Clinical efficacy of transaxillary endoscopic-assisted nipple-sparing mastectomy versus conventional open mastectomy_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHANG Songbo ¹ , YU Miao ¹ , ZHANG Purong ¹ , CHEN Wei ¹ , WANG Hao ¹ , LI Junjie ¹ ,  DU Zhenggui ²

1. Breast Cancer Department, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, 610041, P. R. China;
2. Breast Cancer Department, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;

Corresponding?author：

DU Zhenggui, Email: docduzg@163.com

Keywords：

Endoscopic-assisted; nipple-sparing mastectomy; conventional open mastectomy; aesthetic outcomes; postoperative complications; patient-reported outcome

DOI：

10.7507/1007-4848.202606019

Video：

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Objective To preliminarily compare the aesthetic outcomes, complication risks, and safety between endoscopic nipple-sparing mastectomy (E-NSM) and conventional open mastectomy (COM). Methods Patients who underwent E-NSM at Sichuan Cancer Hospital and West China Hospital of Sichuan University between January 2023 and October 2024 were consecutively enrolled as the endoscopic group. Patients who underwent COM at the two centers during the same period were enrolled as the open (control) group through 1:2 propensity score matching. The two groups were compared with respect to patient-reported aesthetic outcomes (BREAST-Q, SCAR-Q, and Harris scores), postoperative complication rates, and oncological safety events. Results All enrolled patients were female. Forty-four patients were included in the endoscopic group and 84 in the open group, with mean ages of (50.3±9.2) years and (50.8±9.2) years, respectively. The median follow-up durations were 5.5 (2.0, 10.0) months in the endoscopic group and 5.0 (1.9, 11.0) months in the open group (P=0.912). Regarding postoperative BREAST-Q scores, the endoscopic group scored significantly higher than the open group in satisfaction with breasts [58.0 (53.0, 66.0) points vs. 44.0 (39.0, 53.0) points ], psychosocial well-being [(79.0±12.1) points vs. (71.0±10.0) points], sexual well-being [(41.8±4.8) points vs. (35.3±6.7) points], and chest function [50.0 (40.0, 55.0) points vs. 40.0 (36.0, 50.0) points] (all P<0.001). In terms of the Harris score, the proportions of patients rated as "fair" and "poor" were lower in the endoscopic group than those in the open group (P<0.001). Regarding SCAR-Q scores, the endoscopic group scored significantly better than the open group in the appearance, symptom, and psychosocial domains (P<0.001). There was no significant between-group difference in shoulder abduction range of motion (P=0.875), and the scar length was significantly shorter in the endoscopic group (P<0.001). No tumor recurrence or metastasis was observed in either group during follow-up. Conclusion For female patients with breast cancer, E-NSM provides better short-term aesthetic outcomes than COM, and there is no significant difference in complication rates between the two procedures.

1.	Lai HW, Lin SL, Chen ST, et al. Single-axillary-incision endoscopic-assisted hybrid technique for nipple-sparing mastectomy: technique, preliminary results, and patient-reported cosmetic outcome from preliminary 50 procedures[J]. Ann Surg Oncol, 2018, 25(5): 1340-1349.
2.	Zhang S, Xie Y, Liang F, et al. Video-assisted transaxillary nipple-sparing mastectomy and immediate implant-based breast reconstruction: a novel and promising method[J]. Aesthetic Plast Surg, 2022, 46(1): 91-98.
3.	Yang B, Ren G, Song E, et al. Current status and factors influencing surgical options for breast cancer in China: a nationwide cross-sectional survey of 110 hospitals[J/OL]. Oncologist, 2020, 25(10): e1473-e1480. DOI: 10.1634/theoncologist.2020-0001.
4.	Galimberti V, Vicini E, Corso G, et al. Nipple-sparing and skin-sparing mastectomy: review of aims, oncological safety and contraindications[J/OL]. Breast, 2017, 34: S82-S84. DOI: 10.1016/j.breast.2017.06.034.
5.	Valero MG, Muhsen S, Moo TA, et al. Increase in utilization of nipple-sparing mastectomy for breast cancer: indications, complications, and oncologic outcomes[J]. Ann Surg Oncol, 2020, 27(2): 344-351.
6.	Agarwal S, Agarwal S, Neumayer L, et al. Therapeutic nipple-sparing mastectomy: trends based on a national cancer database[J]. Am J Surg, 2014, 208(1): 93-98.
7.	De Cicco C, Cremonesi M, Luini A, et al. Lymphoscintigraphy and radioguided biopsy of the sentinel axillary node in breast cancer[J]. J Nucl Med, 1998, 39(12): 2080-2084.
8.	Gatzemeier W, Mann GB. Which sentinel lymph-node (SLN) positive breast cancer patient needs an axillary lymph-node dissection (ALND)-ACOSOG Z0011 results and beyond[J]. Breast, 2013, 22(3): 211-216.
9.	Dai H, Cao X, Wu H, et al. Reverse-sequence endoscopic nipple-sparing mastectomy with direct-to-implant breast reconstruction and air inflation adjustment technique in patients with large or severely ptotic breast: a single-center prospective cohort study[J]. Int J Surg, 2025, 111(6): 3838-3849.
10.	Madden JL. Modified radical mastectomy[J]. Surg Gynecol Obstet, 1965, 121(6): 1221-1230.
11.	Pusic AL, Klassen AF, Cano SJ. Use of the BREAST-Q in clinical outcomes research[J/OL]. Plast Reconstr Surg, 2012, 129(1): 166e-167e. DOI: 10.1097/PRS.0b013e3182362e65.
12.	Harris JR, Levene MB, Svensson G, et al. Analysis of cosmetic results following primary radiation therapy for stages Ⅰ and Ⅱ carcinoma of the breast[J]. Int J Radiat Oncol Biol Phys, 1979, 5(2): 257-261.
13.	Klassen AF, Ziolkowski N, Mundy LR, et al. Development of a new patient-reported outcome instrument to evaluate treatments for scars: the SCAR-Q[J/OL]. Plast Reconstr Surg Glob Open, 2018, 6(4): e1672. DOI: 10.1097/GOX.0000000000001672.
14.	Al-Hilli Z, Wilkerson A. Breast surgery: management of postoperative complications following operations for breast cancer[J]. Surg Clin North Am, 2021, 101(5): 845-863.
15.	Hirsch EM, Seth AK, Dumanian GA, et al. Outcomes of tissue expander/implant breast reconstruction in the setting of prereconstruction radiation[J]. Plast Reconstr Surg, 2012, 129(2): 354-361.
16.	Petit JY, Veronesi U, Luini A, et al. When mastectomy becomes inevitable: the nipple-sparing approach[J]. Breast, 2005, 14(6): 527-531.
17.	Petit JY, Veronesi U, Orecchia R, et al. Nipple-sparing mastectomy in association with intra operative radiotherapy (ELIOT): a new type of mastectomy for breast cancer treatment[J]. Breast Cancer Res Treat, 2006, 96(1): 47-51.
18.	Eaves FF 3rd, Bostwick J 3rd, Nahai F, et al. Endoscopic techniques in aesthetic breast surgery: augmentation, mastectomy, biopsy, capsulotomy, capsulorrhaphy, reduction, mastopexy, and reconstructive techniques[J]. Clin Plast Surg, 1995, 22(4): 683-695.
19.	Liu H, Huang CK, Yu PC, et al. Retromammary approach for endoscopic resection of benign breast lesions[J]. World J Surg, 2009, 33(12): 2572-2578.
20.	Ito KI, Kanai T, Gomi K, et al. Endoscopic-assisted skin-sparing mastectomy combined with sentinel node biopsy[J]. ANZ J Surg, 2008, 78(10): 894-898.
21.	Kuo YL, Chang CH, Chang TY, et al. Endoscopy-assisted total mastectomy with and without immediate reconstruction: an extended follow-up, multicenter study[J]. Plast Reconstr Surg, 2021, 147(2): 267-278.
22.	Yang JD, Lee J, Lee JS, et al. Aesthetic scar-less mastectomy and breast reconstruction[J]. J Breast Cancer, 2021, 24(1): 22-33.
23.	Panchal H, Matros E. Current trends in postmastectomy breast reconstruction[J]. Plast Reconstr Surg, 2017, 140(5S): 7S-13S.
24.	Song WJ, Kang SG, Kim EK, et al. Current status of and trends in post-mastectomy breast reconstruction in Korea[J]. Arch Plast Surg, 2020, 47(2): 118-125.
25.	Héquet D, Zarca K, Dolbeault S, et al. Reasons of not having breast reconstruction: a historical cohort of 1937 breast cancer patients undergoing mastectomy[J/OL]. Springerplus, 2013, 2(1): 325. DOI: 10.1186/2193-1801-2-325.
26.	De La Cruz L, Moody AM, Tappy EE, et al. Overall survival, disease-free survival, local recurrence, and nipple-areolar recurrence in the setting of nipple-sparing mastectomy: a meta-analysis and systematic review[J]. Ann Surg Oncol, 2015, 22(10): 3241-3249.
27.	Moyer HR, Ghazi B, Daniel JR, et al. Nipple-sparing mastectomy: technical aspects and aesthetic outcomes[J]. Ann Plast Surg, 2012, 68(5): 446-450.
28.	Gerber B, Krause A, Dieterich M, et al. The oncological safety of skin sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction: an extended follow-up study[J]. Ann Surg, 2009, 249(3): 461-468.
29.	Wei CH, Scott AM, Price AN, et al. Psychosocial and sexual well-being following nipple-sparing mastectomy and reconstruction[J]. Breast J, 2016, 22(1): 10-17.
30.	Arora N, Patel R, Sohi G, et al. A scoping review of the application of BREAST-Q in surgical research[J]. JPRAS Open, 2023, 37: 9-23.
31.	Shamsunder MG, Polanco TO, McCarthy CM, et al. Understanding preoperative breast satisfaction among patients undergoing mastectomy and immediate reconstruction: BREAST-Q insights[J/OL]. Plast Reconstr Surg, 2021, 148(6): 891e-902e. DOI: 10.1097/PRS.0000000000008521.
32.	Ziolkowski NI, Pusic AL, Fish JS, et al. Psychometric findings for the SCAR-Q patient-reported outcome measure based on 731 children and adults with surgical, traumatic, and burn scars from four countries[J/OL]. Plast Reconstr Surg, 2020, 146(3): 331e-338e. DOI: 10.1097/PRS.0000000000007078.
33.	Toesca A, Sangalli C, Maisonneuve P, et al. A randomized trial of robotic mastectomy versus open surgery in women with breast cancer or BrCA mutation[J]. Annals of surgery, 2022, 276(1): 11-19.
34.	Yang H, Liang F, Feng Y, et al. Single axillary incision reverse sequence endoscopic nipple-sparing mastectomy in the management of gynecomastia: short-term cosmetic outcomes, surgical safety, and learning curve of the preliminary 156 consecutive procedures from a prospective cohort study[J]. Aesthetic Plast Surg, 2024, 48(16): 3120-3127.

1. Lai HW, Lin SL, Chen ST, et al. Single-axillary-incision endoscopic-assisted hybrid technique for nipple-sparing mastectomy: technique, preliminary results, and patient-reported cosmetic outcome from preliminary 50 procedures[J]. Ann Surg Oncol, 2018, 25(5): 1340-1349.
2. Zhang S, Xie Y, Liang F, et al. Video-assisted transaxillary nipple-sparing mastectomy and immediate implant-based breast reconstruction: a novel and promising method[J]. Aesthetic Plast Surg, 2022, 46(1): 91-98.
3. Yang B, Ren G, Song E, et al. Current status and factors influencing surgical options for breast cancer in China: a nationwide cross-sectional survey of 110 hospitals[J/OL]. Oncologist, 2020, 25(10): e1473-e1480. DOI: 10.1634/theoncologist.2020-0001.
4. Galimberti V, Vicini E, Corso G, et al. Nipple-sparing and skin-sparing mastectomy: review of aims, oncological safety and contraindications[J/OL]. Breast, 2017, 34: S82-S84. DOI: 10.1016/j.breast.2017.06.034.
5. Valero MG, Muhsen S, Moo TA, et al. Increase in utilization of nipple-sparing mastectomy for breast cancer: indications, complications, and oncologic outcomes[J]. Ann Surg Oncol, 2020, 27(2): 344-351.
6. Agarwal S, Agarwal S, Neumayer L, et al. Therapeutic nipple-sparing mastectomy: trends based on a national cancer database[J]. Am J Surg, 2014, 208(1): 93-98.
7. De Cicco C, Cremonesi M, Luini A, et al. Lymphoscintigraphy and radioguided biopsy of the sentinel axillary node in breast cancer[J]. J Nucl Med, 1998, 39(12): 2080-2084.
8. Gatzemeier W, Mann GB. Which sentinel lymph-node (SLN) positive breast cancer patient needs an axillary lymph-node dissection (ALND)-ACOSOG Z0011 results and beyond[J]. Breast, 2013, 22(3): 211-216.
9. Dai H, Cao X, Wu H, et al. Reverse-sequence endoscopic nipple-sparing mastectomy with direct-to-implant breast reconstruction and air inflation adjustment technique in patients with large or severely ptotic breast: a single-center prospective cohort study[J]. Int J Surg, 2025, 111(6): 3838-3849.
10. Madden JL. Modified radical mastectomy[J]. Surg Gynecol Obstet, 1965, 121(6): 1221-1230.
11. Pusic AL, Klassen AF, Cano SJ. Use of the BREAST-Q in clinical outcomes research[J/OL]. Plast Reconstr Surg, 2012, 129(1): 166e-167e. DOI: 10.1097/PRS.0b013e3182362e65.
12. Harris JR, Levene MB, Svensson G, et al. Analysis of cosmetic results following primary radiation therapy for stages Ⅰ and Ⅱ carcinoma of the breast[J]. Int J Radiat Oncol Biol Phys, 1979, 5(2): 257-261.
13. Klassen AF, Ziolkowski N, Mundy LR, et al. Development of a new patient-reported outcome instrument to evaluate treatments for scars: the SCAR-Q[J/OL]. Plast Reconstr Surg Glob Open, 2018, 6(4): e1672. DOI: 10.1097/GOX.0000000000001672.
14. Al-Hilli Z, Wilkerson A. Breast surgery: management of postoperative complications following operations for breast cancer[J]. Surg Clin North Am, 2021, 101(5): 845-863.
15. Hirsch EM, Seth AK, Dumanian GA, et al. Outcomes of tissue expander/implant breast reconstruction in the setting of prereconstruction radiation[J]. Plast Reconstr Surg, 2012, 129(2): 354-361.
16. Petit JY, Veronesi U, Luini A, et al. When mastectomy becomes inevitable: the nipple-sparing approach[J]. Breast, 2005, 14(6): 527-531.
17. Petit JY, Veronesi U, Orecchia R, et al. Nipple-sparing mastectomy in association with intra operative radiotherapy (ELIOT): a new type of mastectomy for breast cancer treatment[J]. Breast Cancer Res Treat, 2006, 96(1): 47-51.
18. Eaves FF 3rd, Bostwick J 3rd, Nahai F, et al. Endoscopic techniques in aesthetic breast surgery: augmentation, mastectomy, biopsy, capsulotomy, capsulorrhaphy, reduction, mastopexy, and reconstructive techniques[J]. Clin Plast Surg, 1995, 22(4): 683-695.
19. Liu H, Huang CK, Yu PC, et al. Retromammary approach for endoscopic resection of benign breast lesions[J]. World J Surg, 2009, 33(12): 2572-2578.
20. Ito KI, Kanai T, Gomi K, et al. Endoscopic-assisted skin-sparing mastectomy combined with sentinel node biopsy[J]. ANZ J Surg, 2008, 78(10): 894-898.
21. Kuo YL, Chang CH, Chang TY, et al. Endoscopy-assisted total mastectomy with and without immediate reconstruction: an extended follow-up, multicenter study[J]. Plast Reconstr Surg, 2021, 147(2): 267-278.
22. Yang JD, Lee J, Lee JS, et al. Aesthetic scar-less mastectomy and breast reconstruction[J]. J Breast Cancer, 2021, 24(1): 22-33.
23. Panchal H, Matros E. Current trends in postmastectomy breast reconstruction[J]. Plast Reconstr Surg, 2017, 140(5S): 7S-13S.
24. Song WJ, Kang SG, Kim EK, et al. Current status of and trends in post-mastectomy breast reconstruction in Korea[J]. Arch Plast Surg, 2020, 47(2): 118-125.
25. Héquet D, Zarca K, Dolbeault S, et al. Reasons of not having breast reconstruction: a historical cohort of 1937 breast cancer patients undergoing mastectomy[J/OL]. Springerplus, 2013, 2(1): 325. DOI: 10.1186/2193-1801-2-325.
26. De La Cruz L, Moody AM, Tappy EE, et al. Overall survival, disease-free survival, local recurrence, and nipple-areolar recurrence in the setting of nipple-sparing mastectomy: a meta-analysis and systematic review[J]. Ann Surg Oncol, 2015, 22(10): 3241-3249.
27. Moyer HR, Ghazi B, Daniel JR, et al. Nipple-sparing mastectomy: technical aspects and aesthetic outcomes[J]. Ann Plast Surg, 2012, 68(5): 446-450.
28. Gerber B, Krause A, Dieterich M, et al. The oncological safety of skin sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction: an extended follow-up study[J]. Ann Surg, 2009, 249(3): 461-468.
29. Wei CH, Scott AM, Price AN, et al. Psychosocial and sexual well-being following nipple-sparing mastectomy and reconstruction[J]. Breast J, 2016, 22(1): 10-17.
30. Arora N, Patel R, Sohi G, et al. A scoping review of the application of BREAST-Q in surgical research[J]. JPRAS Open, 2023, 37: 9-23.
31. Shamsunder MG, Polanco TO, McCarthy CM, et al. Understanding preoperative breast satisfaction among patients undergoing mastectomy and immediate reconstruction: BREAST-Q insights[J/OL]. Plast Reconstr Surg, 2021, 148(6): 891e-902e. DOI: 10.1097/PRS.0000000000008521.
32. Ziolkowski NI, Pusic AL, Fish JS, et al. Psychometric findings for the SCAR-Q patient-reported outcome measure based on 731 children and adults with surgical, traumatic, and burn scars from four countries[J/OL]. Plast Reconstr Surg, 2020, 146(3): 331e-338e. DOI: 10.1097/PRS.0000000000007078.
33. Toesca A, Sangalli C, Maisonneuve P, et al. A randomized trial of robotic mastectomy versus open surgery in women with breast cancer or BrCA mutation[J]. Annals of surgery, 2022, 276(1): 11-19.
34. Yang H, Liang F, Feng Y, et al. Single axillary incision reverse sequence endoscopic nipple-sparing mastectomy in the management of gynecomastia: short-term cosmetic outcomes, surgical safety, and learning curve of the preliminary 156 consecutive procedures from a prospective cohort study[J]. Aesthetic Plast Surg, 2024, 48(16): 3120-3127.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Latest ArticlesClinical efficacy of transaxillary endoscopic-assisted nipple-sparing mastectomy versus conventional open mastectomy

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