Talcott Wesley J, Marta Gustavo N, Moran Meena S
Department of Radiation Medicine, Northwell Health, New York.
Department of Radiation Oncology, Hospital Sírio-Libanês, Brazil.
Adv Radiat Oncol. 2024 Jul 14;9(9):101569. doi: 10.1016/j.adro.2024.101569. eCollection 2024 Sep.
Nipple areola complex-sparing surgeries, such as nipple-sparing mastectomy (NSM), are increasingly used for women with early-stage breast cancer. In the postoperative setting, 2 major indications for postoperative radiation (PORT) with/without regional nodal irradiation (RNI) are: positive margins (margin+) and pathologically involved lymph nodes (pN+). The frequency of these adverse pathologic features and the rate of PORT utilization following NSM for these 2 indications are unknown. We determined the frequency of margin+ and pN+ following NSM compared with nipple-sparing lumpectomy/breast-conserving surgery [BCS] and identified trends in appropriate PORT administration for these standard indications in the NSM setting.
Using the National Cancer Database (NCDB), women diagnosed with cT1 to cT3,N0M0 invasive carcinoma between 2004 and 2017 who underwent NSM were compared with those who underwent BCS (with nipple preservation). The frequencies of margin+ and pN+ by surgical subtype and use of PORT with/without RNI were assessed by cohort to determine if the type of surgery was associated with radiation delivery. Overall survival between the 2 cohorts was also compared. We performed univariable/multivariable logistic and Cox regression with ORs to control for confounders.
Of 624,075 women included, 611,907 underwent BCS, and 12,168 underwent NSM. The surgical margin+ rate was significantly higher for NSM at 4.5% (n = 544) than for BCS at 3.7% (n = 22,449) ( < .001) and remained significant on multivariable analysis (MVA; OR, 1.13; CI, 1.03-1.25; = .012). Use of PORT for margins+ was significantly lower by MVA after NSM (OR, 0.07; CI, 0.06-0.09; < .001). Similarly, pN+ rate was significantly higher for NSM at 22.5% (n = 2740) versus BCS at 13.5% (n = 82,288) ( < .001), retaining significance on MVA (OR, 1.12; CI, 1.06-1.19; < .001). For pN+ undergoing NSM, PORT with RNI was delivered significantly less often on MVA (OR, 0.73; CI, 0.67-0.81; < .001). Neither high-risk subgroup had differences in overall survival on MVA.
NSM is associated with a higher rate of margin+ and pN+ compared with BCS. Radiation is underused after NSM for these standard indications. Our results highlight the need to further refine patient selection for NSM and the importance of communicating the higher potential for adverse pathologic features (and thus, the potential need for radiation) to patients undergoing NSM.
保留乳头乳晕复合体的手术，如保留乳头的乳房切除术（NSM），越来越多地应用于早期乳腺癌女性患者。在术后情况下，术后放疗（PORT）联合或不联合区域淋巴结照射（RNI）的两个主要指征是：切缘阳性（margin+）和病理证实的淋巴结受累（pN+）。这些不良病理特征的发生率以及NSM术后这两个指征的PORT利用率尚不清楚。我们确定了NSM后切缘阳性和pN+的发生率，并与保留乳头的肿块切除术/保乳手术（BCS）进行比较，同时确定了NSM情况下这些标准指征的合适PORT应用趋势。
利用国家癌症数据库（NCDB），将2004年至2017年间诊断为cT1至cT3、N0M0浸润性癌且接受NSM的女性与接受BCS（保留乳头）的女性进行比较。通过队列评估手术亚型的切缘阳性和pN+频率以及PORT联合或不联合RNI的使用情况，以确定手术类型是否与放疗实施相关。还比较了两个队列的总生存期。我们进行了单变量/多变量逻辑回归和Cox回归，并计算比值比以控制混杂因素。
纳入的624075名女性中，611907名接受了BCS，12168名接受了NSM。NSM的手术切缘阳性率显著高于BCS，分别为4.5%（n = 544）和3.7%（n = 22449）（P <.001），多变量分析（MVA）时仍具有显著性（比值比，1.13；置信区间，1.03 - 1.25；P =.012）。NSM后MVA显示切缘阳性的PORT使用率显著较低（比值比，0.07；置信区间，0.06 - 0.09；P <.001）。同样，NSM的pN+率显著高于BCS，分别为22.5%（n = 2740）和13.5%（n = 82288）（P <.001），MVA时仍具有显著性（比值比，1.12；置信区间，1.06 - 1.19；P <.001）。对于NSM的pN+患者，MVA显示PORT联合RNI的实施频率显著较低（比值比，0.73；置信区间，0.67 - 0.81；P <.001）。两个高危亚组在MVA时的总生存期无差异。
与BCS相比，NSM与更高的切缘阳性率和pN+率相关。对于这些标准指征，NSM术后放疗使用不足。我们的结果强调需要进一步优化NSM的患者选择，并向接受NSM的患者传达不良病理特征的更高可能性（以及因此潜在的放疗需求）的重要性。
