BACKGROUND: Different types of mastectomies leave different amounts of residual breast tissue. The significance of the residual breast volume (RBV) is not clear. Therefore, we developed an MRI tool that allows to easily assess the RBV. In this study we evaluated factors associated with RBV after skin or nipple sparing mastectomy (SSM/NSM) in breast cancer BRCA pathogenic variant (PV) carriers who underwent both therapeutic and risk reducing SSM/NSM and its relation to breast cancer outcomes using an innovative MRI-based tool.
METHODS: Data of breast cancer BRCA PV who were treated between 2006 and 2020 were retrieved from of the oncogenetics unit databases. Only patients who underwent SSM/NSM and had a postoperative breast MRI available for analysis were included. Data collected included demographics, clinicopathological features, and outcomes. The MRI tool was developed by a breast cancer imaging laboratory. A logistic regression test and 95% confidence interval (CI) were used to assess the associated risk of increased RBV. A forward stepwise linear regression was used to correlate tumour-patient specific factors and RBV, and a Kaplan-Meier curve to show the probability of locoregional relapse.
RESULTS: A total of 84 patients undergoing 89 mastectomies were included. At a median follow-up of 98 months, 5 local, 2 regional, and 4 distant recurrences were observed. RBV was not significantly related with breast cancer outcomes (p value = NS). A higher body mass index (BMI) was associated with a higher RBV (p < 0.0001). A larger number of involved axillary nodes was associated with a smaller RBV (p = 0.025). The RBV on the risk-reducing mastectomy side was significantly higher compared to the breast cancer side (p value = 0.007). Local recurrences occurred in the vicinity of the primary tumour.

The present study aimed to investigate whether local recurrence (LR) after nipple-sparing mastectomy (NSM) and reconstruction was associated with i) Ki67 values and molecular subtypes of the initial lesions, and ii) the size of the initial tumor and the size of the implant. A total of 156 patients with breast cancer with a mean age of 51.58 years (age range, 26-75 years) who underwent NSM with primary implant breast reconstruction were analyzed. After surgery, the mean follow-up time was 59.26 months (range, 17-85 months). Molecular subtypes, Ki67 values, estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status were recorded for each patient. Additionally, information regarding the size of the implant and the initial tumor size were collected. The information was used to assess LR. For univariate analyses of risk factors, χ2 test, Fisher\'s exact test, Mann-Whitney U test and Student\'s t-test for independent samples were used. For multivariate analyses, a Cox proportional-hazards model was used. NSM was the primary treatment for breast cancer in 34/156 patients (21.8%), while 122/156 (78.2%) of patients received neoadjuvant chemotherapy followed by surgery. Luminal B was the most frequent molecular subtype, detected in 82/156 patients (52.6%), whereas the luminal A subtype was detected in 37 patients (23.7%) and the HER2-enriched subtype was detected in 17/156 patients (10.9%). Ki67 expression was low in 13/156 patients (8.3%), while medium expression was detected in 78/156 patients (50.0%) and high expression was present in 58/156 patients (37.2%). LR was noted in 17/156 patients (10.9%). As determined by univariate analysis, lower ER (P=0.010) and PR (P=0.008) expression were indicated to be significant risk factors for LR. In conclusion, in the present patient cohort, low ER and PR expression were risk factors for LR of breast cancer, whereas Ki67 status and molecular subtype were not statistically significant risk factors for LR. Additionally, the size of the initial tumor and the size of the implant were not risk factors for LR. These findings are consistent with the current literature, and should be utilized when discussing treatment options and potential clinical outcomes with patients prior to surgical management.

BACKGROUND: Intraoperative examination of retro-areolar margin (IERM) often is used during nipple-sparing mastectomy (NSM) for cancer, but there is no robust data regarding its real advantage.
METHODS: Consecutive patients undergoing NSM for cancer with omission of IERM according to institutional protocols from 2016 to 2021 were retrospectively analyzed. The decision to maintain or remove the Nipple-Areola Complex (NAC) after definitive pathology was taken at the multidisciplinary meeting.
RESULTS: Among 162 women operated in the study period, the presence of neoplastic cells within 2 mm from the inked retroareolar margin (RAM) was detected at permanent pathology in 17 cases (10.5%). Nipple-Areola-Complex (NAC) was removed postoperatively in five patients (3%) for margins <1 mm, the other 12 were observed, whereas postoperative NAC necrosis required surgical removal in additional five cases (3%). The NAC was thus preserved in 152 of 162 patients (94%). At multivariate analysis, RAM ≤2 mm was associated with radiological tumor-to-nipple distance less than or equal to 1 cm (p = 0.04) and Ki67 label index ≥ 20 (p = 0.04), whereas multifocality/multicentricity showed a trend towards significance (p = 0.07). At a median follow-up of 46 months, five locoregional relapses occurred (3%), only one of them involving the NAC (0, 6%). Locoregional relapse and overall survival for patients with RAM > or < 2 mm were not different.
CONCLUSIONS: IERM is not routinely necessary during NSM for cancer, because its omission is associated with a very low return to the operating room, it is oncologically safe, and associated pitfalls are avoided. Further studies are necessary to confirm these findings.

The current review paper was written in collaboration with breast cancer surgeons from the European Breast Cancer Research Association of Surgical Trialists (EUBREAST), a breast pathologist from the Danish Breast Cancer Group (DBCG), and representatives from the European SocieTy for Radiotherapy & Oncology (ESTRO) breast cancer course. Herein we summarize the different mastectomies and reconstruction procedures and define high-risk anatomical areas for breast cancer recurrences, to further specify the challenges in the surgical procedure, histopathological evaluation, and target volumes in case of postmastectomy irradiation, as recommended by the ESTRO guidelines according to the surgical procedure. The paper has original figures and illustrations for all disciplines for in-depth understanding of the differences between the procedures.

OBJECTIVE: We performed a systematic review to document the spatial location of local recurrences (LR) after mastectomy.
METHODS: A PubMed search was conducted in August 2019 for the following terms: breast [Title/Abstract] AND cancer [Title/Abstract] AND recurrence [Title/Abstract] AND mastectomy [Title/Abstract]. The search was filtered for English language. Exclusion criteria included studies that did not specify the LR location or studies reporting LR associated with inflammatory breast cancer, or other breast cancers such as phyllodes tumours, lymphoma or associated with sarcoma/angiosarcoma.
RESULTS: A total of 3922 titles were identified, of which 21 publications were eligible for inclusion in the final analysis. A total of 6901 mastectomy patients were included (range 25-1694). The mean LR proportion was 3.5%. Among the total of 351 LR lesions, 81.8% were in the subcutaneous tissue and the skin, while 16% were pectoral muscle recurrences.
CONCLUSIONS: Local recurrences are mostly located within the subcutaneous tissue and the skin, assumed to result from unrecognized/subclinical tumour foci left behind after mastectomy, surgical implantation of tumour cells in the wound/scar and/or tumour emboli within the subcutaneous lymphatics. Pectoral muscle recurrences are less frequent and may be attributed to residual disease along the posterior surgical margin and/or lymphatic involvement.

BACKGROUND: Breast reconstruction is routinely used to alleviate the psychological adverse effects of mastectomy. Nipple preservation further improves the cosmetic result, and causes less trauma on the body surface. Nipple-sparing mastectomy, however, comes with challenges, especially in the case of large, ptotic breasts to the degree that large-sized breasts have conventionally been a contraindication for nipple preservation. In this report, we describe a novel technique for nipple preservation in immediate reconstruction of large, ptotic breasts.
METHODS: From 2013 to 2018, 24 patients (30 breasts) with large, ptotic breasts were treated with mastectomy and immediate reconstruction with nipple preservation. Median BMI was 28 and 8 patients were smokers. The technique involves the de-epithelialisation of a large area of the breast skin, the mastectomy through a lateral full-thickness incision within the de-epithelialised area, imbrication of the de-epithelialised skin, lifting of the nipple to a higher position and finally closure of wound.
RESULTS: There were no full, 4 partial nipple necroses and 3 re-operations were done under local anaesthetic to correct partial peripheral necrosis of the areola. Six patients needed seroma aspiration and 4 presented with cellulitis. No implants were lost and there were no delays to adjuvant treatment.
CONCLUSIONS: The proposed technique has significant advantages and may be ideal when large skin reductions are necessary in immediate breast reconstruction with nipple preservation. The low complication rate makes the method ideal when adjuvant treatment is to follow and/or patients are of high risk for surgical complications.

Nipple-sparing mastectomies (NSMs) are accepted as safe oncologic procedures for select patient populations, but objective evaluation of aesthetic outcomes has not been clearly established. The purpose of this study was to utilize BCCT.core computer software to objectively evaluate NAC malposition following bilateral NSM with implant reconstruction and compare the analysis to an expert panel. Postoperative photographs of 43 patients who underwent bilateral NSM were analyzed with the BCCT.core and by an expert panel of plastic surgery residents and attendings. The panel was asked to only evaluate nipple asymmetry and position. The intraclass correlation coefficient (ICC) was used to determine interrater reliability (n = 12) and between expert panel ratings and BCCT.core ratings. Statistics were performed using SPSS statistical package version 24.0. The ICC for the expert panel interrater reliability was excellent (ICC = 0.941, 95% CI: 0.912-0.964). The analysis between BCCT.core individual parameters, specifically the breast retraction assessment (ie, BRA score = the difference in nipple position between the two breasts assessing breast symmetry) and expert panel, showed statistically significant positive correlation. The parameters provided by the BCCT.core software were correlated with both the mean expert panel rating and BCCT.core ratings. Therefore, it is plausible that BCCT.core parameters could be used to objectively quantify NAC malposition/asymmetry and guide treatment in patients undergoing bilateral NSM with implant reconstruction.

We sought to explore the correlation between BMI and postoperative sexual function, body image, and breast-specific sensuality before and after breast cancer surgery.
A cross-sectional survey of patients at least 1 year from surgery employed the Female Sexual Function Index (FSFI) and investigator-generated questions. Patients who underwent lumpectomy (L), mastectomy (M), and mastectomy with reconstruction (MR) were compared across three BMI groups: normal weight, overweight, and obese.
Two hundred fifty-five patients underwent lumpectomy (L, n = 174), mastectomy (M, n = 22), or mastectomy with reconstruction (MR, n = 59). Median age was 57 (range 30-93) and median BMI was 28 (range 19-45). Obese and overweight women reported more appearance dissatisfaction (18.1 and 13.0%) than normal weight women (4.1%) (p = 0.01). Lower satisfaction was associated with increasing BMI within the MR group (p = 0.05). The obese group\'s median FSFI score met criteria for sexual dysfunction (25.90, range 11.30-33.10). More overweight women reported their chest played an important role in intimacy before and after surgery, but a postoperative decline in the importance of this role was observed in all groups.
Greater post-treatment BMI is inversely related to postoperative appearance satisfaction, particularly in those undergoing mastectomy with reconstruction. The role of the breast in intimacy is greatest in overweight women, but decreases postoperatively in all BMI groups.
Postoperative appearance satisfaction and sexual function seems to be correlated to post-treatment BMI, which highlights the need to encourage perioperative weight management for improved survivorship outcomes.

BACKGROUND: As mastectomy rates increase and overall survival for early breast cancer improves, a better understanding of the long-term consequences of mastectomy is needed. We sought to explore the correlation of specific mastectomy type with the Female Sexual Function Index (FSFI), body image satisfaction, and the reconstructed breast\'s role in intimacy.
METHODS: This study is a secondary analysis of a cross-sectional survey including a retrospective chart review. Patients at least one year from primary surgery were invited to complete the survey between 2012 and 2014. Baseline characteristics and survey responses were compared between three mastectomy groups: total/modified radical (TMRM), skin-sparing (SSM), and nipple-sparing (NSM). All patients underwent reconstruction.
RESULTS: Of 453 invited, 268 (59%) completed the survey. Sixty underwent mastectomy with reconstruction: 16 (27%) TMRM, 36 (60%) SSM, and 8 (13%) NSM. There were no significant differences in median total FSFI scores between groups, yet median FSFI scores for the NSM group indicated sexual dysfunction. After adjusting for receipt of chemotherapy and/or radiation, NSM had the lowest median desire score. There was a trend for the NSM group to be the least satisfied with postoperative appearance, but also more likely to report that the chest was \"often\" caressed during intimacy. However, nearly 40% of the NSM group reported that caress of the reconstructed breast was unpleasant.
CONCLUSIONS: NSM offers patients the greatest opportunity for preservation of their native skin envelope and potentially enhanced cosmetic outcome, but our results did not demonstrate superior sexual function or body image outcomes in this group. By highlighting surgical consequences of mastectomy preoperatively, surgeons may better set realistic patient expectations regarding both aesthetic and functional outcomes after breast cancer surgery. With clearer expectations, patients will have a better opportunity for improved surgical decision-making.

More high-risk women with breast cancer are identified using genetic testing at a younger age. These young women often opt for prophylactic surgery. Most patients are reluctant for extra donor-site scars besides infections and necrosis. In order to reduce these risks, a two-stage breast reconstruction technique is used for high-risk women with large or ptotic breasts. We presume that this procedure will reduce the risk of skin envelope and nipple-areola complex (NAC) necrosis to less than 1%. In the first stage, an inferior pedicle reduction is performed to obtain large volume reduction with maximal safety for the NAC. The ptosis, skin excess, and malpositioning of the NAC are corrected safely at this stage. In the second stage, the skin-sparing mastectomy is performed with or without nipple sparing. During this procedure, the areola is never removed. A bilateral breast reconstruction is then performed with an immediate subpectoral prothesis or delayed with the use of a subpectoral tissue expander. In this way, we aim to meet the patient\'s wish to undergo bilateral risk reducing mastectomy in breasts that need ptosis correction without donor-site scarring. This article describes the procedure and reports the preliminary data.