PD02-06: Outcomes after Total-Skin Sparing Mastectomy and Immediate Reconstruction in 657 Breasts.
Authors: Warren Peled A , Stover AC , Foster RD , Alvarado MD , Ewing CA , Hwang ES , Esserman LJ 
Published: June 2012

INTRODUCTION: Total skin-sparing mastectomy (TSSM) is increasingly offered to women for both therapeutic and prophylactic indications. When combined with immediate breast reconstruction, patients can achieve excellent aesthetic results and high satisfaction. However, the oncologic safety of the procedure remains controversial. Further, the technique can be associated with higher rates of postoperative ischemic complications. We conducted this study to determine oncologic and ischemic outcomes in a large cohort of patients undergoing TSSM and immediate reconstruction.

METHODS: Patient and tumor characteristics and treatment details were collected in a prospectively maintained database. All patients undergoing TSSM and immediate breast reconstruction at our institution from 2001 to 2010 were included in the analysis. The development of any post-operative complications or local or distant recurrence was determined.

RESULTS: TSSM with immediate reconstruction was performed in 428 patients for a total of 657 breasts. Mean patient age was 46.9 years. 210 patients (49%) had neoadjuvant chemotherapy for locally advanced disease. 114 patients (26.7%) had post-mastectomy radiation therapy. 54% of patients had bilateral mastectomies. Prophylactic mastectomies (either unilateral or bilateral) accounted for 244 (37.1%) of cases, which included bilateral mastectomies in 15 patients (30 cases) who were known BRCA-1 or -2 mutation carriers. Expander-implant reconstruction was performed in 80% of the cases, while the rest of the cases involved autologous reconstruction (15.3%) or immediate implant placement (4.7%). On pathologic examination, nipple tissue from 11 breasts (1.7%) contained in situ cancer and from 9 breasts (1.4%) contained invasive cancer; re-excision was performed in 7 of these cases, the nipple-areolar complex was removed entirely in 9 cases, and radiation therapy was given without further excision in the rest of cases. Ischemic or necrotic post-operative complications included 13 cases (1.9%) of partial nipple loss, 10 cases (1.5%) of complete nipple loss, and 78 cases (11.8%) of skin flap necrosis or incisional dehiscence. At a median follow-up of 23 months (range 3–116 months), 5 patients (1.2%) had developed a local recurrence alone, 10 patients (2.4%) had developed a distant recurrence alone, and 6 patients (1.4%) had developed both loco-regional recurrence and distant metastases. In the subset of patients with at least 3 years’ follow-up, rates of local and of distant recurrence were 1.7% at a median of 45 months follow-up. None of the patients who underwent bilateral prophylactic mastectomy for BRCA-1 or -2 mutations developed subsequent breast cancers.

CONCLUSIONS: In this large, high-risk cohort, TSSM was associated with low rates of nipple involvement and loco-regional recurrence. Ischemic complications, although uncommon, often resulted in nipple loss. These short-term outcomes are encouraging, although longer follow-up will be important for confirmation of long-term oncologic safety. Serial improvements in surgical technique can improve selection criteria and reduce post-operative complication rates.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD02-06.