The impacts of neoadjuvant or adjuvant chemotherapy on surgical complications and cosmetic outcomes of reverse-sequence endoscopic nipple-sparing-mastectomy with immediate breast reconstruction

Background: The Reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) combined with immediate breast reconstruction (IBR) has garnered significant attention in China and is increasingly being adopted as a preferred surgical approach for breast cancer patients. However, limited data are available on how different chemotherapy regimens influence the outcomes of R-E-NSM with IBR. To address this gap, this prospective study aims to comprehensively compare postoperative complications and aesthetic outcomes among patients undergoing R-E-NSM with IBR who received no chemotherapy (NC), neoadjuvant chemotherapy (NAC), or adjuvant chemotherapy (AC). We hope to provide valuable insights that will inform clinical decision-making and optimize patient care. Methods: Patients who underwent R-E-NSM with IBR at the Breast Center of West China Hospital, Sichuan University, between April 2020 and December 2023, were stratified into three distinct groups: NC, NAC, and AC. This classification enabled a comprehensive analysis of surgical complications and cosmetic outcomes across the different treatment cohorts, providing valuable insights into the impact of chemotherapy timing on surgical outcomes and patient satisfaction. Findings: A total of 692 patients were prospectively enrolled in this study, including 241 (34.8%) patients who received NC, 113 patients (16.3%) who underwent NAC, and 338 (48.8%) who underwent AC. Compared to the other two groups, patients in the NAC group were younger (P < 0.05) and had a shorter median follow-up (P < 0.05). The AC group, but not the NAC group, showed higher rates of any complications compared to the NC group (26.6% vs. 14.2%, 2.188 [1.415-3.383], P=0.001). Specifically, the AC group had higher rates of particular treatment complications [Clavien-Dindo classification (CDC) ≥ 2] (20.7% vs. 12.6%, 1.820 [1.144-2.895], P=0.036) and surgical site infections (SSI) (18.0% vs. 8.8%, 2.240 [1.322-3.797], P=0.003). Further analysis found that these differences mainly arose more than 30 days after the surgery (any, CDC ≥ 2, SSI, P<0.05). On multivariable analysis, there were significant differences in any complications across the entire time (OR, 1.680 [95% CI, 1.015-2.711], p=0.044) and SSI that occurred more than 30 days after surgery (OR, 2.346 [95% CI, 0.991-5.556], p=0.052) between NC and AC groups. After controlling for clinical covariates, no significant differences were observed between the three groups in terms of the BREAST-Q subscales and Ueda score. Interpretation: In patients undergoing R-E-NSM followed by IBR, the administration of adjuvant chemotherapy (AC), but not neoadjuvant chemotherapy (NAC) when surgery is performed more than 21 days after NAC, may lead to a higher incidence of postoperative complications compared to those who do not receive chemotherapy. However, cosmetic outcomes, as assessed by Breast-Q and Ueda scores, are not significantly influenced by the use of no chemotherapy (NC), NAC, or AC.