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Published in: Annals of Surgical Oncology 2/2020

01-02-2020 | Mastectomy | Breast Oncology

Increase in Utilization of Nipple-Sparing Mastectomy for Breast Cancer: Indications, Complications, and Oncologic Outcomes

Authors: Monica G. Valero, MD, Shirin Muhsen, MD, Tracy-Ann Moo, MD, Emily C. Zabor, DrPH, Michelle Stempel, MPH, Andrea Pusic, MD, MHS, Mary L. Gemignani, MD, MPH, Monica Morrow, MD, Virgilio S. Sacchini, MD

Published in: Annals of Surgical Oncology | Issue 2/2020

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Abstract

Background

Nipple-sparing mastectomy (NSM) is increasingly performed for invasive breast cancer. Growing evidence supporting the oncologic safety of NSM has led to its widespread use and broadened indications. In this study, we examine the indications, complications, and long-term outcomes of therapeutic NSM.

Methods

From 2003 to 2016, women undergoing NSM for invasive cancer or ductal carcinoma in situ (DCIS) were identified from a prospectively maintained database. Patient and disease characteristics were compared by procedure year, while complications were compared by procedure year using generalized mixed-effects models accounting for a random surgeon effect. Overall survival and time to recurrence were examined.

Results

Of the 467 therapeutic NSMs, 337 (72%) were invasive cancer, 126 (27%) were DCIS, and 4 (1%) were phyllodes tumors. Median age was 45 years (range 24–75) and median follow-up among survivors was 39.4 months. Three hundred and fifty-seven (76.4%) cases were performed in 2011 or after. When comparing NSMs performed before and after 2011, there was a significant increase in NSMs performed for invasive tumors (58% vs. 77%; p < 0.001). There was no difference in family history, genetic mutations, smoking status, neoadjuvant chemotherapy, prior radiation, nodal involvement, or tumor subtype. Twenty-one (4.5%) nipple excisions were performed, of which 14 were performed for cancer at the nipple margin. Forty-four breasts (9.4%) had complications that required re-operation. Fifteen patients had locoregional recurrence or distant metastasis.

Conclusions

NSM use for invasive carcinoma has doubled at our institution since 2011, while postoperative complications and recurrence rates remain low. Our experience supports the selective use of NSM in the malignant setting with careful patient selection.
Literature
1.
go back to reference Toth BA, Lappert P. Modified skin incisions for mastectomy: the need for plastic surgical input in preoperative planning. Plast Reconstr Surg. 1991;87(6):1048–53.PubMed Toth BA, Lappert P. Modified skin incisions for mastectomy: the need for plastic surgical input in preoperative planning. Plast Reconstr Surg. 1991;87(6):1048–53.PubMed
2.
go back to reference Freeman BS. Subcutaneous mastectomy for benign breast lesions with immediate or delayed prosthetic replacement. Plast Reconstr Surg Transplant Bull. 1962;30:676–82.PubMed Freeman BS. Subcutaneous mastectomy for benign breast lesions with immediate or delayed prosthetic replacement. Plast Reconstr Surg Transplant Bull. 1962;30:676–82.PubMed
3.
go back to reference Eldor L, Spiegel A. Breast reconstruction after bilateral prophylactic mastectomy in women at high risk for breast cancer. Breast J. 2009;15(Suppl 1):S81–9.PubMed Eldor L, Spiegel A. Breast reconstruction after bilateral prophylactic mastectomy in women at high risk for breast cancer. Breast J. 2009;15(Suppl 1):S81–9.PubMed
5.
go back to reference Morrow M, Mehrara B. Prophylactic mastectomy and the timing of breast reconstruction. Br J Surg. 2009;96(1):1–2.PubMed Morrow M, Mehrara B. Prophylactic mastectomy and the timing of breast reconstruction. Br J Surg. 2009;96(1):1–2.PubMed
6.
go back to reference Peled AW, Irwin CS, Hwang ES, Ewing CA, Alvarado M, Esserman LJ. Total skin-sparing mastectomy in BRCA mutation carriers. Ann Surg Oncol. 2014;21(1):37–41.PubMed Peled AW, Irwin CS, Hwang ES, Ewing CA, Alvarado M, Esserman LJ. Total skin-sparing mastectomy in BRCA mutation carriers. Ann Surg Oncol. 2014;21(1):37–41.PubMed
7.
go back to reference Warren Peled A, Foster RD, Stover AC, et al. Outcomes after total skin-sparing mastectomy and immediate reconstruction in 657 breasts. Ann Surg Oncol. 2012;19(11):3402–9.PubMed Warren Peled A, Foster RD, Stover AC, et al. Outcomes after total skin-sparing mastectomy and immediate reconstruction in 657 breasts. Ann Surg Oncol. 2012;19(11):3402–9.PubMed
8.
go back to reference Lanitis S, Tekkis PP, Sgourakis G, Dimopoulos N, Al Mufti R, Hadjiminas DJ. Comparison of skin-sparing mastectomy versus non-skin-sparing mastectomy for breast cancer: a meta-analysis of observational studies. Ann Surg. 2010;251(4):632–9.PubMed Lanitis S, Tekkis PP, Sgourakis G, Dimopoulos N, Al Mufti R, Hadjiminas DJ. Comparison of skin-sparing mastectomy versus non-skin-sparing mastectomy for breast cancer: a meta-analysis of observational studies. Ann Surg. 2010;251(4):632–9.PubMed
9.
go back to reference Kroll SS, Schusterman MA, Tadjalli HE, Singletary SE, Ames FC. Risk of recurrence after treatment of early breast cancer with skin-sparing mastectomy. Ann Surg Oncol. 1997;4(3):193–7.PubMed Kroll SS, Schusterman MA, Tadjalli HE, Singletary SE, Ames FC. Risk of recurrence after treatment of early breast cancer with skin-sparing mastectomy. Ann Surg Oncol. 1997;4(3):193–7.PubMed
10.
go back to reference Kroll SS, Khoo A, Singletary SE, et al. Local recurrence risk after skin-sparing and conventional mastectomy: a 6-year follow-up. Plast Reconstr Surg. 1999;104(2):421–5.PubMed Kroll SS, Khoo A, Singletary SE, et al. Local recurrence risk after skin-sparing and conventional mastectomy: a 6-year follow-up. Plast Reconstr Surg. 1999;104(2):421–5.PubMed
11.
go back to reference Newman LA, Kuerer HM, Hunt KK, et al. Presentation, treatment, and outcome of local recurrence after skin-sparing mastectomy and immediate breast reconstruction. Ann Surg Oncol. 1998;5(7):620–6.PubMed Newman LA, Kuerer HM, Hunt KK, et al. Presentation, treatment, and outcome of local recurrence after skin-sparing mastectomy and immediate breast reconstruction. Ann Surg Oncol. 1998;5(7):620–6.PubMed
12.
go back to reference Gerber B, Krause A, Dieterich M, Kundt G, Reimer T. The oncological safety of skin sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction: an extended follow-up study. Ann Surg. 2009;249(3):461–8.PubMed Gerber B, Krause A, Dieterich M, Kundt G, Reimer T. The oncological safety of skin sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction: an extended follow-up study. Ann Surg. 2009;249(3):461–8.PubMed
13.
go back to reference De La Cruz L, Moody AM, Tappy EE, Blankenship SA, Hecht EM. Overall survival, disease-free survival, local recurrence, and nipple-areolar recurrence in the setting of nipple-sparing mastectomy: a meta-analysis and systematic review. Ann Surg Oncol. 2015;22(10):3241–9. De La Cruz L, Moody AM, Tappy EE, Blankenship SA, Hecht EM. Overall survival, disease-free survival, local recurrence, and nipple-areolar recurrence in the setting of nipple-sparing mastectomy: a meta-analysis and systematic review. Ann Surg Oncol. 2015;22(10):3241–9.
14.
go back to reference Crowe JP, Patrick RJ, Yetman RJ, Djohan R. Nipple-sparing mastectomy update: one hundred forty-nine procedures and clinical outcomes. Arch Surg. 2008;143(11):1106–10. (discussion 10).PubMed Crowe JP, Patrick RJ, Yetman RJ, Djohan R. Nipple-sparing mastectomy update: one hundred forty-nine procedures and clinical outcomes. Arch Surg. 2008;143(11):1106–10. (discussion 10).PubMed
15.
go back to reference Lagios MD, Gates EA, Westdahl PR, Richards V, Alpert BS. A guide to the frequency of nipple involvement in breast cancer. A study of 149 consecutive mastectomies using a serial subgross and correlated radiographic technique. Am J Surg. 1979;138(1):135–42.PubMed Lagios MD, Gates EA, Westdahl PR, Richards V, Alpert BS. A guide to the frequency of nipple involvement in breast cancer. A study of 149 consecutive mastectomies using a serial subgross and correlated radiographic technique. Am J Surg. 1979;138(1):135–42.PubMed
16.
go back to reference de Alcantara Filho P, Capko D, Barry JM, Morrow M, Pusic A, Sacchini VS. Nipple-sparing mastectomy for breast cancer and risk-reducing surgery: the memorial Sloan-Kettering cancer center experience. Ann Surg Oncol. 2011;18(11):3117–22. de Alcantara Filho P, Capko D, Barry JM, Morrow M, Pusic A, Sacchini VS. Nipple-sparing mastectomy for breast cancer and risk-reducing surgery: the memorial Sloan-Kettering cancer center experience. Ann Surg Oncol. 2011;18(11):3117–22.
17.
go back to reference Petit JY, Veronesi U, Orecchia R, et al. Risk factors associated with recurrence after nipple-sparing mastectomy for invasive and intraepithelial neoplasia. Ann Oncol. 2012;23(8):2053–8.PubMed Petit JY, Veronesi U, Orecchia R, et al. Risk factors associated with recurrence after nipple-sparing mastectomy for invasive and intraepithelial neoplasia. Ann Oncol. 2012;23(8):2053–8.PubMed
18.
go back to reference Garcia-Etienne CA, Cody Iii HS, Disa JJ, Cordeiro P, Sacchini V. Nipple-sparing mastectomy: initial experience at the memorial Sloan-Kettering cancer center and a comprehensive review of literature. Breast J. 2009;15(4):440–9.PubMed Garcia-Etienne CA, Cody Iii HS, Disa JJ, Cordeiro P, Sacchini V. Nipple-sparing mastectomy: initial experience at the memorial Sloan-Kettering cancer center and a comprehensive review of literature. Breast J. 2009;15(4):440–9.PubMed
19.
go back to reference Morimoto T, Komaki K, Inui K, et al. Involvement of nipple and areola in early breast cancer. Cancer. 1985;55(10):2459–63.PubMed Morimoto T, Komaki K, Inui K, et al. Involvement of nipple and areola in early breast cancer. Cancer. 1985;55(10):2459–63.PubMed
20.
go back to reference Luttges J, Kalbfleisch H, Prinz P. Nipple involvement and multicentricity in breast cancer. A study on whole organ sections. J Cancer Res Clin Oncol. 1987;113(5):481–7.PubMed Luttges J, Kalbfleisch H, Prinz P. Nipple involvement and multicentricity in breast cancer. A study on whole organ sections. J Cancer Res Clin Oncol. 1987;113(5):481–7.PubMed
21.
go back to reference Santini D, Taffurelli M, Gelli MC, et al. Neoplastic involvement of nipple-areolar complex in invasive breast cancer. Am J Surg. 1989;158(5):399–403.PubMed Santini D, Taffurelli M, Gelli MC, et al. Neoplastic involvement of nipple-areolar complex in invasive breast cancer. Am J Surg. 1989;158(5):399–403.PubMed
22.
go back to reference Vyas JJ, Chinoy RF, Vaidya JS. Prediction of nipple and areola involvement in breast cancer. Eur J Surg Oncol. 1998;24(1):15–6.PubMed Vyas JJ, Chinoy RF, Vaidya JS. Prediction of nipple and areola involvement in breast cancer. Eur J Surg Oncol. 1998;24(1):15–6.PubMed
23.
go back to reference Benediktsson KP, Perbeck L. Survival in breast cancer after nipple-sparing subcutaneous mastectomy and immediate reconstruction with implants: a prospective trial with 13 years median follow-up in 216 patients. Eur J Surg Oncol. 2008;34(2):143–8.PubMed Benediktsson KP, Perbeck L. Survival in breast cancer after nipple-sparing subcutaneous mastectomy and immediate reconstruction with implants: a prospective trial with 13 years median follow-up in 216 patients. Eur J Surg Oncol. 2008;34(2):143–8.PubMed
24.
go back to reference Petit JY, Veronesi U, Rey P, et al. Nipple-sparing mastectomy: risk of nipple-areolar recurrences in a series of 579 cases. Breast Cancer Res Treat. 2009;114(1):97–101.PubMed Petit JY, Veronesi U, Rey P, et al. Nipple-sparing mastectomy: risk of nipple-areolar recurrences in a series of 579 cases. Breast Cancer Res Treat. 2009;114(1):97–101.PubMed
25.
go back to reference Nahabedian MY, Tsangaris TN. Breast reconstruction following subcutaneous mastectomy for cancer: a critical appraisal of the nipple-areola complex. Plast Reconstr Surg. 2006;117(4):1083–90.PubMed Nahabedian MY, Tsangaris TN. Breast reconstruction following subcutaneous mastectomy for cancer: a critical appraisal of the nipple-areola complex. Plast Reconstr Surg. 2006;117(4):1083–90.PubMed
26.
go back to reference Didier F, Radice D, Gandini S, et al. Does nipple preservation in mastectomy improve satisfaction with cosmetic results, psychological adjustment, body image and sexuality? Breast Cancer Res Treat. 2009;118(3):623–33.PubMed Didier F, Radice D, Gandini S, et al. Does nipple preservation in mastectomy improve satisfaction with cosmetic results, psychological adjustment, body image and sexuality? Breast Cancer Res Treat. 2009;118(3):623–33.PubMed
27.
go back to reference Djohan R, Gage E, Gatherwright J, et al. Patient satisfaction following nipple-sparing mastectomy and immediate breast reconstruction: an 8-year outcome study. Plast Reconstr Surg. 2010;125(3):818–29.PubMed Djohan R, Gage E, Gatherwright J, et al. Patient satisfaction following nipple-sparing mastectomy and immediate breast reconstruction: an 8-year outcome study. Plast Reconstr Surg. 2010;125(3):818–29.PubMed
28.
go back to reference Yueh JH, Houlihan MJ, Slavin SA, Lee BT, Pories SE, Morris DJ. Nipple-sparing mastectomy: evaluation of patient satisfaction, aesthetic results, and sensation. Ann Plast Surg. 2009;62(5):586–90.PubMed Yueh JH, Houlihan MJ, Slavin SA, Lee BT, Pories SE, Morris DJ. Nipple-sparing mastectomy: evaluation of patient satisfaction, aesthetic results, and sensation. Ann Plast Surg. 2009;62(5):586–90.PubMed
29.
go back to reference Dossett LA, Lowe J, Sun W, et al. Prospective evaluation of skin and nipple-areola sensation and patient satisfaction after nipple-sparing mastectomy. J Surg Oncol. 2016;114(1):11–6.PubMed Dossett LA, Lowe J, Sun W, et al. Prospective evaluation of skin and nipple-areola sensation and patient satisfaction after nipple-sparing mastectomy. J Surg Oncol. 2016;114(1):11–6.PubMed
30.
go back to reference Kurian AW, Lichtensztajn DY, Keegan TH, Nelson DO, Clarke CA, Gomez SL. Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998–2011. JAMA. 2014;312(9):902–14.PubMedPubMedCentral Kurian AW, Lichtensztajn DY, Keegan TH, Nelson DO, Clarke CA, Gomez SL. Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998–2011. JAMA. 2014;312(9):902–14.PubMedPubMedCentral
31.
go back to reference Tuttle TM, Habermann EB, Grund EH, Morris TJ, Virnig BA. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment. J Clin Oncol. 2007;25(33):5203–9.PubMed Tuttle TM, Habermann EB, Grund EH, Morris TJ, Virnig BA. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment. J Clin Oncol. 2007;25(33):5203–9.PubMed
32.
go back to reference Agarwal S, Agarwal S, Neumayer L, Agarwal JP. Therapeutic nipple-sparing mastectomy: trends based on a national cancer database. Am J Surg. 2014;208(1):93–8.PubMed Agarwal S, Agarwal S, Neumayer L, Agarwal JP. Therapeutic nipple-sparing mastectomy: trends based on a national cancer database. Am J Surg. 2014;208(1):93–8.PubMed
33.
go back to reference Orzalesi L, Casella D, Santi C, et al. Nipple sparing mastectomy: surgical and oncological outcomes from a national multicentric registry with 913 patients (1006 cases) over a six year period. Breast. 2016;25:75–81.PubMed Orzalesi L, Casella D, Santi C, et al. Nipple sparing mastectomy: surgical and oncological outcomes from a national multicentric registry with 913 patients (1006 cases) over a six year period. Breast. 2016;25:75–81.PubMed
35.
go back to reference Coopey SB, Tang R, Lei L, et al. Increasing eligibility for nipple-sparing mastectomy. Ann Surg Oncol. 2013;20(10):3218–22. Coopey SB, Tang R, Lei L, et al. Increasing eligibility for nipple-sparing mastectomy. Ann Surg Oncol. 2013;20(10):3218–22.
36.
go back to reference Krajewski AC, Boughey JC, Degnim AC, et al. Expanded indications and improved outcomes for nipple-sparing mastectomy over time. Ann Surg Oncol. 2015;22(10):3317–23.PubMed Krajewski AC, Boughey JC, Degnim AC, et al. Expanded indications and improved outcomes for nipple-sparing mastectomy over time. Ann Surg Oncol. 2015;22(10):3317–23.PubMed
37.
go back to reference Santoro S, Loreti A, Cavaliere F, et al. Neoadjuvant chemotherapy is not a contraindication for nipple sparing mastectomy. Breast. 2015;24(5):661–6.PubMed Santoro S, Loreti A, Cavaliere F, et al. Neoadjuvant chemotherapy is not a contraindication for nipple sparing mastectomy. Breast. 2015;24(5):661–6.PubMed
38.
go back to reference Smith BL, Tang R, Rai U, et al. Oncologic safety of nipple-sparing mastectomy in women with breast cancer. J Am Coll Surg. 2017;225(3):361–5.PubMed Smith BL, Tang R, Rai U, et al. Oncologic safety of nipple-sparing mastectomy in women with breast cancer. J Am Coll Surg. 2017;225(3):361–5.PubMed
39.
go back to reference Alperovich M, Choi M, Frey JD, et al. Nipple-sparing mastectomy in patients with prior breast irradiation: are patients at higher risk for reconstructive complications? Plast Reconstr Surg. 2014;134(2):202e–6e.PubMed Alperovich M, Choi M, Frey JD, et al. Nipple-sparing mastectomy in patients with prior breast irradiation: are patients at higher risk for reconstructive complications? Plast Reconstr Surg. 2014;134(2):202e–6e.PubMed
40.
go back to reference Tang R, Coopey SB, Colwell AS, et al. Nipple-sparing mastectomy in irradiated breasts: selecting patients to minimize complications. Ann Surg Oncol. 2015;22(10):3331–7. Tang R, Coopey SB, Colwell AS, et al. Nipple-sparing mastectomy in irradiated breasts: selecting patients to minimize complications. Ann Surg Oncol. 2015;22(10):3331–7.
41.
go back to reference Burdge EC, Yuen J, Hardee M, et al. Nipple skin-sparing mastectomy is feasible for advanced disease. Ann Surg Oncol. 2013;20(10):3294–302.PubMed Burdge EC, Yuen J, Hardee M, et al. Nipple skin-sparing mastectomy is feasible for advanced disease. Ann Surg Oncol. 2013;20(10):3294–302.PubMed
42.
go back to reference Janssen S, Holz-Sapra E, Rades D, Moser A, Studer G. Nipple-sparing mastectomy in breast cancer patients: the role of adjuvant radiotherapy (review). Oncol Lett. 2015;9(6):2435–41.PubMedPubMedCentral Janssen S, Holz-Sapra E, Rades D, Moser A, Studer G. Nipple-sparing mastectomy in breast cancer patients: the role of adjuvant radiotherapy (review). Oncol Lett. 2015;9(6):2435–41.PubMedPubMedCentral
43.
go back to reference Reish RG, Lin A, Phillips NA, et al. Breast reconstruction outcomes after nipple-sparing mastectomy and radiation therapy. Plast Reconstr Surg. 2015;135(4):959–66.PubMed Reish RG, Lin A, Phillips NA, et al. Breast reconstruction outcomes after nipple-sparing mastectomy and radiation therapy. Plast Reconstr Surg. 2015;135(4):959–66.PubMed
44.
go back to reference Carlson GW, Styblo TM, Lyles RH, et al. The use of skin sparing mastectomy in the treatment of breast cancer: the Emory experience. Surg Oncol. 2003;12(4):265–9.PubMed Carlson GW, Styblo TM, Lyles RH, et al. The use of skin sparing mastectomy in the treatment of breast cancer: the Emory experience. Surg Oncol. 2003;12(4):265–9.PubMed
45.
go back to reference Boneti C, Yuen J, Santiago C, et al. Oncologic safety of nipple skin-sparing or total skin-sparing mastectomies with immediate reconstruction. J Am Coll Surg. 2011;212(4):686–93. (discussion 93–5).PubMed Boneti C, Yuen J, Santiago C, et al. Oncologic safety of nipple skin-sparing or total skin-sparing mastectomies with immediate reconstruction. J Am Coll Surg. 2011;212(4):686–93. (discussion 93–5).PubMed
46.
go back to reference Lohsiriwat V, Martella S, Rietjens M, et al. Paget’s disease as a local recurrence after nipple-sparing mastectomy: clinical presentation, treatment, outcome, and risk factor analysis. Ann Surg Oncol. 2012;19(6):1850–5.PubMed Lohsiriwat V, Martella S, Rietjens M, et al. Paget’s disease as a local recurrence after nipple-sparing mastectomy: clinical presentation, treatment, outcome, and risk factor analysis. Ann Surg Oncol. 2012;19(6):1850–5.PubMed
47.
go back to reference Brachtel EF, Rusby JE, Michaelson JS, et al. Occult nipple involvement in breast cancer: clinicopathologic findings in 316 consecutive mastectomy specimens. J Clin Oncol. 2009;27(30):4948–54.PubMed Brachtel EF, Rusby JE, Michaelson JS, et al. Occult nipple involvement in breast cancer: clinicopathologic findings in 316 consecutive mastectomy specimens. J Clin Oncol. 2009;27(30):4948–54.PubMed
48.
go back to reference Voltura AM, Tsangaris TN, Rosson GD, et al. Nipple-sparing mastectomy: critical assessment of 51 procedures and implications for selection criteria. Ann Surg Oncol. 2008;15(12):3396–401.PubMed Voltura AM, Tsangaris TN, Rosson GD, et al. Nipple-sparing mastectomy: critical assessment of 51 procedures and implications for selection criteria. Ann Surg Oncol. 2008;15(12):3396–401.PubMed
Metadata
Title
Increase in Utilization of Nipple-Sparing Mastectomy for Breast Cancer: Indications, Complications, and Oncologic Outcomes
Authors
Monica G. Valero, MD
Shirin Muhsen, MD
Tracy-Ann Moo, MD
Emily C. Zabor, DrPH
Michelle Stempel, MPH
Andrea Pusic, MD, MHS
Mary L. Gemignani, MD, MPH
Monica Morrow, MD
Virgilio S. Sacchini, MD
Publication date
01-02-2020
Publisher
Springer International Publishing
Published in
Annals of Surgical Oncology / Issue 2/2020
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-019-07948-x

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