NAC-sparing Mastectomy Research Articles

The Predictive Factors of Combined Implant Application for Breast Cancer Patients Receiving Immediate Breast Reconstruction with a Pedicled Omental Flap.

Whether a laparoscopically harvested omental flap is adequate for total breast reconstruction could not be determined preoperativaly due to lack of reliable assessment methods. This study aimed to establish a statistical model to predict the probability of omental flap insufficiency. In this study, 200 female patients with breast cancer receiving immediate breast reconstruction with pure pedicled omental flaps or pedicled omental flaps combined with implants after nipple-areolar complex-sparing mastectomy were divided into two groups depending on whether implants were needed or not. The clinical characteristics of these two groups were compared. Correlation of body mass index (BMI) and omental volume was analyzed. Binary logistic regression was performed to predict the probability of implant requirement based on clinical parameters, showing significant differences between the two groups. The patients who needed implants in adjunct treatment were younger. In addition, they had larger breast specimens and smaller omental volumes than the others whose omental flaps were sufficient for total breast reconstruction. Body mass index and omental volume showed a moderately positive correlation. Age, specimen volume, and BMI all were entered into the logistic regression equation. For the patients with a BMI lower than 24.0kg/m2, the probability of requiring implants was 5.467 times that of comparable patients with a BMI of 24.0kg/m2 or higher. At the cutoff of 0.61, the regression equation yielded a sensitivity of 84.2% and a specificity of 72.1% in recognizing subjects with the necessity of implant application. The combination of BMI, age, and volume of breast specimen could predict with high accuracy whether implants are required for breast cancer patients receiving pedicled omental flap-based breast reconstruction.

Surgical Delay of Nipple Areola Complex: A Powerful Technique to Extend the Indication of Nipple-Sparing Mastectomy

BackgroundSurgical delay (SD) techniques, performed before the nipple sparing mastectomy (NSM), are procedures conceived to improve the blood supply to the nipple-areola complex (NAC) in order to overcome the ischemic risk. The aim of the study is reporting our experience with SD of the NAC in the setting of NSM, identify the rate of nipple and skin necrosis and other complications and to evaluate patient satisfaction with cosmetic outcome. Patients and MethodsA retrospective review of female patients, who underwent NSM and breast reconstruction between the July 2014 and the July 2019, was performed at the Breast Unit of San Giovanni-Addolorata Hospital in Rome. Eighty-nine NSM after SD procedure were performed in 66 patients. In all cases immediate breast reconstruction was performed with a direct to implant technique and polyurethane implants in prepectoral plan were used in all reconstructions. ResultsWe registered only 1 case of total NAC necrosis and 3 skin flap necrosis. Furthermore, patient satisfaction with breast reconstruction resulted excellent or good in 23 cases and good in 36 cases; the external plastic surgeon considered the breast reconstruction excellent or good in 63 cases. ConclusionWe support the thesis that SD techniques may expand indications for NAC sparing mastectomy and immediate breast reconstruction in women with known risk factors for local complications.MicroabstractThis is the largest single center series on surgical delay of nipple areola complex providing interesting data on follow-up and complication rates and we support the thesis that surgical delay techniques may expand indications for nipple-areola complex sparing mastectomy and immediate breast reconstruction in women with known risk factors for local complications.

Surgical management of nipple areola complex in central breast cancer

Objective: To explore the surgical strategy of nipple areola complex (NAC) management in central breast cancer. Methods: A retrospective analysis was conducted on 164 cases of central breast cancer who underwent surgery treatment from December 2017 to December 2020 in the Breast Center of Beijing Tongren Hospital, Capital Medical University. Prior to the surgery, the tumor-nipple distance (TND) and the maximum diameter of the tumor were measured by magnetic resonance imaging (MRI). The presence of nipple invagination, nipple discharge, and nipple ulceration (including nipple Paget's disease) were recorded accordingly. NAC was preserved in patients with TND≥0.5 cm, no signs of NAC invasion (nipple invagination, nipple ulceration) and negative intraoperative frozen pathological margin. All patients with signs of NAC involvement, TND<0.5 cm or positive NAC basal resection margin confirmed by intraoperative frozen pathology underwent NAC removal. χ(2) test or Fisher exact test was used to analyze the influencing factors. Results: Of the 164 cases of central breast cancer, 73 cases underwent breast-conserving surgery, 43 cases underwent nipple-areola complex sparing mastectomy (NSM), 34 cases underwent total mastectomy, and the remaining 14 cases underwent skin sparing mastectomy (SSM). Among the 58 cases of NAC resection (including 34 cases of total mastectomy, 14 cases of SSM, and 10 cases of breast-conserving surgery), 25 cases were confirmed tumor involving NAC (total mastectomy in 12 cases, SSM in 9 cases, and breast-conserving surgery in 4 cases). The related factors of NAC involvement included TND (P=0.040) and nipple invagination (P=0.031). There were no correlations between tumor size (P=0.519), lymph node metastasis (P=0.847), bloody nipple discharge (P=0.742) and NAC involvement. During the follow-up period of 12 to 48 months, there was 1 case of local recurrence and 3 cases of distant metastasis. Conclusions: For central breast cancer, data suggest that patients with TND≥0.5cm, no signs of NAC invasion (nipple invagination, nipple ulceration) and negative NAC margin in intraoperative frozen pathology should be treated with NAC preservation surgery, whereas for those with TND<0.5 cm or accompanied by signs of NAC invasion, NAC should be removed. In addition, nipple reconstruction can be selected to further improve the postoperative appearance of patients with central breast cancer.

Abstract P3-21-01: A higher locoregional recurrence rate of nipple areolar complex sparing mastectomy with immediate implant reconstruction

Abstract Background The rate of Nipple Areolar Complex (NAC) sparing mastectomy with implant reconstruction is rapidly increasing as the Korean National Health Insurance reimbursed reconstructive surgery for breast cancer patients from 2015. However, only a few reports about oncologic safety have been reported in the absence of large-scale data. We have analyzed the oncologic outcomes of all consecutive breast cancer patients who had NAC sparing mastectomy with immediate implant reconstruction. Methods We used the data from prospectively collected clinical data of patients who underwent immediate implant reconstruction after NAC sparing mastectomy at the National Cancer Center between January 2012 and December 2017. Demographics, clinicopathological characteristics and the follow-up results were analyzed. The statistical analysis was done to infer relations between risk factors and oncologic outcomes such as death, distant metastasis or locoregional recurrence. Results: A total of 538 breasts was analyzed in 486 patients. The mean age of the patients was 44.6 years. The mean BMI was 22.48 kg/m2. The number of bilateral cases was 52 (10.7%) and 135 patients (27.8%) had multiple tumors. Median follow-up was 4.5 years. Molecular subtypes were 373 HR(+)/HER2(-) (69.3%), 31 HR(+)/HER2(+) (5.8%), 76 HR(-)/HER2(+) (14.1%) and 35 HR(-)/HER2(-) (6.5%). Chemotherapy was performed in a total of 212 (43.6%) patients, of which 68 (32.1%) were neoadjuvant and 144 (67.9%) were adjuvant purposes. Trastuzumab was administered to 53 (10.9%) of patients whose tumor size are larger than 1cm under guideline of reimbursement. Postoperative radiotherapy was performed in 131 patients (26.9%). Distant metastasis occurred in 20 patients (3.7%), and seven (1.4%) died. Locoregional recurrence occurred in 43 cases (8.0%) of 538 breasts, including 14 nipples (2.6%) and 12 subareolar lesions (2.2%). Analyzing risk factors related to locoregional recurrence, HR(-)/HER2(+) type showed the highest incidence of 11/76 (14.7%) among four subtypes. The incidence was statistically significantly lower in the group that received postmastectomy radiotherapy than in the group that did not. (6/131 (4.6%) vs 37/355 (10.4%), p=0.001). The node negative group who did not have postmastectomy radiotherapy (31/377 (8.2%)) showed a numerically higher incidence than the node positive group (8/121 (6.6%)). Conclusion Our results showed that NAC sparing mastectomy with immediate implant reconstruction had similar oncologic outcome in terms of overall survival or distant metastasis, however the locoregional recurrence was rather high. Even this is remediable problems we would admit that NAC sparing mastectomy is a bit different from traditional mastectomy. In case that we inevitably apply this operation to relatively young women with multifocal breast cancer, careful consideration would be needed. In addition, identifying risk factors of locoregional recurrence and tailored post-operative radiation therapy are expected to improve the disease-free survival of breast cancer. Citation Format: Ji Young You, Eun-Gyeong Lee, Soo Jin Park, Byeong Nam Kim, Seeyoun Lee, Eun Sook Lee, So-Youn Jung, Youngmi Kwon, Yun Ju Kim, Chan Wha Lee, Tae Hyun Kim. A higher locoregional recurrence rate of nipple areolar complex sparing mastectomy with immediate implant reconstruction [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-21-01.

A Prospective Investigation of Predictive Parameters for Preoperative Volume Assessment in Breast Reconstruction.

Preoperative breast volume estimation is very important for the success of the breast surgery. In this study four different breast volume determination methods were compared. The end-point of this prospective study was to evaluate the concordance between different modalities of breast volume assessment (MRI, BREAST-V, mastectomy specimen weight, conversion from weight to volume of mastectomy specimen) and the breast prosthetic volume implanted. The study enrolled 64 patients between 2017 and 2019, who had all been treated by the same surgeons for monolateral nipple–areola complex-sparing mastectomy and implant breast reconstruction. Only patients who had a breast reconstruction classified as “excellent” from an objective (BCCT.core software) and subjective (questionnaire) point of view at the 6-month interval after the operation were included in the study. Data analysis highlighted a strong correlation between the volumes of the chosen prostheses and the weights of mastectomy converted into volume, especially for patients with grades B and C parenchymal density. The values of the agreement between the volumes of the chosen prostheses and the assessments from MRI and BREAST -V proved to be lower than expected from the literature. None of the four studied methods presented any strong correlation with the initial breast width. Our results suggest that conversion from weight to volume of mastectomy specimen should be used to assist in determining the volume of the breast implant to be implanted. This method would help the reconstructive surgeon guide the choice of the most appropriate implant preoperatively.

Narrative review of the application of radiotherapy in nipple-areola-complex–sparing mastectomy

: In the treatment of breast cancer, the effective removal of the tumor was once the sole aim of surgery. However, the goals of breast cancer surgery have shifted, with considerable emphasis now placed on improving the appearance and function of the breast while leaving the curative effect unaffected or even improved. Nipple-areola-complex-sparing mastectomy (NSM) facilitates breast reconstruction by preserving the skin and nipple-areola complex (NAC) of the breast. In recent years, this approach has become increasingly popular; however, it still carries a high risk of local recurrence in the NAC. Therefore, for patients who NSM, adjuvant radiotherapy (RT) is recommended. Although adjuvant radiation therapy is the standard of care for breast cancer treatment following lumpectomy, the application of RT after NSM is controversial. Previous studies on the roles of pre-, intra-, and/or postoperative RT combined with NSM have produced inconsistent results. Conventional preoperative or postoperative RT for breast cancer can cause contracture deformation of the implanted prosthesis. The emergence of intraoperative RT technology has further optimized radiotherapy-assisted NSM combined with breast reconstruction as a therapeutic strategy for breast cancer. The main complications of this treatment include fat necrosis, radiation fibrosis, and prosthesis contracture. Based on the selection of suitable patients, adjuvant RT is applied in combination with NSM according to the risk of local disease recurrence. In this article, we review the application of RT in NSM and compare studies on NSM combined with pre-, intra-, and/or postoperative RT.

Sub-muscular Reconstruction after NAC Sparing Mastectomy: Direct to Implant Breast Reconstruction with Human ADM Versus Tissue Expander.

Nipple areola complex (NAC) sparing mastectomy allows good oncological and aesthetic results. The study compares the results, in terms of self-evaluated satisfaction and symmetry, of direct to implant (DTI) sub-muscular breast reconstruction, with the aid of human acellular dermal matrix (ADM) versus two-stage reconstruction with sub-muscular tissue expander, followed by implant. This is a retrospective, observational, single-center, non-randomized, case-control study. Inclusion criteria were: unilateral NAC sparing mastectomy at Forlì Hospital between 2014 and 2018; sub-muscular reconstruction; minimum follow-up of 12months from the reconstructive stage; no history of radiotherapy. Patients were divided into two groups: group A included patients who underwent DTI breast reconstruction with the aid of human ADM; group B were those who underwent a two-stage reconstruction with tissue expander then implant. We collected data on: (1) Self-evaluated satisfaction by Breast Q questionnaire (scores from 0 to 100). (2) Observer-evaluated symmetry. Bi-dimensional photographs were collected and evaluated by 11 breast surgeons blinded to each other, who assigned a score for symmetry (from 0 to 10). (3) Symmetry of anthropometric measures collected by hand and volume estimated by Breast V application. Group A included 28 patients; group included B 26 patients. Breast-Q questionnaires reported the following results: satisfaction with breasts in group A 65 ± 12 versus group B 68 ± 14; satisfaction with outcome in group A 88 ± 16 versus group B 93 ± 11; psychosocial well-being in group A 71 ± 20 versus group B 76 ± 17; sexual well-being in group A 63 ± 26 versus group B 60 ± 13; physical well-being in group A 68 ± 15 versus group B 60 ± 12. The average symmetry breast score assigned to group A was 6.9, versus group B 7.2. Regarding the anthropometric measures in group A, the differences between right and left were major to those in group B. Regarding breast volume, the mean difference between right and left in group A was 31.89cc ± 24.97, whereas in group B was 25.46cc ± 23.59. Our data show better symmetry and better psychosocial well-being in the two-stage reconstruction, and higher satisfaction with sexual and physical well-being in DTI reconstructions. These aspects should be discussed with the patient while collecting the informed consent. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Bipedicled Nipple-Sparing Mastectomy Versus Traditional Nipple-Sparing Mastectomy: Comparison of 2 Alternative Techniques in Order to Save Nipple-Areola Complex.

Nipple-areola complex-sparing mastectomy (NSM) represents, when a mastectomy is unavoidable, the best treatment possible that can be offered to attenuate the negative impact of surgery on patients' quality of life. Unfortunately, NSM can be used only in selected patients with small and nonptotic breasts. In order to save the nipple-areola complex (NAC) also in patients with large and ptotic breast, otherwise subjected to a skin-sparing mastectomy with the sacrifice of the NAC, we described the bipedicled nipple-sparing mastectomy (BNSM). The aim of this study is to obtain a formal outcome assessment of BNSM and analyze the complications rate of this technique compared with traditional NSM. We furthermore attempt to describe the surgical procedures present in the literature that allow to preserve NAC also in large and ptotic breasts presenting the complication rates observed and comparing with our technique. Aesthetic outcome has also been evaluated. We retrospectively reviewed 42 procedures of consecutive patients undergoing immediate reconstruction with tissue expanders after NSM (20 patients) or BNSM (19 patients). We divided them in 2 groups focused on surgical complications and aesthetic outcome. On a total of 42 procedures, the principal major complication was dehiscence of surgical wound procedures needing 1-day surgery revision occurring in 3 (14.3%) of the BNSM group and 1 (4.8%) of the NSM group, whereas as principal minor complication 4 partial NAC necrosis not requiring surgery in BNSM (19%) and 2 (9.5%) in NSM. No tissue expanders required explantation. Concerning cosmetic results, the overall appearance of the breast and NAC was acceptable in 85.7 % and 77.2%, respectively, in the NSM group and 80.7% and 66.7%, respectively, in the BNSM group. Bipedicled nipple-sparing mastectomy is a valid technique to improve patients' quality of life in large and ptotic breasts otherwise candidate to a skin-sparing mastectomy, but only a progressive learning curve can minimize complications. No significant statistical differences have been observed in terms of complication rates and aesthetical outcomes between the 2 groups. An accurate selection of patients is mandatory in order to obtain low complication rates and good aesthetical outcome.

22P - Clinical outcomes after skin-sparing or nipple areolar complex-sparing mastectomy with sentinel lymph node biopsy in early breast cancer patients

BackgroundThe purpose of this study was to evaluate the characteristics and outcomes of early breast cancer patients who underwent skin-sparing mastectomy or nipple areolar complex-sparing mastectomy with sentinel lymph node biopsy without radiotherapy. MethodsA total 104 patients with early breast cancer who underwent mastectomy with sentinel lymph node biopsy were identified in Korea Ansan University Hospital between 2007 and 2017. 85 total mastectomies (TM), 11 nipple areolar complex-sparing mastectomies (NSM), and 8 Skin-sparing mastectomiesm (SSM) were included. All these patients did not undergo adjuvant radiotherapy on chest wall or axillary area. We divided the patients into two groups, TM group and NSM/SSM group. We retrospectively collected clinitopathologic data for these patients. Locoregional recurrence rate, distant recurrence rate, overall recurrence free survival, and overall survival were determined. All statistical analysis was performed using SPSS 20.0 software (SPSS, Inc., Chicago, IL, USA). ResultsMedian follow-up was 53 months. Fifty-five percentage of TM group patients received chemotherapy and 63.7 % of NSM/SSM patients received chemotherapy. Locoregional recurrence free survival was 95.3% vs. 78.9% in TM group and NSM/SSM group (p = 0.037). Locoregional failure rate was significantly high in NSM/SSM group than TM group. Distant recurrence free survival was 97.6% vs. 89.5% in TM group and NSM/SSM group (p = 0.128). Overall recurrence free survival was 92.9% vs. 78.9% in TM group and NSM/SSM group (p = 0.118). Overall survival was 98.8% and 94.7% in TM group and NSM/SSM group (p = 0.289). Total two deaths were observed in enrolled patients, one in TM group and another in NSM/SSM group. One death in TM group was unrelated to breast cancer and cause of death was complication from end-stage renal disease. One death in NSM/SSM group was related to breast cancer. ConclusionsIn conclusion, early breast cancer patients who underwent total mastectomy, skin-sparing mastectomy or nipple areolar complex-sparing mastectomy with sentinel lymph node biopsy had excellent outcomes without additional axillary surgery or radiotherapy. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Application of reconstruction of submammary fold with lateral thoracic wall adipofascial flap after nipple-areola complex sparing mastectomy in elderly breast cancer

Objective To evaluate the value of reconstruction of submammary fold with lateral thoracic wall adipofascial flap after nipple-areola complex sparing mastectomy(NSM) in elderly patients with breast cancer. Methods To retrospective analysis 20 cases of elderly patients with breast cancer were admitted from March 2016 to June 2018 in Beijing Tongren Hospital, Capital Medical University using reconstruction of submammary fold with lateral thoracic wall adipofascial flap after NSM(study group). Twenty-two elderly patients with breast cancer who had breast-conserving and sentinel lymph node biopsy were selected as control group. The operation time, drainage tube retention time, postoperative hospitalization time, postoperative complications, breast contour satisfaction were statistically analyzed. The measurements were expressed as mean±standard deviation (Mean±SD), and t-test was used for inter-group comparison, and Chi-square test was used for inter-group comparison of counting data. Results All cases were followed up for 3-27 months without local recurrence and distant metastasis. The difference in operative time between the study group and control group was statistically significant [(2.085±0.163 1) h vs (1.918±0.159 3) h, P=0.002]. There was no significant difference between the study group and control group in drainage tube removal time(5.25±0.910) d vs (5.27±0.767) d, hospitalization days(6.25±0.910) d vs (6.27±0.767) d, breast contour satisfaction rate (90.0% vs 81.8%) (P>0.05). Postoperative necrosis and liquefaction of adipofascial flaps occurred in 1 case in the study group and delayed healing occurred. Conclusion For some early-stage elderly breast cancer, reconstruction of submammary fold with lateral thoracic wall adipofascial flap after NSM, at the same time of radical surgery, can ensure the basic breast shape, avoid the chest wall deformity caused by traditional radical mastectomy, and improve the appearance and quality of life after mastectomy. Key words: Aged; Breast neoplasms; Lateral thoracic wall adipofascial flap; Reconstruction of submammary fold

A New Human-Derived Acellular Dermal Matrix for Breast Reconstruction Available for the European Market: Preliminary Results.

The introduction of acellular dermal matrices (ADMs) contributed to the growing diffusion of direct-to-implant breast reconstruction (DTI-BR) following mastectomy for breast cancer. According to specific legislations, European specialists could not benefit from the use of human-derived ADMs, even though most evidence in the literature are available for this kind of device, showed optimal outcomes in breast reconstruction. The Skin Bank of the Bufalini Hospital (Cesena, Italy) obtained in 2009 the approval for the production and distribution of a new human cadaver-donor-derived ADM (named with the Italian acronym, MODA, for matrice omologa dermica acellulata) from the Italian National Transplant Center and National Health Institute. We report preliminary results of MODA application in direct-to-implant breast reconstruction following nipple-areola complex (NAC)-sparing mastectomy for breast cancer treatment. We prospectively enrolled all women undergoing NAC-sparing mastectomy for breast cancer and DTI-BR in our breast surgical unit from June 2015 to January 2017. We enrolled a selected population without previous chest wall irradiation, not being heavy tobacco smokers or diabetic, with a BMI<30kg/m2 and requiring less than 550cc silicone implants. We assessed short-term outcomes, defined as postoperative complications presenting in the first 30 postoperative days and long-term outcomes at 6 and 12months. From June 2015 to January 2017, we treated 56 breasts. At a mean follow-up of 14months, we observed only two minor complications described as limited wound dehiscences, conservatively managed with complete resolution without implant exposure or re-intervention. Our preliminary results show very good performance of MODA in direct-to-implant breast reconstruction following NAC-sparing mastectomy for breast cancer treatment. This is particularly relevant for the European market, where no other human-derived devices are available for breast reconstruction due to regulatory restrictions. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Primary tumor location predicts the site of local relapse after nipple-areola complex (NAC) sparing mastectomy.

To assess the oncological safety of nipple-areola complex (NAC) sparing mastectomy in breast cancer patients. From 2010 to 2015, 518 breast cancer patients were submitted to NAC sparing mastectomy. Breast MRI and intraoperative assessment of the subareolar (SD) and proximal (ND) nipple ducts were performed to predict NAC involvement. Significant associations between pre- and postoperative variables with SD/ND involvement and with the risk of local recurrence were retrospectively investigated. SD/ND were involved in 26.1% of the cases. Final pathology of SD/ND was predicted by tumor-NAC distance at MRI and intraoperative pathology with 75 and 93% accuracy, respectively. NAC involvement was more frequent in case of positive ND than positive SD (68.3 vs. 38.3%; p=0.003). Fourteen (2.7%) local relapses developed over a mean follow-up of 33months. Ki-67 ≥25% (p=0.002) and high tumor grade (p=0.027) correlated with local recurrence. Most relapses developed in the subcutaneous tissue of the quadrant where the primary tumor was located (12/14; 85.7%). No local relapses occurred in patients who received post-mastectomy radiotherapy as compared to patients who did not, although they had a higher rate of positive surgical margins (40.5 vs. 16.2%; p=0.000). NAC involvement can be predicted by MRI and intraoperative pathology of ND/SD. Local recurrences after NAC sparing mastectomy almost invariably develop in the same quadrant where the primary tumor was located and in highly proliferative tumors.

Abstract P3-14-11: Risk factors affecting post-operative complication after immediate reconstruction with implant for operable breast cancer patients

Abstract Purpose : Immediate breast reconstruction (IBR) with implant after nipple-areola complex (NAC) sparing mastectomy is an increasing treatment for breast cancer patients. Old age, obesity, smoking history, large volume of implant and adjuvant oncologic therapies have been known as risk factors for post-operative complication after IBR. However, less is known about the risk factors after IBR with implant in Asian women with relatively low body mass index (BMI), small volume of breast and less history of smoking. We analyzed the risk factors for post-operative complications after IBR with implant in patients receiving NAC sparing mastectomy. Methods : We investigated a prospectively maintained database from 2012 to 2015 at National Cancer Center. A total of 278 breast reconstructions (230 unilateral, 24 bilateral) in 254 patients were performed by a single surgeon; 99.3% (276 of 278 breasts) were oncologic, and 0.7% (2 of 278 breasts) were prophylactic mastectomy. For each patient, we collected data on age, BMI, history of smoking and diabetes mellitus, volume of implant, adjuvant oncologic therapies, distances from tumor to nipple and skin, imprecise magnetic resonance image (MRI) finding (no discernible enhancing, non-mass enhancement, and multifocal tumor), and use of acellular dermal matrix (ADM). Results : Mean age was 44.8±7.6 years and mean BMI was 22.5±2.9 kg/m2. Patients with smoking history was 4.3% (n=11). Mean implant size was 242.3±57.7mL. Patients underwent chemotherapy in 39% (n=99) and radiotherapy in 29.1% (n=74). Compared to western studies, our patients showed lower BMI, less history of smoking, and smaller size of implant insertion. Overall post-operative complication rate was 8.3% (n=23) and the complication rate was similar to the results of western studies; which included wound dehiscence (4.3%, n=12), infection (2.9%, n=8), and implant loss (2.9%, n=8). The use of ADM was independently associated with post-operative complications (30.0% in patients used ADM vs 6.6% in patients without ADM, respectively; OR, 6.016, 95% CI, 2.018-17.939; p=0.001). Other factors were not significantly related to post-operative complications. Conclusions : Our study is the largest study to investigate the risk factors for post-operative complications after IBR with implant in Asian countries. Compared to western studies, the patients had lower BMI, less history of smoking and smaller size of implant. Although known risk factors, such as smoking, obesity and size of implant, were not significantly associated with post-operative complication in our study, the incidence of post-operative complication was similar to that of western studies. These results might be caused by higher post-operative complication rate after use of ADM compared with western studies. Further study is warranted to evaluate the impact of ADM on post-operative complication on Asian countries. Citation Format: Park SJ, Choi JH, Lee MH, Jung S-Y, Lee ES. Risk factors affecting post-operative complication after immediate reconstruction with implant for operable breast cancer patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-14-11.

Optimising aesthetic outcome after nipple-areola complex-sparing mastectomy and immediate one-stage prosthetic reconstruction: A simple surgical trick to fix nipple-areola complex position.

Background:Nipple-areola complex (NAC) sparing mastectomy (NSM) is mostly indicated in patients with small-/medium-sized and non-ptotic breasts, while skin-reducing mastectomy is used in patients with medium or large breasts with severe ptosis. NAC location on the reconstructed breast is one of the major factors in determining the final aesthetic result and patients’ satisfaction. An optimum result obtained at the end of surgical procedure may be altered and compromised by skin redistribution and consequently NAC depositioning during the post-operative period in patients with medium-sized breasts and a moderate degree of ptosis.Aims:In the present study, we propose a simple surgical trick to fix the NAC in the desired position with a long-lasting result.Methods:We selected 35 patients undergoing NAC sparing mastectomy for breast cancer and immediate one-stage prosthetic reconstruction and we performed a single suture to fix NAC in the desired position before closing the skin envelope. We evaluated NAC complex position stability overtime comparing pre-operative standard photographs with early (3 weeks after surgery) and late (1 year after surgery).Results:In all patients, we were able to place the NAC complex on the desired position, and the result was stable at 1 year follow-up. The aesthetic outcome was satisfactory in all patients with no change in the complication rate.Conclusions:This simple surgical trick has been shown to be safe and effective in optimising the aesthetic outcome in a patient undergoing NAC sparing mastectomy and immediate one-stage prosthetic reconstruction. Level IV: evidence obtained from multiple time series with or without the intervention, such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

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

BackgroundNipple–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 MethodsFrom 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. ResultsThe 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). ConclusionNSM 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.

MRI and intraoperative pathology to predict nipple–areola complex (NAC) involvement in patients undergoing NAC-sparing mastectomy

BackgroundNipple–areola sparing mastectomy (NSM) with immediate implant reconstruction is an option for patients with non-locally advanced breast cancer. The prediction of occult tumour involvement of the nipple–areola complex (NAC) may help select candidates to NSM. Patients and methodsWe prospectively recorded clinical and pathological data, magnetic resonance imaging (MRI) results and intraoperative pathological assessments of the subareolar (SD) and proximal nipple ducts (ND) of 112 consecutive breast cancer patients scheduled for NSM. All parameters were correlated with final pathological NAC assessment by univariate and multivariate analysis. ResultsThirty-one patients (27.7%) had tumour involvement of the NAC. At univariate analysis, age (p=0.001), post-menopausal status (0.003), tumour central location (p=0.03), tumour–NAC distance measured by MRI (p=0.000) and intraoperative pathologic assessment (SD+ND) (p=0.000) were significantly correlated with NAC involvement. At multivariate analysis, only MRI tumour–NAC distance (p=0.008) and menopausal status (p=0.039) among all preoperative variables retained statistical significance. The sensitivity and specificity of MRI tumour–NAC distance were 32.2% and 88.6% and those of intraoperative pathologic assessment were 46.7% and 100%, respectively. Sensitivity, specificity and accuracy of the double assessment (MRI plus intraoperative pathology) were 50.0%, 96.2% and 84.1%, respectively. ConclusionIntraoperative pathologic assessment and tumour–NAC distance measured by MRI are the most important predictors of occult NAC involvement in breast cancer patients. A negative pathological assessment and a tumour–NAC distance⩾5mm allow optimal discrimination between NAC positive and NAC negative cases and may serve as a guide for the optimal planning of oncological and reconstructive surgery.

What is the evidence behind conservative mastectomies?

Besides the diffusion of breast reconstructive techniques, several "conservative" approaches in mastectomy have been developed, in order to perform an immediate reconstruction with better aesthetic results: the skin-sparing mastectomy (SSM), the nipple-areola complex (NAC)-sparing mastectomy (NSM) and the skin-reducing mastectomy (SRM). During the last decade, SSMs and NSMs have gained widespread acceptance and are currently considered standard treatment for early breast cancer. We would like to investigate the evidence behind this radical shift towards conservative mastectomies, where there has been a renewed interest worldwide. We reviewed English literature by consulting the following databases: Medline, Embase, Cochrane Register of Controlled Trials, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal and Clinicaltrials.gov. The objective is to include any randomized controlled trial (RCT) comparing a "conservative mastectomy" technique to breast conservative surgery or modified radical mastectomy (MRM) for the treatment of early-stage breast cancer. In the absence of randomized trials, we took into account prospective cohorts and retrospective series for a narrative description of available evidence. Our review included 58 studies [19 prospective cohorts (34%) and 39 retrospective series (66%)] considering NSM and immediate reconstruction and ten studies [1 prospective cohort (10%) and 9 (90%) retrospective series] considering SSM and immediate reconstruction. In the NSM group, 29 studies reported data about complication rates and 42 studies presented data on NAC partial or complete necrosis. In the NSM group 45 studies and all the studies in the SSM group presented data on local and NAC recurrence. In order to achieve higher levels of evidence, RCTs comparing conservative mastectomies to traditional mastectomy and breast conservative surgery would be desirable. However we can conclude that conservative mastectomies offer the psychological advantages of good cosmetics and maintenance of woman body image without compromising the oncological safety of mastectomy.

Nipple areola complex sparing mastectomy.

Breast conservative therapy (BCT) is established as a safe option for most women with early breast cancer (BC). The best conservative mastectomy that can be performed, when mastectomy is unavoidable, is nipple-areola-complex sparing mastectomy (NSM), which allows the complete glandular dissection preserving the skin envelope and the nipple areola complex. In the treatment of BC, the cosmetic outcomes have become fundamental goals, as well as oncologic control. NSM is nowadays considered an alternative technique to improve the overall quality of life for women allowing excellent cosmetic results because it provides a natural appearing breast. The breast surgeon must pay attention to details and skin incision must be planned to minimize vascular impairment to the skin and the nipple. Preservation of the blood supply to the nipple is one of the most important concern during NSM because nipple or areolar necrosis is a well-described complication of this surgery. Another issue associated with the nipple preservation and the surgical technique is oncological safety related to nipple-areola-complex (NAC) involvement in patients with invasive BC. The authors present their experience on 252 NSM performed in the Breast Surgery Unit in Forlì. Careful selection of patients for this surgical procedure is imperative and many patients are not ideal candidates for this procedure because of concerns about nipple-areolar viability as women with significant large/ptotic breast, pre-existing breast scars and history of active cigarette smoking. To extend the benefits of nipple preservation to patients who are perceived to be at higher risk for nipple necrosis the authors describe technical modifications of NSM to allow nipple preservation and obtain good cosmetic outcomes.

The current pattern of reconstructive surgery for breast cancer

In Russia, breast cancer (BC) occupies a leading place in the pattern of cancers, the incidence of which is 20.9 %, among the female population; in 2013 there were 60,717 new cases, including women under the age of 40 years (15 %). While considering the history of the development of breast surgery from the operation performed by W. S. Halsted to its technique modified by J. L. Madden and the identification of sentinel lymph nodes, we can observe improved quality of life in patients in reference to the lower rate of the manifestation of lymphedemas. However, patients who have undergone this or that mastectomy are observed to have lower self-appraisal scores, a change in their professional sphere, irritability and apprehensiveness Thus, the decreased rate of the manifestation of lymphedema and obvious postoperative traumatization are not the only components of quality of life in patients with BC. According to the data obtained by E. Frank et al. (1978), G.P. Maguire et al. (1978), and F. Meerwein (1981), removal of the breast itself leads to a woman’s loss of femininity, attractiveness, and sexiness, which was also confirmed and reported by L. Aerts et al. (2014). In this connection, classical radical mastectomy begins to give way to organ-sparing treatment. Taking into account that psychotherapy and external prosthetics do not alleviate the above problems and that there are always women with established BC who have contraindications to organ-sparing treatment, breast reconstructive plastic operations arouse more and more interest. Reconstruction of the breast implies restoration of both its shape and contours to be maximally brought closer to its preoperative level. However, with regard to cancer alertness to breast reconstructive surgery, not only aesthetic requirements are imposed. The next step in improving quality of life in patients with BC was the emergence and development of breast-sparing mastectomies, the first point of these operations were skin-sparing radical mastectomies that were first described and performed by B. A. Tothu P. Lappert in 1991. In 1997 G. W. Carlson proposed to classify incisions for skin-sparing mastectomy successfully used to the present day. The investigation conducted by R. M. Simmons et al. (1999) indicated that skin-sparing mastectomy did not result in an increase in the incidence of local recurrences. The types of skin incisions, which were offered by G. W. Carlson in 1997 and used by R. M. Simmons in 1999, imply the preservation of the inframammary crease and a major portion of a skin graft, on the one hand, and the removal of the nipple-areolar complex (NAC), on the other hand, which in turn diminishes the final aesthetic result. B. Gerber et al. were the first to describe NAC preservation for BC. As regards the rate of local recurrences after NAC-sparing mastectomies, the vast majority of investigations performed in the past 10–15 years allude to the fact that NAC involvement is not more than 25 %. A. M. Munhoz in turn proposed a classification of incisions during NAC-saving mastectomies. In spite of all advantages of NAC-sparing mastectomies, their results are not always predictable. Main problems, such as wound healing difficulties or ischemic necrosis, are associated with the larger number of postoperative complications. Transfer of the patient’s own flaps does not always presume skin- or NAC-sparing mastectomy, as the possibility exists of preserving the skin on the most transferable flap. However, ruling out a patch symptom during subcutaneous or skin-sparing radical mastectomy considerably improves the aesthetic result of a performed operation. Taking into consideration that the incision types offered by G. W. Carlson and A. M. Munhoz depend on the site of a tumor, the surgical visibility problem is of relevance: visible postoperative scars, a difference in the skin texture, or restored NAC, all cause the women less satisfied. Thus, by achieving good results in restoring the contours, shape, volume, and symmetry of the breast, a visible postoperative scar is the only element that reveals a performed operation for BC.

Skin and Nipple-Areola Complex Sparing Mastectomy in Breast Cancer Patients

Skin and nipple-areola complex sparing mastectomy (SNSM) and primary reconstruction have been popular for breast cancer treatment in the last decade. An advantage of the SNSM technique is the removal of all breast tissue as a radical surgical procedure while preserving native breast integrity, nipple-areola complex (NAC), and submammary fold. This retrospective 15-year clinical study analyzes medical records from our breast surgery database collected at our department between 1997 and 2012. A total number of 3757 patients were treated for breast cancer; 411 (10.9%) patients had a skin-sparing mastectomy with the median (range) length follow-up of 63 months. This is the longest follow-up for SNSM in breast cancer patients; 3.7% of patients who underwent SNSM developed disease local recurrence, whereas occult NAC involvement with cancer occurred in 7.7% and local recurrence in the NAC in 1.2%. Partial necrosis of the NAC developed in 9.4% and total necrosis in 0.7% of operated breasts. All disease recurrences occurred in the first 10 years of the follow-up period. Local recurrence developed as first recurrence event has longer median cancer-specific survival time of 70 months than those with only distant metastases with 50 months and locoregional plus distant metastases with 35.5 months. The "Omega" pattern incision combines an oncological radical procedure with a lower incidence of skin flap necrosis. Patients reconstructed with autologous tissue were the group most satisfied. SNSM is an oncological safe procedure for breast cancer treatment with low recurrence in properly selected patients.