title: Expanding the Indications for Total Skin-Sparing Mastectomy: Is It Safe for Patients with Locally Advanced Disease?
abstract: BACKGROUND
  Indications for total skin-sparing mastectomy (TSSM) continue to expand. Although initially used only for early-stage breast cancer, TSSM currently is offered in many centers to patients with locally advanced disease. However, despite this practice change, limited data on oncologic outcomes in this population have been reported.
  
  
  METHODS
  A retrospective review of a prospectively collected database of all patients undergoing TSSM and immediate reconstruction from 2005 to 2013 was performed. The outcomes for patients with stage 2b and stage 3 cancer were included in the analysis. The primary outcomes included the development of locoregional or distant recurrences.
  
  
  RESULTS
  Of 753 patients undergoing TSSM, 139 (18 %) presented with locally advanced disease. Of these 139 patients, 25 (18 %) had stage 2b disease, and 114 (82 %) had stage 3 disease. Most of the patients (97 %) received chemotherapy (77 % neoadjuvant, 20 % adjuvant), whereas 3 % received adjuvant hormonal therapy alone. Of the neoadjuvant patients, 13 (12 %) had a pathologic complete response (pCR) to treatment. During a mean follow-up period of 41 months (range 4-111 months), seven patients (5 %) had a local recurrence, 21 patients (15.1 %) had a distant recurrence, and three patients (2.2 %) had simultaneous local and distant recurrences. None of the local recurrences occurred in the preserved nipple-areolar complex skin.
  
  
  CONCLUSIONS
  Patients with locally advanced breast cancer are most at risk for distant rather than local recurrence, even after TSSM. When used in conjunction with appropriate multimodal therapy, TSSM is not associated with an increased risk for local recurrence in this population, even in the setting of low pCR rates.
authors.affiliation: Division of Breast Surgery, Department of Surgery, UCSF Carol Franc Buck Breast Care Center, University of California, San Francisco, San Francisco, CA, USA.|Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Anne Warren
authors.initials: AW
authors.lastname: Peled
authors.affiliation: Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Frederick
authors.initials: F
authors.lastname: Wang
authors.affiliation: Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Robert D
authors.initials: RD
authors.lastname: Foster
authors.affiliation: Division of Breast Surgery, Department of Surgery, UCSF Carol Franc Buck Breast Care Center, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Alvarado
authors.affiliation: Division of Breast Surgery, Department of Surgery, UCSF Carol Franc Buck Breast Care Center, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Cheryl A
authors.initials: CA
authors.lastname: Ewing
authors.affiliation: Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Hani
authors.initials: H
authors.lastname: Sbitany
authors.affiliation: Division of Breast Surgery, Department of Surgery, UCSF Carol Franc Buck Breast Care Center, University of California, San Francisco, San Francisco, CA, USA. laura.Esserman@ucsfmedctr.org.
authors.forename: Laura J
authors.initials: LJ
authors.lastname: Esserman
mesh_terms: D000328:Adult; D000368:Aged; D014408:Biomarkers, Tumor / Q000378:metabolism; D001943:Breast Neoplasms / Q000378:metabolism / Q000473:pathology / Q000601:surgery*; D062109:Dermatologic Surgical Procedures; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016462:Mammaplasty; D008408:Mastectomy; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D009558:Nipples / Q000601:surgery; D059351:Organ Sparing Treatments; D011379:Prognosis; D011446:Prospective Studies; D018719:Erb-b2 Receptor Tyrosine Kinases / Q000378:metabolism; D011960:Receptors, Estrogen / Q000378:metabolism; D011980:Receptors, Progesterone / Q000378:metabolism; D012189:Retrospective Studies; D012867:Skin / Q000378:metabolism / Q000473:pathology*; D013524:Surgical Flaps; D015996:Survival Rate
chemical_list: D014408:Biomarkers, Tumor; D018719:Erb-b2 Receptor Tyrosine Kinases; D011960:Receptors, Estrogen; D011980:Receptors, Progesterone; C508053:ERBB2 protein, human