Reply: The Effect of Neoadjuvant Chemotherapy Compared to Adjuvant Chemotherapy in Healing after Nipple-Sparing Mastectomy.

Abstract

Sir: We would like to thank Dr. Altundag for his comments regarding our recently published study, “The Effect of Neoadjuvant Chemotherapy Compared to Adjuvant Chemotherapy in Healing after Nipple-Sparing Mastectomy.”1 Nipple-sparing mastectomy places increased stress on the breast skin envelope, which can place patients at risk for ischemia-related complications such as mastectomy and nipple-areola complex necrosis, among other complications. Therefore, nipple-sparing mastectomy was initially offered routinely only to very carefully selected patients, usually undergoing mastectomy for prophylactic indications, because of both reconstructive and oncologic concerns. Nevertheless, as experience with nipple-sparing mastectomy has grown, oncologic outcomes have been shown to approach those reached with traditional mastectomy techniques, such as skin-sparing mastectomy. Likewise, complication rates with nipple-sparing mastectomy have been shown to be acceptably low. As such, nipple-sparing mastectomy is now being offered to more and more patients, even those with advanced disease.2 Patients with advanced disease, however, are more likely to require neoadjuvant or adjuvant therapies, such as radiation therapy or chemotherapy. These modalities are notable risk factors for adverse outcomes in healing, especially after breast reconstruction, and place more stress on the breast skin envelope after nipple-sparing mastectomy.3,4 It is therefore important to investigate the effect of these therapies on reconstructive outcomes in nipple-sparing mastectomy. In examining our outcomes in patients receiving neoadjuvant or adjuvant chemotherapy, we found that reconstructive outcomes were acceptable; however, neoadjuvant chemotherapy portended a greater risk of complications. This is likely attributable in part to a shorter period between neoadjuvant chemotherapy and nipple-sparing mastectomy than between nipple-sparing mastectomy and adjuvant therapy. Unfortunately, we were not able to assess the chemotherapy regimens of all patients to determine any differences in outcomes between regimens. This is certainly a focus of future investigation and may aid oncologists in designing patient-specific therapies. Of note, hormonal and biological therapies, including tamoxifen, trastuzumab, and others, were not included in this analysis, as they are not expected to negatively impact wound healing. Likewise, breast tumor subtypes were not included in the analysis. However, in our study, patients receiving chemotherapy were found to have significantly higher clinical breast cancer staging compared with those not undergoing chemotherapy, as would be expected. Tumor markers specifically will help dictate the adjuvant modalities offered to patients, such as chemotherapy, which will influence reconstructive outcomes. They are also likely to have an impact on oncologic outcomes with nipple-sparing mastectomy as in all cases of breast cancer. However, any potential independent effects that these markers may have on reconstructive complications are less clear. As both oncologic and reconstructive outcomes with nipple-sparing mastectomy continue to be defined, it is important to examine potential risk factors, both oncologic and reconstructive, to improve risk stratification and patient selection. Cancer subtypes and chemotherapy regimens, among other patient-specific factors, certainly deserve continued and further investigation with regard to nipple-sparing mastectomy. We greatly appreciate these important points and considerations raised by Dr. Altundag. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Jordan D. Frey, M.D.Mihye Choi, M.D.Nolan S. Karp, M.D.Hansjörg Wyss Department of Plastic SurgeryNew York University Langone Medical CenterNew York, N.Y.