Nipple-Sparing Mastectomy and Adequate Margins for Patients With Ductal Carcinoma In Situ.

BACKGROUND: For patients with ductal carcinoma in situ (DCIS) undergoing breast conservation surgery (BCS), guidelines advise a margin width of at least 2 mm, with studies demonstrating decreased recurrence risk compared to narrower margins. However, limited data exist establishing if this margin is appropriate in mastectomies, and specifically for nipple-sparing mastectomy (NSM). Consequently, we evaluated the margins of DCIS patients undergoing NSM and resulting oncologic outcomes. METHODS: A single-institution retrospective review was performed in patients with DCIS or DCIS with microinvasion (DCIS + MI) undergoing NSM from April 2010 to December 2021. Patient and tumor characteristics, margin status, treatment, and outcomes information were collected. The association between margins and local-regional (LRR) and distant recurrence (DR) were examined. RESULTS: 161 patients were included, comprising 284 NSM (164 therapeutic, 120 prophylactic). 153 patients had DCIS and 8 had DCIS + MI. Most patients had hormone sensitive, 123 (76.4%), and nuclear grade 2, 72 (44.7%), disease. In total, 35 (21.7%) patients had positive or <2 mm margins. Of these, 21 (60%) involved the anterior margin. At a median follow-up of 45 months (range 0-151), 2.5% (n = 4) had a LRR and .6% (n = 1) had a DR. Of patients with a recurrence, only 2 had positive or <2 mm margins, 1 had received endocrine therapy, and none received adjuvant radiation. DISCUSSION: No specific margin status was found to correlate with recurrence for patients with DCIS or DCIS + MI undergoing NSM, with an altogether low recurrence risk. Overall, this suggests that recommended DCIS margins in BCS doesn't necessarily apply in NSM, where margins of <2 mm may be acceptable.

Positive Nipple Margins and Oncologic Outcomes of Nipple-Sparing Mastectomy in a Large Community-Based Hospital System.

The American Society of Breast Surgeons recommends sending separate nipple margins (NMs) when performing nipple-sparing mastectomies (NSMs). However, the definition of a positive NM is vague. We evaluated NM management and outcomes in breast cancer patients undergoing NSM from 2010 to 2021 at our community-based hospital system through a retrospective review and descriptive analysis. A total of 619 patients (1086 NSM) were included. Median invasive tumor size was 1.5cm and median follow-up 30 months. Fourteen therapeutic NSMs had tumor within the NMs. Nine were positive using the definition "any tumor within the separate NM," and nipple-areolar complex (NAC) excised. Two were negative when positive was defined as "any tumor on ink," and were observed without recurrence. Our results suggest positive NMs warranting NAC excision could be interpreted as "any tumor on ink" and NSMs can be safely performed with low rates of positive NMs and recurrences in high-volume hospitals.

Nipple-Sparing Mastectomy: Are We Providing Proper Prophylactic Antibiotic Coverage?

BACKGROUND: Infection after nipple-sparing mastectomy (NSM) and implant-based reconstruction (IBR) can be a devastating complication. The retained nipple may act as a portal or nidus for different ductal organisms, and as such, the bacteriology of surgical-site infections (SSIs) in this setting may not be adequately covered by current antibiotic recommendations. This study sought to evaluate SSI and reconstruction outcomes in relation to antibiotic choice and identify the different microbial species implicated. METHODS: A prospective database was reviewed for patients who underwent NSM with IBR from 2010 to 2019. Patient characteristics, operative details, antibiotic regimens, and subsequent treatment details were evaluated. The study analyzed SSI incidence, timing, and type of causative organisms. RESULTS: The study analyzed 571 NSMs with IBR performed for 347 patients (55% with direct implants and 45% with tissue expanders). The preoperative antibiotics consisted of cephalosporin alone for 65% of the patients, a more broad single-antibiotic use for 12% of the patients, and dual-coverage antibiotics for 20% of the patients. During a median follow-up of 1.7 years, SSI developed in 12% of the reconstructions, with 6% requiring prosthesis removal. The most common SSI organism cultured was Staphylococcal species. Neither pre- nor postoperative antibiotic choice was associated with incidence of infection, type of bacteria, or need for prosthetic explanation. CONCLUSION: For patients undergoing NSM with IBR, a more aggressive antibiotic choice is not associated with an improved SSI rate. Patient and treatment factors continue to carry the highest risk for SSI.

Lymphedema Prevention Surgery: Improved Operating Efficiency Over Time.

BACKGROUND: Lymphedema prevention surgery (LPS), which identifies, preserves, and restores lymphatic flow via lymphaticovenous bypasses (LVB), has demonstrated potential to decrease lymphedema in breast cancer patients requiring axillary lymph node dissection. Implementing this new operating technique requires additional operating room (OR) time and coordination. This study sought to evaluate the improvement of LPS technique and OR duration over time. METHODS: A prospective database of patients who underwent LPS at our institution from 2016 to 2019 was queried. Type of breast and reconstruction surgery, number of LVB performed, and OR times were collected. LPS details were compared by surgical group and year performed. RESULTS: Ninety-four patients underwent LPS, and 88 had complete OR time data available for analysis. Average age was 51 years, body mass index of 28, with an average of 15 lymph nodes removed. Reconstructive treatment groups included prosthetic reconstruction 56% (49), oncoplastic reduction 10% (9), and no reconstruction 34% (30). The number of patients undergoing LPS increased significantly from 2016 to 2019, and average number of LVB per patient doubled. In patients without reconstruction, the average time for LPS improved significantly from 212 to 87 min from 2016 to 2019 (p = 0.015) and similarly in patients undergoing LPS with prosthetic reconstruction from 238 to 160 min (p = 0.022). CONCLUSIONS: LVB is an emerging surgical lymphedema prevention technique. While requiring additional surgical time, our results show that with refinement of technique, over 4 years, we were able to perform double the number of LVB per patient in half the OR time.

Obesity increases malignant risk in patients with branch-duct intraductal papillary mucinous neoplasm.

BACKGROUND: Obesity is an established risk factor for pancreatic adenocarcinoma. No study has examined specifically the influence of obesity on malignant risk in patients with intraductal papillary mucinous neoplasm (IPMN), a group at substantial risk of pancreatic adenocarcinoma. We hypothesize that obesity is associated with a greater frequency of malignancy in IPMN. METHODS: Data on patients undergoing resection for IPMN between 1992 and 2012 at a high-volume university institution were collected prospectively. Clinicopathologic and demographic parameters were reviewed. Patients were classified according to World Health Organization categories of body mass index (BMI). Malignancy was defined as high-grade dysplastic or invasive IPMN. RESULTS: We collected data on 357 patients who underwent resection for IPMN. Of these, 274 had complete data for calculation of preoperative BMI and 31% had malignant IPMN. Of 254 patients with a BMI of <35 kg/m(2), 30% had malignant IPMN versus 50% in patients with BMI of ≥35 (P = .08). In branch-duct IPMN, patients with a BMI of <35 had 12% of malignant IPMN compared with 46% in severely obese patients (P = .01). Alternatively, in main-duct IPMN, no difference was found in the malignancy rate (48% vs 56%; P = .74). CONCLUSION: These findings suggest that obesity is associated with an increased frequency of malignancy in branch-duct IPMN. Obesity is a potentially modifiable risk factor that may influence oncologic risk stratification, patient counseling, and surveillance strategy.

Allergenicity and cross-reactivity of coconut oil derivatives: A double-blind randomized controlled pilot study.

BACKGROUND: Counseling of patients with cocamidopropyl betaine (CAPB) allergy is difficult because the cross-reactivity of CAPB with other coconut-derived surfactants, coconut oil, and coconut fatty acids is largely unknown. OBJECTIVE: To provide pilot data regarding the cross-reactivity and allergenicity of surfactants derived from coconut oil. METHODS: A randomized double-blind controlled pilot study of 10 control patients and 12 patients previously found to be allergic to CAPB. Eleven coconut-derived surfactants, as well as coconut oil and lauric acid, were applied in random order according to standardized patch-test procedures with readings at 48 and 92 hours. The primary outcome measure was the frequency of positive patch-test reactions to each allergen. RESULTS: Only 3 of the 12 patients with previous reactions to CAPB reacted on retesting, and all of these reactions were doubtful. Fifty-nine percent of the study patients had reactions to triethanolamine polyethylene glycol-3 (TEA-PEG-3) cocamide sulfate as compared to none of the controls (p = .005). CONCLUSIONS: Reactions to CAPB were only 25% reproducible. These results substantiate previous experience that doubtful and mild reactions to CAPB may represent irritant reactions as opposed to true allergic reactions. TEA-PEG-3 cocamide sulfate was the only agent that had a statistically significant higher rate of reactions in the study group as compared to the control group.