Success achieved with skin-sparing mastectomy has led surgeons to reconsider the necessity of nipple-areola complex removal. This study reports our short- and mid-term postoperative outcomes with nipple-sparing mastectomy (NSM) and an updated review of reported literature. Data were retrospectively abstracted from medical records at our institution. Patients underwent NSM based on patient preference, oncologic criteria, and cosmesis. A literature review was undertaken through a PUBMED search and selected based on title and abstract relevance. Twenty-five patients underwent 42 NSMs at our institution from July 2000 to October 2005. Patient mean age was 44 years (29-59 years). Indications for mastectomy were: 34 (81%) for prophylaxis, 5 (12%) for invasive ductal carcinoma, 2 (5%) for ductal carcinoma in situ, and 1 (2%) for a malignant phyllodes tumor. One prophylactic mastectomy specimen showed ductal carcinoma in situ in the retroareolar tissue, and the nipple-areola complex was removed at a second operation. Mean tumor size in cases with invasive carcinoma (n = 5) was 1.9 cm (0.7-2.5 cm). All tumors were peripherally located, and no cases showed occult nipple involvement. The nipple-areola complex was entirely preserved in 39 (93%) mastectomies. One nipple-areola complex was surgically removed, and two (5%) cases had partial loss due to infection or ischemia. Cosmetic result from surgeon's assessment was excellent in 30 mastectomies, good in 7, acceptable in 3, and poor in 2, with slight nipple asymmetry in 8 cases. At a median follow-up of 10.5 months (range, 0.4-56.4 months), the 39 nipple-areola complexes were intact and there were no local or systemic recurrences in cases treated for cancer. NSM represented approximately 1% of all mastectomies performed at our institution during the reported period. It was mostly used for prophylaxis and for the treatment of malignant tumors in few selected cases. NSM can be performed with a high success rate of nipple-areola complex preservation. Conclusions about the oncologic safety of this procedure cannot be drawn from our study due to small size series and short follow-up. However, available published data show that NSM can be safely performed for breast cancer treatment in carefully selected cases. Further studies and longer follow-up are necessary to refine selection criteria for NSM.
BackgroundTo report results in terms of feasibility and early toxicity of hypofractionated simultaneous integrated boost (SIB) approach with Volumetric Modulated Arc Therapy (VMAT) as adjuvant treatment after breast-conserving surgery.MethodsBetween September 2010 and May 2011, 50 consecutive patients presenting early-stage breast cancer were submitted to adjuvant radiotherapy with SIB-VMAT approach using RapidArc in our Institution (Istituto Clinico Humanitas ICH). Three out of 50 patients were irradiated bilaterally (53 tumours in 50 patients). All patients were enrolled in a phase I-II trial approved by the ICH ethical committee. All 50 patients enrolled in the study underwent VMAT-SIB technique to irradiate the whole breast with concomitant boost irradiation of the tumor bed. Doses to whole breast and surgical bed were 40.5 Gy and 48 Gy respectively, delivered in 15 fractions over 3 weeks. Skin toxicities were recorded during and after treatment according to RTOG acute radiation morbidity scoring criteria with a median follow-up of 12 months (range 8–16). Cosmetic outcomes were assessed as excellent/good or fair/poor.ResultsThe median age of the population was 68 years (range 36–88). According to AJCC staging system, 38 breast lesions were classified as pT1, and 15 as pT2; 49 cases were assessed as N0 and 4 as N1. The maximum acute skin toxicity by the end of treatment was Grade 0 in 20/50 patients, Grade 1 in 32/50, Grade 2 in 0 and Grade 3 in 1/50 (one of the 3 cases of bilateral breast irradiation). No Grade 4 toxicities were observed. All Grade 1 toxicities had resolved within 3 weeks. No significant differences in cosmetic scores on baseline assessment vs. 3 months and 6 months after the treatment were observed: all patients were scored as excellent/good (50/50) compared with baseline; no fair/poor judgment was recorded. No other toxicities or local failures were recorded during follow-up.ConclusionsThe 3-week course of postoperative radiation using VMAT with SIB showed to be feasible and was associated with acceptable acute skin toxicity profile. Long-term follow-up data are needed to assess late toxicity and clinical outcomes.
Reoperative SLN biopsy is feasible in the setting of LR after previous BCT/axillary surgery and deserves further study in this increasingly common clinical scenario. The added benefit of lymphoscintigraphy in identifying sites of non-axillary drainage may be greater in the setting of reoperative SLN than for the initial SLN procedure.
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