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Hindawi Publishing Corporation International Journal of Surgical Oncology Volume 2011, Article ID 876520, 7 pages doi:10.1155/2011/876520 Clinical Study Retrospective Comparison of Non-Skin-Sparing Mastectomy and Skin-Sparing Mastectomy with Immediate Breast Reconstruction 1 2 2 1 1 Satoki Kinoshita, Kimihiro Nojima, Meisei Takeishi, Yoshimi Imawari, Shigeya Kyoda, 1 1 1 3 3 Akio Hirano, Tadashi Akiba, Susumu Kobayashi, Hiroshi Takeyama, Ken Uchida, and Toshiaki Morikawa Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita, Kashiwa City, Chiba 277-8567, Japan Department of Plastic-Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita, Kashiwa City, Chiba 277-8567, Japan Department of Breast and Endocrine Surery, The Jikei University School of Medicine, Tokyo 105-8461, Japan Correspondence should be addressed to Satoki Kinoshita, email@example.com Received 10 October 2010; Revised 13 May 2011; Accepted 13 June 2011 Academic Editor: Perry Shen Copyright © 2011 Satoki Kinoshita et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. We compared Skin-sparing mastectomy (SSM) with immediate breast reconstruction and Non-skin-sparing mastectomy (NSSM), various types of incision in SSM. Method. Records of 202 consecutive breast cancer patients were reviewed retrospectively. Also in the SSM, three types of skin incision were used. Type A was a periareolar incision with a lateral extension, type B was a periareolar incision and axillary incision, and type C included straight incisions, a small elliptical incision (base line of nipple) within areolar complex and axillary incision. Results. Seventy-three SSMs and 129 NSSMs were performed. The mean follow-up was 30.0 (SSM) and 41.1 (NSSM) months. Respective values for the two groups were: mean age 47.0 and 57; seven-year cumulative local disease-free survival 92.1% and 95.2%; post operative skin necrosis 4.1% and 3.1%. In the SSM, average areolar diameter in type A & B was 35.4 mm, 43.0 mm in type C and postoperative nipple-areolar plasty was performed 61% in type A & B, 17% in type C, respectively. Conclusion. SSM for early breast cancer is associated with low morbidity and oncological safety that are as good as those of NSSM. Also in SSM, Type C is far superior as regards cost and cosmetic outcomes. 1. Introduction Halsted’s procedure is based on the theory that breast cancer progresses anatomically, that is, from the mammary The establishment of modern radical surgery for breast gland via the regional lymph nodes to the entire body. It was cancer started with standard radical mastectomy, conducted therefore essential to resect the regional lymph nodes and by William Stewart Halsted in 1882. This procedure consisted intervening lymphatics and to remove the entire mammary of extensive resection of overlying skin centered around the gland with radical surgery. This procedure became the basis focus of cancer, the entire mammary gland, and the pec- for further extension of the surgical procedure, that is, inter- toralis major and minor muscles, as well as complete lymph nal mammary and supraclavicular lymph node dissection, node dissection. At a time when most cases of breast cancer after the long-term postoperative results peaked in the 1920– 30s. This theory, however, rapidly lost favor after Fisher et were, what is now called, locally advanced or metastatic breast cancer, the procedure was considered an operative al. introduced new concepts [3–5], and the usefulness of method to be implemented with curative intent because extended surgery for improving the prognosis was refuted by a clinical trial in the early 1980s . On the other hand, the three-year survival after surgery was over 40% and the outcomes of local control were astounding at the time . the gradual movement toward limited surgery that started The procedure was reﬁned by his second-generation in the 1950s arose primarily because the detection of breast pupil, Cushman Davis Haagensen, profoundly inﬂuencing cancer at an early stage became possible, which was further many surgeons around the world . reinforced by the requests for this surgery from women at 2 International Journal of Surgical Oncology the time. The transition to modiﬁed radical mastectomy 3. Results progressed rapidly from 1975 to 1980 in the USA , and Table 1 shows the patient (73 in the SSM group and 129 in Japan the procedure became mainstream in the late 1980s in the NSSM group) and tumor characteristics and tumor . Later, after the NSABP (National Surgical Adjuvant staging determined based on the American Joint Committee Breast Project) protocol B-06 was conducted in 1985 , on Cancer Staging System. breast conserving surgery (BCS) was chosen more frequently, The mean age was 47.0 ± 9.0 (31–71) years in the SSM and the long-term (20-year) results demonstrated that BCS group and 57.7 ± 11.9 (31–83) years in the NSSM group, produced outcomes comparable to mastectomy [10, 11]. signiﬁcantly lower in the former group (P< 0.000). The Today local control of breast cancer is the major objective mean follow-up period in the SSM group was 30.0 ± 22.6 of surgical treatment and considered a part of systemic (1–85) months, which was signiﬁcantly shorter than the 41.1 therapy . BCS is now the mainstream of breast cancer ± 21.3 (1–86) months in the NSSM group (P< 0.000). treatment. Even now, however, about one-third of women Stage 0 noninvasive cancer accounted for 15.1% of the SSM with breast cancer choose mastectomy, based on the size or group and 7.8% of the NSSM group (P = 0.1). Neoadjuvant site of the lesion and the presence of an extensive intraductal chemotherapy (NAC) was carried out in four cases in the lesion . SSM group (5.5%) and in ﬁve cases in the NSSM group Skin-sparing mastectomy (SSM) with immediate breast (3.9%) (P = 0.6). reconstruction reported by Toth and Lappert in 1991 is Table 2 shows an overview of the operative procedures. generally acknowledged to be the method that can achieve In the SSM group, 48.0% of the patients underwent both radical cure and resolve cosmetic issues . At our hos- total mastectomy (Bt) and axillary lymph node dissection pital, we have adopted this method in cooperation with (ALND), 34.2% underwent sentinel lymph node biopsy (SLNB) alone, and 17.8% additionally underwent ALND plastic surgeons and have produced excellent results since after SLNB. In the NSSM group, the percentages were 75.9%, 20.2%, and 3.9% respectively. The average time required for In the following sections, we report an overview of the mastectomy was 140 minutes in the SSM group and 130 ﬁndings and a retrospective case control study of skin- minutes in the NSSM group (P = 0.06); the intraoperative sparing mastectomy (SSM) and non skin-sparing mastec- blood loss was 212 g in the SSM group and 197 g in the NSSM tomy (NSSM) performed by a single surgeon during the group (P = 0.5). same period. Table 3 shows the type of skin incision and type of reconstruction, and Figure 2 shows the appearance of each 2. Patients and Methods type after reconstruction. Also in Table 3, the number of cases was compared between the ﬁrst half of the study (July The subjects were 202 female Japanese patients who under- 2003 to June 2007) and the second half of the study (July 2007 went mastectomy by a single surgeon (SK) at the Jikei to June 2010) in the SSM group alone—26 cases (35.6%) University Kashiwa Hospital during the period from July were in the ﬁrst half and 47 cases (64.4%) were in the 2003 to June 2010. Of these patients, 73 were assigned to the second half. The average operative duration decreased from SSM group and 129 to the NSSM group. 148 minutes to 132 minutes (P = 0.03), and the average In the SSM group, removal of the nipple with/without intraoperative blood loss also decreased from 232 g to 196 g areola complex, biopsy scars (excluding the core needle (P = 0.27). While type A accounted for 84.6% in the ﬁrst biopsy scar), and the entire breast parenchyma were planned half of the study, type B and C accounted for 53.2% and . Immediate breast reconstruction was performed by a 38.3%, respectively, in the second half of the study (P< plastic surgeon in all patients in the SSM group. 0.000). The percentage of DIEP ﬂap breast reconstructions In the SSM group, the patients were assigned to undergo increased from 15.4% in the ﬁrst half to 53.2% in the second three types of skin incision. Type A was a periareolar incision half (P = 0.002). The average length of the long axis of with a lateral extension (the so-called “tennis racquet”), type the periareolar incision was 3.7 cm in the SSM group. The B was a periareolar incision and axillary incision, and type average diameter was 35.4 mm in types A and B and 43.0 mm C included straight incisions, a small elliptical incision (base in type C, respectively (P = 0.0002). line of nipple) within areola complex (the so-called “areolar Table 4 shows the relation between nipple-areolar plasty sparing”) and axillary incision (Figure 1). and type of incision. Postoperative nipple-areolar plasty was Appropriate adjuvant therapy was carried out for all requested in 48 cases (88.9%) and received in 33 cases patients based on their own choice after they under- (61.1%) of types A and B and in 3 cases (16.7%) of type C, went postoperative pathological examination and adequate respectively (P = 0.001). informed consent was obtained. Table 5 shows a summary of postoperative complica- The chi-square test and t-test were used in the statistical tions. Skin necrosis that required debridement and further treatment was seen in 4.1% of the SSM group and in 3.1% of analysis. The cumulative overall survival (OAS), cumulative distant disease-free survival (DDFS), and cumulative local the NSSM group, showing no signiﬁcant diﬀerence between disease-free survival (LDFS) were calculated by the Kaplan- the two groups (P = 0.69). In the SSM group, ﬂap loss and Meier method, and a signiﬁcant diﬀerence was evaluated by deep vein thrombosis (DVT) due to circulatory insuﬃciency the Wilcoxon test (P ≤ 0.05). were each seen in 1.4%, fat lysis in the ﬂap associated with International Journal of Surgical Oncology 3 Table 1: Patients and tumor characteristics and stage in SSM and NSSM (%). SSM NSSM Number of patients 73 129 July 2003–June 2007 26 (35.6) 81 (62.8) July 2007–June 2010 47 (64.4) 48 (37.2) Age (yrs.) 47.0 ± 9.0 57.7 ± 11.9 Follow-up time (months) 30.0 ± 22.6 41.1 ± 21.3 Microcalciﬁcations on mammography 26 (35.6) 45 (34.9) Multicentricity 9 (12.3) 15 (11.6) Nipple discharge 14 (19.2) 13 (10.1) Distance between nipple and tumor < 20 mm 52 (71.2) 82 (63.6) Stage 0: TisN0M0 11 (15.1) 10 (7.8) Stage I:T1N0M0 25 (34.2) 33 (25.6) Stage IIA 28 (38.4) 58 (43.0) T1N1M0 13 T2N0M0 27 55 Stage IIB 9 (12.3) 28 (21.6) T2N1M0 823 T3N0M0 15 (Neoadjuvant chemotherapy: NAC) 4 (5.5) 5 (3.9) Table 2: Operation characteristics in SSM and NSSM (%). SSM NSSM Operation (mastectomy) time (min.) 140.1 ± 30.4 130.0 ± 33.8 Blood loss during mastectomy (g.) 212.0 ± 131.8 197.0 ± 146.4 Type of mastectomy Bt + ALND 35 (48.0) 98 (75.9) Bt + SLNB 25 (34.2) 26 (20.2) Bt + SLNB → ALND 13 (17.8) 5 (3.9) Bt: total mastectomy, ALND: axillary lymphnode dissection, and SLNB: sentinel lymphnode biopsy. Table 3: Chronological changes in SSM between July 2003–June 2007 and July 2007–June 2010 in SSM (%). July 2003–June 2007 July 2007–June 2010 Number of patients 26 (35.6) 47 (64.4) Operation (mastectomy) time (min.) 148.3 ± 26.9 132.1 ± 50.6 Blood loss during operation (g.) 232.1 ± 174.8 196.6 ± 99.8 Type of skin incision for SSM Type A 22 (84.6) 4 (8.5) Type B 4(15.4) 25 (53.2) Type C 0 (0) 18 (38.3) Type of reconstruction following SSM LDMC ﬂap 4 (15.4) 6 (12.8) TRAM ﬂap 18 (69.2) 15 (31.9) DIEP ﬂap 4 (15.4) 25 (53.2) Silicon implant 0 1 (2.1) LDMC: latissimus dorsi musculocutaneous, TRAM: transverse rectus abdominis musculocutaneous, and DIEP: deep inferior epigastric perforator. 4 International Journal of Surgical Oncology Type A Type B Type C Figure 1: Classiﬁcation of skin incisions for SSM. Type A Type B Type C Figure 2: Appearance of the breast following SSM and reconstruction with a TRAM ﬂap. Type A: left breast, type B: right breast, and type C: left breast. infection that required surgical approaches and a hernia at Table 4: Relations between nipple-areolar complex and type of incision (%). the donor site each occurred in 2.7%. Table 6 shows the complications observed in smokers and No desire for Desire for NAP nonsmokers in the SSM group. The combined incidences NAP of skin and ﬂap-related problems and DVT were 20% and Received Not received 5.7%, respectively (P = 0.06). As regards local recurrence Types A and B 48 (88.9) 33 (61.1) 15 (27.8) 6 (11.1) during the follow-up period, two episodes were reported in Type C 3 (16.7) 3 (16.7) — 15 (83.3) the SSM group (2.7%) and ﬁve episodes in the NSSM group NAP: nipple-areolar plasty. (3.9%). One case of cancer death was reported in the SSM group (1.4%) and six cases were reported in the NSSM group (4.7%). Figure 3 shows the local disease-free survival (LDFS) and overall survival (OAS) determined by the Kaplan-Meier 4. Discussion method. Seven-year LDFS was 92.1% in the SSM group and 95.2% in the NSSM group (P = 0.75), and seven-year OAS SSM with immediate breast reconstruction has rapidly was 96.9% in the SSM group and 90.1% in the NSSM group spread during the past 20 years, and its origin dates back (P = 0.69). There was no signiﬁcant diﬀerence in rates to subcutaneous mastectomy, ﬁrst performed by Freeman between the two groups. in1962 . International Journal of Surgical Oncology 5 100 100 80 80 60 60 40 40 20 20 0 0 0 2468 0 2468 Years Years SSM SSM NSSM NSSM (a) (b) Figure 3: Kaplan-Meier survival curve for SSM and NSSM. (a) Local disease-free survival P = 0.75. (b) Overall survival P = 0.69. Table 5: Complications in SSM and NSSM (%). Table 6: Relation between smoking and complications in SSM (%). SSM NSSM Smoker Nonsmoker Postoperative hemorrhage 1 (1.4) 0 Number of patients 20 53 Skin necrosis 3 (4.1) 4 (3.1) Troubles of skin and ﬂap 3 (15.0) 3 (5.7) DVT 1 (1.4) 0 DVT 1 (5.0) 0 Flap loss 1 (1.4) 0 DVT: deep vein thrombosis. Fat lysis of ﬂap with infection 2 (2.7) 0 Hernia at donor site 2 (2.7) 0 high percentage of 58% reported in one study [13, 15]. On DVT: deep vein thrombosis. the other hand, Simmons et al. examined the nipple and areola separately and reported that areolar involvement was In SSM, the nipple-areolar complex and all biopsy seen in just 0.9% . At our institution, during the second scars excluding the core needle biopsy scar are resected, half of this case series we tried an approach that uses the inframammary fold and most of the native breast skin are type C skin incision while taking account of the information preserved, and the entire breast parenchyma is removed. obtained from preoperative, contrast-enhanced CT/MRI to Usually SSM is followed by immediate breast reconstruction, achieve better cosmetic outcomes and obtained the positive through which better cosmetic outcomes are produced, the outcomes seen in the study by Simmons et al. , although anesthetic risk and the patient’s emotional trauma from the our study period was relatively short. loss of a breast are reduced, and, ultimately, cost-eﬀectiveness The average areolar diameter of type C was signiﬁcantly is achieved [17, 18]. larger than that of types A and B. Therefore, we consider The mean age of the SSM group is generally lower than that areolar sparing mastectomy can be performed safely in that of the NSSM group . This may reﬂect bias not only patients with at least 4 cm or more of the length of the long among patients who choose the operative procedure but also axis of the areola. Also, type C is considered far superior as oncological surgeons who propose the operative procedure. regards cost and cosmetic outcomes, because the patients, We believe that the follow-up period was signiﬁcantly who desire to receive postoperative nipple-areolar plasty, are shorter in the SSM group in this case series because 64% of signiﬁcantly fewer. Since April 2010, we have been trying to SSMs were performed in the second half. apply the nipple-areolar complex made with silicon material In view of the anatomical course of ducts, resection of the (Figure 4) instead of surgical approach. nipple-areolar complex has been considered to be essential Axillary incision is additionally performed in all type B because the tumor cells may spread to the adjacent ducts. The and type C skin incisions at our institution. This is primarily involvement of tumor cells at the nipple-areolar complex is because, in this case series: (1) it was diﬃcult to perform reported to occur in about 3–10%, except for the extremely total mastectomy due to the small average areolar diameter (%) (%) 6 International Journal of Surgical Oncology (a) (b) Figure 4: nipple-areolar complex made with silicon material. (3.7 cm) , (2) 65% of the cases underwent complete level The relationship between skin necrosis observed in SSM and I-III ALND, and (3) 97% of the cases chose a microvascularly smoking habits has often been examined, and nicotine is augmented TRAM ﬂap that required microscopic vascular thought to be a risk factor for skin necrosis because it reduces anastomosis not only in the DIEP ﬂap but also in the TRAM capillary blood ﬂow [15–17]. In our case series, skin necrosis ﬂap, and the plastic surgeon preferred an axillary incision, in occurred in 5% of nonsmokers but in 15% of smokers. order to use thoracodorsal vessels. In fact, an axillary incision Although no prospective randomized study that com- is hardly noticeable when seen from the front and we believe pares SSM and NSSM has been conducted so far, it can it has no inﬂuence on the cosmetic outcomes. be said to be commonly acknowledged that local control, Currently in Japan, it is diﬃcult to perform breast recon- prognosis, and risk of complications are the same for SSM struction using implants because of some problems with the and NSSM, at least in stages 0, I, and II. medical insurance system—this is the reason why 99% of the SSM is still considered to be contraindicated for inﬂam- cases underwent reconstruction using autogenous tissues. matory breast cancer and breast cancer with skin invasion. Compared with NSSM,itismorediﬃcult to ensure a Although there have been some studies on the usefulness of clear operative ﬁeld in SSM, and SSM involves more extensive SSM in locally advanced breast cancer [24, 25], its application subcutaneous dissection. Therefore, the surgery took longer is still controversial. Nonetheless, SSM is considered to be an and the intraoperative blood loss tended to be greater in operativeprocedure thatcan be of greatbeneﬁttopatients the ﬁrst half of the study. In the second half, however, the with relatively early stage breast cancer who are potential duration of the SSM procedure and the intraoperative blood candidates for breast conservation but are ineligible for loss were comparable to those of NSSM, despite an increase BCS. in the percentages of type B and type C incisions, which are supposed to have a narrower ﬁeld than the type A incision. 5. Conclusion We believe this ﬁnding was greatly inﬂuenced by the technical improvement achieved due to the accumulated experience When SSM with immediate breast reconstruction is per- of a single surgeon and due to the bipolar scissors used for formed in patients with relatively early stage (stages 0–II) subcutaneous dissection in the second half of the study. breast cancer with tumor size classiﬁed as Tis, T1, and Most of local recurrences after mastectomy occur in the T2, the rate of local recurrence, survival, and incidence of chest wall skin [13, 15]. There was therefore concern that postoperative complications are equal to those achieved with SSM, in which breast skin is conserved to the maximum NSSM. extent possible, may induce local recurrence. Previous stud- Compared with NSSM, SSM is far superior as regards ies have reported that the local recurrence rate is about 2–7% cosmetic outcomes and is expected to remarkably reduce the [13, 15–18, 21–23]. It is now widely known that not only the emotional trauma due to the sense of loss of a breast that is local recurrence rate but also the overall survival in SSM is perceived by the patient just after surgery. comparable to those in NSSM, at least for stages 0, I, and II, And in SSM, type C is considered far superior as regards as seen in the results of our case series. cost and cosmetic outcomes, because fewer patients desire to A complication common to SSM and NSSM is skin receive postoperative nipple-areolar plasty. necrosis. Its incidence has been reported to be about 10% [15, 23], and the risk of developing skin necrosis is thought References to be equal between the two groups. SSM requires some technical considerations such as (1) avoiding the application  W. S. 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