Local Recurrence in the Nipple-Areola-Complex After Nipple-Sparing Mastectomy and Skin-Sparing Mastectomy With Immediate Breast Reconstruction in the After Nipple-Sparing Mastectomy and Skin-Sparing With Immediate Reconstruction.

offer removing all the while preserving the Abstract Objective: The most important problem associated with Nipple-Sparing Mastectomy (NSM) and Skin-Sparing Mastectomy (SSM) for breast cancer patients is the risk of local recurrence. Local recurrence is associated with concurrent or following distant metastasis and mortality. Patients also suffer from second operation and worse quality of life if local recurrence or distant metastasis occurs. Long-term follow-up data regarding the oncologic safety of NSM and SSM with cancer recurrence at the Nipple-Areola-Complex (NAC) and survival are limited. This is a single center retrospective review and reported as an observational result. Methods: A retrospective review of 168 female breast cancer patients who had undergone SSM or NSM with immediate breast reconstruction in Chang Gung Memorial Hospital, Linkou, from January 1, 2014 to November 2, 2018, was performed. The focus of this review is simply to determine the local recurrence rate after SSM or NSM in breast cancer patients with immediate reconstruction. Results: Overall, 172 mastectomies (59 SSM and 113 NSM) of 168 female breast cancer patients were performed. Among these 172 mastectomies, 150 were immediate reconstruction with autologous flap or one-stage prosthesis implantation, 22 were two-stage tissue expander breast reconstructions followed by prosthesis implantation months later. Median follow-up duration was 51 months, ranged from 24 months to 78 months. Local recurrence was found in only one patient. The recurrence location was below NAC (Nipple-Areola-Complex) and it was 45 months after first surgery. There were two patients with distant metastasis during the follow-up period. However, these two patients with distant metastasis had no evidence of local recurrence. Conclusion: SSM and NSM with immediate reconstruction are both safe surgical intervention methods compared with traditional simple mastectomy and breast-conserving surgery for breast cancer patients regarding to local recurrence rate and long-term overall survival. Local Recurrence Nipple-Areola-Complex Breast

was from Hinton et al. [3], who mentioned that NSM achieved the same local recurrence rates and survival rates compared to radical mastectomy [1]. Many prospective and retrospective studies [4][5][6] of NSM have shown the oncologic and surgical safety of NSM as well as the superior aesthetic outcomes and improved quality of life achieved when NSM is with immediate breast reconstruction.
Present National Comprehensive Cancer Network guidelines state that NSM is an acceptable surgical option for carefully selected patients with breast cancer [7].
Nevertheless, the application of NSM for breast cancer remains controversial because of the limited long-term follow-up data, such as the rate of local recurrence rate and distant metastasis, and mortality rate after local recurrence or distant metastasis [8].
Because increasing numbers of patients with breast cancer are selecting NSM [9,10], it is important to identify the incidence of cancer recurrence at the NAC after NSM, describe the associated factors, and determine its association with prognosis. Previous studies [11][12][13][14][15]  Staging Manual [16]. These 168 patients all have regular followups. The patients were regularly followed up postoperatively every 3 to 6 months for the first 5 years and 6 to 12 months 5 years after surgery if no recurrence or metastasis occurs. Local recurrence or distant metastasis was identified by clinical physical examination, breast ultrasonography, mammography, or chest radiography.
Abnormal clinical findings were evaluated through further studies, including computed tomography of the chest, bone scan, and liver ultrasonography. Core needle biopsy was performed to evaluate suspicious lesion below the NAC.

Results
Overall, 172 mastectomies (59 SSM and 113 NSM) of 168 female breast cancer patients were performed. Among these 172 mastectomies, 150 were immediate reconstruction with permanent autologous tissue or one-stage prosthesis implantation, 22 were two-stage tissue expander breast reconstruction followed by prosthesis implantation months after adjuvant chemotherapy and radiation therapy. Median follow-up duration was 51 months, ranged from 24 months to 78 months. Local recurrence was found in only one patient. The recurrence location was below NAC (nipple-areola-complex) and it was 45 months after first surgery.
There were two patients who developed distant metastasis during the follow up period. However, these two patients with distant metastasis had no evidence of local recurrence. The basic characteristics of these 168 breast cancer patients are shown in Table 1. The median age of patients at diagnosis was 44 years (range, 27-76 years). One hundred and thirty-six patients were less than fifty years old. Thirty-six patients were older than fifty years old. One hundred and thirty-six patients had invasive carcinoma and thirty-six patients had carcinoma in situ. Among the 136 patients with invasive disease, 101 were node negative, 2 had malignant cells in regional lymph node(s) no greater than 0.2 mm(pN0i+), 5 had micrometastases lymph nodes(N1mic), 19     Therapy (RT) are at risk for locoregional recurrence. For women treated for early breast cancer, the recurrence rate ranges from 4 to 7 percent after mastectomy or breast-conserving therapy, respectively [17]. If locoregional recurrence occurs within two years after primary treatment, distant metastatic disease is already present in 25 to 30 percent of cases [18]. Available studies [11][12][13][14][15][19][20][21][22] have shown low rates of cancer recurrence at the NAC (0%-3.7%) after NSM. The recurrence rate (4%-7%) after NSM was even lower than that after traditional mastectomy or breastconserving surgery [17]. Most of these findings were obtained in a heterogeneous population of patients, including those with invasive and noninvasive disease, and reported variable follow-up durations. In a series by Jensen et al. [21], no cancer recurrence at the NAC was reported among 149 patients who underwent NSM during a mean follow-up of 60.2 months; however, 57% of these cases had only noninvasive disease. In a study by Wang et al. [22], no case of cancer recurrence at the NAC was found among 981 patients who underwent NSM; however, the follow-up evaluation was only 29 months, and 52% of the surgeries were performed for in situ disease [20]. During a median follow-up duration of 78 months, Sakurai et al. [13] reported a cancer recurrence rate at the NAC of 3.7% among 788 patients who underwent NSM without radiotherapy between 1985 and 2004. In one study [8], it included patients with invasive breast cancer who underwent NSM and immediate breast reconstruction between 2003 and 2015 and identified a 5-year local recurrence at the NAC of 3.5%.
The indication for adjuvant radiation therapy after breast cancer treatment surgeries in our hospital include breastconserving surgery, primary tumor larger than 5 centimeters, final pathology showing lymphovascular invasion, and more than two metastatic ipsilateral axillary lymph nodes found. So most of our study populations did not undergo adjuvant radiation therapy after SSM or NSM. It was because the whole breast tissue was removed.
Only two studies investigated variables through a multivariate analysis. One of these two studies was published by Petit et al. [22].

Limitations
The limitation of our data is that it is retrospective review. Our patient numbers are small and populations are heterogeneous.