1. Both prophylactic and therapeutic nipple-sparing mastectomies were associated with low locoregional occurrence or recurrence.
2. Occurrence or recurrence of cancer was not found within the preserved nipple-areolar complex.
Evidence Rating Level: 2 (Good)
Study Rundown: While prevalence of nipple-sparing mastectomies (NSM) is increasing, concern exists that in high-risk cancers NSM may be less effective than the total mastectomy in which the nipple-areolar complex (NAC) is removed. Early investigations have suggested NSM results are comparable to total or skin-sparing mastectomies. However, few studies of NSM have been completed in high-risk BRCA1/2 patients where the remaining tissue may be of greater consequence. This recent retrospective study investigates the success of NSM as a preventative or therapeutic action in 201 BRCA1/2 carriers. Complications associated with the surgery included flap necrosis and NAC loss as a consequence of cancer involvement or necrosis. Incidental cancers were low (3-4%) in cases of both preventative and therapeutic NSM. At the time of surgery, three cases of cancer in the NAC were found in therapeutic NSM patients, while none were found in the prophylactic NSM recipients. No patients who received therapeutic NSM developed recurrence in the NAC. These findings must be considered in the context of the study, which had a mean follow-up time of 36 months. As follow-up time increases, the incidences of cancer in both groups will likely climb. The study authors go on to consider their findings in the context of other recent studies of NSM for BRCA1/2 patients, concluding that NSM may be a reasonable course of treatment even in the aggressive BRCA1/2 setting.
In-Depth [retrospective cohort]: This study compiled pathology findings and patient outcomes for 201 BRCA1/2 mutation carriers who underwent NSM at one of two institutions. Three-fourths of patients underwent preventative NSM to lower risk of primary cancer occurrence, while a quarter of patients underwent NSM for cancer. Patients were excluded from the study if clinical examinations revealed cancer in the NAP prior to surgery. The NSM approach involves the removal of all breast tissue while preserving the NAC and skin. Breasts were reconstructed after surgery using single stage implants, tissue expanders or autologous flap reconstructions. Patient follow up ranged from 1 to 76 months. Collected patient and surgery characteristics included age at surgery, tumor stage and location, body mass index, incision location and mastectomy weight. Events of NAC loss, NAC/flap necrosis, and incidental cancers were recorded. Therapeutic NSP patients were evaluated for local, regional and distant recurrence while preventative NSP patients were evaluated for primary breast cancer occurrence. Complication rates with the surgeries was low, with 2.5% exhibiting flap necrosis and 1.8% experience NAC loss as a result of cancer or necrosis. Incidental cancers were found in 2.7% of preventative NSP patients and in 3.9% of cancer NSP patients. No patients that underwent cancer NSP experienced cancer recurrence in the NAC.
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