histologic grade, lymphovascular invasion, and post-NACT Ki67 status were associated with increased LRR risk, and post-NACT Ki67 status was the only significant risk factor for NR. In multivariate analysis, post-NACT Ki67 ≥10% (hazard ratio, 4.245; 95% confidence interval, 1.865-9.663; P = 0.001) was an independent risk factor for LRR.

CONCLUSIONS

NSM and immediate reconstruction seem to be oncologically safe with acceptable LRR and NR rates for appropriately selected breast cancer patients treated with NACT. Post-NACT Ki67 ≥10% was associated with increased risk of LRR or NR, and therefore, necessitates cautious follow-up.

Increase in Utilization of Nipple-Sparing Mastectomy for Breast Cancer: Indications, Complications, and Oncologic Outcomes

BACKGROUND

Nipple-sparing mastectomy (NSM) is increasingly performed for invasive breast cancer. Growing evidence supporting the oncologic safety of NSM has led to its widespread use and broadened indications. In this study, we examine the indications, complications, and long-term outcomes of therapeutic NSM.

METHODS

From 2003 to 2016, women undergoing NSM for invasive cancer or ductal carcinoma in situ (DCIS) were identified from a prospectively maintained database. Patient and disease characteristics were compared by procedure year, while complications were compared by procedure year using generalized mixed-effects models accounting for a random surgeon effect. Overall survival and time to recurrence were examined.

RESULTS

Of the 467 therapeutic NSMs, 337 (72%) were invasive cancer, 126 (27%) were DCIS, and 4 (1%) were phyllodes tumors. Median age was 45 years (range 24-75) and median follow-up among survivors was 39.4 months. Three hundred and fifty-seven (76.4%) cases were performed in 2011 or after. When comparing NSMs performed before and after 2011, there was a significant increase in NSMs performed for invasive tumors (58% vs. 77%; p < 0.001). There was no difference in family history, genetic mutations, smoking status, neoadjuvant chemotherapy, prior radiation, nodal involvement, or tumor subtype. Twenty-one (4.5%) nipple excisions were performed, of which 14 were performed for cancer at the nipple margin. Forty-four breasts (9.4%) had complications that required re-operation. Fifteen patients had locoregional recurrence or distant metastasis.

CONCLUSIONS

NSM use for invasive carcinoma has doubled at our institution since 2011, while postoperative complications and recurrence rates remain low. Our experience supports the selective use of NSM in the malignant setting with careful patient selection.

Update in Direct-to-Implant Breast Reconstruction

Implant-based reconstruction (IBR) remains the most commonly utilized breast reconstruction option for post-mastectomy patients. IBR can be approached as either a one-stage reconstruction or a two-stage reconstruction. Facilitated by improvements in surgical technology and advanced techniques, one-stage reconstruction, also known as direct-to-implant (DTI) reconstruction, involves the insertion of an implant at the time of mastectomy. The decision to pursue either a DTI or a two-stage reconstruction is based on several factors, including the patient's overall health, expected risk of postoperative complications, and associated costs to both the patient and hospital.

Implant Reconstruction in Nipple Sparing Mastectomy

Nipple sparing mastectomy has been popularized in the modern era of breast cancer treatment due to its touted advantages with regard to resultant body image and reconstructive outcome. Implant-based techniques remain the most prevalent means of breast reconstruction. Special considerations regarding patient selection and technique are reviewed for implant reconstruction in the setting of mastectomy with nipple preservation. Applications for prepectoral and direct-to-implant reconstruction are discussed and published outcomes are summarized.

Direct-to-implant breast reconstruction after neoadjuvant chemotherapy: A safe option?

INTRODUCTION

Immediate reconstruction (IBR) after mastectomy in patients who have received neoadjuvant chemotherapy (NACT) remains controversial. The aim of this study is to analyze and compare oncological results as well as complication and reoperation rates in patients undergoing NACT and a control group.

METHODS

Retrospective observational case-control study of patients with breast cancer who underwent bilateral mastectomy and direct-to-implant IBR (BMIBR) from 2000-2016. The group that received NACT was matched 1:5 to patients without NACT (Control group). We evaluated differences between groups using the χ² or Fisher test (qualitative variables), Mann-Whitney U or Student's t-test (quantitative variables). The survival analysis was performed using Kaplan-Meier curves and log-rank test (SPSS 22.0).

RESULTS

The study included a total of 171 patients with BMIBR: 62 patients (36.3%) after NACT and 109 patients (63.7%) in the control group without NACT. Median follow-up was 52.0 (IQR: 23.0-94.0) months. In both groups, the indication for BMIBR was patient choice (32.7%). There were no statistically significant differences between groups in terms of complication rate (24.2% in the NACT group and 19.3% in the control group [P=.44]), but differences in oncological results were found. Patients in the NACT Group had three times more risk of recurrence at a given time than patients in the control group (3.009 [1.349-6.713]) according to the univariate analysis.

CONCLUSIONS

Direct-to-implant IBR after skin-sparing mastectomy is a viable option for breast cancer patients undergoing NACT.

Nipple-Sparing Mastectomy and Immediate Breast Reconstruction With a Deep Inferior Epigastric Perforator Flap: A Study of Patient Satisfaction

INTRODUCTION

The morphological result of nipple-areola complex (NAC) reconstruction may be disappointing for patients who undergo skin-sparing mastectomies and immediate breast reconstruction, followed by secondary reconstruction of the nipple-areola complex.The aim of this study was to analyze patient satisfaction after nipple-sparing mastectomy and immediate breast reconstruction with a deep inferior epigastric perforator flap.

MATERIALS AND METHODS

Our retrospective study involved all patients who underwent an immediate breast reconstruction after unilateral mastectomy with conservation of the NAC. The following three kinds of surgical approach were used: mastectomy with periareolar incision, mastectomy with hemiperiareolar incision and lateral extension, and mastectomy with inverted-T mammoplasty incision. Our study was based on a survey using a standardized questionnaire and a Likert scale to report patient satisfaction on the basis of criteria defined by the investigators.

RESULTS

We evaluated 17 patients. All reconstruction patients were satisfied or very satisfied with the overall aesthetic appearance, projection, and volume as well as the appearance of scarring on the reconstructed breast. None of our patients reported dissatisfaction in response to the criteria under evaluation. A periareolar incision was used most often to perform the mastectomy (10 patients). Partial NAC necrosis was observed in five patients, without negatively influencing their perception of the morphological outcome of their reconstruction.

CONCLUSIONS

Immediate breast reconstruction using a deep inferior epigastric perforator free flap after nipple-sparing mastectomies met with a high rate of general satisfaction among patients and resulted in a low rate of nipple-areola complex necrosis.

Effectiveness and Safety of Implant-Based Breast Reconstruction in Locally Advanced Breast Carcinoma: A Matched Case-Control Study

Background

Immediate implant-based breast reconstruction (IBBR) is rarely performed in patients with locally advanced breast carcinoma (LABC). It has not been considered the best indication, and the literature is scarce about this subject.

Patients and Methods

A retrospective matched case-control study was performed in patients with LABC submitted to neoadjuvant chemotherapy (NCT). Forty-eight patients undergoing immediate IBBR were matched with 96 patients undergoing conventional mastectomy. Patients were matched according to 2 models based on prognostic characteristics prior to NCT and response to NCT. Local recurrence and disease-free survival were compared between the groups. In the IBBR group, local complications were evaluated.

Results

In all, 196 patients were evaluated. The mean tumour size of IBBR patients was 5.8 cm. 83.3% (180/196) of the patients had clinical stage III. At a mean follow-up of 74.7 months, the local recurrence rate was 6.2% (3/48), 15.6% (15/96) and 13.7% (13/95) in the IBBR, model 1 and model 2 groups, respectively (p > 0.05). Disease-free survival was higher in the IBBR group than in the model 1 group (mean 88.8 vs. 73.7 months; p = 0.05). In the group submitted to IBBR, 14.6% (7/48) of patients presented loss of prosthesis and 48.8% (20/41) developed capsular contracture.

Conclusion

Immediate IBBR may be a safe and effective surgical procedure in selected patients with LABC.

Surgical delay may extend the indications for nipple-sparing mastectomy: A multicentric study

INTRODUCTION

Nipple-sparing mastectomy (NSM) is considered an oncologically sound procedure but necrosis of the nipple-areola complex (NAC) or skin flaps is a concern, particularly in the presence of risk factors. To increase the indications for NSM and decrease such complications, different procedures of "surgical delay" (SD) have been described.

MATERIALS AND METHODS

A retrospective analysis of patients who underwent SD for NSM at four Italian Breast Centers from 2014 to 2017 was performed. SD generally consisted of a periareolar or "hemi-batwing" incision, dissecting the skin and the NAC from the underlying breast tissue. NSM was scheduled after 2-3 weeks.

RESULTS

Eighty-eight procedures were analyzed. Mild complications of SD were registered in 7.9% of cases. NSM was performed in 85 cases, whereas in three cases (3.4%) a "skin-sparing" mastectomy was necessary due to positivity of the retroareolar biopsy for cancer at SD. A direct-to- implant (DTI) reconstruction was performed in 42 cases (49.4%), while in 43 (50.6%) a tissue-expander (TE) was inserted. After NSM, eight complications (9.4%) were recorded: one total necrosis (1.2%), one partial necrosis (1.2%) and four minimal ischemia (4.7%) of NAC, one skin flap necrosis (1.2%), one haematoma (1.2%). In only two cases (2.3%) prosthesis removal was needed. Aesthetic outcome was evaluated excellent or good in 92.9% of cases. At a median follow-up of 24 months no local recurrences were seen.

CONCLUSION

This is the largest series of SD with NSM presented so far in the literature. In our experience, SD extends indications for NSM in high-risk women.

Surgical Management of Breast Cancer Treated with Neoadjuvant Therapy

Neoadjuvant therapy (NAT) allows downstaging in some cases of breast cancer. By consequence, it may enable a more conservative surgical approach or make surgery possible in cases ineligible for surgery before NAT. In this article, we review the evidence and management recommendations for optimal surgical treatment in this setting.

The Evolution from Subcutaneous to Prepectoral Prosthetic Breast Reconstruction

Prosthetic breast reconstruction is the most common method of reconstruction offered to women following mastectomy. Prepectoral breast reconstruction has recently reemerged as an alternative technique to the partial and total muscle coverage methods. Though this technique has been demonstrated to be safe and effective in the recent published literature, many surgeons have been hesitant to adopt it out of fear of incurring the same complications associated with subcutaneous reconstructions of the past. However, recent advancements in plastic surgery including the use of acellular dermal matrices, autologous fat grafting, and improved breast implants and improved mastectomy techniques have enabled plastic surgeons to revisit the prepectoral space. In this review, the authors describe the evolution of prosthetic-based breast reconstruction from subcutaneous to prepectoral and review outcomes.

Modern Approaches to the Surgical Management of Malignant Breast Disease: The Role of Breast Conservation, Complete Mastectomy, Skin- and Nipple-Sparing Mastectomy

The armamentarium of the modern breast surgeon includes the time-tested procedures of modified radical mastectomy and lumpectomy with sentinel lymph node biopsy with postoperative radiation, but has evolved to include several options that produce excellent oncologic endpoints and improved cosmesis. These options include skin- and nipple-sparing mastectomies with immediate reconstruction as well as oncoplastic procedures that allow larger excisions and better postoperative breast shape. This article provides an overview of these modern surgical approaches for breast cancer treatment.

De-escalating and escalating treatments for early-stage breast cancer: the St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017

The 15th St. Gallen International Breast Cancer Conference 2017 in Vienna, Austria reviewed substantial new evidence on loco-regional and systemic therapies for early breast cancer. Treatments were assessed in light of their intensity, duration and side-effects, seeking where appropriate to escalate or de-escalate therapies based on likely benefits as predicted by tumor stage and tumor biology. The Panel favored several interventions that may reduce surgical morbidity, including acceptance of 2 mm margins for DCIS, the resection of residual cancer (but not baseline extent of cancer) in women undergoing neoadjuvant therapy, acceptance of sentinel node biopsy following neoadjuvant treatment of many patients, and the preference for neoadjuvant therapy in HER2 positive and triple-negative, stage II and III breast cancer. The Panel favored escalating radiation therapy with regional nodal irradiation in high-risk patients, while encouraging omission of boost in low-risk patients. The Panel endorsed gene expression signatures that permit avoidance of chemotherapy in many patients with ER positive breast cancer. For women with higher risk tumors, the Panel escalated recommendations for adjuvant endocrine treatment to include ovarian suppression in premenopausal women, and extended therapy for postmenopausal women. However, low-risk patients can avoid these treatments. Finally, the Panel recommended bisphosphonate use in postmenopausal women to prevent breast cancer recurrence. The Panel recognized that recommendations are not intended for all patients, but rather to address the clinical needs of the majority of common presentations. Individualization of adjuvant therapy means adjusting to the tumor characteristics, patient comorbidities and preferences, and managing constraints of treatment cost and access that may affect care in both the developed and developing world.

Determinants of short and long term outcomes in patients undergoing immediate breast reconstruction following neoadjuvant chemotherapy

BACKGROUND

We evaluated oncologic outcomes and complications of skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) with immediate reconstruction (IR) after neoadjuvant chemotherapy (NAC) in patients with early-stage and locally advanced breast cancer (BC).

METHODS

BC patients from 2000 to 2014 treated with NAC followed by SSM/NSM and IR were reviewed. Patient demographics, tumor characteristics, NAC response, complications, and recurrence were analyzed.

RESULTS

Two hundred sixty-nine patients with 280 BCs were treated with NAC followed by SSM (94%) or NSM (6%) with IR. Median age was 47 (26-72) years with a median follow-up of 45 months. Pathologic complete response (pCR) was noted in 49 (17.5%) cases. Overall 30-day complication rate was 13.2%. Variables associated with complications included BMI (P < 0.0001), tobacco use (P = 0.015), and adjuvant radiation (P = 0.025). Local-regional recurrence was 3.2% and metastatic recurrence was 13.2%. Variables predicting recurrence risk were pre-NAC tumor size (P < 0.001), residual tumor size (P = 0.002), Grade III (P = 0.002), HER-2 negative (P = 0.025), pre-NAC nodal disease (P = 0.05), and lack of pCR (P = 0.045).

CONCLUSION

Following NAC, risk factors for complications in patients undergoing SSM/NSM with IR are high BMI, smoking, and adjuvant XRT. SSM/NSM following NAC is associated with excellent local control. These data support expanding the indications for NSM/SSM to include patients receiving NAC.

Nipple-sparing and skin-sparing mastectomy: Review of aims, oncological safety and contraindications

Skin-sparing (SSM) and nipple-sparing (NSM) mastectomies are relatively new conservative surgical approaches to breast cancer. In SSM most of the breast skin is conserved to create a pocket that facilitates immediate breast reconstruction with implant or autologous graft to achieve a quality cosmetic outcome. NSM is closely similar except that the nipple-areola complex (NAC) is also conserved. Meta-analyses indicate that outcomes for SSM and NSM do not differ from those for non-conservative mastectomies. Recurrence rates in the NAC after NSM are acceptably low (0-3.7%). Other studies indicate that NSM is associated with high patient satisfaction and good psychological adjustment. Indications are carcinoma or DCIS that require mastectomy (including after neoadjuvant chemotherapy). NSM is also suitable for women undergoing risk-reducing bilateral mastectomy. Tumor not less than 2 cm from the NAC is recommended, but may be less important than no evidence of nipple involvement on mandatory intraoperative nipple margin assessment. A positive margin is an absolute contraindication for nipple preservation. Other contraindications are microcalcifications close to the subareolar region and a positive nipple discharge. Complication rates are similar to those for other types of post-mastectomy reconstructions. The main complication of NSM is NAC necrosis, however as surgeon experience matures, frequency declines. Factors associated with complications are voluminous breast, ptosis, smoking, obesity, and radiotherapy. Since the access incision is small, breast tissue may be left behind, so only experienced breast surgeons should do these operations in close collaboration with the plastic surgeon. For breast cancer patients requiring mastectomy, NSM should be the option of choice.

Highlights from the 15th St Gallen International Breast Cancer Conference 15-18 March, 2017, Vienna: tailored treatments for patients with early breast cancer

The 15th St Gallen International Breast Cancer Conference was held in Vienna for the second time, from 15th–18th March 2017. 4000 people from 105 countries all over the world were invited to take part in the event. The real highlight of the conference was the last day with the International Consensus Session which was chaired by around 50 experts on breast cancer worldwide. With reference to data from scientific research, the consensus panel tried to offer guidelines for the management of breast cancer with the aim of providing patients with optimal treatment. The topics covered focused on the treatment of breast cancer, consideration of surgery, radiotherapy, neo-adjuvant, and adjuvant systemic therapy for breast cancer, as well as genetics and prevention of breast cancer.

In particular, in terms of precision medicine, an important topic of the conference was ‘is it possible to think that it could become routine in clinical practice to use immunotherapy and targeted therapy based on genetic signatures?’

In view of personalised therapy, it is important to take into consideration women’s treatment preferences. It is also important not only to offer guidelines which help breast cancer experts all over the world to choose the proper treatment for women with breast cancer but also to discuss the pros and cons of the therapy with the patient. This allows for a better understanding of the disease.

‘From the maximum tolerable to the minimum effective treatment: it is essential to escalate treatment when necessary and to de-escalate when unnecessary’. These few words could summarise the meaning of the 15th St Gallen International Breast Cancer Conference. Prof Martine Piccart-Gebhart was awarded with the St Gallen International Breast Cancer Award 2017 for her fundamental clinical research contribution and Prof Giuseppe Curigliano with the Umberto Veronesi Memorial Award which aims to recognise a physician’s leading role in advancing the science and care of breast cancer patients. Curigliano, in his lecture, spoke about the revolutionary immunotherapy in the clinical management of breast cancer (BC). For the development of these therapies, it is necessary to identify the genetic determinants of BC immune phenotypes in which The Cancer Genome Atlas (TCGA) has contributed towards this.

For example, the T helper (Th-1) phenotype (ICR4), which also exhibits upregulation of immune-regulatory transcripts (eg. PDL1, PD1, FOXP3, IDO1, and CTLA4), was associated with prolonged patients’ survival. Chromosome segment 4q21, which includes genes encoding the Th-1 chemokines CXCL9-11, was significantly amplified only in the immune favourable phenotype (ICR4). The mutation and neo-antigen load progressively decreased from ICR4 to ICR1 but could not explain immune phenotypic differences. Mutations of TP53 were enriched in the immune favourable phenotype (ICR4). Instead, the presence of MAP3K1 and MAP2K4 mutations were closely associated with an immune unfavourable phenotype (ICR1). Using both the TCGA and the validation dataset, the degree of MAPK deregulation segregates BC according to their immune disposition. These findings suggest that mutational-driven deregulation of MAPK pathways is linked to the negative regulation of intratumoural immune response in BC.

The main themes of this congress were: 1) Surgery of the primary tumour and margins; 2) Surgery of the axilla; 3) Radiotherapy: hypofractionated, ‘boost’ to tumour bed, partial breast, regional node, after mastectomy, advanced technology; 4) Pathology: subtypes, TILs; 5) Multi-gene signatures and therapy; 6) Endocrine therapy: pre- and post-menopausal and duration; 7) Chemotherapy: subtypes, stages; 8) Anti-HER-2 therapy; 9) Neo-adjuvant therapy; 10) Adjuvant bisphosponates; 11) Adjuvant diet and exercise.

Evaluation of Local Oncologic Safety in Nipple-Areola Complex-sparing Mastectomy After Primary Chemotherapy: A Propensity Score-matched Study

BACKGROUND

Nipple-areola complex-sparing mastectomy (NSM), extending the concept of skin-sparing mastectomy, allows for the provision of a better cosmetic result. Large operable T2-T3 breast cancer might theoretically appear suitable for this surgical option as an alternative to conventional mastectomy or breast-conserving surgery, when a good response to primary chemotherapy has been achieved.

PATIENTS AND METHODS

From January 2009 to May 2013, 422 patients with invasive breast cancer were progressively accrued to NSM. Of the 422 patients, 361 underwent NSM as first-line treatment (NSM group), and 61 underwent surgery after primary chemotherapy (NSM-PC group). A total of 151 breast cancer patients, who had undergone PC and conventional total mastectomy (TM-PC group) from 2004 to 2009 were evaluated as comparative group with respect to the NSM-PC group. Using propensity score matching, local disease-free survival (LDFS) was evaluated comparatively.

RESULTS

The rate of nipple-areola involvement in the NSM and NSM-PC groups was 13.3% and 9.8%, respectively (P = .539). The nipple-areola involvement in the NSM and NSM-PC groups was significantly associated with the tumor size (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.13-1.95; P = .004), plurifocal or pluricentric tumor (OR, 3.18; 95% CI, 1.72-5.89; P < .001), and the presence of an intraductal component (OR, 2.38; 95% CI, 1.22-4.64; P = .011). The LDFS in the NSM-PC and TM-PC matched cohorts did not show a significant difference, with a 4-year LDFS of 0.89 (95% CI, 0.77-0.95) and 0.93 (95% CI, 0.83-0.97), respectively (hazard ratio [HR], 1.31; 95% CI, 0.40-4.35; P = .655). The NSM-PC cohort was also compared with the NSM cohort in terms of LDFS using 2 different matching criteria, with the tumor size before and after neoadjuvant chemotherapy as the balancing covariate. In the first of the 2 comparisons, the hazards of local relapse were comparable between the 2 matched groups (HR, 1.23; 95% CI, 0.37-4.04; P = .739). In the second comparison, the NSM-PC patients showed a significant greater hazard of local relapse than did the NSM patients (HR, 3.60; 95% CI, 1.10-11.80; P = .035).

CONCLUSION

NSM might be a valuable option for large breast cancer treated by primary chemotherapy. The rate of local relapse seemed to be related to the disease stage, and no significant association with the type of surgery was detected.

Oncologic Safety of Immediate Breast Reconstruction in Breast Cancer Patients Who Underwent Neoadjuvant Chemotherapy: Short-Term Outcomes of a Matched Case-Control Study

INTRODUCTION

Although the indication for immediate breast reconstruction (IBR) after skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM) has been expanded, IBR after neoadjuvant chemotherapy (NACT) is still controversial. We conducted retrospective matched case-control study to analyze oncologic outcomes between patients who underwent TM only and those who underwent IBR after SSM or NSM after NACT.

PATIENTS AND METHODS

A retrospective review of breast cancer patients who underwent IBR after SSM or NSM after NACT between 2008 and 2015 at a single center was conducted. These cases were maximally matched by 1:5 to patients who underwent total mastectomy (TM) alone after NACT. Matching variables included age, clinical T and N stage before NACT, response to NACT, and pathologic stage after NACT. Pathologic stage followed the 7th edition of the American Joint Committee on Cancer (AJCC) classification.

RESULTS

Overall, 31 patients were enrolled onto the IBR after SSM or NSM group (study group) and matched to 85 patients (control group). In the study group, 13 patients (41.9%) underwent NSM and 18 (58.1%) underwent SSM. Median follow-up duration was 29.2 (range, 7-31) and 38.8 (range, 11-85) months for the study and control groups (P = .012), respectively, and median age was 37.0 (range, 26-57) and 40.0 (range, 24-56) years (P = .890), respectively. Overall survival (P = .971), disease-free survival (P = .520), distant metastasis-free survival (P = .795), and local recurrence-free survival (P = .628) did not differ significantly between the 2 groups.

CONCLUSION

IBR after SSM or NSM might be a feasible surgical treatment option even in breast cancer patients who underwent NACT.

Oncologic Outcomes After Nipple-Sparing Mastectomy

BACKGROUND

Nipple-sparing mastectomy (NSM) is increasingly used as an alternative to traditional mastectomy because it provides improved aesthetic results. The data on its oncologic safety are limited. The authors' institution has performed NSM during the past 10 years for both oncologic and prophylactic indications. This study aimed to examine oncologic outcomes after NSM for breast cancer.

METHODS

The study retrospectively examined all NSM cases managed between July 2007 and July 2013. Descriptive statistics were used to characterize the study cohort. Kaplan-Meier survival analysis was performed to estimate recurrence-free survival, specifically the 36-month recurrence-free survival proportion.

RESULTS

A total of 721 nipple-sparing mastectomies were performed for 413 patients: 45 (10.9 %) to reduce risk and 368 (89.1 %) for breast cancer. In the breast cancer group, 29.8 % of the patients had ductal carcinoma in situ, and 70.2 % had invasive cancer. The mean follow-up time was 32 months (range 0.01-90.2 months). In the breast cancer group, the Kaplan-Meier 3-year recurrence-free survival rate was 93.6 % (95 % confidence interval, 89.9-96.0 %). Eight patients (2.2 %) had locoregional recurrences, including one in the nipple. Nine patients (2.4 %) had distant recurrence, and six patients (1.6 %) had a diagnosis of both local and distant recurrences.

CONCLUSIONS

The findings showed a locoregional recurrence rate of 2.2 %, with an overall recurrence rate of 6.3 % for patients undergoing NSM for the treatment of breast cancer. The majority of these recurrences were distant, with one recurrence at the nipple. These results are promising, but a longer follow-up evaluation of this cohort is necessary.