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Nipple-Sparing Mastectomy May Be Suitable for Growing Number of Well-Selected Patients


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As nipple-sparing mastectomy gains favor, it is being performed on a broader spectrum of patients once considered off limits by surgeons. A Mayo Clinic study in a contemporary cohort found no increase in complication rates or decrease in reconstruction success with this surgical approach.1

Judy Boughey, MD

Judy Boughey, MD

Whitney Young, MD

Whitney Young, MD

Tina Hieken, MD

Tina Hieken, MD

“We actually showed that with broadened indications for nipple-sparing mastectomy, we observed lower rates of 30-day complications requiring treatment over time,” said Judy Boughey, MD, of the Mayo Clinic, Rochester, Minnesota, at a press briefing at the 2019 American Society of Breast Surgeons Annual Meeting in Dallas. The study’s first author was Whitney Young, MD, and the senior author was Tina Hieken, MD, both also with the Mayo Clinic.

The goal of nipple-sparing mastectomy is to provide the best possible cosmetic outcome without sacrificing oncologic outcomes or increasing complications. The initial criteria for the procedure were stringent: patients with small breast size; no prior operations; and cancers that were small, peripheral, and node-negative.

The data demonstrate a learning curve with nipple-sparing mastectomy and show that it is suitable for appropriately selected higher-risk patients for both risk reduction and cancer treatment.
— Judy Boughey, MD

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More recently, the procedure has been performed on patients with more advanced disease and more risk factors, said Dr. Boughey. “Patient factors initially thought to be contraindications to nipple-sparing surgery—such as prior surgery, prior radiation, larger breast size, and ptosis—have been reconsidered,” she added. “We’ve seen an increase in indications among our population.”

“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,” added Dr. Hieken. “They 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 Details

Nipple-sparing mastectomy was performed occasionally starting in about 2001, and its use has steadily grown. Mayo Clinic researchers conducted a study to evaluate the complication rates and reconstruction success in a contemporary patient cohort with expanded indications, treated from 2009 to 2017. They looked at 30-day complications requiring treatment, including infection, hematoma/seroma, flap necrosis, and unplanned reoperation, for patients at their institution, along with 1-year reconstruction success.

Nipple-Sparing Mastectomy

  • The Mayo Clinic experience shows the use of nipple-sparing mastectomy has broadened to patients once considered off limits.
  • Between 2009 and 2017, complication rates actually diminished from 16% to 6%, and 1-year reconstruction success rates rose from 88%
    to 100%.
  • Risk factors for poor outcomes include prior radiation and adjuvant radiation, as well as current or recent smoking.

The study evaluated 769 patients (median age of 42) who underwent 1,301 preventive or therapeutic mastectomy. Researchers found that over time, the average body mass index increased, and the use of neoadjuvant chemotherapy increased, suggesting the procedure is being performed on more patients with obesity and more with advanced disease.

“With broadening indications, we observed a dramatic decrease in 30-day complications rates, from nearly 16% in 2009 to just over 6% in recent years,” Dr. Boughey reported. Factors associated with higher complication rates included prior radiation (odds ratio = 2.3; P = .04) and recent or current smoking status (odds ratio = 3.3; P < .001).

The rates of successful reconstruction increased over time, from 88% to 100%. Reconstruction failure was associated with prior radiation (odds ratio = 4.6; P < .001) and adjuvant radiation therapy (odds ratio = 3.3; P = .002).

“The data demonstrate a learning curve with nipple-sparing mastectomy and show that it is suitable for appropriately selected higher-risk patients for both risk reduction and cancer treatment,” Dr. Boughey said. She added that patient selection and treatment by a multidisciplinary team, along with appropriate counseling, are important. 

DISCLOSURE: Drs. Boughey and Hieken reported no conflicts of interest.

REFERENCE

1. Young W, Degnim A, Hoskin T, et al: Outcomes of > 1,300 nipple-sparing mastectomies with immediate reconstruction: The impact of expanding indications on complications. 2019 American Society of Breast Surgeons Annual Meeting. Presented May 2, 2019.


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“The investigators at Mayo Clinic achieved excellent results in improving 30-day and 1-year reconstruction rates in patients undergoing nipple-sparing mastectomy,” commented Sarah Blair, MD, a surgical oncologist at the University of California San Diego. “They clearly...

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