Current Evidence on Surgical Approach to Local Recurrence After Nipple-Sparing Mastectomy: Is It Time to Classify in Order to Decide Better?

Abstract

Aim: Nipple-sparing mastectomy has become an increasingly preferred surgical option for selected breast cancer patients, enabling immediate breast reconstruction with either prosthetic implants or autologous tissues while ensuring oncologic safety alongside favorable aesthetic and psychosocial outcomes. Despite its benefits, managing local recurrence remains a clinical concern. Current guidelines recommend complete excision when feasible, following the principles of conservative surgery. However, a standardized classification of local recurrence after conservative mastectomy is still lacking. This review aims to gather current evidence on the incidence, characteristics, and treatment of local recurrence following nipple-sparing mastectomy with immediate breast reconstruction. Additionally, it seeks to propose the development of a standardized classification system to support treatment decision-making and future research.

Methods: A targeted literature search was conducted in PubMed/MEDLINE, Scopus, and EMBASE to identify relevant articles published in English between 1 January 2013 and 31 December 2024. The search string used for PubMed was: ("nipple-sparing mastectomy" OR "skin-sparing mastectomy") AND ("local recurrence" OR "nipple recurrence" OR "chest wall recurrence") AND ("immediate reconstruction" OR "implant-based reconstruction"). For Scopus, the adapted string was: (TITLE-ABS-KEY ("nipple-sparing mastectomy" OR "skin-sparing mastectomy") AND TITLE-ABS-KEY ("local recurrence" OR "nipple recurrence" OR "chest wall recurrence") AND TITLE-ABS-KEY ("immediate reconstruction" OR "implant-based reconstruction")). For EMBASE, the adapted strategy was: ('nipple-sparing mastectomy'/exp OR 'skin-sparing mastectomy'/exp) AND ('local recurrence'/exp OR 'nipple recurrence' OR 'chest wall recurrence') AND ('immediate reconstruction' OR 'implant-based reconstruction'). We included only English-language publications and excluded conference abstracts, letters, and case reports. Given the narrative nature of this review, the process did not follow Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines, and no formal records of deduplication or structured screening flow diagrams were maintained.

Results: The reviewed literature reveals significant variability in defining and classifying local recurrence after nipple-sparing mastectomy with immediate reconstruction. This lack of consensus highlights the need for a clear and standardized classification system centered specifically on local recurrences, which could enhance risk stratification and guide personalized treatment strategies, thereby supporting the design of prospective studies and evidence-based guidelines.

Conclusions: The absence of a standardized approach to local recurrence after nipple-sparing mastectomy represents a critical gap in current breast cancer care. Establishing a dedicated classification could streamline clinical decision-making and lay the groundwork for large-scale prospective studies to inform future guidelines.

Keywords: breast cancer; classification system; local recurrence; nipple-sparing mastectomy; surgery.