Peter Mallon

The role of nipple-sparing mastectomy in breast cancer: a comprehensive review of the literature.

Background: The role of nipple-sparing mastectomy for breast cancer is controversial, as there is concern regarding its oncologic safety and complication rate. The authors reviewed the literature to quantify the incidence of occult nipple malignancy in breast cancer, identify the factors influencing occult nipple malignancy, quantify locoregional recurrence rates, and quantify nipple-sparing mastectomy complication rates. Methods: A search of the literature was performed using PubMed. Key words used were “mastectomy,” “nipple involvement,” “nipple-sparing mastectomy,” “skin-sparing mastectomy,” “occult nipple malignancy,” “occult nipple disease,” and “breast cancer recurrence.” Articles were analyzed regarding incidence of occult nipple malignancy, potential factors influencing the incidence of occult malignancy, and recurrence/complications following nipple-sparing mastectomy. The incidence of occult nipple disease was compared between groups using chi-square or Fisher’s exact tests for categorical variables and t tests for continuous variables. Values of p < 0.05 were considered significant. Results: The overall rate of occult nipple malignancy was 11.5 percent. Primary tumor characteristics influencing occult nipple malignancy were tumor-nipple distance less than 2 cm, grade, lymph node metastasis, lymphovascular invasion, human epidermal growth factor receptor-2–positive, estrogen receptor/progesterone receptor–negative, tumor size greater than 5 cm, retroareolar/central location, and multicentric tumors. The overall nipple recurrence rate considered significant was 0.9 percent, and the skin flap recurrence rate was 4.2 percent. Full- and partial-thickness nipple necrosis rates were 2.9 and 6.3 percent, respectively. Conclusions: Nipple-sparing mastectomy for primary breast cancer is appropriate in carefully selected patients. All patients should have retroareolar sampling. There is strong evidence to suggest that suitable cases are well circumscribed single or multifocal lesions that have a tumor-to-nipple distance greater than 2 cm. Tumors should be grade 1 to 2 and not have lymphovascular invasion, axillary node metastasis, or human epidermal growth factor receptor-2 positivity.

Prognostic Impact of Time to Ipsilateral Breast Tumor Recurrence after Breast Conserving Surgery

Background The poor prognosis of patients who experience ipsilateral breast tumor recurrence (IBTR) after breast conserving surgery (BCS) is established. A short time between primary cancer and IBTR is a prognostic factor but no clinically relevant threshold was determined. Classification of IBTR may help tailor treatment strategies. Purpose We determined a specific time frame, which differentiates IBTR into early and late recurrence, and identified prognostic factors for patients with IBTR at time of the recurrence. Methods We analyzed 2209 patients with IBTR after BCS. We applied the optimal cut-points method for survival data to determine the cut-off times to IBTR. A subgroup analysis was performed by hormone receptor (HR) status. Survival analyses were performed using a Cox proportional hazard model to determine clinical features associated with distant-disease-free survival (DDFS) after IBTR. We therefor built decision trees. Results On the 828 metastatic events observed, the majority occurred within the first 3 months after IBTR: 157 in the HR positive group, 98 in the HR negative group. We found different prognostic times to IBTR: 49 months in the HR positive group, 33 in the HR negative group. After multivariate analysis, time to IBTR was the first discriminant prognostic factor in both groups (HR 0.65 CI95% [0.54–0.79] and 0.42 [0.30–0.57] respectively). The other following variables were significantly correlated with the DDFS: the initial number of positive lymph nodes for both groups, the initial tumor size and grade for HR positive tumors. Conclusion A short interval time to IBTR is the strongest factor of poor prognosis and reflects occult distant disease. It would appear that prognosis after IBTR depends more on clinical and histological parameters than on surgical treatment. A prospective trial in a low-risk group of patients to validate the safety of salvage BCS instead of mastectomy in IBTR is needed.

Bilateral poly implant prothèse implant rupture: an uncommon presentation.

Summary: A woman in her 50s underwent delayed bilateral Poly Implant Prothèse implant reconstruction following mastectomy for breast cancer. Symptoms of implant rupture developed 43 months after surgery with an erythematous rash on her trunk. The rash then spread to her reconstructed breast mounds. Initial ultrasound scan and magnetic resonance imaging were normal; however, subsequent magnetic resonance imaging demonstrated left implant rupture only. In theater, following removal of both implants, both were found to be ruptured. The rash on her trunk resolved within 3 weeks in the postoperative period. Chemical analyses of silicone in both implants confirmed a nonauthorized silicone source; in addition, the chemical structure was significantly different between the left and right implant, perhaps explaining the variation in presentation.

The inframammary skin-sparing mastectomy technique

Skin-sparing mastectomy and immediate implant-based breast reconstruction is technically a challenging procedures for women with large, ptotic breasts. This is usually performed using the Wise pattern incision resulting in an inverted T scar, which is associated with postoperative complications. The other challenge is obtaining adequate coverage of the prosthesis. We describe a technique that avoids the inverted T scar and provides a single horizontal scar with a double dermo-muscular layer coverage of the prosthesis.

Skin Lesions after Prophylactic Mastectomy and Immediate Reconstruction

Summary: Metastatic breast carcinoma can mimic benign cutaneous lesions. Breast surgeons should be aware of skin manifestations to be able to distinguish them and set a proper therapeutic strategy. A clinical case of cutaneous lesion after breast cancer is presented. A 41-year-old woman with a history of left breast cancer underwent a prophylactic right nipple-sparing mastectomy with immediate breast implant reconstruction. After surgery, she attended our service due to a right periareolar rash resistant to medical treatment, accompanied by cutaneous induration and fixed axillary adenopathy. A differential diagnosis of skin metastases was considered. Cutaneous metastases should be the first diagnosis of skin lesions in oncological patients due to the implications in terms of treatment and prognosis. However, differential diagnoses have to be discussed.

An uncommon presentation of ductal carcinoma in situ.

A 47-year-old woman presented with 6 weeks history of non-blood-stained nipple discharge. Two separate nipple cytology assessments revealed malignant cells despite normal clinical examination and radiological investigation (mammogram, ultrasound and MRI). The patient elected for a central segmentectomy which revealed a 1.8 cm area of high-grade comedo ductal carcinoma in situ in the subareolar region. The patient made a good postoperative recovery. 6 months follow-up revealed a 5 mm area of new calcification, core biopsy revealed atypical cells. After counselling, the patient elected for bilateral mastectomy which revealed fibrocystic tissue only.