ASBrS 2019: Retrospective Study of Nipple-Sparing Mastectomy Outcomes Over Time
Nipple-sparing mastectomy complication and implant failure rates have decreased significantly since introduction of the procedure, while the patient population undergoing nipple-sparing mastectomy increasingly includes more advanced cancers and women traditionally considered at risk for postsurgical difficulties, according to a new study presented by Young et al at the Annual Meeting of the American Society of Breast Surgeons (ASBrS). Researchers examined surgeries performed on 1,301 breasts in 769 women who retained their own nipples and skin for breast reconstruction following mastectomy from 2009 to 2017 at a major institution.
“Research continues to validate the oncologic safety and enhanced cosmesis of nipple-sparing mastectomies,” commented lead researcher Tina Hieken, MD, of the Mayo Clinic. “Our perception has been that these procedures are increasingly performed on far more complex cases from an oncologic and technical standpoint. However, the results of this study were striking. It not only confirmed this, but showed that these surgeries can safely be offered to a far more diverse and challenging group of well-selected patients.”
Study Methods
The study retrospectively examined the 30-day rate of complications that required treatment and 1-year reconstruction failures from a prospective Mayo Clinic surgery database. Complications ranged from surgical site infections, hematomas, and seromas requiring surgery, to necrosis requiring tissue removal as well as unplanned additional surgeries. Among the patient and tumor variables examined were obesity (> 30 body mass index), recent or current smoking, neoadjuvant chemotherapy, node-positive breast cancer/prior breast surgery, and prior radiation.
Findings
The overall nipple-sparing surgery complication rate declined from 14.8% in 2009 to 6.3% in 2017, with an average rate of 7.5% for this 8-year period. One-year reconstruction success rose from 87% in 2009 to 100% in 2017. During this time, the number of patients classified as obese—an acknowledged risk factor for complications from these surgeries—rose from 17.1% in 2009 to 23.3% in 2017. No patients receiving neoadjuvant chemotherapy were treated using the procedure in 2009, while they made up 26.2% of the population in 2017, suggesting inclusion of patients with higher-risk cancer in the current surgical pool.
However, after 2013, obesity was no longer associated with any negative outcomes, while risk factors of prior radiation and smoking significantly increased complications. Prior radiation also was heavily associated with 1-year reconstruction failure.
“Nipple-sparing mastectomies are difficult procedures, requiring highly perfected skillsets and engagement from the entire surgical team,” commented Dr. Hieken. “Breast surgeons, reconstructive plastic surgeons, oncologists, and skilled nurses must be committed and practiced at working seamlessly as a group to make these surgeries a success. Over the years, techniques, teamwork, and patient selection at Mayo Clinic, and likely at other hospitals, have been optimized to enhance results.”
For example, Dr. Hieken noted that surgeons have learned that incision placement, such as avoiding the areola, can be optimized for better cosmesis and fewer complications. Technology such as SPY angiography, a specialized intraoperative procedure, helps to assess the perfusion and viability of flap tissue. Bundled interventions specifically focused on minimizing infections have also made a difference.
“Offering enhanced aesthetics as a result of surgeries like this to women who have had a devastating diagnosis is extremely rewarding,” she said. “Today, [patients with] breast cancer who are not offered nipple-sparing procedures should ask their surgeons why. As this study demonstrates, these surgeries are proving safer for a far broader patient base.”
Disclosure: For full disclosures of the study authors, visit breastsurgeons.org.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
