PURPOSE: Immunotherapy agents are now increasingly used in the neoadjuvant setting for breast cancer, but little is known about their potential impact on breast reconstructive outcomes. As a clinical trial center with higher use of immune-checkpoint inhibitors, we present our institutional experience with nipple-sparing mastectomy (NSM) outcomes after neoadjuvant immunomodulation.
METHODS: A retrospective review of patients who underwent nipple-sparing mastectomy with any reconstruction from January 2018 through January 2022 was performed. Demographic, chemotherapeutic, intraoperative, and post-operative variables were recorded.
RESULTS: We identified 819 NSMs in 482 patients. 304 (37.1%) were exposed to neoadjuvant cancer therapy, and 41 (13.5%) received immune-checkpoint block with PD1/PDL1 inhibitors. When comparing these 41 to the other 778 NSMs, there were no significant differences in nipple-areolar complex (NAC) necrosis, mastectomy flap necrosis, incisional breakdown, infections, explant, seroma, or expander complications (p>0.05). However, when comparing the 41 patients who were treated with PD1/PDL1 inhibitors to the other 304 neoadjuvant therapy-exposed mastectomies, there was significantly more NAC necrosis (9.8% vs 3%, p=0.040) and full thickness NAC necrosis (7.3% vs 1.9%, p=0.044). In regression analysis, periareolar incisions increased odds of nipple necrosis 18x (OR 18.8, p=0.006) while neoadjuvant immunomodulator therapy was not significant (OR 2.3, p=0.210).
CONCLUSION: Immune-checkpoint blockade was not associated with increased complications, but periareolar incisions increased the odds of NAC necrosis in this neoadjuvant cohort by 18-fold. Neoadjuvant immunotherapy should not preclude any reconstruction, but may impact tissue perfusion and wound healing, as periareolar incisions were increasingly associated with nipple necrosis.