Background: the use of nipple-sparing mastectomy (NSM) in local advanced breast cancer after neoadjuvant chemotherapy (NQT) is increasing, despite few studies on the subject. The aim of this systematic review was to determine the safety of NSM after neoadjuvant chemotherapy. Methods: for this systematic review we searched MEDLINE; Cochrane; Scientific Electronic Library Online (SciELO); Embase and Scopus. A literature search of all original studies including randomized controlled trials, cohort studies and case-control studies comparing women undergoing NSM after neoadjuvant chemotherapy for breast cancer was undertaken. Outcomes were locoregional recurrence (LRR), nipple recurrence and distant recurrence (DR). Data analysis was undertaken to explore the safety of NSM after NQT. The quality of the evidence was assessed with the Cochrane risk of bias tool. This study is registered on PROSPERO, number CRD42021276778. Findings: a total of 437 articles were identified. Four articles were included with 1466 patients all of which had a high to serious risk of overall bias. Local recurrence in the NSM after the NQT group ranged from zero to 9.8%. Nippleareolar complex (NAC) recurrence ranged from zero to 2.1%. The distant recurrence rate ranged from 6.5% to 16%. Due to the lack of pattern among the control groups, it was not possible to perform a meta-analysis. Interpretation: this review provides information for decision making in performing NSM after NQT. Despite the low rates of local recurrence and patients should be counseled about limited oncological information.
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<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<0.05 Table 3. Oncological outcomes in NSM and SSM groups *Model Fine & Gray and Wald test, p<0,05 **Cox Regression Model and Wald test, p<0.05 *** Log-rank test, p<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.
Background: The use of axillary marking before neoadjuvant systemic therapy (NST) is the standard of care in patients with positive lymph nodes (LN). Several methods have been tested leading to reduced false negative rate compared to sentinel lymph node biopsy (SLNB). With the increase in therapies in patients with residual disease, it is necessary to improve the accuracy of the axillary assessment. The aim of this study was to evaluate oncological outcomes in patients undergoing targeted axillary dissection with positive LN pre-NST marked with 4% carbon marker, the secondary objective was to evaluate the association between SLNB and pre-NST marked lymph node. Methods: A prospective study was performed in patients with cT1-T4, cN1-N2 breast cancer who underwent NST. An ultrasound-guided 4% carbon marking was performed before proposed treatment. After NST, the carbon marked lymph node (CMLN) was identified and resected associated with SLNB. When at least one lymph node was positive, axillary dissection was performed. The oncological outcomes registered were overall survival (OS), specific survival (SS), disease-free survival (DFS), axillary recurrence (AR) and local recurrence (LR). Results: 176 patients operated between July 2014 and January 2019 were included in the analysis. The CMLN were identified in 168/176 (95.4%) and the SLNB 145/176 (82.3%) operations. SLNB and CMLN were coincident in 93/176 (52.8%) cases. The LNs were not coincident in 44/176 (25%) cases and at least one of the methods were not identified in 39/176 (22.1%). When condensing the lymph nodes not found as positive lymph node, the sample agreement was 148/176 (81.4%) [Kappa = 0.67 (95%CI: 0.56 – 0.78)], when separating the positive lymph nodes from the lymph nodes not found, the agreement was 133/176 (75.6%) [Kappa = 0.56 (95%CI: 0.46 – 0.66)] (Table 1). With a mean follow-up of 49 months, 168 patients were included in the analysis of oncologic outcomes. Among the patients analyzed, 7/168 (4,1%) had LR, 5/168 (2,9%) had AR, 28/168 (16.6%) had distant recurrences [DFS = 83.3%]. There were 10/168 (5,9%) deaths [OS = 94%], with 5 confirmed by breast cancer and 4 of undetermined cause. There was a significant association between axillary dissection and axillary recurrence (0 versus 6% p = 0.012). OS for clinical stages 2B, 3A and 3B were 97, 88 and 87.5% respectively. Conclusions: The use of 4% carbon marker is a feasible and cheap method for targeted axillary dissection. The oncological outcomes are compatible with the survival curves of the American Joint Committee on Cancer 8th edition, therefore, a safe tool to spare women cN+ from axillary dissection when there is a complete axillary response to NST. The concordance rate between the CMLN and the SLNB was moderate when we took into account the failure of some method, noting the need for a supplementary method to the SLNB after NST. Frequency and percentages of anatomopathological results and methods of lymph node identification. SLNB = sentinel lymph node biopsy; CMLN = carbon marked lymph node Occurrence of oncological outcomes Citation Format: Lucas R. Budel, Cleverton C. Spautz, Maria Helena Louveira, Teresa Cristina S. Cavalcanti, Alessandra C. Fornazari, Plinio Gasperin, Leonardo P. Nissen, Vinicius M. Budel. Oncological outcomes in patients undergoing targeted axillary dissection with carbon marker [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 P2-14-11.
RESUMO Introdução: O uso de mastectomia preservadora de complexo aréolo-papilar (MPCAP) no câncer de mama localmente avançado após quimioterapia neoadjuvante (QTN) é crescente, apesar de ainda haver poucos estudos abordando o assunto. O objetivo desta revisão sistemática foi determinar a segurança da MPCAP após a quimioterapia neoadjuvante. Métodos: para esta revisão sistemática, pesquisamos no MEDLINE; Cochrane; Scientific Electronic Library Online (SciELO); Embase e Scopus. Foi realizada uma busca na literatura de todos os estudos originais, incluindo ensaios clínicos randomizados, estudos de coorte e estudos de caso-controle comparando mulheres submetidas a MPCAP após quimioterapia neoadjuvante para câncer de mama. Os desfechos foram recorrência locorregional, recidiva em papila e recorrência à distância. A análise dos dados foi realizada para avaliar a segurança da mastectomia preservadora de complexo aréolo-papilar após o QTN. A qualidade da evidência foi avaliada com a ferramenta de avaliação de risco de viés da Cochrane - ROBINS-I. Este estudo está registrado no PROSPERO, número CRD42021276778. Resultados: Um total de 437 artigos foram identificados. Quatro artigos foram incluídos na análise, totalizando 1466 pacientes, todos com risco de viés geral moderado a alto. A recorrência local no grupo MPCAP após QTN variou de zero a 9,8%. A recorrência no complexo aréolo-papilar (CAP) variou de zero a 2,1%. A taxa de recorrência à distância variou de 6,5% a 16%. Devido à falta de padrão entre os grupos de controle, não foi possível realizar uma meta-análise. Interpretação: esta revisão fornece informações para a tomada de decisão na realização de NSM após QTN. Apesar das baixas taxas de recorrência local, os pacientes devem ser orientados sobre as informações oncológicas limitadas.
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