Coincidental breast carcinoma detection in reduction mammaplasty specimens

Analysis of Incidentally Found Proliferative Lesions in Oncoplastic and Macromastia Breast Reductions

BACKGROUND

Reduction mammaplasty pathologic specimens can reveal incidentally found proliferative lesions. However, there is a lack of data investigating the comparative incidences and risk factors for such lesions.

METHODS

A retrospective review was conducted of all consecutively performed reduction mammaplasty cases at a single large academic medical institution in a metropolitan city by two plastic surgeons over a 2-year period. All reduction mammaplasties, symmetrizing reductions, and oncoplastic reductions performed were included. There were no exclusion criteria.

RESULTS

A total of 632 breasts were analyzed-502 reduction mammaplasties, 85 symmetrizing reductions, and 45 oncoplastic reductions-in 342 patients. Mean age was 43.9 ± 15.9 years, mean body mass index was 29.2 ± 5.7 kg/m 2 , and mean reduction weight was 610.0 ± 313.1 g. Patients who underwent reduction mammaplasty for benign macromastia had a significantly lower incidence (3.6%) of incidentally found breast cancers and proliferative lesions compared with patients with oncoplastic reductions (13.3%) and symmetrizing reductions (17.6%) ( P < 0.001). On univariate analysis, personal history of breast cancer ( P < 0.001), first-degree family history of breast cancer ( P = 0.008), age ( P < 0.001), and tobacco use ( P = 0.033) were all statistically significant risk factors. Using a backward elimination stepwise reduced multivariable logistic regression model for risk factors associated with breast cancer or proliferative lesions, age ( P < 0.001) was the only retained significant risk factor.

CONCLUSIONS

Proliferative lesions and carcinomas of the breast found in reduction mammaplasty pathologic specimens may be more common than previously reported. The incidence of newly found proliferative lesions was significantly lower in cases of benign macromastia compared with oncoplastic and symmetrizing reductions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Pathology Evaluation of Reduction Mammaplasty Specimens and Subsequent Diagnosis of Malignant Breast Disease: A Claims-Based Analysis

BACKGROUND

This study aimed to measure the use of pathology evaluation of breast specimens among patients undergoing reduction mammaplasty and assess rates of new diagnoses of breast disease and associated cost.

METHODS

We analyzed the Truven MarketScan Databases from 2009 to 2015 to identify adult female patients undergoing reduction mammaplasty for macromastia. We recorded patient age, rates of obtaining pathology evaluation, new diagnoses of benign or malignant breast disease after pathology evaluation, and total cost for the surgery encounter.

RESULTS

Among 17,738 macromastia patients undergoing reduction mammaplasty, 91.3% (n = 16,193) received pathology evaluation. Pathology evaluation rates were clinically similar across age groups <70 years (90.8-92.1%) and slightly lower for patients ≥70 (85.0%). Among 6987 patients less than 40 years who received pathology evaluation, 0.06% (n = 4) were subsequently diagnosed with malignant breast disease within 3 months, compared to 0.23% in the entire cohort (n = 37/16,193). Pathology claims resulted in an added $307 (SD 251) on average for the breast reduction surgery encounters.

CONCLUSIONS

Breast tissue after reduction mammaplasty is routinely submitted for pathology evaluation, without consideration of age-based risk for breast cancer. Routine pathology evaluation of breast tissue in patients in lower risk age groups (less than 40 years) required an additional $536,000 on average to detect a single occult breast cancer compared to an added $85,600 to detect a new malignancy in patients 40 years and older. Clinicians and policy makers should consider whether routine pathology evaluation of breast tissue should be individualized based on risk factors for breast cancer.

Recommendations for Pathologic Evaluation of Reduction Mammoplasty Specimens: A Prospective Study With Systematic Tissue Sampling

CONTEXT

- Breast reduction mammaplasty (RMP) for symptomatic macromastia or correction of asymmetry is performed in more than 100 000 patients per year in the United States. The reported incidence of significant pathologic findings (SPF), that is, carcinoma and atypical hyperplasia, ranges from 0.06% to 12.8%. No standard pathology assessment for RMP exists.

OBJECTIVES

- To propose standard sampling for microscopic evaluation in RMP specimens, to evaluate the incidence of occult carcinoma and atypical hyperplasia, and to identify clinical risk factors for SPF in patients undergoing RMP.

DESIGN

- All RMP specimens from 2006 to 2013 at a single institution were prospectively examined. After baseline gross and microscopic evaluations, each specimen was subjected to systematic additional sampling. The incidence of SPF was tabulated, and variables such as age, specimen weight, previous history of SPF, and results of preoperative mammogram were examined. Clinical follow-up review was also subsequently undertaken.

RESULTS

- A total of 595 patients were evaluated. Significant pathologic findings were present in 9.8% (58 of 595) of patients. No cancer was identified in patients younger than 40 years; the rates of carcinoma were 2.4% (14 of 595) in all patients, 3.6% (14 of 392) in patients aged 40 years or older, and 4.3% (10 of 233) in patients aged 50 years or older. No carcinoma or atypical hyperplasia was identified on preoperative mammogram. Increased sampling was associated with a significantly greater frequency of SPF only in patients aged 40 years or older.

CONCLUSIONS

- In patients younger than 35 years, gross-only evaluation is sufficient. However, increased sampling may be necessary in patients older than 40 years.

Should we be analysing breast reduction specimens? A systematic analysis of over 1,000 consecutive cases

BACKGROUND

Reduction mammoplasty (RM) continues to be popular. The reported incidence of occult breast carcinoma in these specimens varies between 0.05 and 1.8 %. Literature review reveals a wide discrepancy in study methodology, outcome measures, and even what is constituted as a "significant" result. We set out to identify RM patients at increased risk of occult significant pathological findings to engender a systematic improvement in efficiency of those specimens sent for histopathological examination.

METHODS

A single-centre retrospective study of the pathology results for 1,388 consecutive RM patients was undertaken. Patients were divided into three groups according to indication for surgery: group 1, macromastia; group 2, developmental asymmetry; and group 3, symmetrising surgery after breast cancer reconstructive surgery.

RESULTS

Nine cases of occult carcinoma were found among the 1,388 women (0.65 %), all in patients over 35 years of age. Forty percent of all patients were under 35 years old. Histopathological analysis of 59 % of patients revealed nonsignificant findings. Patients with a breast cancer history were 4.3 times more likely to have occult breast cancer. Patients under 30 years of age had a significantly higher chance of nonsignificant findings than those over 30 (relative risk = 2.5).

CONCLUSIONS

Although the overall incidence of occult breast cancer in reduction mammaplasty patients remains low, specific subgroups with a higher risk are identified. It is recommended that histological analysis of specimens should be restricted to high-risk patients and those over 30 years of age as significant pathology is uncommon in younger patients. These results will promote health-care-related economic benefits and a reduction of the burden placed on histopathology departments.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article.

Carcinoma and atypical hyperplasia in reduction mammaplasty: increased sampling leads to increased detection. A prospective study

BACKGROUND

Reduction mammaplasty for symptomatic macromastia or correction of asymmetry is performed more than 100,000 times per year in the United States. The reported incidence of occult breast cancer in reduction mammaplasty ranges from 0.06 to 4.6 percent. No standard pathology assessment for reduction mammaplasty exists. The authors evaluated the incidence of occult carcinoma and atypical hyperplasia in reduction mammaplasty specimens and identified clinical risk factors. Systematic sampling of additional tissue sections was instituted to evaluate the hypothesis that increased sampling would identify more significant pathologic findings.

METHODS

All reduction mammaplasty specimens over a 20-month period at a single institution were prospectively examined. All specimens had baseline gross and microscopic evaluations, and then each was subjected to systematic additional sampling. The incidence of significant pathologic findings (carcinoma and atypical hyperplasia) was tabulated. Variables such as age and preoperative mammogram were examined.

RESULTS

A total of 202 cases were evaluated. Significant pathologic findings (carcinoma and atypical hyperplasia) were present in 12.4 percent. The rate of carcinoma was 4 percent in all patients (6.2 percent in patients >or=40 years and 7.9 percent in patients >or=50 years).

CONCLUSIONS

A significantly higher rate (12.4 percent) of significant pathologic findings was identified in this prospective study compared with published literature. None of the lesions was identified on preoperative mammogram. Age was significantly associated with significant pathologic findings. Increased sampling was associated with significant pathologic findings only in patients 40 years or older, indicating the need for thorough sampling of reduction mammaplasty specimens in patients older than 40.

Incidence of precancerous lesions in breast reduction tissue: a pathologic review of 562 consecutive patients

BACKGROUND

Reduction mammaplasty is the fifth most common reconstructive surgical procedure in the United States. The incidence of invasive breast cancer in breast reduction specimens is between 0.06 and 0.4 percent. However, the incidence of atypical hyperplasia and other precancerous lesions is not well described.

METHODS

The authors conducted a single-center retrospective chart review examining the incidence of benign and precancerous lesions in breast reduction specimens over a 5-year period.

RESULTS

Of the 562 patients who underwent reduction mammaplasty, 52.7 percent had nonproliferative or proliferative breast lesions. Twenty-five patients (4.4 percent) had a specimen containing atypical ductal or lobular hyperplasia. Six patients (1.1 percent) had ductal carcinoma in situ and four patients (0.7 percent) had lobular carcinoma in situ. No occult invasive breast cancer was identified in the breast reduction specimens, but one patient with ductal carcinoma in situ was found to have invasive breast cancer on completion mastectomy (0.2 percent).

CONCLUSION

This study demonstrates the importance of systematic analysis of breast reduction specimens to help identify and guide the management of patients with increased risk of breast cancer following reduction mammaplasty.

Symmetrization reduction mammaplasty combined with sentinel node biopsy in patients operated for contralateral breast cancer

BACKGROUND AND OBJECTIVES

Occult invasive cancer found in reduction mammaplasty specimen in the contralateral breast in breast cancer patients requires axillary lymph node dissection (ALND) to assess the lymph node status. Routine Sentinel node (SN) biopsy in these patients may avoid secondary ALND when an occult cancer is found and the SN is negative in the permanent histological examination.

METHODS

One hundred sixty-nine breast cancer patients underwent contralateral reduction mammaplasty for symmetrization and with SN biopsy of the non-cancer breast. SN mapping was done using a vital blue dye alone (n = 136) or in combination with a radiocolloid (n = 33).

RESULTS

A mean number of 1.4 SNs (range 1-3 SNs) was identified in 158 of 169 patients (identification rate 93.5%). One of 158 patients revealed a positive SN but no tumor was found in the reduction mammaplasty/mastectomy specimen, whereas the SN was negative in 157 patients. Histological examination of the 169 reduction mammaplasty specimen revealed 5 occult invasive cancers and 4 patients with high grade DCIS but due to a negative SN biopsy the patients were spared a secondary ALND.

CONCLUSION

The small number of patients with occult contralateral cancers may not warrant routine SN mapping in patients scheduled for contralateral reduction mammaplasty.

Risk of Breast Cancer among Reduction Mammaplasty Patients and the Strategies Used by Plastic Surgeons to Detect Such Cancer

BACKGROUND

Estimates of the occurrence of breast cancer among reduction mammaplasty patients vary from 0.05 to 1.66 percent, and the chance of finding such cancers is affected by the thoroughness of preoperative and postoperative examinations. The authors' aims were to make a more exact and age-specific estimation of this occurrence and to evaluate the strategies used by Netherlands plastic surgeons to detect these cancers.

METHODS

The annual number of reduction mammaplasty patients per 5-year age group and the annual age-specific incidence rate of breast cancer for the years 1992 through 2001 were obtained from two national registries. Using these, the authors estimated the expected number of breast cancers among reduction mammaplasty patients in each year. In 2002, the authors sent an anonymous questionnaire to 220 Dutch consultant and trainee plastic surgeons to evaluate their detection strategies.

RESULTS

The fraction of patients aged 50 years or older increased from 9.6 percent to 23 percent, and the estimated occurrence of breast cancer among patients increased from 0.05 percent to 0.11 percent. Responders to the questionnaire were inconsistent regarding their preoperative and postoperative detection strategies, with only 3 percent of them routinely requiring a preoperative mammogram and 75 percent of them routinely submitting the surgical specimen for histopathologic examination.

CONCLUSIONS

The occurrence of previously undetected breast cancer among reduction mammaplasty patients in The Netherlands is likely to increase further. The authors advocate preoperative mammography for all reduction mammaplasty patients aged 40 years or older and argue that a history and physical examination should be performed for all patients.

Cancer du sein diagnostiqué par la réduction mammaire. Étude rétrospective sur une période de trois ans

In the wake of three consecutive cases of microscopical examination of resection specimens following breast reduction revealing an adenocarcinoma, we wanted to point out the interest of a complete preoperative senological examination including mammography and postoperative anatomopathological examination. A retrospective study concerning 837 patients over a three-year period was conducted. We found seven patients (0.83%) with malignant breast cancer diagnosed on anatomopathological examination, which is comparable to the incidence found in literature. Of these seven cases there were four ductal adenocarcinomas (0.47%), all of them in situ (DCIS), and three lobular adenocarcinomas (0.36%) of which one invasive (ILA), one in situ (LCIS) and one mixed. The majority was aggressive, multifocal and bilateral. Treatment consisted of mastectomy with or without adjuvant therapy with curative intent in five out of seven cases, and this within two months after a esthetic surgery. In our opinion this shows that breast reduction can help in tracking down breast cancer and underlines the need for systematic and meticulous microscopic examination of resection specimens after breast reduction.

Management of breast carcinoma identified intraoperatively during reduction mammaplasty

Before reduction mammaplasty, patients should be assessed for breast cancer risk and evaluated with physical examination and mammography. Patients determined to be at increased risk should be informed of the possibility of occult breast carcinoma and the potential treatment options. Intraoperative discovery of an occult carcinoma may allow for breast conservation therapy under certain circumstances if an appropriate biopsy sample is taken from the tumor and if clear margins are obtained.