Review

Authors: Viviana Galimberti, Elisa Vicini, Giovanni Corso...

Skin-sparing (SSM) and nipple-sparing (NSM) mastectomies are relatively new conservative surgical approaches to breast cancer. In SSM most of the breast skin is conserved to create a pocket that facilitates immediate breast reconstruction with implant or autologous graft to achieve a quality cosmetic outcome. NSM is closely similar except that the nipple-areola complex (NAC) is also conserved. Meta-analyses indicate that outcomes for SSM and NSM do not differ from those for non-conservative mastectomies. Recurrence rates in the NAC after NSM are acceptably low (0-3.7%). Other studies indicate that NSM is associated with high patient satisfaction and good psychological adjustment. Indications are carcinoma or DCIS that require mastectomy (including after neoadjuvant chemotherapy). NSM is also suitable for women undergoing risk-reducing bilateral mastectomy. Tumor not less than 2 cm from the NAC is recommended, but may be less important than no evidence of nipple involvement on mandatory intraoperative nipple margin assessment. A positive margin is an absolute contraindication for nipple preservation. Other contraindications are microcalcifications close to the subareolar region and a positive nipple discharge. Complication rates are similar to those for other types of post-mastectomy reconstructions. The main complication of NSM is NAC necrosis, however as surgeon experience matures, frequency declines. Factors associated with complications are voluminous breast, ptosis, smoking, obesity, and radiotherapy. Since the access incision is small, breast tissue may be left behind, so only experienced breast surgeons should do these operations in close collaboration with the plastic surgeon. For breast cancer patients requiring mastectomy, NSM should be the option of choice.

Topics: Breast Neoplasms; Carcinoma, Ductal, Breast; Carcinoma, Intraductal, Noninfiltrating; Contraindications, Procedure; Female; Humans; Mastectomy; Nipples; Organ Sparing Treatments; Patient Selection; Prophylactic Mastectomy; Skin

PubMed: 28673535
DOI: 10.1016/j.breast.2017.06.034

Review

Authors: Tracy-Ann Moo, Rachel Sanford, Chau Dang...

Breast cancer treatment is multidisciplinary. Most women with early stage breast cancer are candidates for breast-conserving surgery with radiotherapy or mastectomy. The risk of local recurrence and the chance of survival does not differ with these approaches. Sentinel node biopsy is used for axillary staging, and individualized approaches are minimizing the need for axillary dissection in women with positive sentinel nodes. Adjuvant systemic therapy is used in most women based on proven survival benefit, and molecular profiling to individualize treatment based on risk is now a clinical reality for patients with hormone receptor-positive cancers.

Topics: Breast Neoplasms; Female; Humans; Mastectomy; Mastectomy, Segmental; Neoadjuvant Therapy

PubMed: 30100074
DOI: 10.1016/j.cpet.2018.02.006

Authors: Heather Richardson, Grace Ma

OBJECTIVE

To reconstruct a breast mound from cutaneous mastectomy flap tissue alone, obviating the need for additional flap or implant techniques.

SUMMARY BACKGROUND DATA

With growing numbers of obese and elderly women facing breast cancer, options outside of simple mastectomy without reconstruction and formal breast reconstruction using complex autologous flap harvesting techniques or artificial implants need to be explored.

METHODS

Patients who declined traditional methods of breast reconstruction were offered standard skin sparing mastectomy with closure utilizing a standard Wise pattern. A completely autologous breast mound was created by preserving and de-epithelializing residual mastectomy flap tissue.

RESULTS

Over 24 months, 32 women (50 breasts) underwent mastectomy and closure using this technique. Seromas occurred in 1 of 50 operated breasts and cellulitis developed in 3 of 50 breasts. One of the two patients had active hidradenitis at the time of surgery which made expander placement a contraindication and post operative infection a high risk. There has been no incidence of locoregional breast cancer recurrence.

CONCLUSIONS

Some patients are poor candidates for traditional methods of breast reconstruction secondary to medical comorbidities, while others may decline for more personal reasons. For these patients, we describe an additional option. The procedure is performed in a single stage and does not necessitate closure by a reconstructive surgeon, although a team approach can improve aesthetic results. Disadvantages include limited applicability in patients with small, non-ptotic breasts. Deemed the "Goldilocks Mastectomy", it is neither amputation of the breast, nor is it full reconstruction. It is a third, middle option. This offers an aesthetic advantage for women over simple mastectomy without reconstruction and potentially decreases cost and number of procedures sometimes associated with formal reconstruction.

Topics: Adult; Aged; Aged, 80 and over; Breast; Breast Neoplasms; Female; Humans; Mammaplasty; Mastectomy; Middle Aged; Surgical Flaps

PubMed: 22892093
DOI: 10.1016/j.ijsu.2012.08.003

Authors: Summer E Hanson, Xiudong Lei, Margaret S Roubaud...

IMPORTANCE

Treatment options for early breast cancer include breast-conserving surgery with radiation therapy (RT) or mastectomy and breast reconstruction without RT. Despite marked differences in these treatment strategies, little is known with regard to their association with long-term quality of life (QOL).

OBJECTIVE

To evaluate the association of treatment with breast-conserving surgery with RT vs mastectomy and reconstruction without RT with long-term QOL.

DESIGN, SETTING, AND PARTICIPANTS

This comparative effectiveness research study used data from the Texas Cancer Registry for women diagnosed with stage 0-II breast cancer and treated with breast-conserving surgery or mastectomy and reconstruction between 2006 and 2008. The study sample was mailed a survey between March 2017 and April 2018. Data were analyzed from August 1, 2018 to October 15, 2021.

EXPOSURES

Breast-conserving surgery with RT or mastectomy and reconstruction without RT.

MAIN OUTCOMES AND MEASURES

The primary outcome was satisfaction with breasts, measured with the BREAST-Q patient-reported outcome measure. Secondary outcomes included BREAST-Q physical well-being, psychosocial well-being, and sexual well-being; health utility, measured using the EuroQol Health-Related Quality of Life 5-Dimension, 3-Level questionnaire; and local therapy decisional regret. Multivariable linear regression models with weights for treatment, age, and race and ethnicity tested associations of the exposure with outcomes.

RESULTS

Of 647 patients who responded to the survey (40.0%; 356 had undergone breast-conserving surgery, and 291 had undergone mastectomy and reconstruction), 551 (85.2%) confirmed treatment with breast-conserving surgery with RT (n = 315) or mastectomy and reconstruction without RT (n = 236). Among the 647 respondents, the median age was 53 years (range, 23-85 years) and the median time from diagnosis to survey was 10.3 years (range, 8.4-12.5 years). Multivariable analysis showed no significant difference between breast-conserving surgery with RT (referent) and mastectomy and reconstruction without RT in satisfaction with breasts (effect size, 2.71; 95% CI, -2.45 to 7.88; P = .30) or physical well-being (effect size, -1.80; 95% CI, -5.65 to 2.05; P = .36). In contrast, psychosocial well-being (effect size, -8.61; 95% CI, -13.26 to -3.95; P < .001) and sexual well-being (effect size, -10.68; 95% CI, -16.60 to -4.76; P < .001) were significantly worse with mastectomy and reconstruction without RT. Health utility (effect size, -0.003; 95% CI, -0.03 to 0.03; P = .83) and decisional regret (effect size, 1.32; 95% CI, -3.77 to 6.40; P = .61) did not differ by treatment group.

CONCLUSIONS AND RELEVANCE

The findings support equivalence of breast-conserving surgery with RT and mastectomy and reconstruction without RT with regard to breast satisfaction and physical well-being. However, breast-conserving surgery with RT was associated with clinically meaningful improvements in psychosocial and sexual well-being. These findings may help inform preference-sensitive decision-making for women with early-stage breast cancer.

Topics: Breast Neoplasms; Female; Humans; Mammaplasty; Mastectomy; Mastectomy, Segmental; Middle Aged; Patient Satisfaction; Quality of Life

PubMed: 35416926
DOI: 10.1001/jamasurg.2022.0631

Clinical Trial Comparative Study Randomized Controlled Trial

Authors: Bernard Fisher, Jong-Hyeon Jeong, Stewart Anderson...

BACKGROUND

In women with breast cancer, the role of radical mastectomy, as compared with less extensive surgery, has been a matter of debate. We report 25-year findings of a randomized trial initiated in 1971 to determine whether less extensive surgery with or without radiation therapy was as effective as the Halsted radical mastectomy.

METHODS

A total of 1079 women with clinically negative axillary nodes underwent radical mastectomy, total mastectomy without axillary dissection but with postoperative irradiation, or total mastectomy plus axillary dissection only if their nodes became positive. A total of 586 women with clinically positive axillary nodes either underwent radical mastectomy or underwent total mastectomy without axillary dissection but with postoperative irradiation. Kaplan-Meier and cumulative-incidence estimates of outcome were obtained.

RESULTS

No significant differences were observed among the three groups of women with negative nodes or between the two groups of women with positive nodes with respect to disease-free survival, relapse-free survival, distant-disease-free survival, or overall survival. Among women with negative nodes, the hazard ratio for death among those who were treated with total mastectomy and radiation as compared with those who underwent radical mastectomy was 1.08 (95 percent confidence interval, 0.91 to 1.28; P=0.38), and the hazard ratio for death among those who had total mastectomy without radiation as compared with those who underwent radical mastectomy was 1.03 (95 percent confidence interval, 0.87 to 1.23; P=0.72). Among women with positive nodes, the hazard ratio for death among those who underwent total mastectomy and radiation as compared with those who underwent radical mastectomy was 1.06 (95 percent confidence interval, 0.89 to 1.27; P=0.49).

CONCLUSIONS

The findings validate earlier results showing no advantage from radical mastectomy. Although differences of a few percentage points cannot be excluded, the findings fail to show a significant survival advantage from removing occult positive nodes at the time of initial surgery or from radiation therapy.

Topics: Breast Neoplasms; Combined Modality Therapy; Disease-Free Survival; Female; Follow-Up Studies; Humans; Incidence; Lymphatic Metastasis; Mastectomy, Radical; Mastectomy, Simple; Neoplasm Recurrence, Local; Randomized Controlled Trials as Topic; Survival Analysis

PubMed: 12192016
DOI: 10.1056/NEJMoa020128

Authors: Deborah E Farr, Nicholas T Haddock, Juan Tellez...

IMPORTANCE

Robotic-assisted nipple-sparing mastectomies with multiport robots have been described in the US since 2015; however, significant hurdles to multiport robotic surgery exist in breast surgery.

OBJECTIVE

To demonstrate that the single-port da Vinci SP (Intuitive Surgical) robotic system is feasible in patients undergoing robotic nipple-sparing mastectomy (rNSM).

DESIGN, SETTING, AND PARTICIPANTS

An initial case series of 20 patients at a large university hospital underwent bilateral single-port robotic nipple-sparing mastectomies (SPrNSM) with tissue expander reconstruction from February 1, 2020, through January 4, 2023. Participants included women who met surgical criteria for nipple-sparing mastectomies, per standard of care.

INTERVENTION

Surgery using a single-port robot and the surgical technique of the authors.

MAIN OUTCOMES AND MEASURES

Age, indication, body mass index, breast size, operative time, conversion to open surgery, systemic complications, postoperative skin necrosis, and reported skin and nipple areolar complex (NAC) sensation.

RESULTS

Twenty women aged 29 to 63 years (median, 40 years) underwent bilateral SPrNSM. Eleven patients completed prophylactic surgery due to a high risk for breast cancer (more than 20% lifetime risk) and 9 patients had breast cancer. Breast size ranged from A through D cup with median B cup and a body mass index range of 19.7 through 27.8 (median 24.4). The total duration of the procedure from incision to skin closure for both sides ranged from 205 minutes to 351 minutes (median, 277). The median robotic time for bilateral SPrNSM was 116 minutes and varied by cup size (A cup, 95 minutes; B cup, 140 minutes; C cup, 118 minutes; D cup, 114 minutes) with no inflection point in learning curve. No cases were converted to open and no immediate complications, such as hematoma, positive margins, or recurrence, were seen. In the first 10 patients prior to routine sensation testing, 20 resected breasts had measurable NAC sensation at a range from 4 to 36 months post-index resection (65%). In the second 10 patients of the cohort, measurable NAC was preserved in 13 of 20 resected breasts 2 weeks following the index operation (65%).

CONCLUSION AND RELEVANCE

In this case series, SPrNSM with immediate reconstruction was feasible and performed safely by an experienced breast surgeon with limited previous robotic training. Further studies confirming the preliminary data demonstrating improved NAC and skin sensation following SPrNSM are warranted.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05245812.

Topics: Humans; Female; Mastectomy; Robotics; Robotic Surgical Procedures; Breast Neoplasms; Nipples; Feasibility Studies

PubMed: 38231502
DOI: 10.1001/jamasurg.2023.6999

Review

Authors: Bernadetta Izydorczyk, Anna Kwapniewska, Sebastian Lizinczyk...

European statistics confirm a rise in breast cancer among contemporary women. Those suffering from cancer and undergoing a surgery (mastectomy) are undoubtedly considered to be in difficult situations. The range of the numerous negative and/or positive emotions, thoughts, and behaviours depend on many psychological factors such as psychological resilience. The authors are currently drawing a report on their own studies where they are trying to determine factors that protect body image resilience in women suffering from breast cancer after mastectomies. The research group consisted of 120 women after a short (up to 2 years) or a long (over 2 years) duration having elapsed since their mastectomy. The results of the research groups show that psychological resilience is a significant protecting factor for the body image that prevents the excessive development of negative self-esteem in post-mastectomy women. Female patients ought to be provided aid in the short time immediately after the procedure and afterwards, when they are less capable of tolerating negative emotions. In order to significantly improve the general body image resilience to emotional and cognitive distortions in post-mastectomy women who experienced breast cancer, it is recommended that psychological interventions (from psychoeducation to psychological assistance and specialist psychotherapy) are conducted systematically throughout the course of treatment.

Topics: Adult; Body Image; Breast Neoplasms; Female; Humans; Mastectomy; Middle Aged; Protective Factors; Resilience, Psychological; Time Factors

PubMed: 29874874
DOI: 10.3390/ijerph15061181

Review

Authors: Federica Chiesa, Virgilio S Sacchini

Mastectomy rates have significantly increased over the last decades, likely due to the rising trend of risk-reducing mastectomies (RRM) in the treatment and prevention of breast cancer. Growing evidence suggests that aggressive risk-reducing surgical strategies are only justified in high-risk breast cancer situations. Notably, in this selected cohort of women, prophylactic mastectomies offer evident benefit for local and contralateral disease control, and may also provide a survival benefit. Nevertheless, the extent of the increasing frequency of this operation is not explained by the broadening of the medical indications alone. Here we analyze the current evidence regarding RRM, its clinical practice, and possible explanations for the rising phenomenon of aggressive surgical locoregional control strategies.

Topics: Breast Neoplasms; Female; Humans; Mastectomy; Risk Factors; Survival

PubMed: 26785281
DOI: No ID Found

Review

Authors: Andrea Sisti

The reconstruction of the nipple-areola complex is the last step in the breast reconstruction process. Several techniques have been described over the years. The aim of this review is to provide clarity on the currently available reconstructive options.

Topics: Adult; Breast Neoplasms; Female; Humans; Mastectomy; Middle Aged; Nipples; Plastic Surgery Procedures; Surgical Flaps

PubMed: 32560062
DOI: 10.3390/medicina56060296

Comparative Study Review

Authors: R M Simmons

Topics: Breast Neoplasms; Combined Modality Therapy; Dermatologic Surgical Procedures; Female; Humans; Lymph Node Excision; Mastectomy; Middle Aged; Neoplasm Recurrence, Local; Neoplasm Staging

PubMed: 11113438
DOI: 10.1016/s0002-9610(00)00461-x