Surgical delay may extend the indications for nipple-sparing mastectomy: A multicentric study.

INTRODUCTION: Nipple-sparing mastectomy (NSM) is considered an oncologically sound procedure but necrosis of the nipple-areola complex (NAC) or skin flaps is a concern, particularly in the presence of risk factors. To increase the indications for NSM and decrease such complications, different procedures of "surgical delay" (SD) have been described. MATERIALS AND METHODS: A retrospective analysis of patients who underwent SD for NSM at four Italian Breast Centers from 2014 to 2017 was performed. SD generally consisted of a periareolar or "hemi-batwing" incision, dissecting the skin and the NAC from the underlying breast tissue. NSM was scheduled after 2-3 weeks. RESULTS: Eighty-eight procedures were analyzed. Mild complications of SD were registered in 7.9% of cases. NSM was performed in 85 cases, whereas in three cases (3.4%) a "skin-sparing" mastectomy was necessary due to positivity of the retroareolar biopsy for cancer at SD. A direct-to- implant (DTI) reconstruction was performed in 42 cases (49.4%), while in 43 (50.6%) a tissue-expander (TE) was inserted. After NSM, eight complications (9.4%) were recorded: one total necrosis (1.2%), one partial necrosis (1.2%) and four minimal ischemia (4.7%) of NAC, one skin flap necrosis (1.2%), one haematoma (1.2%). In only two cases (2.3%) prosthesis removal was needed. Aesthetic outcome was evaluated excellent or good in 92.9% of cases. At a median follow-up of 24 months no local recurrences were seen. CONCLUSION: This is the largest series of SD with NSM presented so far in the literature. In our experience, SD extends indications for NSM in high-risk women.

Oncologic Trends, Outcomes, and Risk Factors for Locoregional Recurrence: An Analysis of Tumor-to-Nipple Distance and Critical Factors in Therapeutic Nipple-Sparing Mastectomy.

BACKGROUND: Oncologic outcomes with nipple-sparing mastectomy continue to be established. The authors examine oncologic trends, outcomes, and risk factors, including tumor-to-nipple distance, in therapeutic nipple-sparing mastectomies. METHODS: Demographics, outcomes, and overall trends for all nipple-sparing mastectomies performed for a therapeutic indication from 2006 to 2017 were analyzed. Oncologic outcomes were investigated with specific focus on recurrence and associated factors, including tumor-to-nipple distance. RESULTS: A total of 496 therapeutic nipple-sparing mastectomies were performed, with an average follow-up time of 48.25 months. The most common tumor types were invasive carcinoma (52.4 percent) and ductal carcinoma in situ (50.4 percent). Sentinel lymph node sampling was performed in 79.8 percent of nipple-sparing mastectomies; 4.1 percent had positive frozen sentinel lymph node biopsy results, whereas 15.7 percent had positive nodal status on permanent pathologic examination. The most common pathologic cancer stage was stage IA (42.5 percent) followed by stage 0 (31.3 percent). The rate of local recurrence was 1.6 percent (n = 8), and the rate of regional recurrence was 0.6 percent (n = 3). In all, 171 nipple-sparing mastectomies had magnetic resonance imaging available with which to assess tumor-to-nipple distance. Tumor-to-nipple distance of 1 cm or less (25.0 percent versus 2.4 percent; p = 0.0031/p = 0.1129) and of 2 cm or less (8.7 percent versus 2.0 percent; p = 0.0218/p = 0.1345) trended to higher rates of locoregional recurrence. In univariate analysis, tumor-to-nipple distance of 1 cm or less was the only significant risk factor for recurrence (OR, 13.5833; p = 0.0385). No factors were significant in regression analysis. CONCLUSIONS: In early stage and in situ breast carcinoma, therapeutic nipple-sparing mastectomy appears oncologically safe, with a locoregional recurrence rate of 2.0 percent. Tumor-to-nipple distances of 1 cm or less and 2 cm or less trended to higher recurrence rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Contemporary operative management of T4 breast cancer.

BACKGROUND: Guidelines advise modified radical mastectomy following neoadjuvant systemic therapy for T4 breast cancer. We studied the influence of current systemic therapy and tumor subtype on pathologic stage and practice patterns to identify patients for whom less aggressive operative treatment might be considered. METHODS: We identified 98 clinical T4 M0 cases operated on at our institution from October 2008-July 2015. Patient, tumor, and treatment variables were analyzed. RESULTS: Clinical T4 substage was 7% T4a, 32% T4b, 3% T4c, and 58% T4d. Tumor biologic subtype was 41% ER+/HER2-, 36% HER2+, and 23% ER-/HER2-. A total of 86 patients (88%) had neoadjuvant systemic therapy; 87% of patients underwent total mastectomy, 9% skin-sparing mastectomy, and 4% breast conservation. Axillary dissection was performed in 74% of patients and sentinel node surgery with (14%) or without (11%) axillary dissection in the remainder; 41/98 (42%) were lymph node negative at operation. The pathologic complete response rate in the breast (31%) and axilla (39%, cN+ cases) correlated with biologic subtype (P < .0001). Overall 5-year, disease-free, and breast cancer-specific survival were 68% and 86%. CONCLUSION: Alignment with guidelines was substantial for both breast and axillary operation. Favorable breast cancer-specific survival suggests current multidisciplinary treatment has improved outcomes. Careful assessment of pathology and treatment response may identify clinical T4 patients appropriate for breast or axillary conservation.