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Invited Critique
November 17, 2008

Nipple-Sparing Mastectomy Update—Invited Critique

Arch Surg. 2008;143(11):1110. doi:10.1001/archsurg.143.11.1110

When considering NSM, the most important factor is the oncologic safety of the procedure. There are populations of patients, specifically those undergoing prophylactic mastectomy, where NSM is a good choice. However, in patients with breast cancer, the oncologic safety becomes paramount. The Crowe et al article is a triumph in number of cases and developed technique, but it provides less convincing evidence that NSM is oncologically sound.

To know if this is a safe cancer operation, we must determine if the risk of local recurrence is increased by leaving the NAC. Of the 43 patients with invasive breast cancer reported, 4 developed recurrence, a 9% recurrence rate. The recurrence rate after mastectomy is 3% to 6%, and for lumpectomy and radiation therapy, it is 6% to 8%. One must question whether NSM results in equivalent local control compared with standard therapies. While the recurrences reported herein are not at the NAC, the recurrence rate is relatively high in a breast cancer population selected for low-risk disease. Crowe et al report strict selection criteria that would predict a low risk for local recurrence; however, the evidence establishing those selection criteria is not described nor is the expected local recurrence after standard mastectomy in the same population.