Evolving indications and long-term oncological outcomes of risk-reducing bilateral nipple-sparing mastectomy

Background

Bilateral nipple‐sparing mastectomy (NSM) is a technically feasible operation and is associated with excellent cosmetic outcomes. The aim of this study was to evaluate trends in patient characteristics, indications for surgery and long‐term outcomes of bilateral NSM for breast cancer risk reduction over time.

Methods

A review of a single‐centre experience with bilateral NSM performed between 2001 and 2017 for breast cancer risk reduction in patients without breast cancer was performed. Trends in patient characteristics and indications for surgery were evaluated over four time intervals: 2001–2005, 2006–2009, 2010–2013 and 2014–2017. Statistical analysis was performed using χ² tests.

Results

Over the study period, 272 NSMs were performed in 136 patients; their median age was 41 years. The number of bilateral NSMs performed increased over time. The most common indication was a mutation in breast cancer‐associated genes (104 patients, 76·5 per cent), which included BRCA1 (62 patients), BRCA2 (35), PTEN (2), TP53 (3) and ATM (2). Other indications were family history of breast cancer (19 patients, 14·0 per cent), lobular carcinoma in situ (10, 7·4 per cent) and a history of mantle irradiation (3, 2·2 per cent). The proportion of patients having a bilateral NSM for mutation in a breast cancer‐associated gene increased over time (2001–2005: 2 of 12; 2006–2009: 9 of 17; 2010–2013: 34 of 41; 2014–2017: 61 of 66; P < 0·001). Mean follow‐up was 53 months; no breast cancers were found during follow‐up.

Conclusion

The use of bilateral NSM for breast cancer risk reduction is increasing and the indications have evolved over the past 16 years. These excellent long‐term oncological results suggest that bilateral NSM is a good option for surgical breast cancer risk reduction.

Establishing the Feasibility of Face Transplantation in Granulomatosis With Polyangiitis

Granulomatosis with polyangiitis (GPA; formerly Wegener's granulomatosis) is a rare vasculitis that commonly starts in the craniofacial region. We report a case that was masked by prior facial trauma and associated with pyoderma gangrenosum (PG). Disease progression and aggressive debridements led to severe facial tissue loss. The decision to perform a face transplant was controversial because of the risk of disease relapse on the facial allograft. We reviewed renal transplant outcomes in GPA for possible relevance. A PubMed search retrieved 29 studies. Patient and graft survival, relapse, morbidity, mortality, rejection and immunosuppression were assessed. Ten-year patient survival and graft survival were 84.4% and 72.6%, respectively. GPA relapse occurred in 31.5%, and upper airway/ocular relapse occurred in 17.8% (resolved in 76.9%). Mortality was 12.3%. Acute and chronic rejection rates were 14.9% and 6.8%, respectively. Traditional posttransplant immunosuppression was effective. Our review suggests that GPA renal transplant outcomes are comparable to general renal transplant cohorts. Furthermore, transplanted GPA patients exhibit lower disease relapse secondary to lifelong immunosuppression. This supported our decision to perform a face transplant in this patient, which has been successful up to the present time (1-year posttransplantation). Untreated GPA and PG are potential causes of worse surgical outcomes in the craniofacial region.

Cost analysis of conventional facial reconstruction procedures followed by face transplantation

For the first time, this study analyzes the cost of multiple conventional reconstructions and face transplantation in a single patient. This patient is a 46-year-old female victim of a shotgun blast resulting in loss of multiple functional and aesthetic subunits. For over 5 years, she underwent multiple conventional reconstructions with suboptimal results. In December 2008, she became the recipient of the first U.S. face transplant. This has provided the unique opportunity to present the cost of 23 separate conventional reconstructive procedures and the first face transplant in the United States. The combined cost of conventional reconstructive procedures and the first U.S. face transplant was calculated to be $353 480 and $349 959, respectively. The combined cost posttransplant totaled $115 463. The direct cost pretransplant was $206 646, $232 893 peritransplant and $74 236 posttransplant. The two largest areas of cost utilization were surgical ($79 625; 38.5%) and nursing ($55 860; 27%), followed by anesthesia ($24 808; 12%) and pharmacy ($16 581; 8%). This study demonstrates that the cost of the first U.S. face transplant is similar to multiple conventional reconstructions. Although the cost of facial transplantation is considerable, the alleviation of psychological and physiological suffering, exceptional functional recovery and fulfillment of long-lasting hope for social reintegration may be priceless.

Abstract P5-14-04: Patterns of Locoregional Failure in Women with Invasive Breast Cancer Treated with Mastectomy and Tissue Expander/Implant Reconstruction

BACKGROUND: Breast reconstruction with a tissue expander/implant (TE/I) following mastectomy for invasive breast cancer poses unique challenges in detecting local recurrence and in the technical delivery of post-mastectomy radiotherapy (PMRT). For women identified as having high risk disease, PMRT lowers the risk of locoregional failure (LRF) and enhances long-term survival. The aim of this study was to evaluate the patterns of LRF in women who underwent mastectomy and implant reconstruction, with or without adjuvant PMRT.

METHODS: We performed a retrospective review of all patients undergoing mastectomy with TE/I reconstruction for non-metastatic invasive breast cancer from 2001-2006 at the Cleveland Clinic, after approval from the institutional review board. The presence and location of locoregional recurrence was noted. Kaplan-Meier curves were generated to estimate locoregional recurrence free survival (LRFS) and overall survival (OS) rates.

RESULTS: The study population consisted of 326 patients: 121 (37%) with pathologic stage I disease, 128 (39%) with stage II, 46 (14%) with stage III, and 31 (10%) who underwent neoadjuvant systemic therapy prior to mastectomy. The median number of lymph nodes dissected was 10 and the median follow-up was 5.5 years. The OS for all patients at 5 years was 92.4%. By stage, 5-year OS was 95.9% for stage I, 94.4% for stage II,87.2% for stage III, and 79.6% for those undergoing pre-operative systemic therapy. The LRFS at 5 years for all patients was 91.3%. The 5-year LRFS was 95.4% for stage I, 93.6% for stage II, 79.4% for stage III, and 87.4% for those who underwent pre-operative systemic therapy. 8% of all patients had a LRF. By lymph node status, node-negative patients (N0) had a LRF rate of 4.8% (9/189), those with 1-3 nodes positive (N1) had a LRF rate of 5.0% (4/80), those with 4-9 nodes positive (N2) had a LRF rate of 17.5% (7/40), and those with 10 or more nodes positive (N3) had a LRF rate of 50% (6/12).

The most common sites of LRF were cutaneous chest wall (8/26) and axilla (8/26), followed by the supraclavicular/cervical nodes (5/26) and chest wall with muscle involvement (3/26). The remaining 2/26 failed at a combination of the above sites.

21.2% of the total population (69/326) underwent PMRT to the chest wall and regional nodes. By nodal status, including those who received neoadjuvant systemic therapy, 7.4% of women with zero nodes positive underwent radiation, followed by 18.8% with 1-3 nodes positive, and 76.9% with 4 or more nodes positive.

CONCLUSIONS: The crude rate of LRF in this large institutional series is similar to what has been previously reported in the literature. In our population, LRF in the superficial chest wall occurred at the same rate as the axillary nodes, which was followed in frequency by the supraclavicular/cervical nodes. Nearly 1/4 of women with 4 or more positive axillary nodes underwent no adjuvant radiation therapy following mastectomy, despite being a population of women known to derive benefit from PMRT. Further investigation is required to determine whether the presence of a TE/I reconstruction alters decision-making for adjuvant local therapy and/or impacts the technical delivery of PMRT.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-14-04.