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PurposeIndications for nipple-sparing mastectomy (NSM) have broadened to include the risk reducing setting and locally advanced tumors, which resulted in a dramatic increase in the use of NSM. The Oncoplastic Breast Consortium consensus conference on NSM and immediate reconstruction was held to address a variety of questions in clinical practice and research based on published evidence and expert panel opinion.MethodsThe panel consisted of 44 breast surgeons from 14 countries across four continents with a background in gynecology, general or reconstructive surgery and a practice dedicated to breast cancer, as well as a patient advocate. Panelists presented evidence summaries relating to each topic for debate during the in-person consensus conference. The iterative process in question development, voting, and wording of the recommendations followed the modified Delphi methodology.ResultsConsensus recommendations were reached in 35, majority recommendations in 24, and no recommendations in the remaining 12 questions. The panel acknowledged the need for standardization of various aspects of NSM and immediate reconstruction. It endorsed several oncological contraindications to the preservation of the skin and nipple. Furthermore, it recommended inclusion of patients in prospective registries and routine assessment of patient-reported outcomes. Considerable heterogeneity in breast reconstruction practice became obvious during the conference.ConclusionsIn case of conflicting or missing evidence to guide treatment, the consensus conference revealed substantial disagreement in expert panel opinion, which, among others, supports the need for a randomized trial to evaluate the safest and most efficacious reconstruction techniques.

Background Sentinel lymph node biopsy is the gold standard for axillary assessment of patients with clinically node negative breast cancer. The current internationally accepted methods comprise of the usage of either a radioactive tracer, vital stains or the combination of both. However, in developing countries radioactive tracer is not widely used due to its high cost and limited availability. In addition, the classic retro-areolar blue dye injection has a high failure rate. Objective Our study aimed to assess the efficacy of patent blue dye injection in the upper outer quadrant of the breast after validation by concurrent usage of radioactive nanocolloid, in comparison with the classic retro-areolar injection in identifying the sentinel node. Methods A randomized control study involving 279 patients randomly divided into two groups. In group A lateral injection of 1% patent blue dye (validated by radioactive nanocolloid) was used, while subdermal patent blue dye injection in the retro-areolar space was performed in group B. Results The new technique showed the promising results with lower failure rate (3.4%) in comparison with the classic retro-areolar patent blue injection (13.7%). Conclusions The lateral injection technique can be result in comparable results to the combination technique with the added benefit of being widely available and a cheaper option especially in developing countries.

To evaluate central quadrantectomy and nipple resection with areola preservation (CQ-NR-AP) as a new reconstructive oncoplastic technique Versus Grisotti flap mammoplasty (GFM) in central malignant tumors of the breast extending to the nipple, in terms of time procedures, breast symmetry, patient satisfaction, postoperative complications, and local recurrence. The current study is a single-blind, single-center, randomized, controlled trial that was performed between May 2018 and May 2023 in the breast surgery unit of University Hospitals. This trial involved 40 individuals who had central breast lesions that extended to the nipple and were monitored for two years following surgery. As regards the mean intra-operative time in minutes, in the group (I) was 80.1 with a standard deviation of ± 13.9, and ingroup (II) was 138.9 with a standard deviation of ± 14.02 (p = 0.001). The seroma was detected in zero cases in group (I) and 2(10%) cases in group II (p = 0.487) and those two cases were managed by aspiration only. Regarding, the wound infection was found in one case (5%) in group (I) and 3(15%) cases in group II (p = 0.605). Regarding patient satisfaction and breast, symmetry was much better in the group (I). The safety and ease of central quadrantectomy and nipple resection with areola preservation were demonstrated in a two-year follow-up, with a lower incidence of complications compared to the Grisotti flap mammoplasty technique. Furthermore, this approach was associated with higher patient satisfaction, which is a significant achievement in the management of centrally located breast tumors.

Background Nipple-sparing mastectomy (NSM) is an oncologically safe approach for breast cancer treatment and prevention; however, there are little long-term data to guide management for patients whose nipple margins contain tumor or atypia. Methods NSM patients with tumor or atypia in their nipple margin were identified from a prospectively maintained, single-institution database of consecutive NSMs. Patient and tumor characteristics, treatment, recurrence, and survival data were assessed. Results A total of 3158 NSMs were performed from June 2007 to August 2019. Nipple margins contained tumor in 117 (3.7%) NSMs and atypia only in 164 (5.2%) NSMs. Among 117 nipple margins that contained tumor, 34 (29%) margins contained invasive cancer, 80 (68%) contained ductal carcinoma in situ only, and 3 (3%) contained lymphatic vessel invasion only. Management included nipple-only excision in 67 (57%) breasts, nipple-areola complex excision in 35 (30%) breasts, and no excision in 15 (13%) breasts. Only 23 (24%) excised nipples contained residual tumor. At 67 months median follow-up, there were 2 (1.8%) recurrences in areolar or peri-areolar skin, both in patients with nipple-only excision. Among 164 nipple margins containing only atypia, 154 (94%) nipples were retained. At 60 months median follow-up, no patient with atypia alone had a nipple or areola recurrence. Conclusions Nipple excision is effective management for nipple margins containing tumor. No intervention is required for nipple margins containing only atypia. Our results support broad eligibility for NSM with careful nipple margin assessment.

Methylene blue identification of lesions during microdochectomy is often inaccurate, resulting in large dissection and tissue damage. A wire placed via ductoscopy preoperatively into the pathologic duct may aid identification and reduce the amount of dissection required. A total of 53 patients being evaluated for nipple discharge were randomized to receive ductoscopy with either methylene blue or wire marking of the lesion before microdochectomy. Patient clinical characteristics and surgical outcomes were evaluated. There were 28 patients who received methylene blue marking and 25 who received wire marking of the lesions. There were no differences between the demographic or clinical characteristics of the groups. Wire marking was associated with less surgical time, smaller incisions, and smaller surgical specimens, but the same diagnostic accuracy. Wire marking of lesions for microdochectomy is associated with less dissection and tissue damage than methylene blue, yet the same diagnostic accuracy.

Background Nipple delay (ND) is a staged procedure that improves nipple-areolar complex (NAC) viability in nipple-sparing mastectomy (NSM) patients who are high-risk for NAC or skin-flap necrosis. This study compared postoperative outcomes and risk factors between patients treated with ND-NSM and NSM alone. Methods Patient demographics, risk factors for NAC or skin-flap necrosis, tumor characteristics, and operative outcomes were compared between ND-NSM and NSM groups from 2009 to 2023. Univariate and multivariate analyses were performed to identify significant variables associated with NAC or skin-flap necrosis. Results Overall, 71 ND-NSM patients and 537 NSM patients were compared. ND-NSM patients had larger breasts ( p  < 0.01), body mass index ≥ 30 ( p  = 0.01), prior breast/chest wall radiation (XRT) [ p  < 0.01], prior breast operations ( p  < 0.01), less axillary surgery ( p  < 0.01), more autologous tissue reconstruction over implant-based reconstruction compared with NSM patients ( p  = 0.02), and more prophylaxis ( p  < 0.01). There were no statistically significant differences between groups in regard to infection, skin-flap necrosis, NAC necrosis, seromas, and hematomas. No patients in the ND-NSM group had NAC necrosis and 1 patient had skin-flap necrosis, compared with 17 and 13 patients in the NSM group, respectively ( p  = 0.24). On univariate analysis, prior XRT was associated with increased risk for skin-flap necrosis ( p  = 0.02). Multivariate analysis showed XRT was associated with skin-flap necrosis ( p  = 0.02) and any necrosis ( p  = 0.01). Breast size was associated with NAC or skin-flap necrosis ( p  = 0.04). Conclusion Larger breasts and XRT were risk factors for NAC or skin-flap necrosis; however, despite having more risk factors, ND-NSM patients had very low rates of necrosis. Notably, no nipples were lost. A shared decision should be made with patients regarding the risks and benefits of ND-NSM.

With the popularity of breast screening, more and more intraductal papillary lesions (IDPL)were detected by ultrasound or mammography, which is a spectrum of diseases ranging from benign to malignant lesions. Patients with pathological nipple discharge (PND) may indicate IDPL, but it is difficult to clarify their biological characteristics before the operation. As to patients with IDPL without PND, it is even an enormous challenge to differentiate their benign or malignant characteristics. Therefore, to avoid inadequate treatment, it is necessary to analyze the clinicopathological and imaging characteristics of patients with papillary lesions before surgery for the preliminary diagnosis of benign or malignant papillary lesions. 267 cases of IDPL with or without PND, namely PND group and non-PND group, were studied using continuous clinical data from October 2020 to September 2023. We analyzed the clinicopathological and imaging characteristics in the two groups of patients with malignancy compared with benign patients. Meanwhile, these characteristics were analyzed in malignant papillary patients with PND or not. 267 patients were pathologically diagnosed with IDPL during three years, accounting for 15.4% of surgical cases of the same period. There were 55 patients with malignant lesions (20.6%), including 28 cases in the PND group (16.5%) and 27 cases in the non-PND group (27.8%), and the incidence of malignant lesions was higher in the non-PND group than that of the PND group. There was a close correlation between age and malignant lesions in the two groups; the number of patients older than 50 years in malignant patients (74.5%) exceeded that of benign patients (42.5%). There were nearly one-third of malignancies in patients with nipple bloody discharge, and the rate increased to 50% when the patient was older than 50 years, but the malignant rate was meager in patients without bloody discharge. There were some factors relating to malignancy in non-PND patients, including age, lesion size, the distance from the nipple to the lesson (DFNL), and abnormal mammogram; there was a significant difference in this positive manifestation between benign and malignant patients. In malignant intraductal papillary lesions, 40.8% of the cases were invasive carcinoma in the non-PND group, higher than in the PND group (10.7%). Meanwhile, immunohistochemistry was more likely to be hormone receptor-positive (92.6%) and Her-2 negative in the non-PND group, compared with the PND group. Breast IDPL is a common disease, among which malignant lesions are higher than reports in previous literature. There are some clinical and imaging manifestations indicating malignancy; patients more than 50 years old with bloody nipple discharge are at high risk of malignancy. When old non-PND patients have more significant lesions, remote DFNL, and abnormal mammograms, there is a high probability of malignancy in them. Although there are different biological characteristics in malignant IDPL with or without PND, they are all low-grade malignancies compared with traditional breast cancer.

Background Robotic nipple-sparing mastectomy (RNSM) has emerged as a new treatment option for breast cancer and risk-reducing mastectomy (RRM) for women who have a high risk of pathogenic variants. Even though several studies have reported that RNSM is a feasible procedure, some argue that it should only be performed by specialized surgeons, and data on oncologic outcomes and patient-reported outcomes (PROs) are limited. Recently, the United States Food and Drug Administration and several surgeons warned that robotic breast surgery should be performed only by specialized surgeons and recommended that the benefits, risks, and alternatives of all available treatment options be discussed with patients so they can make informed treatment decisions. The Korea Robot-Endoscopy Minimal Access Breast Surgery Study Group (KoREa-BSG) has been established to evaluate, standardize, and teach this state-of-the-art procedure. We have designed a multicenter prospective cohort study entitled Mastectomy with Reconstruction Including Robot Endoscopic Surgery (MARRES) to report surgical, PRO, and oncologic outcomes. Methods MARRES is a multi-institution cohort study prospectively collecting data from patients undergoing mastectomy and reconstruction. The patient inclusion criteria are adult women older than 19 with breast cancer or a high risk of breast cancer (patients with BRCA1/2 , TP53 , PALB2 mutations, etc.), who have scheduled therapeutic or RRM and want immediate reconstruction. Surgical outcomes, including pre- and postoperative photos, oncologic outcomes, cost-effectiveness, and PRO, are collected. The primary endpoints are postoperative complication rates within 30 postoperative days and the Clavien-Dindo grade of postoperative complications within 180 postoperative days. The secondary endpoints are 5-year postoperative recurrence-free survival and cancer incidence rate (for those who underwent RRM), patient satisfaction with reconstruction expectations preoperative (baseline) and results within 6 to 12 postoperative months, surgeon satisfaction with postoperative results in 6 postoperative months, and cost-effectiveness of the definitive surgery. Patient recruitment will be completed in April 2025, and the target number of enrolled patients is 2000. Discussion This study will provide evidence about the surgical outcomes, oncologic outcomes, and patient satisfaction with RNSM and endoscopic nipple-sparing mastectomy (NSM), compared with conventional NSM. Trial registration ClinicalTrials.gov Identifier NCT04585074. Registered April 8, 2020.

Background We investigated the perioperative outcome and oncologic safety of performing nipple-sparing mastectomy (NSM) through a single axillary incision (NSM-SAI) compared with performing NSM through a conventional incision (NSM-C). Methods We retrospectively reviewed 725 patients who underwent NSM for breast cancer between January 2010 and December 2023; 333 patients who underwent NSM with immediate reconstruction (IR) were enrolled. Surgical outcomes and oncologic outcomes of NSM-C ( n = 184), NSM performed through SAI with a freehand approach (NSM-SAI-F; n = 92), and with an endoscopic approach (NSM-SAI-E; n = 57) were demonstrated. The risk factors for resection margins, nipple-areolar complex (NAC), and skin flap necrosis were evaluated separately for NSM-C and NSM-SAI. Results NAC and skin flap necrosis occurrence rates among the NSM-C, NSM-SAI-F, and NSM-SAI-E groups were similar (insignificant), regardless of autologous or prosthesis reconstruction. The tumor-to-nipple distance among patients who underwent NSM-C was an independent risk factor for NAC necrosis in the NSM-C group (odds ratio [OR] 6.02, p = 0.007); being overweight and tumor location in the lower breast were risk factors for skin necrosis in the NSM-C group (OR 3.36, p = 0.041; and OR 4.32, p = 0.011, respectively). These risk factors were not associated with the NSM-SAI group. The three groups had comparable positive resection margins, local recurrence-free survival, and distant metastasis-free survival rates ( p = 0.857, 0.543, and 0.975, respectively). Conclusions NSM-SAI combined with IR by the freehand or endoscopic approaches can provide good aesthetic outcomes and oncologic safety for well-selected patients with breast cancer. The risk factors for NAC and skin flap necrosis differ between the NSM-SAI and NSM-C groups.