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Nipple-sparing mastectomy complication rates decline despite expanding indications
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Complication and implant failure rates of nipple-sparing mastectomies have decreased significantly over the past several years, even as more higher-risk women undergo the procedure, according to study results presented at American Society of Breast Surgeons Annual Meeting.
“The nipple-sparing mastectomy has gained in popularity over the past decade both for risk-reduction surgery as well as for therapeutic cancer surgery,” Judy Boughey, MD, chair of the division of surgery research at Mayo Clinic, said during a webcast. “Contemporary nipple-sparing mastectomy involves preserving nipple-areolar complex and skin envelope with its blood supply while resecting all breast tissue. [This has] spurred an increased demand for this procedure over recent years. As the multidisciplinary team has gained experience with the technical complexities [of this procedure], patients [originally thought to be ineligible] for this, such as those with prior surgery, radiation and larger breasts, are now being reconsidered.”
Boughey and colleagues analyzed 1,301 breasts of 769 women (median age, 48 years; range, 21-77) undergoing cancer treatment (n = 542 breasts) or a risk reduction (n = 759 breasts) nipple-sparing mastectomy between 2009 and 2017.
Thirty-day complications that required treatment — including surgical site infections, hematoma or seroma requiring operation, necrosis requiring debridement or hyperbaric therapy, and unplanned reoperations — and 1-year reconstruction failure rates served as the study’s primary endpoints.
Researchers also examined patient, tumor and treatment variables, including obesity (> 30 BMI), smoking history, neoadjuvant chemotherapy, node-positive breast cancer/previous breast surgery and prior radiation.
Results showed a 30-day complication rate of 7.5% (n = 97 breasts) and an overall decline in complications from 14.8% in 2009 to 6.3% in 2017 (P < .001), despite a significant increase during that period in the proportion of women with obesity (17.1% to 23.3%; P < .001) or who received neoadjuvant chemotherapy (0% to 26.2%; P < .001).
Researchers observed a reconstruction success rate after 1 year of 98.5% among 1,281 evaluable breasts.
Prior radiation (OR = 2.3; P = .04) and recent or current smoking (OR = 3.3; P < .001) significantly increased the risk for 30-day complications, whereas, to researchers’ surprise, obesity no longer appeared associated with any negative outcomes after 2013.
Adjuvant radiation therapy (OR = 3.3; P = .002) and prior radiation (OR = 4.6; P < .001) were both significantly associated with an increased risk for reconstruction failure at 1 year.
“The study shows that with the broadening indications with nipple-sparing mastectomy, we also observed a lower rate of 30-day complications requiring treatment over the time period,” Boughey said. “These data reflect that the team learning curve is real and also that the nipple-sparing approach is suitable for appropriately selected higher-risk patients both for risk reduction and cancer treatment.” – by John DeRosier
Reference:
Young W, et al. Outcomes of > 1300 nipple-sparing mastectomies with immediate reconstruction: The impact of expanding indications on complications. Presented at: American Society of Breast Surgeons Annual Meeting; April 30-May 5, 2019; Dallas.
Disclosures : HemOnc Today could not confirm the authors’ relevant financial disclosures at the time of reporting.
Perspective
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Hank Schmidt, MD, PhD
There is more awareness and more interest, and we have seen more patients asking for nipple-sparing surgery. As attention to this issue and experience with nipple-sparing mastectomy has grown, there is greater understanding of the importance of patient selection. It is important to avoid scenarios where a patient with significant risk factors who is at higher risk for suboptimal outcomes is offered this procedure.
The type of reconstruction is important among patients who have nipple-sparing mastectomy. Patients may have: prosthetic reconstruction (implants) or autologous reconstruction, using the patient’s own tissue. The rates of success in those two categories can vary based on various factors, and it will be interesting to see this data, as well.
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