King Caroline A, Bartholomew Alex J, Dabic Stefan, Sogunro Olutayo, Perez-Alvarez Idanis M, Welschmeyer Alexandra F, Sosin Michael, Thibodeau Renee M, Fan Kenneth L, Song David H, Greenwalt Ian T, Tousimis Eleni A
From the Division of Breast Surgery, Department of Surgery, MedStar Georgetown University Hospital, Washington, DC.
Department of Surgery, Duke University Medical Center, Durham, NC.
Ann Plast Surg. 2023 Dec 1;91(6):709-714. doi: 10.1097/SAP.0000000000003692. Epub 2023 Sep 4.
Nipple-sparing mastectomy (NSM) offers improved, patient-centered outcomes with demonstrated oncologic safety ( Ann Surg Oncol 2020;27:344-351). Indications for NSM continue to expand to patients outside of the traditional eligibility criteria, including those with prior breast-conserving therapy (BCT) with radiotherapy. Currently, limited data exist evaluating both short- and long-term outcomes in patients proceeding to NSM after prior BCT.
All patients undergoing bilateral NSM in a single institution from 2002 through 2017 with history of prior BCT were included in the final cohort, without exclusions. A retrospective chart review was performed to identify patient demographics, operative details, and complications. Outcomes assessed included early complications (<30 days from NSM), late complications (>30 days), rates of prosthetic failure, unplanned reoperations, and reconstructive failures, as well as oncologic safety. Student t , χ 2 , and Fisher exact tests were used to analyze outcomes of paired (BCT vs non-BCT) breasts within each patient.
A total of 17 patients undergoing 34 NSMs were included. Each had a history of BCT and either ipsilateral breast recurrence (64.7%), risk-reducing NSM (23.5%), or a new contralateral primary cancer (11.8%). The cohort had a mean age of 51.1 years. With regard to acute complications (ischemia, infection, nipple-areolar complex or flap ischemia or necrosis, and wound dehiscence), there was no significant difference noted between breasts with prior BCT versus no prior BCT overall (41.2% vs 35.3%, respectively; P = 0.724). Complications occurring after 30 days postoperatively (capsular contracture, contour abnormality, animation deformity, bottoming out, rotation, and rippling) in prior BCT breasts versus no prior BCT had no significant differences overall (58.8% vs 41.2% respectively; P = 0.303). The mean follow-up was 5.5 years, during which no patients had a reported locoregional or distant recurrence in either breast.
No significant differences in early or late complications were identified between breasts in patients undergoing bilateral NSM with a history of unilateral BCT and XRT. In the 5.5 years of follow-up, there were no recurrences, lending support to NSM for management of recurrent disease in addition to National Comprehensive Cancer Network-recommended total mastectomy. We propose that NSM should not be contraindicated in patients exposed to radiation with BCT.
保留乳头的乳房切除术（NSM）能带来改善的、以患者为中心的结果，且已证明其肿瘤学安全性（《外科肿瘤学杂志》2020年；27:344 - 351）。NSM的适应证持续扩大到传统适应证标准以外的患者，包括那些接受过保乳治疗（BCT）并接受放疗的患者。目前，评估既往接受BCT后行NSM患者短期和长期结果的数据有限。
2002年至2017年在单一机构接受双侧NSM且有既往BCT史的所有患者均纳入最终队列，无排除标准。进行回顾性病历审查以确定患者人口统计学、手术细节和并发症。评估的结果包括早期并发症（NSM后<30天）、晚期并发症（>30天）、假体失败率、计划外再次手术率、重建失败率以及肿瘤学安全性。采用学生t检验、χ²检验和Fisher精确检验分析每位患者配对（BCT与非BCT）乳房的结果。
共纳入17例接受34次NSM的患者。每位患者均有BCT史，且有同侧乳房复发（64.7%）、降低风险的NSM（23.5%）或对侧新发原发性癌症（11.8%）。该队列的平均年龄为51.1岁。关于急性并发症（缺血、感染、乳头乳晕复合体或皮瓣缺血或坏死以及伤口裂开），既往接受BCT的乳房与未接受BCT的乳房总体上无显著差异（分别为41.2%和35.3%；P = 0.724）。既往接受BCT的乳房与未接受BCT的乳房术后30天之后发生的并发症（包膜挛缩、外形异常、动态畸形、底部凹陷、旋转和波纹）总体上无显著差异（分别为58.8%和41.2%；P = 0.303）。平均随访时间为5.5年，在此期间，没有患者报告任何一侧乳房有局部或远处复发。
有单侧BCT和放疗史且接受双侧NSM的患者，其两侧乳房在早期或晚期并发症方面未发现显著差异。在5.5年的随访中，无复发情况，这支持了NSM除用于国家综合癌症网络推荐的全乳切除术外，还可用于复发性疾病的治疗。我们建议，对于接受过BCT放疗的患者，NSM不应被视为禁忌。
