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Nessa A, Shaikh S, Fuller M, Masannat YA, Kastora SL. Postoperative complications and surgical outcomes of robotic versus conventional nipple-sparing mastectomy in breast cancer: meta-analysis. Br J Surg 2024; 111:znad336. [PMID: 37890072 PMCID: PMC10769157 DOI: 10.1093/bjs/znad336] [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: 04/22/2023] [Revised: 07/04/2023] [Accepted: 09/27/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Breast cancer is the most common cancer worldwide, with remarkable advances in early diagnosis, systemic treatments, and surgical techniques. Robotic nipple-sparing mastectomy has been trialled; however, the complication rates, surgical outcomes, and oncological safety of this approach remain obscure. METHODS A systematic search of the literature was conducted from conception until September 2022. Studies examining complications and operative variables where robotic nipple-sparing mastectomy was compared with conventional nipple-sparing mastectomy were included. Primary study outcomes were complications (Clavien-Dindo grade III complications, skin or nipple necrosis, seroma, haematoma, infection, implant loss, and wound dehiscence) and oncological safety (recurrence and positive margins). The secondary outcomes included operative variables, length of stay, cost-effectiveness, learning curve, and aesthetic outcome. RESULTS A total of seven studies of overall fair quality, involving 1674 patients, were included in the systematic review and meta-analysis. Grade 3 complications were reduced in robotic nipple-sparing mastectomy without statistical significance (OR 0.60 (95 per cent c.i. 0.35 to 1.05)). Nipple necrosis was significantly reduced in robotic nipple-sparing mastectomy (OR 0.54 (95 per cent c.i. 0.30 to 0.96); P = 0.03; I2 = 15 per cent). Operating time (mean difference +58.81 min (95 per cent c.i. +28.19 to +89.44 min); P = 0.0002) and length of stay (mean difference +1.23 days (95 per cent c.i. +0.64 to +1.81 days); P < 0.0001) were significantly increased in robotic nipple-sparing mastectomy, whereas the opposite was true for blood loss (mean difference -53.18 ml (95 per cent c.i. -71.78 to -34.58 ml); P < 0.0001). CONCLUSION Whilst still in its infancy, robotic breast surgery may become a viable option in breast surgery. Nonetheless, the oncological safety of this approach requires robust assessment.
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Affiliation(s)
- Ashrafun Nessa
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
- General Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
- Breast Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Shafaque Shaikh
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
- General Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Mairi Fuller
- Breast Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Yazan A Masannat
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
- Breast Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
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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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Youn S, Lee E, Peiris L, Olson D, Lesniak D, Rajaee N. Spare the Nipple: A Systematic Review of Tumor Nipple-Distance and Oncologic Outcomes in Nipple-Sparing Mastectomy. Ann Surg Oncol 2023; 30:8381-8388. [PMID: 37620525 DOI: 10.1245/s10434-023-14143-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 07/24/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Preserving the nipple-areolar complex (NAC) in breast cancer surgery improves patient satisfaction and quality of life. The oncologic safety of NSM in tumors < 2 cm from the nipple remains in question. We conducted a systematic review to determine whether TND < 2 cm was associated with increased risk of LRR in patients undergoing NSM. METHODS We included studies of invasive or in situ breast cancer < 2 cm from NAC undergoing NSM which reported LRR rates. LRR rates were stratified by TND and culminated across studies. Cohort study quality was assessed using Newcastle-Ottawa Criteria. Meta-analysis was not possible due to heterogeneity in reporting survival outcomes. RESULTS We identified seven retrospective cohort studies with 2295 patients and 18 case series with 3507 patients. Direct tumor involvement of NAC was considered an absolute contraindication to NSM in all studies. In cohort studies, median follow-up was 31-112 (range 14-204) months. Cohorts with TND < 2 cm did not have a significantly higher rate of LRR. Amongst case series, 275 patients had TND < 2 cm. Combined LRR in case series was 2.6%, with median follow-up 10.4-71 (range 0-158) months. CONCLUSIONS Our systematic review did not identify TND < 2 cm as a significant risk factor for LRR. NSM appears oncologically safe in select patients with TND < 2 cm. Given the improved quality of life associated with NSM compared to skin-sparing mastectomy, we suggest NSM as the procedure of choice in appropriately selected patients.
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Affiliation(s)
- Susie Youn
- Department of Surgery, University of Alberta Hospital, Edmonton, AB, Canada.
| | - Esther Lee
- Department of Surgery, University of Alberta Hospital, Edmonton, AB, Canada
| | - Lashan Peiris
- Department of Surgery, University of Alberta Hospital, Edmonton, AB, Canada
| | - David Olson
- Department of Surgery, University of Alberta Hospital, Edmonton, AB, Canada
| | - David Lesniak
- Department of Surgery, University of Alberta Hospital, Edmonton, AB, Canada
| | - Nikoo Rajaee
- Department of Surgery, University of Alberta Hospital, Edmonton, AB, Canada
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Abdel-Razeq H. Surgical options for patients with early-stage breast cancer and pathogenic germline variants: an oncologist perspectives. Front Oncol 2023; 13:1265197. [PMID: 37781190 PMCID: PMC10539549 DOI: 10.3389/fonc.2023.1265197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
Breast cancer continues to be the most common cancer diagnosed among women worldwide. Family history of breast cancer is frequently encountered, and 5-15% of patients may carry inherited pathogenic germline variants, identification of which can be helpful for both; patients themselves and their unaffected close relatives. The availability and affordability of molecular diagnostics, like next generation sequencing (NGS), had resulted in wider adoption of such technologies to detect pathogenic variants of cancer-predisposing genes. International guidelines had recently broadened the indications for germline genetic testing to include much more patients, and also expanded the testing to include multi-gene panels, while some professional societies are calling for universal testing of all newly diagnosed patients with breast cancer, regardless of their age, personal or family history. The risk of experiencing a contralateral breast cancer (CBC) or ipsilateral recurrence, is well known. Such risk is highest with variants like BRCA1 and BRCA2, but less well-studied with other less common variants. The optimal local therapy for women with BRCA-associated breast cancer remains controversial, but tends to be aggressive and may involve bilateral mastectomies, which may not have any survival advantage. Additionally, surgical management of unaffected women, known to carry a pathogenic cancer-predisposing gene, may vary from surveillance to bilateral mastectomies, too. The oncological safety, and the higher satisfaction of unaffected women and patients with new surgical techniques, like the skin-sparing (SSM) and nipple-sparing (NSM) mastectomies, eased up the process of counselling. In this review, we address the oncological safety of less aggressive surgical options for both; patients and unaffected carriers.
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Affiliation(s)
- Hikmat Abdel-Razeq
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
- School of Medicine, The University of Jordan, Amman, Jordan
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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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Zhang X, Liu J, Pan L, Zheng W, Chen L, Tang W. Patient satisfaction after nipple-sparing mastectomy with intraoperative radiotherapy and breast reconstruction for breast cancer. Acta Chir Belg 2023; 123:110-117. [PMID: 34236948 DOI: 10.1080/00015458.2021.1952054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The use of nipple-sparing mastectomy (NSM) combined with breast reconstruction is increasing in breast cancer surgeries despite its controversial safety profile. To reduce the recurrence rate of tumors in the nipple-areola complex (NAC), we used intraoperative radiotherapy (IORT). The purpose of this study was to explore patients' feedback on this novel treatment strategy. PATIENTS AND METHODS From January 2014 to May 2018, eligible patients with breast cancer were enrolled in this study and separated into 2 groups. Patients in the NSM group underwent IORT to the NAC flap, and patients in the skin-sparing mastectomy (SSM) group underwent SSM and breast reconstruction. The postoperative satisfaction was collected and assessed using the Breast-Q reconstruction questionnaire and a standardized questionnaire; this was compared between the 2 groups. RESULTS There were 46 patients (52 NSMs) in the NSM group and 20 patients (22 SSMs) in the SSM group. The breast-Q scores were higher in the NSM group than the SSM group, with trends for a 'higher satisfaction with breasts' (67.39 ± 20.59 vs. 55.00 ± 19.33; p = 0.026) and 'higher sexual well-being' (61.74 ± 22.24 vs. 49.50 ± 20.12; p = 0.039). All the patients recognized the importance of nipple preservation. Thirty-seven women (80.40%) were satisfied or very satisfied with the appearance and shape of the NAC in the NSM group, while 38/46 women (82.60%) were very unsatisfied or unsatisfied with the sensitivity of the nipples. CONCLUSIONS The Breast-Q scores showed great satisfaction with breasts and sexual well-being in the NSM group. However, more effort should be made in improving postoperative NAC sensitivity.
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Affiliation(s)
- Xiaoshen Zhang
- Department of Breast Surgery, The First Affiliated Hospital, Guangzhou Medical University, China
| | - Jinhui Liu
- Department of Breast Surgery, The First Affiliated Hospital, Guangzhou Medical University, China
| | - Lingxiao Pan
- Department of Breast Surgery, The First Affiliated Hospital, Guangzhou Medical University, China
| | - Wenbo Zheng
- Department of Breast Surgery, The First Affiliated Hospital, Guangzhou Medical University, China
| | - Lun Chen
- Department of Breast Surgery, The First Affiliated Hospital, Guangzhou Medical University, China
| | - Wei Tang
- Department of Breast Surgery, The First Affiliated Hospital, Guangzhou Medical University, China
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Yamaguchi A, Ishitobi M, Nagura N, Shimo A, Seki H, Ogiya A, Sakurai T, Seto Y, Oshiro C, Sasada S, Kato M, Kawate T, Kondo N, Narui K, Nakagawa T, Nogi H, Yamauchi C, Tsugawa K, Kajiura Y, Shien T. Classification of Local Recurrence After Nipple-Sparing Mastectomy Based on Location: The Features of Nipple-Areolar Recurrence Differ from Those of Other Local Recurrences. Ann Surg Oncol 2023; 30:1678-1686. [PMID: 36371582 DOI: 10.1245/s10434-022-12760-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/17/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Little information is available about the clinical and pathologic characteristics of local recurrence (LR) after nipple-sparing mastectomy according to the locations of LR. METHODS This study classified 99 patients into the following two groups according to the location of LR after nipple-sparing mastectomy: nipple-areolar recurrence (NAR) group and other locations of LR (oLR) group. The study evaluated whether the location of LR was associated with disease-free survival (DFS) after LR resection. RESULTS For about half of the patients (44.4 %) with NAR, the primary cancer was estrogen receptor (ER)-negative and human epidermal growth factor receptor 2 (HER2)-positive. Conversely, in most of the patients with oLR (79.2 %), the primary cancer was ER-positive and HER2-negative. Among the LR tumors, the frequency of noninvasive carcinoma in the NAR tumors was significantly higher than in the oLR tumors (51.9 % vs 4.2 %, respectively). During a median follow-up period of 46 months, the location of LR was not associated with DFS after LR. In the NAR group, the presence or absence of LR tumor invasiveness was the only factor associated with DFS. In the oLR group, age at primary surgery was the only factor associated with DFS. CONCLUSION This multi-institutional retrospective study demonstrated that the features of NAR, such as the characteristics of the primary and recurrent tumors and the prognostic factors after LR resection, were quite different from those of oLR.
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Affiliation(s)
- Ayu Yamaguchi
- Department of Breast Surgery, Mie University School of Medicine, Mie, Japan
| | - Makoto Ishitobi
- Department of Breast Surgery, Mie University School of Medicine, Mie, Japan.
| | - Naomi Nagura
- Department of Breast Surgical Oncology, St. Luke's International Hospital, Tokyo, Japan
| | - Ayaka Shimo
- Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kanagawa, Japan.,Department of Breast and Endocrine Surgery, Kawasaki Municipal Tama Hospital, Kanagawa, Japan
| | - Hirohito Seki
- Department of Breast Surgery, Saitama Medical Center, Saitama, Japan
| | - Akiko Ogiya
- Department of Breast Surgical Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | | | - Yukiko Seto
- Department of Breast and Endocrine Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Chiya Oshiro
- Department of Breast Surgery, Kaizuka City Hospital, Osaka, Japan
| | - Shinsuke Sasada
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Michiko Kato
- Department of Breast Surgical Oncology, Showa University School of Medicine, Tokyo, Japan
| | - Takahiko Kawate
- Department of Breast Surgery and Oncology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Naoto Kondo
- Department of Breast Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kazutaka Narui
- Department of Breast and Thyroid Surgery, Medical Center, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Tsuyoshi Nakagawa
- Department of Breast Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroko Nogi
- Department of Breast and Endocrine Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Chikako Yamauchi
- Department of Radiation Oncology, Shiga General Hospital, Shiga, Japan
| | - Koichiro Tsugawa
- Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Yuka Kajiura
- Department of Breast Surgical Oncology, St. Luke's International Hospital, Tokyo, Japan
| | - Tadahiko Shien
- Department of Breast and Endocrine Surgery, Okayama University Hospital, Okayama, Japan
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8
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Safety of Incision Placement with Nipple-sparing Mastectomy and Immediate Prepectoral Breast Reconstruction. Plast Reconstr Surg Glob Open 2023; 11:e4736. [PMID: 36699216 PMCID: PMC9833453 DOI: 10.1097/gox.0000000000004736] [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: 08/16/2022] [Accepted: 11/03/2022] [Indexed: 01/13/2023]
Abstract
In nipple-sparing mastectomy, adequate perfusion to the nipple-areolar complex (NAC) during reconstruction is paramount to avoiding unwanted outcomes. Previous studies have suggested that periareolar incisions may result in higher rates of NAC complications. However, studies to date have not specifically investigated this in prepectoral reconstruction. The purpose of this study is to evaluate the impact of incision location on NAC complications in patients undergoing prepectoral breast reconstruction. Methods We performed a retrospective review of all patients who underwent immediate two-stage prepectoral breast reconstruction following nipple-sparing mastectomy between 2015 and 2018 at a single institution. We identified two types of incisions utilized: superior periareolar or inframammary fold (IMF). Patient demographics, comorbidities, and surgical details were compared between incision types, as were NAC complications. Results A total of 181 consecutive prepectoral breast reconstructions were included for analysis. A superior periareolar incision was used in 113 reconstructions (62%), and an IMF incision was used in 68 reconstructions (38%). There were 33 (18%) total NAC complications in our series. The periareolar incision group had a higher rate of any NAC complication (25% versus 7.4%; P < 0.01), as well as a higher rate of nipple necrosis requiring debridement (9.7% versus 1.5%; P = 0.03). Conclusions In patients undergoing immediate two-stage prepectoral breast reconstruction following nipple-sparing mastectomy, periareolar incisions are associated with an increased risk of NAC complications compared with IMF incisions. For patients who are candidates for either an IMF or periareolar incision, a periareolar incision should be avoided.
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9
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Baxter CR, Crittenden TA, Yip JM, Smallman A, Dean NR. A comparison of reconstructive outcomes following rotation flap approach (RoFA) versus standard mastectomy: a randomized controlled trial. ANZ J Surg 2023; 93:263-269. [PMID: 36404630 DOI: 10.1111/ans.18167] [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: 06/01/2022] [Revised: 09/02/2022] [Accepted: 11/07/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND The rotation flap approach (RoFA) mastectomy is a skin-sparing technique that actively imports skin to the centre of the skin envelope and therefore aids in achieving natural ptosis to the reconstructed breast. The objective of this study was to compare clinical outcomes, aesthetics, patient satisfaction and health-related quality of life between the ROFA mastectomy and standard mastectomy approach. METHODS This study is a prospective randomised controlled trial of participants undergoing mastectomy using either the RoFA technique or standard technique with breast reconstruction. The BREAST-Q was administered pre-operatively and at 3-, 6-, 9- and 12-months following mastectomy. A panel assessment of clinical photographs was conducted to score aesthetics and outcomes of reconstruction. RESULTS A total of 100 participants were enrolled in the study; of these, 51 underwent RoFA incision, 47 underwent standard incision and 2 were lost to follow up. There were no statistically significant differences in BREAST-Q scores or panellist assessment between the mastectomy groups following breast reconstruction. The post-operative incidence of mastectomy skin flap tip necrosis was high in the RoFA incision group, with rates of other complications such as seroma being similar. CONCLUSION The RoFA skin-sparing mastectomy incision showed no significant difference in results across patient-reported outcomes or aesthetics when compared to the standard approach, however, did rate higher for skin flap tip necrosis.
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Affiliation(s)
- Claire R Baxter
- Department of Plastic and Reconstructive Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Tamara A Crittenden
- Department of Plastic and Reconstructive Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Jia Miin Yip
- Department of Plastic and Reconstructive Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Andrea Smallman
- Department of Plastic and Reconstructive Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Nicola R Dean
- Department of Plastic and Reconstructive Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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10
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Li S, Zhao Y, Yan L, Yang Z, Qiu P, Chen H, Zhou Y, Niu L, Yan Y, Zhang W, Zhang H, He J, Zhou C. Effect of the Nipple-Excising Breast-Conserving Therapy in Female Breast Cancer: A Competing Risk Analysis and Propensity Score Matching Analysis of Results Based on the SEER Database. Front Oncol 2022; 12:848187. [PMID: 35494069 PMCID: PMC9048049 DOI: 10.3389/fonc.2022.848187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/16/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction Due to the lack of randomized controlled trial, the effectiveness and oncological safety of nipple-excising breast-conserving therapy (NE-BCT) for female breast cancer (FBC) remains unclear. We aimed to explore and investigate the prognostic value of NE-BCT versus nipple-sparing breast-conserving therapy (NS-BCT) for patients with early FBC. Methods In this cohort study, data between NE-BCT and NS-BCT groups of 276,661 patients diagnosed with tumor–node–metastasis (TNM) stage 0–III FBC from 1998 to 2015 were retrieved from the Surveillance, Epidemiology, and End Results database. Propensity score matching analysis, Kaplan–Meier, X-tile, Cox proportional hazards model, and competing risk model were performed to evaluate the effectiveness and oncological safety for patients in NE-BCT and NS-BCT groups. Results A total of 1,731 (0.63%) patients received NE-BCT (NE-BCT group) and 274,930 (99.37%) patients received NS-BCT (NS-BCT group); 44,070 subjects died after a median follow-up time of 77 months (ranging from 1 to 227 months). In the propensity score matching (PSM) cohort, NE-BCT was found to be an adversely independent prognostic factor affecting overall survival (OS) [hazard ratio (HR), 1.24; 95% CI, 1.06–1.45, p=0.0078]. Subjects in NE-BCT group had similar breast-cancer-specific survival (BCSS) (HR, 1.15; 95%CI, 0.88–1.52, p=0.30) and worse other-causes-specific death (OCSD) (HR, 1.217; 95%CI, 1.002–1.478, p=0.048<0.05) in comparison with those in the NS-BCT group. Conclusions Our study demonstrated that the administration of NE-BCT is oncologically safe and reliable and can be widely recommended in clinics for women with non-metastatic breast cancer.
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Affiliation(s)
- Shouyu Li
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Yuting Zhao
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Lutong Yan
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Zejian Yang
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Pei Qiu
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Heyan Chen
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Yudong Zhou
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Ligang Niu
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yu Yan
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Wei Zhang
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Huimin Zhang
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Jianjun He
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- *Correspondence: Jianjun He, ; Can Zhou,
| | - Can Zhou
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- *Correspondence: Jianjun He, ; Can Zhou,
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11
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Otani N, Tomita K, Taminato M, Kuroda K, Yano K, Kubo T. Sensory Reinnervation With Subcutaneously Embedded Innervated Flaps: An Experimental Study in Rats. Ann Plast Surg 2022; 88:e1-e8. [PMID: 34387580 DOI: 10.1097/sap.0000000000002973] [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: 11/26/2022]
Abstract
BACKGROUND In breast reconstruction, both aesthetic outcomes and sensory function are important for postoperative quality of life. Innervated flaps are useful in reconstruction after conventional mastectomy (CM), which leaves a large portion of the skin paddle exposed on the body surface. However, whether they are also useful in skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) remains unclear. This study aimed to examine the usefulness of innervated flaps in restoring sensation after SSM and NSM using a rat model. METHODS Dorsal cutaneous nerves of rats were entirely eliminated except for the medial branch of the dorsal cutaneous nerve of thoracic segment 13, resulting in an innervated field surrounded by a denervated field. The innervated field was elevated as an innervated island flap and then subcutaneously embedded, with the skin paddle deepithelialized entirely (NSM group, n = 5) or except at the center (SSM group, n = 6). In the control model (CM group, n = 5), the flap was sutured back into its original position. Postoperative changes in the mechanonociceptive field were evaluated using the cutaneous trunci muscle reflex test. Immunohistochemical evaluation of regenerated nerves in the new mechanonociceptive field was performed at postoperative week 12. RESULTS In the SSM and CM groups, the mechanonociceptive field expanded around the skin paddle. In the NSM group, a new mechanonociceptive field appeared at postoperative week 4 and expanded thereafter. Areas of the mechanonociceptive field at postoperative week 12 did not differ significantly between the SSM and NSM groups, but were significantly smaller compared with the CM group and comparable to original flap areas. Histologically, S100- and PGP9.5-positive nerve fibers were observed in the dermis of the new mechanonociceptive field and subcutaneous flap tissue. CONCLUSIONS Subcutaneously embedded innervated island flaps induced nerve regeneration and sensory reinnervation of the denervated skin, suggesting that innervated flaps may also be useful in reconstruction post-SSM/NSM.
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Affiliation(s)
- Naoya Otani
- From the Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Osaka University
| | - Koichi Tomita
- From the Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Osaka University
| | - Mifue Taminato
- From the Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Osaka University
| | - Kazuya Kuroda
- From the Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Osaka University
| | | | - Tateki Kubo
- From the Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Osaka University
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12
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Fu M, Chen Q, Zeng L, Hong T, Zou Q, Yuan Y, Yi W. Prognosis Comparison Between Nipple-Sparing Mastectomy and Total Mastectomy in Breast Cancer: A Case-Control Study After Propensity Score Matching. Ann Surg Oncol 2021; 29:2221-2230. [PMID: 34802105 PMCID: PMC8933300 DOI: 10.1245/s10434-021-11044-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 10/20/2021] [Indexed: 12/03/2022]
Abstract
Background Currently, the operation rate of nipple-sparing mastectomy (NSM) is increasing. However, the long-term prognosis of NSM is not well documented. We utilized the Surveillance, Epidemiology, and End Results (SEER) database to analyze the long-term prognosis of NSM compared with total mastectomy (TM). Methods Population-level data of female breast cancer patients treated with NSM and TM were extracted from 1998 to 2016 from the SEER database. Propensity score matching (PSM) was performed to reduce the influence of selection bias and confounding variables in comparisons. Kaplan-Meier analysis, log-rank test, and Cox proportional hazard regression were performed. Results A total of 5765 patients underwent NSM, which increased from 266 in 2004–2009 to 5370 in 2010–2016. A total of 134,528 patients underwent TM, and the number of patients undergoing TM continued to decline. The overall survival (OS) and breast cancer-specific survival (BCSS) were similar between the NSM group and the TM group (P = 0.058 and 0.87, respectively). For OS, subgroup analysis showed that patients with age ≥ 46, White race, median household income ≥ $70,000, hormone receptor-positive, and HER2 negative had a better prognosis for treatment with NSM. There was no significant difference in BCSS between the NSM group and the TM group. Conclusions In recent years, the clinical application of NSM has been increasing. NSM is a proper procedure for breast cancer patients to achieve long-term survival. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-11044-4.
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Affiliation(s)
- Mengdie Fu
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qitong Chen
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Liyun Zeng
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Tao Hong
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qiongyan Zou
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yunchang Yuan
- Department of Thoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha, China.
| | - Wenjun Yi
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, China.
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13
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Kelly BN, Faulkner HR, Smith BL, Korotkin JE, Lanahan CR, Brown C, Gadd MA, Specht MC, Hughes KS, Oseni TS, Colwell AS, Coopey SB. Nipple-Sparing Mastectomy versus Skin-Sparing Mastectomy: Does Saving the Nipple Impact Short- and Long-Term Patient Satisfaction? Ann Surg Oncol 2021; 29:1033-1040. [PMID: 34498158 DOI: 10.1245/s10434-021-10767-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/15/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) is an oncologically safe alternative to skin-sparing mastectomy (SSM). This study evaluated whether NSM patients were more satisfied than SSM patients in short- and long-term follow-up. METHODS Women who underwent NSM or SSM between 2009 and 2019 completed a postoperative BREAST-Q survey at least 1 year after surgery and patient characteristics were compared. Patient satisfaction at 1-5 years and 6-10 years after NSM and SSM were analyzed. RESULTS Overall, 431 patients were included; 247 had NSM and 184 had SSM 1-10 years prior to BREAST-Q survey completion. SSM patients were older, had higher body mass index (BMI), larger breast weight, and more hypertension than NSM patients, but oncologic treatments were similar between groups. BREAST-Q Psychosocial Well-Being and Sexual Well-Being scores were significantly higher in NSM patients compared with SSM patients in the 1-5 years cohort; however, scores attenuated in the 6-10 years cohort. Satisfaction with breasts was nearly significantly higher in NSM patients compared with SSM patients in the 1-5 years cohort (p = 0.056), but no different in the 6-10 years cohort. Receipt of adjuvant chemotherapy, receipt of postmastectomy radiation therapy, and BMI ≥30 were independent risk factors for dissatisfaction with breasts. CONCLUSIONS Women who are not candidates for NSM should be reassured that long-term qualify of life is not significantly different between SSM and NSM. Dissatisfaction with reconstructed breasts is linked with other factors (besides the nipple), which patients should be made aware of at the time of surgical decision making.
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Affiliation(s)
- Bridget N Kelly
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Heather R Faulkner
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Barbara L Smith
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Jenna E Korotkin
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Conor R Lanahan
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Carson Brown
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Michele A Gadd
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Michelle C Specht
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Kevin S Hughes
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - T Salewa Oseni
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Amy S Colwell
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Suzanne B Coopey
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA.
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14
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Filipe MD, de Bock E, Postma EL, Bastian OW, Schellekens PPA, Vriens MR, Witkamp AJ, Richir MC. Robotic nipple-sparing mastectomy complication rate compared to traditional nipple-sparing mastectomy: a systematic review and meta-analysis. J Robot Surg 2021; 16:265-272. [PMID: 34128142 PMCID: PMC8960562 DOI: 10.1007/s11701-021-01265-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 06/09/2021] [Indexed: 12/03/2022]
Abstract
Breast cancer is worldwide the most common cause of cancer in women and causes the second most common cancer-related death. Nipple-sparing mastectomy (NSM) is commonly used in therapeutic and prophylactic settings. Furthermore, (preventive) mastectomies are, besides complications, also associated with psychological and cosmetic consequences. Robotic NSM (RNSM) allows for better visualization of the planes and reducing the invasiveness. The aim of this study was to compare the postoperative complication rate of RNSM to NSM. A systematic search was performed on all (R)NSM articles. The primary outcome was determining the overall postoperative complication rate of traditional NSM and RNSM. Secondary outcomes were comparing the specific postoperative complication rates: implant loss, hematoma, (flap)necrosis, infection, and seroma. Forty-nine studies containing 13,886 cases of (R)NSM were included. No statistically significant differences were found regarding postoperative complications (RNSM 3.9%, NSM 7.0%, p = 0.070), postoperative implant loss (RNSM 4.1%, NSM 3.2%, p = 0.523), hematomas (RNSM 4.3%, NSM 2.0%, p = 0.059), necrosis (RNSM 4.3%, NSM 7.4%, p = 0.230), infection (RNSM 8.3%, NSM 4.0%, p = 0.054) or seromas (RNSM 3.0%, NSM 2.0%, p = 0.421). Overall, there are no statistically significant differences in complication rates between NSM and RNSM.
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Affiliation(s)
- M. D. Filipe
- Department of Surgery, Cancer Centre, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - E. de Bock
- Department of Surgery, Cancer Centre, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - E. L. Postma
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - O. W. Bastian
- Department of Surgery, Cancer Centre, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - P. P. A. Schellekens
- Department of Plastic Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - M. R. Vriens
- Department of Surgery, Cancer Centre, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - A. J. Witkamp
- Department of Surgery, Cancer Centre, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - M. C. Richir
- Department of Surgery, Cancer Centre, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
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15
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A Strategic Approach to Nipple-sparing Mastectomy Reconstruction with a Wide-based Inframammary Fold Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3053. [PMID: 32983800 PMCID: PMC7489662 DOI: 10.1097/gox.0000000000003053] [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: 05/05/2020] [Accepted: 06/24/2020] [Indexed: 12/05/2022]
Abstract
The single biggest advancement in the aesthetic outcome of breast reconstruction following mastectomy has been the contribution of nipple-sparing mastectomy. By preserving the nipple–areolar complex, patients do not experience the same sense of loss that is observed in the setting of skin-sparing mastectomy. Despite this significant contribution, the challenge remains as to how surgeons can extend this option to larger-breasted patients or patients with significant breast ptosis. Several strategies have been described, including reduction mammoplasty before mastectomy, bipedicled simultaneous mastopexy with mastectomy, and free nipple grafting. The authors have developed a novel approach to nipple-sparing mastectomy that preserves the nipple–areolar complex on a wide-based inframammary fold (IMF) flap and uses indocyanine green perfusion imaging to successfully and reliably perform nipple-sparing mastectomy with immediate reconstruction in larger-breasted ptotic patients. Six patients underwent bilateral nipple-sparing mastectomies and immediate breast reconstruction with a wide-based IMF flap. All patients underwent immediate reconstruction with prepectoral placement of tissue expanders to treat either breast cancer or ductal carcinoma in situ (DCIS), and all patients successfully completed exchange of expander to implant. There were no complications with infection, seroma, mastectomy flap, or nipple necrosis. Aesthetic results were in line with other nipple-sparing techniques. The wide-based IMF flap with nipple preservation is a viable option for larger-breasted ptotic patients who might not otherwise be candidates for nipple-sparing mastectomy. The approach described is a combination of surgical technique and indocyanine green perfusion technology to deliver reproducible results, with an emphasis on surgical safety and avoidance of complications.
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16
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Oncoplastic Procedures in Preparation for Nipple-Sparing Mastectomy and Autologous Breast Reconstruction: Controlling the Breast Envelope. Plast Reconstr Surg 2020; 145:914-920. [PMID: 32221203 DOI: 10.1097/prs.0000000000006657] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy has been associated with superior aesthetic outcomes and oncologic safety. However, traditional contraindications, such as breast ptosis/macromastia, have excluded a large number of patients. The purpose of this study was to determine whether a staged approach would expand the indications for nipple-areolar complex preservation and permit greater control over nipple-areolar complex position and skin envelope following autologous reconstruction. METHODS A retrospective analysis was conducted of female patients with a diagnosis of breast cancer or BRCA mutation with grade 2 or 3 ptosis and/or macromastia who underwent bilateral (oncoplastic) reduction/mastopexy (stage 1) followed by bilateral nipple-sparing mastectomy with immediate reconstruction with free abdominal flaps (stage 2). The authors were specifically interested in the incidence of mastectomy skin necrosis and nipple-areolar complex necrosis and malposition following stage 2. RESULTS Sixty-one patients with a mean age of 45.1 years (range, 28 to 62 years) and mean body mass index of 32.6 kg/m (range, 23.4 to 49.0 kg/m) underwent reconstruction with 122 flaps. The mean interval between stage 1 and 2 was 16.9 weeks (range, 3 to 31 weeks). Clear margins were obtained in all cases of invasive cancer and in situ disease following stage 1. Complications following stage 2 included partial nipple-areolar complex necrosis (n = 5, 8.2 percent), complete nipple-areolar complex necrosis (n = 4, 6.6 percent), nipple-areolar complex malposition (n = 1, 1.6 percent), and mastectomy skin necrosis (n = 4, 6.6 percent). No flap loss was noted in this series. CONCLUSION Patients with moderate to severe breast ptosis and/or macromastia who wish to undergo mastectomy with reconstruction can be offered nipple-sparing approaches safely if a staged algorithm is implemented. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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17
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Valero MG, Moo TA, Muhsen S, Zabor EC, Stempel M, Pusic A, Gemignani ML, Morrow M, Sacchini V. Use of bilateral prophylactic nipple-sparing mastectomy in patients with high risk of breast cancer. Br J Surg 2020; 107:1307-1312. [PMID: 32432359 DOI: 10.1002/bjs.11616] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/02/2019] [Accepted: 03/14/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) is being performed increasingly for risk reduction in high-risk groups. There are limited data regarding complications and oncological outcomes in women undergoing bilateral prophylactic NSM. This study reviewed institutional experience with prophylactic NSM, and examined the indications, rates of postoperative complications, incidence of occult malignant disease and subsequent breast cancer diagnosis. METHODS Women who had bilateral prophylactic NSM between 2000 and 2016 were identified from a prospectively maintained database. Rates of postoperative complications, incidental breast cancer, recurrence and overall survival were evaluated. RESULTS A total of 192 women underwent 384 prophylactic NSMs. Indications included BRCA1 or BRCA2 mutations in 117 patients (60·9 per cent), family history of breast cancer in 35 (18·2 per cent), lobular carcinoma in situ in 29 (15·1 per cent) and other reasons in 11 (5·7 per cent). Immediate breast reconstruction was performed in 191 patients. Of 384 NSMs, 116 breasts (30·2 per cent) had some evidence of skin necrosis at follow-up, which resolved spontaneously in most; only 24 breasts (6·3 per cent) required debridement. Overall, there was at least one complication in 129 breasts (33·6 per cent); 3·6 and 1·6 per cent had incidental findings of ductal carcinoma in situ and invasive breast cancer respectively. The nipple-areola complex was preserved entirely in 378 mastectomies. After a median follow-up of 36·8 months, there had been no deaths and no new breast cancer diagnoses. CONCLUSION These findings support the use of prophylactic NSM in high-risk patients. The nipples could be preserved in the majority of patients, postoperative complication rates were low, and, with limited follow-up, there were no new breast cancers.
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Affiliation(s)
- M G Valero
- Breast Service, Department of Surgery, New York, USA
| | - T-A Moo
- Breast Service, Department of Surgery, New York, USA
| | - S Muhsen
- Breast Service, Department of Surgery, New York, USA
| | - E C Zabor
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - M Stempel
- Breast Service, Department of Surgery, New York, USA
| | - A Pusic
- Division of Plastic Surgery, Brigham and Women's Hospital at Harvard Medical School, Boston, Massachusetts, USA
| | - M L Gemignani
- Breast Service, Department of Surgery, New York, USA
| | - M Morrow
- Breast Service, Department of Surgery, New York, USA
| | - V Sacchini
- Breast Service, Department of Surgery, New York, USA
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18
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Is There a Preferred Incision Location for Nipple-Sparing Mastectomy? A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2019; 143:906e-919e. [DOI: 10.1097/prs.0000000000005502] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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19
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Oncologic outcomes and radiation safety of nipple-sparing mastectomy with intraoperative radiotherapy for breast cancer. Breast Cancer 2019; 26:618-627. [PMID: 30888580 DOI: 10.1007/s12282-019-00962-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 03/11/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy combined with breast reconstruction helps to optimize the contour of the breast after mastectomy. However, the indications for nipple-sparing mastectomy are still controversial. Local radiation to the nipple-areola complex may play some roles in improving the oncological safety of this procedure. METHODS From January 2014 to December 2017, 41 consecutive patients who underwent nipple-sparing mastectomy combined with Intrabeam intraoperative radiotherapy to the nipple-areola complex flap and breast reconstruction were enrolled in this prospective study. The prescribed radiation dose at the surface of the spherical applicator was 16 Gy. RESULTS In eight cases, carcinomas were in the central portion of the breast. Partial necrosis of the nipple-areola complex occurred in three cases. Over 90% of patients reported "no or poor sensation" of the nipple-areola complex postoperatively. With a median follow-up time of 26 months, no recurrences or metastases were identified; however, breast-cancer mortality occurred in one patient. Pathologic evaluation of paraffin-embedded sections showed ductal carcinoma in situ in the remaining tissues deep to the nipple-areola complex flap in two patients. Although no further treatment was administered to the nipple-areola complexes postoperatively, no recurrences or metastases were identified 20 months and 24 months later, respectively. Optical microscopy and transmission electron microscopy revealed changes in some normal tissues immediately after Intrabeam intraoperative radiotherapy. Karyopyknosis were observed in gland tissues, and the collagenous fibers became sparse and arranged chaotically. As assessed by thermoluminescence, radiation doses at different sites in the nipple-areola complex flap varied considerably and were about 10 Gy at the areola surface. No Intrabeam intraoperative radiotherapy-related acute or chronic radiation injuries of the lung, heart or bone marrow were identified. CONCLUSIONS Our findings indicate that Intrabeam intraoperative radiotherapy during nipple-sparing mastectomy combined with breast reconstruction is safe and feasible. TRIAL REGISTRATION The current study was approved by the Ethics Committee of the First Affiliated Hospital of Guangzhou Medical University (registering order 201750). All participants gave their written informed consent.
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20
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Giannotti DG, Hanna SA, Cerri GG, Barbosa Bevilacqua JL. Analysis of Skin Flap Thickness and Residual Breast Tissue After Mastectomy. Int J Radiat Oncol Biol Phys 2018; 102:82-91. [DOI: 10.1016/j.ijrobp.2018.05.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 05/01/2018] [Accepted: 05/08/2018] [Indexed: 10/16/2022]
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21
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Romanoff A, Zabor EC, Stempel M, Sacchini V, Pusic A, Morrow M. A Comparison of Patient-Reported Outcomes After Nipple-Sparing Mastectomy and Conventional Mastectomy with Reconstruction. Ann Surg Oncol 2018; 25:2909-2916. [PMID: 29968023 DOI: 10.1245/s10434-018-6585-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Nipple-sparing mastectomy (NSM) is increasingly used for breast cancer risk reduction and treatment. Prior small studies with variable control for baseline characteristics suggest superior satisfaction with NSM. The purpose of this study was to compare patient satisfaction following NSM and total mastectomy (TM) utilizing the BREAST-Q patient-reported outcome measure in a well-characterized patient population. METHODS Patients at a single institution undergoing NSM or TM with immediate tissue expander/implant reconstruction who completed a follow-up BREAST-Q from 2007 to 2017 were identified by retrospective review of a prospective database. Baseline characteristics were compared, and linear mixed models were used to analyze associations with BREAST-Q scores over time. RESULTS Of 1866 eligible patients, 219 (12%) underwent NSM, and 1647 (88%) underwent TM. Median time from baseline to BREAST-Q was 658 days. Patients with NSM were younger, more likely to be white, and had lower BMI. They more often had prophylactic surgery, bilateral mastectomies, lower-stage disease, and less often received chemotherapy/radiation than patients with TM. On multivariable analysis, after controlling for relevant clinical variables, there was no difference in satisfaction with breasts or satisfaction with outcome overall between NSM and TM patients. Psychosocial well-being and sexual well-being were significantly higher in the NSM group. After additionally controlling for preoperative BREAST-Q score in a subset of patients (72 NSM; 443 TM), only psychosocial well-being remained significantly higher in NSM patients. CONCLUSIONS Patient-reported outcomes should be discussed with women weighing the risks and benefits of NSM to provide a better understanding of expected quality of life.
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Affiliation(s)
- Anya Romanoff
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emily C Zabor
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michelle Stempel
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Virgilio Sacchini
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea Pusic
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Radovanovic Z, Ranisavljevic M, Radovanovic D, Vicko F, Ivkovic-Kapicl T, Solajic N. Nipple-Sparing Mastectomy with Primary Implant Reconstruction: Surgical and Oncological Outcome of 435 Breast Cancer Patients. Breast Care (Basel) 2018; 13:373-378. [PMID: 30498425 DOI: 10.1159/000489317] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background This study aimed to examine the incidence of surgical complications associated with nipple-sparing mastectomy (NSM) with primary implant reconstruction, analyze risk factors for early and late surgical complications of NSM, and determine the incidence of local recurrences and the safety of sparing the nipple-areola complex (NAC). Methods This retrospective cohort study included 435 patients with 441 NSM procedures over a period of 9 years (2004-2012). All surgical complications and the oncological outcome were recorded during follow-up. Results The most common early surgical complication was skin flap ischemia/necrosis (26 patients, 5.9%). Prosthesis explantation due to complications was carried out in 11 (2.5%) cases. Neoadjuvant chemotherapy, implant size >500 ml, diabetes mellitus, body mass index > 25 kg/m2, and incisions other than lateral were risk factors for early complications (p < 0.001). The NAC excision rate was 5.4% (24 cases) due to confirmed presence of cancer cells in the subareolar tissue. Capsular contracture as a late complication occurred in 33 (7.48%) cases. Local relapse occurred in 32 (7.3%) patients. Distant metastases were diagnosed in 68 (15.6%) patients, and 53 (12.2%) patients died during the follow-up period. Conclusions NSM with immediate implant reconstruction has an acceptable morbidity rate and is an oncologically and surgically appropriate treatment for most women requiring mastectomy.
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Affiliation(s)
- Zoran Radovanovic
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
| | - Milan Ranisavljevic
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
| | - Dragana Radovanovic
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
| | - Ferenc Vicko
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
| | - Tatjana Ivkovic-Kapicl
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
| | - Nenad Solajic
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
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