Expanded Indications and Improved Outcomes for Nipple-Sparing Mastectomy Over Time.

Abstract

Demand for nipple-sparing mastectomy (NSM) has increased. The authors' initial NSM guidelines included risk reduction and cancers 2 cm or smaller located more than 2 cm from the nipple. The relative contraindications included obesity, large and/or ptotic breasts, and prior radiation. This study aimed to evaluate changes over time in NSM indications, surgical approach, and early outcomes. After institutional review board approval, the study identified 354 patients scheduled for 588 NSMs, 341 (96%) of whom underwent 566 NSMs. Changes across time [early (2009-2010), mid (2011-2012), and recent (2013-6/2014)] were assessed using tests for linear trend. For patients undergoing reconstruction, NSMs increased from 24% (early) to 40% (recent) (p = 0.004). Among the NSM patients, average body mass index, proportion with bra cup sizes of C or larger, and prior radiation increased significantly over time. Performance of NSM for tumors 2 cm or less from the nipple increased from 5 to 18%, and after neoadjuvant therapy, from 8 to 21.5% (p = 0.02). Use of inframammary, radial, and reduction-type incisions increased over time, together with intraoperative laser angiography (both p < 0.0001). Concomitantly, the overall complication rate, complications requiring treatment, and postoperative nipple loss decreased. During a median follow-up period of 19 months, five locoregional recurrences (LRR) were observed, for an estimated 2-year LRR rate of 1.7% [95% confidence interval (CI), 0-3.9%]. Over time, the indications for NSM expanded in terms of patient characteristics, tumor stage, and prior therapy, whereas the complication rates decreased. Excellent short-term outcomes suggest that NSM is a reasonable approach for many risk-reduction and cancer patients without disease in the nipple-areolar complex. Further study is needed to assess long-term aesthetics, patient satisfaction, and oncologic safety.