Accepted Manuscript Breast Cancer Recurrence after Nipple-Sparing Mastectomy: One Institution’s Experience Katherine E. Poruk, MD Jian Ying, PhD Jeremy R. Chidester, MD Joshua R. Olson, MD Cindy B. Matsen, MD Leigh Neumayer, MD Jayant Agarwal, MD PII:
S0002-9610(14)00208-6
DOI:
10.1016/j.amjsurg.2014.04.001
Reference:
AJS 11163
To appear in:
The American Journal of Surgery
Received Date: 19 October 2013 Revised Date:
19 March 2014
Accepted Date: 1 April 2014
Please cite this article as: Poruk KE, Ying J, Chidester JR, Olson JR, Matsen CB, Neumayer L, Agarwal J, Breast Cancer Recurrence after Nipple-Sparing Mastectomy: One Institution’s Experience, The American Journal of Surgery (2014), doi: 10.1016/j.amjsurg.2014.04.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Breast Cancer Recurrence after Nipple-Sparing Mastectomy: One Institution’s Experience
RI PT
Katherine E Poruk, MD, the Johns Hopkins Hospital, Department of Surgery, Baltimore MD 21287 Jian Ying, PhD, University of Utah School of Medicine, Department of Internal Medicine, Salt Lake City, UT 84132
SC
Jeremy R Chidester, MD, Loma Linda University Medical Center, Department of Plastic and Reconstructive Surgery, Loma Linda, CA 92354
M AN U
Joshua R Olson, MD, University of Utah School of Medicine, Division of Plastic and Reconstructive Surgery, Salt Lake City, UT 84132 Cindy B Matsen, MD, University of Utah School of Medicine, Department of Surgery, Salt Lake City, UT 84132 Leigh Neumayer, MD, University of Utah School of Medicine, Department of Surgery, Salt Lake City, UT 84132
TE D
Jayant Agarwal, MD, University of Utah School of Medicine, Division of Plastic and Reconstructive Surgery, Salt Lake City, UT 84132
EP
Running Title: Nipple sparing mastectomy and breast cancer recurrence
AC C
CORRESPONDING AUTHOR: Jayant Agarwal, MD 30 North 1900 East 3B 400 Salt Lake City, UT 84132 Phone: (801) 585-2318 email: [email protected]
Research reported in this publication utilized Biostatistics Shared Resource and was supported by the National Cancer Institute of the National Institutes of Health under Award Number P30CA042014. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
ACCEPTED MANUSCRIPT
TABLE OF CONTENTS SUMMARY:
We retrospectively reviewed 261 consecutive patients
undergoing therapeutic or prophylactic skin sparing or nipple sparing mastectomies. We found
RI PT
no difference in cancer recurrence or survival between the two techniques.
AC C
EP
TE D
M AN U
prophylaxis, cancer recurrence, local, distant
SC
KEYWORDS: NSM, nipple sparing mastectomy, NAC, nipple areola complex, breast cancer,
ACCEPTED MANUSCRIPT
INTRODUCTION Breast cancer is the most commonly diagnosed cancer in women in the United States
RI PT
each year [1]. Most women with breast cancer are treated by surgical resection, either with lumpectomy (breast conserving therapy) or mastectomy depending on the size and location of the tumor and preference of the patient. Women requiring a mastectomy often undergo a
SC
skin-sparing mastectomy (SSM), in which the breast tissue along with a small skin island including the nipple-areola complex (NAC) is removed but the majority of the native skin
M AN U
envelope of the breast is preserved [2]. Preserving a majority of the skin envelope in skinsparing mastectomy facilitates immediate reconstruction, but is less aesthetically pleasing to some women due to the removal of the NAC. In recent years, nipple-sparing mastectomy (NSM) has been increasingly utilized by surgeons to treat breast cancer.
Nipple-sparing
TE D
mastectomy is a modification of a SSM, which involves preservation of the nipple-areola complex skin [3]. Patients often choose this method of mastectomy due to the preservation of the NAC, which can result in improved cosmesis after reconstruction, greater satisfaction with
EP
results, and a better quality of life [4-5].
AC C
Despite an increasing number of women opting for NSM, questions regarding the oncological safety of the procedure make its use controversial. Concerns remain as to whether preservation of the NAC can leave behind unseen cancer and therefore increase the risk of local and distant tumor recurrence [6]. In this study we aim to contribute to the literature by evaluating the outcomes including recurrence and survival for patients in our institution who
ACCEPTED MANUSCRIPT
underwent NSM compared to SSM for breast cancer treatment and prophylaxis over a six-year
RI PT
period.
MATERIAL AND METHODS
SC
Study Participants: A retrospective review was performed to identify patients undergoing a nipple sparing mastectomy (NSM) or skin-sparing mastectomy (SSM) between April 2005 and
M AN U
April 2011 at the Huntsman Cancer Institute at the University of Utah. All patients underwent mastectomy for either the treatment or prophylaxis of breast cancer. NSM was defined as a mastectomy preserving the nipple-areolar skin. SSM was defined as any mastectomy with a skin island (as measured by the pathologist) of less than 10 centimeters in its largest dimension. All
TE D
specimens underwent pathologic review including tumor size, grade, nodal status, and hormone-receptor status. Demographic variables included patient age, race, body mass index (BMI), family and genetic risk, smoking status, diabetes, breast weight, tumor characteristics,
EP
hormone-receptor analysis, lymph node dissection type, chemoradiation therapy, and tumor
AC C
recurrence. This study was approved by the University of Utah Institutional Review Board. Data Analysis: Patient characteristics were compared by T-test for continuous variables and Chi-square test for categorical variables. Cox models were used to assess the association between surgery type and recurrence and overall survival. All analysis was performed using SAS 9.3.
ACCEPTED MANUSCRIPT
RESULTS Patient Characteristics
RI PT
This study included 130 consecutive female patients who underwent a nipple sparing mastectomy (NSM) and 131 consecutive patients who underwent a skin-sparing mastectomy (SSM) for either breast cancer or prophylaxis (Table 1). This involved NSM surgery on 205
SC
breasts (104 right and 101 left, 75 of which were bilateral mastectomies) and SSM surgery on 195 breasts (99 right and 96 left, 65 of which were bilateral mastectomies). The patients
M AN U
undergoing NSM were on average 10 years younger than those undergoing SSM (p
S0002-9610(14)00208-6
DOI:
10.1016/j.amjsurg.2014.04.001
Reference:
AJS 11163
To appear in:
The American Journal of Surgery
Received Date: 19 October 2013 Revised Date:
19 March 2014
Accepted Date: 1 April 2014
Please cite this article as: Poruk KE, Ying J, Chidester JR, Olson JR, Matsen CB, Neumayer L, Agarwal J, Breast Cancer Recurrence after Nipple-Sparing Mastectomy: One Institution’s Experience, The American Journal of Surgery (2014), doi: 10.1016/j.amjsurg.2014.04.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Breast Cancer Recurrence after Nipple-Sparing Mastectomy: One Institution’s Experience
RI PT
Katherine E Poruk, MD, the Johns Hopkins Hospital, Department of Surgery, Baltimore MD 21287 Jian Ying, PhD, University of Utah School of Medicine, Department of Internal Medicine, Salt Lake City, UT 84132
SC
Jeremy R Chidester, MD, Loma Linda University Medical Center, Department of Plastic and Reconstructive Surgery, Loma Linda, CA 92354
M AN U
Joshua R Olson, MD, University of Utah School of Medicine, Division of Plastic and Reconstructive Surgery, Salt Lake City, UT 84132 Cindy B Matsen, MD, University of Utah School of Medicine, Department of Surgery, Salt Lake City, UT 84132 Leigh Neumayer, MD, University of Utah School of Medicine, Department of Surgery, Salt Lake City, UT 84132
TE D
Jayant Agarwal, MD, University of Utah School of Medicine, Division of Plastic and Reconstructive Surgery, Salt Lake City, UT 84132
EP
Running Title: Nipple sparing mastectomy and breast cancer recurrence
AC C
CORRESPONDING AUTHOR: Jayant Agarwal, MD 30 North 1900 East 3B 400 Salt Lake City, UT 84132 Phone: (801) 585-2318 email: [email protected]
Research reported in this publication utilized Biostatistics Shared Resource and was supported by the National Cancer Institute of the National Institutes of Health under Award Number P30CA042014. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
ACCEPTED MANUSCRIPT
TABLE OF CONTENTS SUMMARY:
We retrospectively reviewed 261 consecutive patients
undergoing therapeutic or prophylactic skin sparing or nipple sparing mastectomies. We found
RI PT
no difference in cancer recurrence or survival between the two techniques.
AC C
EP
TE D
M AN U
prophylaxis, cancer recurrence, local, distant
SC
KEYWORDS: NSM, nipple sparing mastectomy, NAC, nipple areola complex, breast cancer,
ACCEPTED MANUSCRIPT
INTRODUCTION Breast cancer is the most commonly diagnosed cancer in women in the United States
RI PT
each year [1]. Most women with breast cancer are treated by surgical resection, either with lumpectomy (breast conserving therapy) or mastectomy depending on the size and location of the tumor and preference of the patient. Women requiring a mastectomy often undergo a
SC
skin-sparing mastectomy (SSM), in which the breast tissue along with a small skin island including the nipple-areola complex (NAC) is removed but the majority of the native skin
M AN U
envelope of the breast is preserved [2]. Preserving a majority of the skin envelope in skinsparing mastectomy facilitates immediate reconstruction, but is less aesthetically pleasing to some women due to the removal of the NAC. In recent years, nipple-sparing mastectomy (NSM) has been increasingly utilized by surgeons to treat breast cancer.
Nipple-sparing
TE D
mastectomy is a modification of a SSM, which involves preservation of the nipple-areola complex skin [3]. Patients often choose this method of mastectomy due to the preservation of the NAC, which can result in improved cosmesis after reconstruction, greater satisfaction with
EP
results, and a better quality of life [4-5].
AC C
Despite an increasing number of women opting for NSM, questions regarding the oncological safety of the procedure make its use controversial. Concerns remain as to whether preservation of the NAC can leave behind unseen cancer and therefore increase the risk of local and distant tumor recurrence [6]. In this study we aim to contribute to the literature by evaluating the outcomes including recurrence and survival for patients in our institution who
ACCEPTED MANUSCRIPT
underwent NSM compared to SSM for breast cancer treatment and prophylaxis over a six-year
RI PT
period.
MATERIAL AND METHODS
SC
Study Participants: A retrospective review was performed to identify patients undergoing a nipple sparing mastectomy (NSM) or skin-sparing mastectomy (SSM) between April 2005 and
M AN U
April 2011 at the Huntsman Cancer Institute at the University of Utah. All patients underwent mastectomy for either the treatment or prophylaxis of breast cancer. NSM was defined as a mastectomy preserving the nipple-areolar skin. SSM was defined as any mastectomy with a skin island (as measured by the pathologist) of less than 10 centimeters in its largest dimension. All
TE D
specimens underwent pathologic review including tumor size, grade, nodal status, and hormone-receptor status. Demographic variables included patient age, race, body mass index (BMI), family and genetic risk, smoking status, diabetes, breast weight, tumor characteristics,
EP
hormone-receptor analysis, lymph node dissection type, chemoradiation therapy, and tumor
AC C
recurrence. This study was approved by the University of Utah Institutional Review Board. Data Analysis: Patient characteristics were compared by T-test for continuous variables and Chi-square test for categorical variables. Cox models were used to assess the association between surgery type and recurrence and overall survival. All analysis was performed using SAS 9.3.
ACCEPTED MANUSCRIPT
RESULTS Patient Characteristics
RI PT
This study included 130 consecutive female patients who underwent a nipple sparing mastectomy (NSM) and 131 consecutive patients who underwent a skin-sparing mastectomy (SSM) for either breast cancer or prophylaxis (Table 1). This involved NSM surgery on 205
SC
breasts (104 right and 101 left, 75 of which were bilateral mastectomies) and SSM surgery on 195 breasts (99 right and 96 left, 65 of which were bilateral mastectomies). The patients
M AN U
undergoing NSM were on average 10 years younger than those undergoing SSM (p
