Early Results of an Endoscopic Nipple-Sparing Mastectomy for Breast Cancer

Abstract

Background. Endoscopic mastectomy has been reportedly associated with smaller scars and greater patient satisfaction; however, few reports on this topic have been made. The purpose of this retrospective study was to examine the early results of endoscopic nipple-sparing mastectomy (E-NSM) and to investigate the safety of this procedure. Methods. Between January 2002 and December 2005, a total of 87 patients with breast cancer but without skin and nipple involvement, including two cases of bilateral breast cancer, underwent E-NSM. In case of bloody nipple discharge and suspicious extension near the nipple as assessed by magnetic resonance imaging, the major ducts within the nipple were cored (nipple coring). In other cases, nipple coring was not performed. Results. Of the 89 breasts in 87 patients, 42 had tumors of [2 cm and 80 were diagnosed as having invasive carcinoma. Lymph node involvement was observed in 36 procedures. The overall rate of nipple necrosis was 18% (16 of 89). The rate of nipple necrosis among the procedures with nipple coring was statistically higher than that among those without nipple coring (7 of 17, 41%, vs. 9 of 72, 13%) (P = .01). Nipple involvement was observed in 2.2% (2 of 89). After a median follow-up period of 52 months, distant metastasis was observed in nine cases; no local recurrences occurred in this series.Conclusions. E-NSM is an oncologically safe procedure and an acceptable method in selected patients requiring a mastectomy. The higher rate of nipple necrosis may have been the result of a technical problem, indicating the need for continued improvement in nipple coring procedures.The removal of the nipple as part of a mastectomy has been routinely performed on the basis of the presumed risk of occult nipple involvement, which reportedly occurs in 5.6% to 58% of cases.1-11 However, many patients are dissatisfied with the reconstructed nipple for various reasons, including nipple projection, color matching, shape, size, texture, and position.12 A nipple-sparing mastectomy (NSM) is a procedure that can be applied as part of a skinsparing mastectomy, in which the nipple-areola complex (NAC) is preserved for cosmetic reasons. 9,11,[13][14][15][16][17][18][19] For patients without skin and nipple involvement, NSM has evolved as an alternative to a mastectomy with a safe oncologic profile and a better cosmetic outcome. 9,11,[13][14][15][16][17][18][19][20][21] In the early 1990s, endoscopic surgery of the breast was first applied for the treatment of patients with capsular contracture after breast augmentation. 22 Since then, it has been used for aesthetic breast surgery, breast lump excision, and breast surgery for breast cancer. [23][24][25][26][27][28][29][30][31][32][33][34] The addition of endoscopy to NSM for patients with breast cancer has been reportedly associated with smaller scars and greater patient satisfaction.27-29 However, few reports on endoscopic nipple-sparing mastectomy (E-NSM) have been made, and most of these studies had relatively short followup peri...

Endoscopic breast surgery: where are we now and what might the future hold for video-assisted breast surgery?

“…The length and number of axillary incisions varies, with some surgeons being able to proceed through a small single axillary point of entry [7][8][9], whilst others require lengthier incisions (~8cm) [10] or multiple axillary incisions seemingly to mirror the triangulation set-up of traditional abdominal laparoscopy [11][12][13]. Additional periareolar incisions are adopted for cases in which tumours are located in the inner breast quadrant [14][15][16] to facilitate subcutaneous dissection [17] or if the patient's breasts are especially large [18]. Finally, depending on tumour location, it may be necessary to place incisions in the infra-mammary crease [10].…”

“…The majority of surgeons employed a 10mm, 0° endoscope (Olympus, Co) as the visualisation system of choice. However, 5mm and 30° endoscopes have been used without any obvious increase in adverse events or ergonomic challenges [7,17,18,21].…”

“…Tumour size appears to be the single most important eligibility criteria defining entry into endoscopic mastectomy trials. Several researchers have limited their trials of endoscopic breast cancer surgery to T1 and small T2 tumours (<3cm in size) [14,18,[21][22][23], whilst others have included patients with larger T2/T3 tumours (>3 but <6cm) and/ or multifocal disease [11,[15][16][17]24]. Patients with a distribution of invasive disease that would otherwise be suitable for standard BCS, but in whom post-operative radiotherapy was not deemed acceptable were also candidates for endoscopic mastectomy in certain trials [18].…”

“…Common exclusion criteria include the presence of nipple deviation or retraction or suspicion of nipple-areolar complex involvement detected clinically or radiologically [9,13,[16][17][18][19][20], Paget's disease [17], obvious skin involvement [9,[15][16][17][19][20][21], confirmation of distant metastasis [9,13,14], associated co-morbidity or poor performance status [9,20], and in certain cases the presence of obvious axillary lymph node involvement [9,13,21,23]. In circumstances where endoscopic techniques were employed to achieve BCS, disease multifocality was also an exclusion criterion [21].…”

“…following an average follow-up duration of 24.1 months there was no reported LR [7,9,11,13,17,19,23,24]. However, notwithstanding some exceptions [17,24], the average duration of follow-up has been less than two years and investigators have observed LR following endoscopic resection when follow-up is extended beyond three years [15].…”