Nipple-sparing mastectomy feasible in Node + early breast cancer
By: NEIL OSTERWEIL, Oncology Practice Digital Network
October 1, 2015
AT THE 2015 ASCO BREAST CANCER SYMPOSIUM
It was long taught that you did not spare the nipple in women with breast cancer and lymph node positive breast cancer. I t has long been desired by patients that the nipple be spared in breast conserving surgery if possible, including when there were positive lymph nodes. This three year follow-up study suggest that indeed nipple sparing is possible if you carefully select your patients, Again one must always look long term with breast cancer- at least ten years of follow up with multi institutional involvement and careful classification, as these authors do, of their patients. Dr Ryan
Key clinical point: Some women with lymph-node positive early breast cancer may safely undergo nipple-sparing mastectomy.
Major finding: Three-year breast cancer-specific survival estimates were 97% for node positive patients and 99% for node-negative patients.
Data source: Retrospective review of data on 226 women with 240 early breast cancers.
SAN FRANCISCO – Nipple-sparing mastectomy can be a safe surgical option for carefully selected patients with node-positive breast cancers, investigators reported at the 2015 ASCO Breast Cancer Symposium.
In a series of 226 patients with a total of 240 breast tumors, there was no significant difference between patients with node-positive or node-negative disease in the rate of conversion from a planned nipple-sparing procedure to a skin-sparing procedure, reported Dr. Brittany L. Murphy, a general surgery resident, and her colleagues at the Mayo Clinic in Rochester, Minn.
|Dr. Brittany L. Murphy|
“Among women with node-positive breast cancer, nipple-sparing surgery may be appropriate for patients who do not have T4 or inflammatory carcinoma, patients that do not have multifocal disease, and who clinically and on imaging modalities do not appear to have nipple involvement,” Dr. Murphy said in an interview at the symposium.
In general, surgeons consider nipple-sparing mastectomies to be most appropriate for patients with early-stage disease; nodal involvement is often considered a contraindication, she said.
To see whether nipple-sparing surgery could be safely performed in patients with node-positive disease, the researchers took a retrospective look at data on 226 patients (14 with bilateral cancers) scheduled for nipple-sparing mastectomy at their center from 2009 through 2014.
In all, 182 of the cancers were lymph-node negative, and 58 were positive. Of the 58 node-positive cases, 27 (47%) were T2/T3 tumors, compared with 31 of 182 (17%) node-negative cases (P less than .0001). There were no significant differences between the groups in either estrogen receptor or HER2 receptor positivity, however.
Of the node-positive cases, 19 (33%) had cN1 (clinical) nodal involvement with pathology confirmed by fine-needle aspiration at the time of diagnosis, and 10 of these patients underwent neoadjuvant therapy followed by surgery. At the time of surgery, 6 of the 10 had pathologically confirmed positivity, and 4 were found to have ypN0 status. The remaining 9 patients in this group went on to primary surgery without neoadjuvant therapy.
Of the 39 patients who were clinically node negative, 4 had neoadjuvant therapy followed by surgery, and 35 went on to primary surgery.
The nipple-sparing procedure was successfully performed in 13 of the 14 node-positive patients who received neoadjuvant therapy and in 39 of 44 node-positive patients who went on to primary surgery. Six of the node-positive patients required conversion to a skin-sparing technique, either at the time of initial surgery based on frozen section pathology (five patients) or at a second procedure (one patient).
There were a total of seven locoregional recurrences among all patients treated with nipple-sparing mastectomy, including five in node-positive patients and two in node-negative patients. This difference was not significant.
Among the node-positive patients, three of the recurrences were in subcutaneous flaps away from the nipple at 13, 30, and 46 months of follow-up. In two cases, involved ipsilateral supraclavicular and mediastinal lymph nodes were detected at 24 and 32 months.
In the node-negative patients, one recurrence was in the nipple-areolar complex at 82 months, and one was in axillary nodes after negative sentinel lymph node biopsy at 20 months.
The 3-year locoregional disease-free estimates were 87% for lymph node positive patients compared with 99% for node negative patients (P = .007).
There were no differences between the groups regarding 3-year breast cancer–specific survival estimates, at 97% for lymph-node positive patients, and 99% for node-negative patients.
“Short-term oncologic outcomes were satisfactory. These data suggest that nipple-sparing mastectomy may be appropriate for carefully selected lymph node-positive breast cancer patients,” Dr, Murphy and colleagues wrote in a poster presented at the symposium.