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

Abstract

Background-Nipple-sparing mastectomy (NSM) is increasingly performed for invasive breast cancer. Growing evidence supporting NSM's oncologic safety has led to its widespread use and broadened indications. Here we examine indications, complications, and long-term outcomes of therapeutic NSM.Methods-From 2003-2016, 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. 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); median follow-up among survivors was 39.4 months. 357 (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<.001). There was no difference in family history, genetic mutations, smoking status, neoadjuvant chemotherapy, prior radiation, nodal involvement, or tumor subtype. 21 (4.5%) nipple excisions were performed; of which 14 were performed for cancer at the nipple margin. 44 breasts (9.4%) had complications that required re-operation. 15 patients had locoregional recurrence or distant metastasis.Terms of use and reuse: academic research for non-commercial purposes, see here for full terms. https://www.springer.com/aamterms-v1

The modern approach to the nipple‐sparing mastectomy

“…A single institution study by Wang et al 51 showed that while 16.5% of patients had some nipple ischemia, eschar, or necrosis, only 5.6% ultimately required reoperation to remove the nipple. Valero et al 18 similarly reported a low rate of nipple excision of 4.5%.…”

“…Garcia‐Etienne et al published the Memorial Sloan Kettering Cancer Center (MSKCC) indications for NSM in breast cancer patients in 2009, and these served as a guideline for many major institutions at the time; (a) no clinical involvement of the nipple areolar complex (NAC); (b) tumor size up to T2; (c) tumor‐to‐nipple distance of more than equal to 2 cm; (d) inflammatory breast cancer was a contraindication 8 . Ten years later, Valero et al 10 reported the current criteria for NSM at MSKCC which excluded only those with locally advanced breast cancer, extensive disease in the periphery of the breast, direct invasion of the nipple with cancer, and tumor‐to‐nipple distance of less than and equal to 1 cm.…”

“…The use of therapeutic NSM has become more widespread as more recent data supports the oncologic safety. A recent study from MSKCC demonstrated that for all NSM performed for cancer between 2003 and 2016, 76.4% of cases were performed in 2011 or later, and the use of NSM for invasive carcinomas had doubled since 2011 18 . A National Cancer Database study looking at NSM trends showed that the use of NSM increased from 1.7% in 2005 to 14.3% in 2015, with increased utilization among those with early‐stage and locally advanced disease 19 .…”

“…Many studies show no increase in complication rates with NSM compared to SSM, specifically infection, seroma, capsular contracture, and hemorrhage 51,52 . More recent publications have focused on complication rates with NSM in the setting of prior radiation and similarly show good outcomes 18,53 . Tang et al 54 showed that while complication rates appear slightly higher in irradiated breasts, reconstruction failure and NAC necrosis was infrequent, concluding that prior radiation should not be considered a contraindication to NSM.…”

Much Ado About Nipples

“…In this issue of Annals of Surgical Oncology, Valero and colleagues review the outcomes of 449 women with breast cancer who underwent 770 NSMs at Memorial Sloan Kettering Cancer Center (MSKCC) from 2003 to 2016. 2 Of 467 therapeutic NSMs, 337 (72.2%) were for invasive cancer, 126 (27.0%) were for ductal carcinoma in situ (DCIS), and 4 (0.9%) were for phyllodes tumors. They excluded patients with locally advanced disease, disease B 1 cm from the nipple, direct nipple involvement, and those with extensive disease in the periphery of the breast (due to concerns about limited exposure).…”