Nipple-sparing Mastectomy Patients Research Articles

Staged Nipple Delay Procedure Expands Candidacy for Nipple-Sparing Mastectomy.

Nipple delay (ND) is a staged procedure that improves nipple-areolar complex (NAC) viability in nipple-sparing mastectomy (NSM) patients who are high-risk for NAC or skin-flap necrosis. This study compared postoperative outcomes and risk factors between patients treated with ND-NSM and NSM alone. Patient demographics, risk factors for NAC or skin-flap necrosis, tumor characteristics, and operative outcomes were compared between ND-NSM and NSM groups from 2009 to 2023. Univariate and multivariate analyses were performed to identify significant variables associated with NAC or skin-flap necrosis. Overall, 71 ND-NSM patients and 537 NSM patients were compared. ND-NSM patients had larger breasts (p<0.01), body mass index ≥ 30 (p=0.01), prior breast/chest wall radiation (XRT) [p<0.01], prior breast operations (p<0.01), less axillary surgery (p<0.01), more autologous tissue reconstruction over implant-based reconstruction compared with NSM patients (p=0.02), and more prophylaxis (p<0.01). There were no statistically significant differences between groups in regard to infection, skin-flap necrosis, NAC necrosis, seromas, and hematomas. No patients in the ND-NSM group had NAC necrosis and 1 patient had skin-flap necrosis, compared with 17 and 13 patients in the NSM group, respectively (p=0.24). On univariate analysis, prior XRT was associated with increased risk for skin-flap necrosis (p=0.02). Multivariate analysis showed XRT was associated with skin-flap necrosis (p=0.02) and any necrosis (p=0.01). Breast size was associated with NAC or skin-flap necrosis (p=0.04). Larger breasts and XRT were risk factors for NAC or skin-flap necrosis; however, despite having more risk factors, ND-NSM patients had very low rates of necrosis. Notably, no nipples were lost. A shared decision should be made with patients regarding the risks and benefits of ND-NSM.

Breast Modular Resection (BMR) in Nipple-Sparing Mastectomy (NSM) With Intraoperative Laser Speckle Contrast Imaging (LSCI) Monitoring Improved Surgical Training Outcome Among Fellows

BackgroundNipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM) are challenging for surgical training among fellow trainees. We developed a surgical training course with novel concept of breast modular resection (BMR) for NSM/SSM procedure, and performed this study to investigate whether BMR could improve surgical outcomes compared to classical procedure resection (CPR). MethodsThe records of 105 breast cancer patients undergoing NSM/SSM with immediate reconstruction performed by fellow trainees were reviewed. Clinicopathological characteristics and surgical outcomes were compared between 2 groups. Laser speckle contrast imaging (LSCI) was performed to intraoperatively evaluate the blood supply of the NAC, and the absolute perfusion unit (PU) values and relative perfusion unit (rPU) values were further compared. ResultsSurgical training outcomes of BMR group (N = 52) were insignificantly improved compared to CPR group (N = 53). The rates of NAC necrosis, flap necrosis and implant removal all reduced respectively. Among the 60 NSM patients, the blood loss (P = .011) and surgery time (P < .001) was significantly reduced in BMR group (N = 30) and all the other outcomes were insignificantly improved. Both the absolute PU values and rPU values were significantly higher among patients without NAC necrosis (P < .001). The absolute PU values were significantly higher in BMR group (P = .002). ConclusionCompared to CPR, the BMR-based surgical training course for NSM demonstrated the reduction in complications and operating time, offering a potential streamlined, efficient, and safe method for NSM procedure. LSCI was effective for intraoperative visualized evaluation of NAC blood supply and could provide effective real-time feedback for fellow trainees.

Positive Nipple Margins in Nipple-Sparing Mastectomy: Management of Nipples Containing Cancer or Atypia.

Nipple-sparing mastectomy (NSM) is an oncologically safe approach for breast cancer treatment and prevention; however, there are little long-term data to guide management for patients whose nipple margins contain tumor or atypia. NSM patients with tumor or atypia in their nipple margin were identified from a prospectively maintained, single-institution database of consecutive NSMs. Patient and tumor characteristics, treatment, recurrence, and survival datawere assessed. A total of 3158 NSMs were performed from June 2007 to August 2019. Nipple margins contained tumor in 117 (3.7%) NSMs and atypia only in 164 (5.2%) NSMs. Among 117 nipple margins that contained tumor, 34 (29%) margins contained invasive cancer, 80 (68%) contained ductal carcinoma in situ only, and 3 (3%) contained lymphatic vessel invasion only. Management included nipple-only excision in 67 (57%) breasts, nipple-areola complex excision in 35 (30%) breasts, and no excision in 15 (13%) breasts. Only 23 (24%) excised nipples contained residual tumor. At 67 months median follow-up, there were 2 (1.8%) recurrences in areolar or peri-areolar skin, both in patients with nipple-only excision. Among 164 nipple margins containing only atypia, 154 (94%) nipples were retained. At 60 months median follow-up, no patient with atypia alonehad a nipple or areola recurrence. Nipple excision is effective management for nipple margins containing tumor. No intervention is required for nipple margins containing only atypia. Our results support broad eligibility for NSM with careful nipple margin assessment.

Bilateral Implant-based Breast Reconstruction with Unilateral Radiotherapy: A Matched Cohort Study Comparing Nipple-sparing Mastectomy and Skin-sparing Mastectomy.

Nipple-sparing mastectomy (NSM) preserves the natural nipple-areola complex and entire native breast skin, with the goal of better cosmetic outcomes in breast reconstruction. In bilateral TE/implant-based reconstruction requiring unilateral postmastectomy radiotherapy (PMRT), progressive radiation-induced fibrosis can lead to increasing nipple asymmetry with cosmetic dissatisfaction. Thus, PMRT may ultimately negate the intended positive cosmetic value of NSM compared with skin-sparing mastectomy (SSM). This study compares (1) surgical complications, (2) patient satisfaction, and (3) aesthetic outcomes between NSM versus SSM in bilateral implant-based reconstruction with unilateral PMRT. This retrospective matched cohort study included consecutive NSM patients with bilateral TE/implant breast reconstruction + unilateral PMRT matched 1:2 to SSM group. Patients completed PMRT and TE exchange to implants. Demographics, oncologic stage, comorbidities, and complications were collected. Patient satisfaction was evaluated by BREAST-Q. Aesthetic outcomes were assessed by blinded reviewers with a five-point Likert scale. Among 58 patients who underwent bilateral TE/implant reconstruction with unilateral PMRT, 17 NSM patients were matched to 41 SSM patients by age, body mass index, and comorbidities. No significant differences existed in overall surgical complications and individual BREAST-Q questionnaire scores between cohorts. However, aesthetic outcomes scores were higher in SSM compared with NSM. Although NSM is generally associated with superior cosmetic outcomes compared with SSM, it has far less impact in bilateral implant-based breast reconstruction with unilateral PMRT due to the negative postradiotherapy effect on nipple symmetry.

Low rate of complications in nipple-sparing mastectomy for patients with BRCA1 and BRCA2 mutation.

Background: To describe the indications and outcomes of BRCA mutation carriers undergoing nipple-sparing mastectomy (NSM). Methods: In this retrospective study, 76 BRCA mutation carriers with no cancer who opted to undergo risk reduction NSM or diagnosed with breast cancer (BC) who opted to undergo therapeutic NSM were included. Results: Indications for NSM: cancer treatment (n=33), bilateral risk reduction (n=39) and contralateral prophylactic NSM (n=4). In a mean follow-up of 45months (median: 30months), one patient (2.5%) undergoing risk-reducing NSM developed a new BC. One (3%) local, one (3%) ipsilateral axillary and one (3%) distant recurrence were observed in BC patients. No partial or total nipple necrosis occurred. Conclusion: NSM is safe for reducing the risk of BC development in BRCA mutation carriers and for treating cancer.

Omission of Chest Wall/Scar Boost and Skin Bolus Does Not Increase Risk of Local Recurrence for Breast Cancer Patients

For breast cancer patients receiving postmastectomy radiation (PMRT), little is known about the value of Chest Wall Boost (CWB) and Skin Bolus (SB) across different biological subtypes and patients with high-risk features. We reviewed 2,917 charts of breast cancer patients treated with mastectomy between 2000-2020 at our institution. Only patients treated with PMRT were included. Patients with and without reconstruction were included. Reconstruction types included autologous or single-stage-direct-implant or two stages expanders/implant. PMRT was delivered with 3D conformal technique using photons and conventional fractionation (50-50.4 Gy in 25-28 fractions). CWB using enface electrons and 3-5 mm SB applied every other day were delivered at the discretion of the physician. Primary objectives were locoregional failure (LF) rates between CWB and No CWB groups; SB and No SB groups. Different subgroup analyses exploring the benefits of CWB and SB in different biological subtypes, patients with lymphovascular invasion (LVI+), positive margins (PM) and nipple sparing mastectomy (NSM) were conducted. Secondary objectives were toxicity of CWB and SB on different reconstruction outcomes and PMRT side effects. Logistic and cox regressions were used. A total of 1,103 patients with an overall median follow-up of 7.8 years were available for analysis. Among the entire cohort, 55.4% received CWB, 76% received SB, 48% had LVI, 23% with PM, 41% with NSM, 67% with Luminal A, 15% with Luminal B, 7% with HER2 enriched and 11% with triple negative. The 10 years incidence of LF was 6.5% and 4.0% for CWB and NO CWB, respectively (HR 1.6, p = 0.1); and 5.6% and 5.1% for SB and NO SB respectively (HR 0.9, p = 0.8). Multivariable analysis of LF adjusted for LVI, ECE, grade, tumor size, number of malignant nodes, and biological subtype showed no association of CWB and SB with local control (HR:1.4, p = 0.2 and HR:0.9, p = 0.8), respectively. Subgroup analyses confirmed no association of CWB or SB with improved local control across different biological subtypes, (LVI+), PM and NSM patients. On multivariable level CWB significantly increased reconstruction complications (OR 2.3, p = 0.001, OR 1.7, p = 0.008) for infection/necrosis (I/N) and overall reconstruction failure (ORF), respectively; while SB did not (OR 1.1, p = 0.8, OR 1.0, p = 0.9) for I/N and ORF, respectively. 56 patients needed treatment break, 49 of them (87%) had SB. Both CWB and SB significantly increased the risk of higher grade radiation dermatitis (2-4) in the entire cohort OR 2.1 p = 0.01, and OR 2.3, p = 0.02 for CWB and SB, respectively. CWB and SB did not improve local control across different biological subtypes, patients with LVI, Positive Margins and NSM. CWB significantly increased reconstruction complications and SB increased treatment breaks and radiation dermatitis. These findings do not support routine usage of CWB and SB.

Nipple-Sparing Mastectomies in Patients over the Age of 60 Years: Factors Associated with Surgical Outcomes.

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. 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. 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. 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.

PC40. Evaluating Outcomes for Nipple-Sparing Mastectomy in Patients Over the Age of 60

PURPOSE: 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. METHODS: A single-institution retrospective review was performed for patients over age 60 with NSM from January 2004 to January 2022. Demographic, intraoperative, and post-operative variables were collected. RESULTS: 136 individuals were identified accounting for 200 mastectomies, with mean age 65.2 years. 56% had invasive carcinoma, 15% required neoadjuvant chemotherapy, and 17.5% had prior radiation. 61.5% had concurrent axillary node surgery. The majority had tissue expanders placed initially (91%). Overall, the infection rate was 19%, with 11.5% requiring expander explantation. In logistic regression analysis, prior radiation increased the odds of any complication 2.9x (OR 2.93, CI 1.30-6.58, p=0.009) and infection 5.7x (OR 5.70, CI 1.95-16.66, p=0.001) but no associations were seen for other covariates including age, comorbidities, chemotherapy, or invasive disease. There were no associations seen for risk of cancer recurrence. Diabetes increased the odds of wound breakdown by 9x (OR 8.97, CI 2.01-39.92, p=0.004). Final reconstruction was implant-based in 70.5% and autologous in 10%. Local recurrence was 3% in mean 3.4 year follow up. CONCLUSION: Our data demonstrates NSM in patients over 60 has 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 the desired oncologic and reconstructive outcomes.

D134. Comparison of Nipple-sparing Mastectomy versus Skin-sparing Mastectomy in Bilateral Implant-based Breast Reconstruction with Unilateral Radiotherapy: A Matched Cohort Study

PURPOSE: Nipple-sparing mastectomy (NSM) preserves natural nipple-areola complex and entire native breast skin with a goal of better cosmetic outcomes in breast reconstruction. In bilateral tissue expander (TE)/implant-based reconstruction requiring unilateral post-mastectomy radiotherapy (PMRT), progressive radiation-induced fibrosis can lead to increasing nipple asymmetry with cosmetic dissatisfaction. Thus, PMRT may ultimately negate the intended positive cosmetic value of NSM compared to skin-sparing mastectomy (SSM). This study compares, 1) surgical complications, 2) patient satisfaction, and 3) aesthetic outcomes between NSM vs. SSM in bilateral implant-based reconstruction with unilateral PMRT. METHOD: This retrospective matched cohort study included consecutive NSM patients with TE/implant breast reconstruction + unilateral PMRT matched 1:2 to SSM group. All patients completed PMRT and TE exchange to implants. Demographics, oncologic stage, co-morbidities, and complication data were collected. Patient satisfaction was evaluated by BREAST-Q. Aesthetic outcome was assessed by blinded reviewers with a 5-point Likert scale. RESULTS: Among 58 patients who underwent bilateral TE/implant reconstruction with unilateral PMRT, 17 NSM patients were matched to 41 SSM patients by age, BMI, and co-morbidities. No significant difference existed between overall surgical complications (p=0.2) and BREAST-Q questionnaire scores. The average adverse effects of radiation score was higher in the NSM. Preliminary aesthetic outcomes demonstrated higher total average aesthetic score in SSM compared to NSM. CONCLUSION: Although NSM is generally associated with better cosmetic outcome compared to SSM, it has far less impact in bilateral implant-based breast reconstruction with unilateral PMRT. This may be related to the additional negative post-radiotherapy impact on nipple asymmetry.

PC35. PATIENT REPORTED OUTCOMES AND NIPPLE POSITION FOLLOWING NIPPLE-SPARING MASTECTOMY (NSM): A PROSPECTIVE EXAMINATION OF PREPECTORAL AND SUBPECTORAL PATIENTS

PURPOSE: Nipple-sparing mastectomy (NSM) is becoming more popular. The role of pocket dissection (prepectoral vs subpectoral) in implant-based reconstruction on patient reported outcomes (PRO’s) and nipple position following NSM has not yet been explored. We hypothesize that prepectoral reconstruction results in superior PRO’s and more anatomical nipple position compared to subpectoral reconstructions following NSM. METHODS: Surgical details and short-term complication in NSM patients from 2018 to 2021 were prospectively collected. PROs were obtained preoperatively, 6 and 12 months postoperatively. Nipple displacement from baseline was analyzed using three-dimensional(3D) surface imaging by three independent researchers. RESULTS: 216 patients who underwent 391 NSM were divided into two cohorts, subpectoral and prepectoral. There were no differences in demographics or comorbidities between cohorts. Prepectoral patients (N=83 (86%) vs. 54 (44%); p<0.001) reported better physical well-being of the chest preoperatively (median 76, IQR 67,92 vs 72, IQR 64,80; p=0.022). No other differences in PRO’s or complications were observed. Linear regression suggested that radiation is the most important factor impacting satisfaction following NSM. 3D photographs for 97 patients were analyzed and 175 nipple positions were measured in 3 dimensions. Controlling for implant size, there was greater elevation and less projection of the nipple compared to baseline in subpectoral cohort (elevation: median -16 mm, IQR -24,-7 vs -3 mm, IQR -12,5; p<0.001; projection: median -1 mm, IQR -9,6 vs -6 mm, IQR -14,4; p=0.002). CONCLUSION: Implant pocket did not impact PRO’s or short-term complications in patients who underwent NSM. Patients with prepectoral reconstruction had less nipple displacement and more nipple projection following NSM.

Abstract P2-14-09: Sensory Evaluation of Nipple-Areolar Complex after Nipple-Sparing Mastectomy: A Comparison of Incision Approaches

Abstract Background: Since nipple-sparing mastectomy (NSM) has been widely practiced, majority of previous studies have evaluated the effects of Nipple-areolar complex (NAC) preservation on body image adjustment. However, few have evaluated NAC sensation after NSM in a large sample size. This study aims to assess NAC sensation after NSM and compare the results according to different incisional approaches; specifically, inframammary fold (IMF) and peri-areolar. Methods: Post NSM patients from Oct 2019 to Nov 2021 have been recruited prospectively. A total of 115 patients (IMF 69 and peri-areolar 36) were evaluated for NAC sensory at various time points during follow up within 1.5 to 4 years after surgery. NAC sensation was scored by pin-prick test in a scale of 0 to 2 (0: no sensation, 1: dull sensation, 2: sharp sensation), divided in 5 areas of the NAC and summed up to a total of 10. Results: In all patients, a median of the pin-prick test total score on NAC was 3 (0-10). Pin-prick test of NAC showed numerically higher NAC sensory score in the IMF incision than in the peri-areolar group without a statistical significance (IMF: Median 4 Mean 3.83 ± 3.04, Peri-areolar Median 2 Mean 2.69 ± 3.64, p=0.062). When sensory scores were evaluated depending on NAC zones (A: Nipple, B: Upper outer, C: Upper inner, D: Lower outer, E: Lower inner) the IMF incision group showed better outcomes in zone B (p=0.015) and E (p=0.043). Simple linear regression analysis showed the possibility of incisional approach, diabetes mellitus (DM) history, previous radiotherapy of ipsilateral breast, post mastectomy radiotherapy (PMRT), adjuvant chemotherapy, tumor to nipple distance and laterality influencing NAC sensory with p&amp;lt; 0.2. When these factors were taken to multiple linear regression analysis, DM history (p=0.045), previous radiotherapy (p=0.001), postop radiotherapy (p=0.001), and adjuvant chemotherapy (p=0.001). Conclusion: NAC sensory deteriorated postoperatively in general. Scores of NAC sensation were numerically higher in the patients with IMF incision, although the difference was not statistically significant. NAC sensation was negatively affected by DM history, previous ipsilateral breast radiotherapy and post-NSM treatments such as chemotherapy and PMRT. While incision type may improve aesthetic outcomes, additional efforts are necessary to ameliorate the post-NSM NAC desensitization. Table 1. Patient characteristics Table 2. Linear regression analysis for clinical factors affecting NAC sensory Citation Format: Yoonwon Kook, Ji Soo Jang, Seung Ho Baek, Soong June Bae, Sung Gwe Ahn, Joon Jeong. Sensory Evaluation of Nipple-Areolar Complex after Nipple-Sparing Mastectomy: A Comparison of Incision Approaches [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-14-09.

Abstract P2-14-18: Oncological Outcomes of Nipple-Sparing Mastectomy after Neoadjuvant Chemotherapy

Abstract Introduction: Surgery is the mainstay treatment of breast cancer and has been improving in aesthetic outcomes even in locally advanced disease. Radical mastectomies are being replaced by less aggressive surgeries with immediate breast reconstruction. Nipple-Sparing Mastectomy (NSM) preserves Nipple Areolar Complex (NAC) along with the entire breast skin envelope and is associated with better aesthetic results and quality of life, improving patient satisfaction. Since NSM is a relatively recent technique and few studies have shown the feasibility of NSM after neoadjuvant chemotherapy (NACT), there are some concerns and controversies about its oncological safety, especially, with regard to the NAC recurrence due to the remaining tissue in the retroareolar area. This study compares the long-term oncological outcomes and correlated factors of NSM and skin-sparing mastectomy (SSM) after NACT. Methods: After approval by the institution’s ethics committee a retrospective review was conducted to identify all patients who underwent NSM and SSM with immediate breast reconstruction after NACT between January 2011 and December 2018 at Centro de Doenças da Mama- Breast Unit Hospital Nossa Senhora das Graças. Metastatic disease, recurrent breast cancer, and other types of mastectomies were excluded. Clinicopathological and survival data, as well as recurrence events were collected from the electronic medical records. NSM was offered to the patients without involvement of the NAC and skin clinically and on imaging. All patients underwent ultrasonography, mammography and breast MRI in the preoperative period, as well as breast MRI after NACT. The decision to undergo adjuvant radiotherapy was determined by the treating radiation oncologists according to NCCN and ASTRO recommendation. A propensity score match was used to reduce the effect of selection bias on type of surgery and create well-balanced groups. The covariates included for matching were: anatomical stage, radiotherapy and molecular subtype. Results: A total of 188 patients underwent mastectomy in this period, 134 NSM and 54 SSM. After propensity score matching, 92 patients in the NSM group were matched to the 54 patients in the SSM group. The median follow up time was 44,7 months to NSM and 40,3 months to NSM. The characteristics of patients included in both groups after propensity score matching are described in Table 1. NAC recurrence was observed in 5 (5.4%) of 92 NSM patients, and median time of recurrence was 24.2 (11.7- 40.1) months. Ki67 showed a significant relationship with relapse in the NAC. The distance from the tumor to the NAC and other clinicopathologic variables were not correlated with NAC recurrence (Table 2). There were no significative differences between the groups in locorregional recurrence (p=0.102), distant metastasis (p=0.223) and death (p=0.610) (Table 3). Conclusion: In this matched control study, there was no difference in oncological outcomes in patients submitted to NSM and SSM after NACT, suggesting NSM with immediate breast reconstruction is a feasible option in this setting. Table 1. Characteristics of patients treated with NSM and SSM after propensity score matching *Student’s t test for independent samples or non-parametric Mann-Whitney test (quantitative variables); Fisher’s exact test or chi square test (categorical variables); p&amp;lt;0.05 Table 2. Correlation between clinicopathologic variables and recurrence in the NAC *Fine and Gray Regression Model including death as a competitive risk and Wald test, p&amp;lt;0.05 Table 3. Oncological outcomes in NSM and SSM groups *Model Fine &amp; Gray and Wald test, p&amp;lt;0,05 **Cox Regression Model and Wald test, p&amp;lt;0.05 *** Log-rank test, p&amp;lt;0,05 Citation Format: IRIS RABINOVICH, Leonardo P. Nissen, Isabela C. Soares, Alessandra C. Fornazari, Cleverton C. Spautz, Ana Paula M. Sebastião, CICERO A. URBAN, Karina F. Anselmi, Eduardo Schunemann, Flavia Kuroda, Maira T. Doria, Ana Clea S. Andrade, Rubens S. Lima. Oncological Outcomes of Nipple-Sparing Mastectomy after Neoadjuvant Chemotherapy [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-14-18.

Outcomes Using Two Unique Methods of Immediate Implant-Based Breast Reconstruction After Nipple-Sparing Mastectomy in Ptotic Patients.

After nipple-sparing mastectomy (NSM) and immediate implant-based reconstruction, patients with significant ptosis are at increased risk for nipple-areolar complex (NAC) necrosis. Attempts to salvage the nipple using inferior dermal pedicles have yielded unsatisfactory results. This study aims to evaluate complications using 2 unique methods of breast reconstruction using either a Wise incision with dermal infolding or batwing incision after NSM. A retrospective chart review was conducted on all patients who underwent NSM and immediate implant reconstruction using the methods described by a single surgeon between 2016 and 2022. Outcomes were assessed by comparing average complications rates. Seventy-three reconstructions were performed after NSM in patients with ptosis. Sixteen reconstructions used a prior technique, Wise pattern with inferior dermal flap. Thirty reconstructions used the Wise incision with dermal infolding, while 27 other reconstructions used a batwing incision. For the Wise with inferior dermal flap technique, NAC necrosis occurred in 43.8%. In the cases in which the newer techniques were used, NAC necrosis occurred in 11.1% in the batwing group and 10% in the dermal infolding group. Other complications measured were within acceptable percentiles between both groups. Aesthetic outcomes were acceptable for most of the cases involving NAC necrosis. A batwing pattern incision or a Wise pattern with a broad, infolded dermal pedicle is a more effective method of immediate reconstruction after NSM in patients with ptosis according to these findings. Nipple-areolar complex necrosis continues to be a major complication that is important to discuss with patients. However, these methods offer patients with ptosis the benefit of preserving a native NAC while allowing for simultaneous skin reduction during an immediate reconstruction.

Does positive resection margin affect local recurrence in nipple sparing mastectomy in patients with invasive breast cancer?

Does positive resection margin affect local recurrence in nipple sparing mastectomy in patients with invasive breast cancer?

Surgical Nipple Delay and its Expanded Indications for Nipple-sparing Mastectomy.

A single-institution retrospective review was done of patients who underwent ND and NSM or NSM alone from 2012 to 2022. Patient demographics, risk factors, and outcomes were compared. Forty-two breasts received ND-NSM and 302 breasts received NSM alone. The ND-NSM group had significantly more high-risk factors, including elevated BMI (26.3 versus 22.9; P < 0.001), elevated prior breast surgery (50% versus 25%; P < 0.001), and greater mastectomy specimen weight (646.6 versus 303.2 g; P < 0.001). ND-NSM was more likely to have undergone preparatory mammoplasty before NSM (27% versus 1%; P < 0.001). There was no delay in NSM treatment from decision to pursue NSM (P = 0.483) or difference in skin necrosis (P = 0.256), NAC necrosis (P = 0.510), hematoma (P = 0.094), seroma (P = 0.137), or infection (P = 0.437) between groups. ND-NSM and NSM patients differed in total NAC necrosis (0% versus 3%) and implant loss (0% vs 13%), but not significantly. We demonstrated no NAC necrosis and no significant delay of treatment in higher risk ND-NSM patients. ND may allow higher risk patients to undergo NSM with similar morbidity as lower risk patients.

65 (PB-065) Poster - Quality of life and patient satisfaction after nipple sparing mastectomy versus skin sparing mastectomy and immediate one stage versus two stages breast reconstruction

Background: Nipple Sparing Mastectomy (NSM) and Skin Sparing Mastectomy (SSM) are oncologically safe procedures compared to classical modified radical mastectomy. This study evaluates whether NSM patients are more satisfied and have better quality of life than matched SSM patients and assesses patients’ quality of life after immediate one stage breast reconstruction with prepectoral permanent implants (IBR) compared to a matched group undergoing two stages breast reconstruction with expander and later with permanent implant.

Local recurrence of mammary Paget’s disease after nipple-sparing mastectomy and implant breast reconstruction: a case report and literature review

ObjectiveTo provide a rare case of local recurrent Paget’s disease after nipple-sparing mastectomy (NSM) with immediate breast reconstruction with 10 years of disease-free survival and to analyze the clinical and pathological characteristics.BackgroundMammary Paget’s disease can be considered a rare type of local recurrence after breast cancer treatment, both in cases of conservative surgery and NSM with immediate breast reconstruction (Lohsiriwat et al, Ann Surg Oncol 19:1850-1855, 2012). Recurrent patients who present with nipple-areolar Paget’s disease usually have unfavorable primary pathological characteristics and different latency periods. However, the recurrent status in patients with favorable primary pathological characteristics and the latency periods after NSM with immediate breast reconstruction are unclear.MethodsFirst, we present a case of local recurrent Paget’s disease in a young patient diagnosed with invasive breast carcinoma at age 30 who underwent NSM with primary silicone reconstruction. Then, the keywords “Paget’s disease” and “nipple-sparing mastectomy” were selected. Articles including the local recurrence of Paget’s disease after NSM were collected from the PubMed, Springer, and OVID databases, and the acquired relevant data were analyzed. We did not restrict our search by study design or publication date.ResultsFive studies describing 31 cases of local recurrent Paget’s disease after NSM with implant breast reconstruction were included. The mean patient age reported was 45 years, and the average latency period from NSM to the local recurrence of Paget’s disease was 40.2 months. Recurrent tumor histological features were Paget’s disease with ductal carcinoma in situ (DCIS) in 16 patients (50%), Paget’s disease without DCIS in 13 patients (40.6%), and Paget’s disease with ductal intraepithelial neoplasia (DIN) in 3 patients (9.4%). The primary tumor histological feature was estrogen receptor (ER)(−)/progesterone receptor (PR)(−)/human epidermal growth factor receptor (HER-2)(+) in 21 patients (77.8%). Neither locoregional relapse nor metastatic events were found in these recurrent patients who accepted NAC excision after 4–5 years of follow-up. Our reported case showed that the patient experienced pregnancy and lactation after primary adjuvant chemotherapy and endocrine therapy. However, she developed an eczematoid lesion in the NAC 120 months after breast surgery. The histopathological examination was consistent with Paget’s disease of the breast. Complete NAC and breast silicone prosthesis removal were performed. The patient accepted no systematic or local therapy and is currently alive. It is noteworthy that the biological features of the primary tumor were ER(+), PR(+), and HER-2(−); however, the recurrent tumor changed to ER(−), PR(−), and HER-2(+).ConclusionsThe local recurrence of Paget’s disease after NSM is uncommon; it may develop at a very early age and have a very long time to recurrence, as in our patient, who presented with recurrence 10 years after primary surgery. Surgeons should be wary of local recurrence of the nipple-areola complex after NSM in patients with ER-negative and HER-2-positive primary tumors. However, patients with ER/PR-positive and HER-2-negative tumors should not be neglected; we reported a case of an ER/PR-positive and HER-2-negative primary tumor, and ER-positive recurrent cases have the longest latency period. The local recurrence rate of Paget’s disease after NSM is low, and the prognosis is good in recurrent patients who accept further extensive NAC excision. Further systematic treatment was not considered for this patient.

A descriptive comparison of satisfaction and well-being between expander-based and direct-to-implant breast reconstruction after Nipple-Sparing Mastectomy.

The literature that has explored differences between direct-to-implant (DTI) and expander-based (EB) breast reconstruction has mainly focused on complications, with results not always unambiguous. Moreover, there are limited data 1) comparing DTI and EBbreast reconstruction after nipple-sparing mastectomy (NSM) and 2) from the patient's perspective. The aim of this study was to compare satisfaction and well-being in patients undergoing DTI and EB reconstruction after NSM in a Comprehensive Cancer Center, exploring what factors can be related to satisfaction and well-being. The study design is monocentric, observational and retrospective. The participants completed an online questionnaire containing the Breast-Q and some socio-demographic variables (year of birth, level of education, civil status). Clinical information was obtained from the institutional database. Surgical techniques in the two branches of NSM were similar: all skin incisions, lateral to the areola; all implants, subpectoral (EB: conventionally submuscular; DTI: dual-plane pocket); all without synthetic mesh or acellular tissue matrix. A total of120 patients (45% with EB and 55% with DTI) completed the questionnaire. We found that there are no differences between EB and DTI concerning the satisfaction and well-being of NSM patients, except for satisfaction with information, which is greater in the DTI group. In EB patients, no variables among those explored are related to satisfaction and well-being. In DTI patients, level of education is positive related to satisfaction with implants and physical well-being, Tumor-Node-Metastasis (TNM) and body mass index (BMI) are negative related to satisfaction with information and TNM also with satisfaction for plastic surgery. EB and DTI do not differ in terms of patient well-being, but EB requires a more careful counselling by the surgeon. 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 .

Nipple-Sparing Mastectomy versus Skin-Sparing Mastectomy: Does Saving the Nipple Impact Short- and Long-Term Patient Satisfaction?

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. 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 1-5years and 6-10years after NSM and SSM were analyzed. Overall, 431 patients were included; 247 had NSM and 184 had SSM 1-10years 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 1-5years cohort; however, scores attenuated in the 6-10years cohort. Satisfaction with breasts was nearly significantly higher in NSM patients compared with SSM patients in the 1-5years cohort (p=0.056), but no different in the 6-10years cohort. Receipt of adjuvant chemotherapy, receipt of postmastectomy radiation therapy, and BMI ≥30 were independent risk factors for dissatisfaction with breasts. 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.

Oncologic Safety of Nipple-Sparing Mastectomy for Patients with Breast Cancer

In patients undergoing mastectomy, benefits of nipple preservation include improved esthetics and quality of life. The purpose of this review is to evaluate the oncologic safety of nipple-sparing mastectomy (NSM) in women with breast cancer, focusing on complications, recurrence, and patient reported outcomes. Clinical presentation, risk factors for nipple involvement, and preoperative imaging may be helpful in choosing appropriate candidates. Recent series suggest that complications after NSM are slightly increased when compared to traditional mastectomy but likely related to increased risk of nipple necrosis. Pathologic assessment of the nipple is necessary. Local recurrence after NSM appears similar to patients after traditional mastectomy; however, studies evaluating local recurrence are of lower quality and have short follow-up. NSM is associated with improved psychosocial and sexual well-being after surgery. Studies evaluating oncologic safety of therapeutic NSM suggest that it is a viable option for appropriate patients, as risk of local recurrence and survival appears to be similar to patients undergoing traditional mastectomy. However, careful patient selection is critical.