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.

Rate of Incidental Pathological Lesions ın Reduction Mammoplasty Specimens and Incidence of Invasive Breast Carcinoma Following Breast Reduction Operation

INTRODUCTION

Reduction mammoplasty (RM) is one of the most frequently performed surgical procedures. The incidental determination of significant pathologic lesions (SPL), that is precursor and malignant lesions, in RM specimens is rare. The aim of this study was to determine the frequency of SPL in RM specimens, to evaluate the relationship between SPL and clinicopathological factors, and to examine the incidence of invasive breast carcinoma forming in the remaining breast tissue during the postoperative follow-up period developing in patients after RM operation.

MATERIAL AND METHOD

This retrospective study included 874 females who underwent RM operation between January 2012 and January 2021. Demographic, clinicopathological findings, and preoperative radiological findings were recorded. The patients were followed up after the RM operation in respect of the first occurrence of breast cancer.

RESULTS

Invasive carcinoma was determined in 0.2% and SPL in 3.5% in RM. The probability of SPL determination was greater in patients aged ≥ 40 years and with ≥ 4 paraffin blocks (p=0.038, p=0.01, respectively). No statistically significant difference was found between patients with and without SPL in respect of radiological findings (p=0.35). The mean postoperative follow-up period was 53.6 months, and invasive carcinoma was diagnosed during follow-up in 0.2% of all patients (6.9% of the patients with SPL).

CONCLUSION

Age over 40 years and an increased number of sampled blocks were found to be factors increasing the possibility of the determination of precursor and malignant lesions in RM specimens. RM could decrease the risk of the development of breast cancer.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Mastectomy in Transgender and Cisgender Patients: A Comparative Analysis of Epidemiology and Postoperative Outcomes

Background:

Mastectomy is a commonly requested procedure in the transmasculine population and has been shown to improve quality of life, although there is limited research on safety. The aim of this study was to provide a nationwide assessment of epidemiology and postoperative outcomes following masculinizing mastectomy and compare them with outcomes following mastectomy for cancer prophylaxis and gynecomastia correction in cisgender patients.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2017 was queried using International Classification of Diseases and Current Procedural Terminology codes to create cohorts of mastectomies for 3 indications: transmasculine chest reconstruction, cancer risk-reduction (CRRM), and gynecomastia treatment (GM). Demographic characteristics, comorbidities, and postoperative complications were compared between the 3 cohorts. Multivariable regression analysis was used to control for confounders.

Results:

A total of 4,170 mastectomies were identified, of which 14.8% (n = 591) were transmasculine, 17.6% (n = 701) were CRRM, and 67.6% (n = 2,692) were GM. Plastic surgeons performed the majority of transmasculine cases (85.3%), compared with the general surgeons in the CRRM (97.9%) and GM (73.7%) cohorts. All-cause complication rates in the transmasculine, CRRM, and GM cohorts were 4.7%, 10.4%, and 3.7%, respectively. After controlling for confounding variables, transgender males were not at an increased risk for all-cause or wound complications. Multivariable regression identified BMI as a predictor of all-cause and wound complications.

Conclusion:

Mastectomy is a safe and efficacious procedure for treating gender dysphoria in the transgender male, with an acceptable and reassuring complication profile similar to that seen in cisgender patients who approximate either the natal sex characteristics or the new hormonal environment.

Combined Breast Reduction Augmentation

BACKGROUND

Numerous methods have been designed to reduce breasts size and weight. The goal today is to not only to reduce size but also to create a pleasing shape. Breast reduction techniques do not obtain the desired upper pole fullness, and commonly recurrent ptosis develops. To improve and maintain breast shape in the late postoperative period, we combine breast reduction with implants.

METHODS

Three hundred and sixty-six patients who underwent combined breast reduction or mastopexy with implants from January 2014 to November 2017 at IM Clinic were retrospectively reviewed. We present the indications, surgical technique, and outcomes of these patients to determine the safety and efficacy of our technique.

RESULTS

No major complications were noted in an average of 2 years of follow-up (range 2 months to 4 years). Minor complications occurred in 61 patients, of whom 46 required revision surgery (12.6%). The most common tissue-related complications were dog ears (7.6%) and poor scarring (4.9%). The most common implant-related complication was capsular contracture (0.8%).

CONCLUSIONS

Breast reduction with implants is a reliable option to provide additional volume to the upper pole of the breast to improve long-term breast shape and avoid ptosis recurrence. Our study indicates that the procedure is safe and has complication and revision rates comparable to traditional breast reduction or augmentation mastopexy techniques.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Risk-reducing mastectomy for the prevention of primary breast cancer

BACKGROUND

Recent progress in understanding the genetic basis of breast cancer and widely publicized reports of celebrities undergoing risk-reducing mastectomy (RRM) have increased interest in RRM as a method of preventing breast cancer. This is an update of a Cochrane Review first published in 2004 and previously updated in 2006 and 2010.

OBJECTIVES

(i) To determine whether risk-reducing mastectomy reduces death rates from any cause in women who have never had breast cancer and in women who have a history of breast cancer in one breast, and (ii) to examine the effect of risk-reducing mastectomy on other endpoints, including breast cancer incidence, breast cancer mortality, disease-free survival, physical morbidity, and psychosocial outcomes.

SEARCH METHODS

For this Review update, we searched Cochrane Breast Cancer's Specialized Register, MEDLINE, Embase and the WHO International Clinical Trials Registry Platform (ICTRP) on 9 July 2016. We included studies in English.

SELECTION CRITERIA

Participants included women at risk for breast cancer in at least one breast. Interventions included all types of mastectomy performed for the purpose of preventing breast cancer.

DATA COLLECTION AND ANALYSIS

At least two review authors independently abstracted data from each report. We summarized data descriptively; quantitative meta-analysis was not feasible due to heterogeneity of study designs and insufficient reporting. We analyzed data separately for bilateral risk-reducing mastectomy (BRRM) and contralateral risk-reducing mastectomy (CRRM). Four review authors assessed the methodological quality to determine whether or not the methods used sufficiently minimized selection bias, performance bias, detection bias, and attrition bias.

MAIN RESULTS

All 61 included studies were observational studies with some methodological limitations; randomized trials were absent. The studies presented data on 15,077 women with a wide range of risk factors for breast cancer, who underwent RRM.Twenty-one BRRM studies looking at the incidence of breast cancer or disease-specific mortality, or both, reported reductions after BRRM, particularly for those women with BRCA1/2 mutations. Twenty-six CRRM studies consistently reported reductions in incidence of contralateral breast cancer but were inconsistent about improvements in disease-specific survival. Seven studies attempted to control for multiple differences between intervention groups and showed no overall survival advantage for CRRM. Another study showed significantly improved survival following CRRM, but after adjusting for bilateral risk-reducing salpingo-oophorectomy (BRRSO), the CRRM effect on all-cause mortality was no longer significant.Twenty studies assessed psychosocial measures; most reported high levels of satisfaction with the decision to have RRM but greater variation in satisfaction with cosmetic results. Worry over breast cancer was significantly reduced after BRRM when compared both to baseline worry levels and to the groups who opted for surveillance rather than BRRM, but there was diminished satisfaction with body image and sexual feelings.Seventeen case series reporting on adverse events from RRM with or without reconstruction reported rates of unanticipated reoperations from 4% in those without reconstruction to 64% in participants with reconstruction.In women who have had cancer in one breast, removing the other breast may reduce the incidence of cancer in that other breast, but there is insufficient evidence that this improves survival because of the continuing risk of recurrence or metastases from the original cancer. Additionally, thought should be given to other options to reduce breast cancer risk, such as BRRSO and chemoprevention, when considering RRM.

AUTHORS' CONCLUSIONS

While published observational studies demonstrated that BRRM was effective in reducing both the incidence of, and death from, breast cancer, more rigorous prospective studies are suggested. BRRM should be considered only among those at high risk of disease, for example, BRCA1/2 carriers. CRRM was shown to reduce the incidence of contralateral breast cancer, but there is insufficient evidence that CRRM improves survival, and studies that control for multiple confounding variables are recommended. It is possible that selection bias in terms of healthier, younger women being recommended for or choosing CRRM produces better overall survival numbers for CRRM. Given the number of women who may be over-treated with BRRM/CRRM, it is critical that women and clinicians understand the true risk for each individual woman before considering surgery. Additionally, thought should be given to other options to reduce breast cancer risk, such as BRRSO and chemoprevention when considering RRM.

Bilateral mastectomy and the retreat from breast-conserving surgery

The purpose of this study is to assess the consequences for breast cancer patients of the trend away from breast conservation in favor of bilateral and contralateral mastectomy. The methods are followed from the review of the literature from 1991 to 2015. Breast-conserving surgery and sentinel lymph node biopsy, introduced into mainstream practice in the 1980s and 1990s, respectively, are now the standard of care for early-stage breast cancer. Disruptive change has unexpectedly supervened in the guise of bilateral mastectomy for cancer or prophylaxis and contralateral prophylactic mastectomy. These operations are now being resorted to at a rate which cannot be explained by any of the biological imperatives related to breast cancer and related diseases. This phenomenon extends across the Western world and beyond, driven by patients' cancer concern, a misunderstanding of what surgery can and cannot achieve and preserve, and the current popular media/cultural environment. These developments and their consequences for patients are reviewed. Surgical complications, especially those related to reconstruction, are unusually common. Of equal or greater concern are the physical, esthetic, psychosocial, psychosexual morbidities, and other adverse sequelae of these operations.

Quality of Life Following Symptomatic Macromastia Surgery: Short- and Long-term Evaluation

Mammary hypertrophy or macromastia can cause a wide range of symptoms (physical, psychosomatic or behavioral), which affect patients' quality of life. Breast reduction can, in most of the cases, solve the problem. However, certain factors could have a negative effect on the outcome of surgery. The aims of this study were to discover the degree of patient satisfaction (short- and long-term) and to evaluate results of reduction mammoplasty, and also to ascertain which factors may have a negative role on the effectiveness of breast reduction surgery. We carried out a prospective and longitudinal study of 121 patients who underwent breast reduction surgery. Quality of life, outcome of surgery (complications and sequelae) and degree of patient satisfaction were evaluated at 1 month and at 1 year after reduction mammoplasty. Mean patient age was 40.71 (SD = 12.02). Among them, 35.5% were overweight, 44.6% were obese and 34.7% were smokers. The most common symptom was pain. The mean amount of resected breast tissue was 1785 g (SD = 876). A total of 27.3% of the patients suffered complications and 30.60% suffered sequelae. Our results show an improvement in symptoms (p < 0.001) and quality of life (p < 0.001 to p = 0.002) 1 month after and 1 year after breast reduction compared with the preoperative situation. Neither age, body mass index, smoking habit nor the amount of tissue removed had a negative effect on the results of surgery. One year after surgery, the majority of patients were satisfied with the outcome (96.6%), they would recommend it to others (96.6%), and they would undergo surgery a second time (95.8%).

CONCLUSIONS

Breast reduction is highly efficient in resolving symptoms and in improving quality of life. It leads to a high level of short- and long-term satisfaction irrespective of each patient's individual characteristics.

Impact of increasing age on breast reduction surgery: A single centre analysis

BACKGROUND

Women with hypertrophic breasts suffer for physical and psychological reasons. Breast reduction surgery is a safe procedure that can effectively improve symptoms and quality of life. As most studies have been performed in younger women, little is known about complications and long-term patient satisfaction in elderly women.

PATIENTS AND METHODS

We analysed complication rates and patient satisfaction in women aged 60 years and older who underwent a bilateral reduction mammaplasty. Patient satisfaction was measured with a validated questionnaire (client satisfaction questionnaire (CSQ)-8). The results obtained were compared to those of a control group including women aged 35 years and younger.

RESULTS

Twenty-five women met the inclusion criteria in each group. The mean age in the elderly and young was 65.4 and 23.4 years, respectively. Older women had more comorbidities (35 vs. 9, p < 0.05). The average overall resection weight was 1684.4 g with slightly lower resection weights in younger women (1541 vs. 1828 g; p = 0.34). Eight women in the young group and 11 in the elderly developed minor complications (p = 0.56). Two women in the young group had major complications. Patient satisfaction was significantly higher in older women, with a mean score of 27.3 in the young and 30.3 in the elderly (maximum score of CSQ-8: 32, p < 0.05).

CONCLUSIONS

Age is not a contraindication for reduction mammaplasty. Breast reduction surgery is a safe procedure in elderly women and leads to even higher patient satisfaction. Level of evidence: IV.

Breast size and breast cancer: a systematic review

BACKGROUND

There are many known breast cancer risk factors, but traditionally the list has not included breast size. The aim of this study was to synthesize the literature on breast size as a risk factor for breast carcinoma by examining studies addressing this question both directly and indirectly.

METHODS

A systematic review was performed searching MEDLINE from 1950 to November 2010, and updated again in February 2014. Literature was sought to assess the relationship between the following variables and breast cancer: 1) breast size; 2) breast reduction; 3) breast augmentation; and 4) prophylactic subcutaneous mastectomy. Findings were summarized and the levels of evidence were assessed.

RESULTS

50 papers were included in the systematic review. Increasing breast size appears to be a risk factor for breast cancer, but studies are limited by their retrospective nature, imperfect size measurement techniques and confounding variables. The evidence is stronger for risk reduction with breast reduction, including prophylactic subcutaneous mastectomy at the extreme. Generally the breast augmentation population has a lower risk of breast cancer than the general population, but it is unclear whether or not this is related to the bias of small breasts in this patient population and the presence of other confounders.

CONCLUSIONS

There is direct and indirect evidence that breast size is an important factor in the risk of developing breast cancer. Plastic surgeons are in a unique position to observe this effect. Well-designed prospective studies are required to further assess this risk factor.

Nipple-sparing mastectomy: considerations and techniques

SUMMARY Nipple-sparing mastectomy (NSM) is the next step in the natural progression of tissue preservation breast cancer surgery. NSM selection criteria are a balance between oncologic and cosmetic considerations; accurate ascertainment of nipple involvement is critical. Further selection should be based on patients with the greatest likelihood of viable flaps and the ability to maintain symmetrical breasts. Surgical technique focuses on incision selection and creating thin flaps with removal of the majority of breast tissue. Risk assessment for long-term recurrence is necessary with proponents for pre-, intra- and post-operative assessment. Prospective studies show low rates of local recurrence of the nipple–areolar complex and are comparable to skin-sparing mastectomy with short-term follow-up in highly select groups of patients. Extended follow-up will be helpful in determining long-term outcomes. Nipple necrosis is an outcome that should be considered. Studies may support improved quality of life and patient satisfaction with NSM, and it is likely to be a safe and feasible procedure that may benefit carefully selected patients.

Comparing breast-reduction techniques: time-to-event analysis and recommendations

BACKGROUND

Breast reduction is a common procedure used to improve physical and aesthetic factors associated with breast hypertrophy. This study investigated how surgical technique alone affects the risk factors for complications and profiled differences between techniques. Complications were assessed by the use of time-to-event methods.

METHODS

Patient information was extracted from a cohort of 283 patients. Demographic, surgical, and follow-up information was analyzed for patients undergoing surgical procedures using the inferior pedicle Wise pattern (IPWP) and modified Hall-Findlay (MHF) techniques. The patients managed with the IPWP technique were considered control subjects. The failure rates were described using the Kaplan-Meier failure estimator to provide a true estimate of the experienced complication rates.

RESULTS

Overall, few differences were noted between the groups except for total tissue removed. The overall failure (complication) rate at 6 months was 18.8%, with 9% of all the patients experiencing a major complication that required operative intervention/revision. As expected, the period with the greatest risk of complication was the first month after surgery. Surgical technique, total tissue removed, and age were nonpredictive of complications. Overall, the IPWP group had significantly more total tissue removed than the MHF group (median difference, 227 g; P=0.002). There was no evidence of a learning curve when an experienced surgeon moved from the one technique to the other.

CONCLUSION

At 6 months after surgery, 19% of patients are expected to have experienced a complication. There appears to be few differences in outcomes between the techniques of breast reductions used, and the success or otherwise almost certainly relates to factors independent of surgical technique and includes patient selection, operative skill, and experience. Time-to-event analysis provides a precise assessment and description of the complication profile.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Macromastia: a risk factor for carpal tunnel syndrome?

PURPOSE

To evaluate the prevalence of carpal tunnel syndrome (CTS) in a cohort of women with macromastia and to assess the evolution of the CTS signs and symptoms after breast surgery.

POPULATION

A series of 123 women was evaluated. CTS was defined by co-existence of symptoms, two physical findings and electrophysiological evaluation. One year after reduction mammaplasty, the 22 patients who had been diagnosed CTS were re-evaluated.

RESULTS

CTS group of women had a mean age of 38.8 years, mean body mass index of 28.5 kg/m(2) and mean breast size of 35.9 cm. Age and nipple-to-sternal notch distance were statistically significantly associated with CTS (p = 0.001 and p = 0.001, respectively). A year after surgery 15 patients were re-assessed: nine patients reported absence or improvement of CTS symptoms while six patients reported symptoms persistence or worsening.

CONCLUSION

Age, breast size, but not body mass index, have a positive correlation with the CTS.

The evaluation of contralateral breast lesions in breast cancer patients using reduction mammoplasty

Purpose

This study evaluated the importance of routine pathological examination of contralateral breast specimens in breast cancer patients using reduction mammoplasty.

Methods

The weight of breast tissue resected from the contralateral breast in 71 patients and the number of slices used for pathological evaluation were recorded. Breast lesions found in the contralateral breast and accompanying lesions with tumors were examined.

Results

High risk proliferative lesions were reported in the contralateral breast of eight (11.2%) patients, and low-risk lesions were detected in 18 (25%). While the mean age of the patients with high-risk lesions was 45.6, it was 52.8 for the other patients (p=0.036).

Conclusion

Bilateral reduction mammoplasty may be beneficial to delineate some pathologies in contralateral breasts even in those patients with normal clinical and radiological findings. The incidental discovery of these pathologies is much more likely in young breast cancer patients.

Extended indications for nipple-sparing mastectomy

Ablative breast cancer surgery still includes the routine excision of the nipple-areola complex (NAC). Nipple-sparing mastectomy (NSM) removes the breast tissue leaving no or little retroareolar ductal tissue but preserves the entire skin of the breast and the NAC. There is some consensus that NSM might be an oncologically safe option for patients with small and peripherally located tumors and probably for high-risk patients with prophylactic mastectomy. Several studies demonstrated that NSM may be feasible even in patients with large centrally located tumors or multicentric invasive carcinoma. So far, no generally applicable indications for NSM have been defined because long-term data are still limited. However, from our review of the literature obtained from a MEDLINE search (2003-2009) we conclude that the range of indications for NSM needs not to be limited to small peripheral tumors or to prophylactic treatment.

Prophylactic mastectomy for the prevention of breast cancer

BACKGROUND

Recent progress in understanding the genetic basis of breast cancer has increased interest in prophylactic mastectomy (PM) as a method of preventing breast cancer.

OBJECTIVES

(i) To determine whether prophylactic mastectomy reduces death rates from any cause in women who have never had breast cancer and in women who have a history of breast cancer in one breast, and (ii) to examine the effect of prophylactic mastectomy on other endpoints, including breast cancer incidence, breast cancer mortality, disease-free survival, physical morbidity, and psychosocial outcomes.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2002), MEDLINE and Cancerlit (1966 to June 2006), EMBASE (1974 to June 2006), and the WHO International Clinical Trials Registry Platform (WHO ICTRP) search portal (until June 2006). Studies in English were included.

SELECTION CRITERIA

Participants included women at risk for breast cancer in at least one breast. Interventions included all types of mastectomy performed for the purpose of preventing breast cancer.

DATA COLLECTION AND ANALYSIS

At least two authors independently abstracted data. Data were summarized descriptively; quantitative meta-analysis was not feasible due to heterogeneity of study designs and insufficient reporting. Data were analyzed separately for bilateral prophylactic mastectomy (BPM) and contralateral prophylactic mastectomy (CPM).

MAIN RESULTS

All 39 included studies were observational studies with some methodological limitations; randomized trials were absent. The studies presented data on 7,384 women with a wide range of risk factors for breast cancer who underwent PM.BPM studies on the incidence of breast cancer and/or disease-specific mortality reported reductions after BPM particularly for those with BRCA1/2 mutations. For CPM, studies consistently reported reductions in incidence of contralateral breast cancer but were inconsistent about improvements in disease-specific survival. Only one study attempted to control for multiple differences between intervention groups and this study showed no overall survival advantage for CPM at 15 years. Another study showed significantly improved survival following CPM but after adjusting for bilateral prophylactic oophorectomy, the CPM effect on all-cause mortality was no longer significant.Sixteen studies assessed psychosocial measures; most reported high levels of satisfaction with the decision to have PM but more variable satisfaction with cosmetic results. Worry over breast cancer was significantly reduced after BPM when compared both to baseline worry levels and to the groups who opted for surveillance rather than BPM.Case series reporting on adverse events from PM with or without reconstruction reported rates of unanticipated re-operations from 4% in those without reconstruction to 49% in patients with reconstruction.

AUTHORS' CONCLUSIONS

Sixteen studies have been published since the last version of the review, without altering our conclusions. While published observational studies demonstrated that BPM was effective in reducing both the incidence of, and death from, breast cancer, more rigorous prospective studies (ideally randomized trials) are needed. BPM should be considered only among those at very high risk of disease. There is insufficient evidence that CPM improves survival and studies that control for multiple confounding variables are needed.

Outcome of oncoplastic breast surgery in 90 prospective patients

BACKGROUND

Oncoplastic breast surgery refers to a wide range of techniques with a parallel goal of safely removing all malignant breast tissue while achieving the best possible esthetic outcome. We report the results of our oncoplastic breast operations from 2005 to 2007.

METHODS

Ninety selected breast cancer patients were treated with a variety of oncoplastic operations. The patients were prospectively monitored. Radiotherapy and systemic adjuvant treatment were given according to national guidelines.

RESULTS

Fifteen patients had an immediate surgical complication, of which 8 required a reoperation. Eleven patients had an inadequate surgical margin and required a completion mastectomy. During a median follow-up of 26 months no local or regional recurrences were noticed. Three patients developed distant metastases.

CONCLUSIONS

Oncoplastic breast surgery offers tools for breast conservation in patients otherwise destined for mastectomy or poor esthetic outcome. Despite the high proportion of patients in this series with large-volume ductal carcinoma in situ (DCIS) or extensive intraductal component, the use of oncoplastic techniques achieved negative margins with acceptable cosmetic results in the majority (84%) of patients.

Familial and racial determinants of tumour suppressor genes promoter hypermethylation in breast tissues from healthy women

To determine the hypermethylation status of the promoter regions of tumour suppressor genes in breast tissues from healthy women and identify the determinants of these epigenetic changes. Questionnaires and breast tissues were collected from healthy women without a history of cancer and undergoing reduction mammoplasty (N= 141). Methylation for p16^INK4, BRCA1, ERα and RAR-β promoter regions from breast tissues were determined by methylation specific PCR. Associations were examined with chi-square and Fisher’s exact test as well as logistic regression. All statistical tests were two-sided. p16^INK4, BRCA1, ERα and RAR-β hypermethylation were identified in 31%, 17%, 9% and 0% of the women, respectively. Women with BRCA1 hypermethylation had an eight-fold increase in the risk of ERα hypermethylation (P= 0.007). p16^INK4 hypermethylation was present in 28% of African-Americans, but 65% in European-Americans (P= 0.02). There was an increased likelihood of p16^INK4 or BRCA1 hypermethylation for women with family history of cancer (OR 2.3; 95%CI: 1.05–4.85 and OR 5.0; 95%CI: 1.55–15.81, respectively). ERα hypermethylation was associated with family history of breast cancer (OR 6.6; 95%CI: 1.58–27.71). After stratification by race, p16^INK4 in European-Americans and BRCA1 hypermethylation in African-Americans were associated with family history of cancer (OR 3.8; 95%CI: 1.21–12.03 and OR 6.5; 95%CI: 1.33–31.32, respectively). Gene promoter hypermethylation was commonly found in healthy breast tissues from women without cancer, indicating that these events are frequent and early lesions. Race and family history of cancer increase the likelihood of these early events.

Nipple-sparing mastectomy: where are we now?

Surgical treatment of breast cancer has evolved from radical mastectomy with routine removal of the nipple-areolar complex (NAC) to breast conservative therapy with preservation of the breast and NAC. When breast conservation is not appropriate or the patient desires mastectomy for risk reduction, conventional therapy still consists of mastectomy with removal of the NAC, followed by reconstruction. Rising interest in improved cosmesis has led to the introduction of the skin-sparing and nipple-sparing mastectomy (NSM) as potential alternatives to mastectomy. There has been much controversy regarding the oncologic safety of these procedures, and the NSM has also introduced a set of complications, such as nipple and areolar necrosis, that are not a concern with total mastectomy. From our review of the literature, we feel that NSM may be a viable option in the appropriate setting, and that its risks and complications are acceptable when compared to the traditional surgical treatment of breast cancer.

Oncoplastic surgery of the breast: Rationale and experience of 30 cases

A definition of oncoplastic surgery of the breast is presented, and its objectives and advantages over the usual conservative procedures are discussed. The oncological safety of these procedures are demonstrated, especially in surgery of larger tumors. Technical possibilities are discussed and a classification of the procedures presented. Data from 30 cases operated in our institution are depicted. The need for better training of the breast surgeon is discussed and the advantages of the same surgeon to perform the whole procedure presented.

The influence of reduction mammaplasty techniques in synchronous breast cancer diagnosis and metachronous breast cancer prevention

BACKGROUND

Although reduction mammaplasty (RM) is a well-described technique for cosmetic objectives, there are few reports regarding its bilateral application combined with oncologic breast surgery in patients with breast cancer. The purpose of this study is to analyze the role of RM in the contralateral breast (CB) synchronous cancer (SBC) incidence, the impact in risk reduction for metachronous breast cancer (MBC), the disease-free period, and overall survival

METHODS

Patients were divided into 2 groups; group I: 114 pts submitted to oncologic surgery associated with immediate CB RM. Group II: 135 pts without CB RM. Mean time of follow-up was 51.5 months for both groups. Data regarding age, tumor size, histologic type and grade, clinical stage, and adjuvant therapy were collected

RESULTS

Except for the CB RM, no differences were observed between the groups. In group I, the diagnosis of an occult, synchronic, and invasive carcinoma was noted in 1.8%, in situ in 2.6%, and MBC in 1.8%. In group II, MBC was observed in 6.7%. No difference was observed between the 2 groups (P = 0.062). The initiation of adjuvant therapy, the disease-free period, and overall survival were not influenced by the CB RM.

CONCLUSION

CB RM is a reliable technique providing an opportunity for diagnosis of an occult SBC. There is evidence of reduction of MBC; however, a larger number of patients are necessary for significant conclusions. The technique should be considered in combination with immediate breast reconstruction. Success depends on patient selection and careful intraoperative management.

Management of the BRCA Mutation Carrier or High-Risk Patient

Women who are at high risk of breast cancer are eligible for several risk management strategies including intensified surveillance, chemoprevention, and prophylactic surgery. This article reviews and summarizes the risk factors associated with breast cancer, the different risk calculation models available, and risk management strategies.

Cancer incidence in a cohort of Ontario and Quebec women having bilateral breast augmentation

The possibility that women, who receive breast implants for cosmetic purposes, have increased long-term risks of developing cancer continues to be debated. The objective of our study was to prospectively examine cancer incidence among women who received breast implants. A cohort was assembled of 24,558 women, 18 years of age and older, who underwent bilateral cosmetic breast augmentation, and 15,893 women who underwent other cosmetic procedures in Ontario or Quebec between 1974 and 1989. These plastic surgery patients were selected from the same clinics as the implant population. Incident cancers were identified by linking to Canadian registry data up to December 31, 1997. In total, 676 cancers were identified among women who received breast implants compared to 899 expected based on general population rates (standardized incidence ratio (SIR) = 0.75; 95% confidence interval (CI) = 0.70-0.81). Overall cancer incidence rates among women who received breast implants were similar to that of the other plastic surgery patients (relative risk (RR) = 0.91, 95% CI = 0.81-1.02). However, women who received breast implants had lower breast cancer rates than the plastic surgery patients (RR = 0.64, 95% CI = 0.53-0.79). No increased risks were observed among the implant population for any of the other cancer sites examined. Comparisons involving only women who received breast implants found no association between long-term breast cancer incidence and implant site (submuscular vs. subglandular), fill (saline vs. silicone) or envelope (polyurethane-coated or not). In conclusion, women undergoing cosmetic breast augmentation do not appear to be at an increased long-term risk of developing cancer.

Excellent survival, cancer type, and Nottingham grade after atypical lobular hyperplasia on initial breast biopsy

BACKGROUND

Atypical lobular hyperplasia (ALH) is associated with a 10% to 20% risk of subsequent invasive carcinoma, primarily in the ipsilateral breast. Nottingham grading, special tumor types, and survival after invasive cancer diagnosis were analyzed consistently for the first time.

METHODS

A longitudinal follow-up study of 252 women who underwent 261 benign surgical biopsies between 1950 and 1985 with a diagnosis of ALH was undertaken. Subsequent invasive breast cancers were graded and subtyped based on histologic features and the cohort assessed for cancer survival.

RESULTS

Forty-eight (19%) women developed invasive breast cancer at an average of 15.1 years. Twenty (42%) of the tumors were special subtype tumors with good prognosis. By an average of 13 years after invasive cancer diagnosis, 2 (10%) of 20 women with special type and variant tumors had died of breast cancer, compared with 9 (32%) of 28 women with tumors of no special type (24 tumors) or an unknown type (4 tumors). Only 1 patient with a tumor of low Nottingham grade died of breast cancer.

CONCLUSIONS

ALH is a nonobligate cancer precursor associated with a moderate risk of breast cancer and predicts that later cancers are associated with overall excellent survival. Nearly half of the subsequent cancers show classic or variant patterns of special types with a good prognosis and the majority are of low or intermediate combined histologic grade. Treatment of women with ALH should be influenced by their modest elevation in breast cancer risk and the good prognosis and low mortality of many of these cancers.

Breast reduction and subsequent cancer: a prophylactic perspective

The aim of this paper was to evaluate the impact of breast-gland remodelling, for cosmetic or functional purposes, on cancer incidence during long-term post-surgical follow-up. We reviewed the literature investigating the ratio between the amount of breast tissue resected and cancer incidence during follow-up. Our analysis of the published data suggested that hypertrophic breast remodelling decreases the risk of breast and other types of cancer in post-operative patients. The actual risk reduction for patients over 40 years of age is related to the weight of the surgical specimens during the previous operation. Our conclusions support the use of breast-reduction surgery as a preventive measure in patients complaining of symptomatic breast enlargement, especially those with a family history of breast cancer.

A nationwide epidemiologic study of breast cancer incidence following breast reduction surgery in a large cohort of Swedish women

While it has been demonstrated that prophylactic mastectomy reduces breast cancer incidence among women at high risk, many women often consider this disfiguring surgery unacceptable. One alternative approach may be breast reduction surgery. In order to evaluate the long-term incidence of breast cancer following surgical removal of breast tissue, we have extended by 9 years the follow-up period of our earlier retrospective cohort study of Swedish women electing cosmetic breast reduction surgery (n=30,444) between 1965 and 1993, yielding an average of nearly 16 years of follow-up. Cancer incidence through 2002 was ascertained via the Swedish Cancer Registry. Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were calculated comparing women who underwent breast reduction surgery with women in the general Swedish population. Breast cancer was observed in 443 women versus 624 expected for a statistically significant reduced SIR of 0.71 (95% CI=0.65-0.78). Analyses by age at surgery, time since surgery or calendar year of surgery revealed similar reductions in risk. Our study of over 30,000 women with long-term follow-up offers further evidence that women undergoing breast reduction surgery have reduced breast cancer risk. As the evidence from large-scale cohort studies accumulates, direct testing of this reduction in risk through clinical trials should be considered.

Invasive breast cancer following bilateral subcutaneous mastectomy in a BRCA2 mutation carrier: a case report and review of the literature

Background

Primary prevention of breast cancer through prophylactic mastectomy can reduce the risk of malignancy in high-risk individuals. No type of mastectomy completely removes all breast tissue, but a subcutaneous mastectomy leaves more tissue in situ than does a simple mastectomy.

Case presentation

We report a case of invasive breast cancer in a BRCA2-positive woman 33 years after bilateral subcutaneous mastectomy. To our knowledge, only one case of primary breast cancer after prophylactic mastectomy in a BRCA1-positive patient has been reported in the literature and none in BRCA2-positive individuals.

Conclusion

Careful documentation and long follow-up is essential to fully assess the benefits and risks of preventive surgical procedures in BRCA1 and BRCA2 mutation carriers.

Cosmesis with bilateral mammoreduction for conservative breast cancer treatment

Over 7 years, 57 women with breast cancer underwent lumpectomy and bilateral mammoreduction. Physical complaints about large or lax breast shape were the predominate rationale. Two patients were immediately lost to follow-up, 55 patients remained and were followed every 3 months for an average of 1.6 years. This is the largest series traceable by computer and literature search. Chart review and patient examination in this retrospective review were utilized as the basis for data within the article. Collated notes from patients' doctors were assessed, as well as documented patient responses to the procedure. Pictures without head/face for identifiers were taken of the patients. Chart data were collected by clinicians, but were reviewed blindly by a statistician. The overall control and cosmesis rates as well as alleviation of heavy breast problems were noted. Only 6% of women had fair to poor cosmetic results; the majority (82%) had excellent to good results. Women with very large breasts or markedly relaxed breast tissue of concern to the patients proved optimal candidates for lumpectomy of cancer and bilateral mammoreduction in the conservative treatment of these cancers. There was a significant reduction in the physical complaints of the patients as well. For women with very pendulous or extremely large breasts, lumpectomy and bilateral mammoreduction may prove to be the optimal course of action.

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.

Genomic instability in histologically normal breast tissues: implications for carcinogenesis

Breast cancer is an important contributor to morbidity and mortality in society, but factors that affect the cause of the disease are poorly defined. Genomic instability drives tumorigenic processes in invasive carcinomas and premalignant breast lesions, and might promote the accumulation of genetic alterations in apparently normal tissues before histological abnormalities are detectable. Evidence suggests that genomic changes in breast parenchyma affect the behaviour of epithelial cells, and ultimately might affect tumour growth and progression. Inherent instability in genes that maintain genomic integrity, as well as exogenous chemicals and environmental pollutants, have been implicated in breast-cancer development. Although molecular mechanisms of tumorigenesis are unclear at present, carcinogenic agents could contribute to fields of genomic instability localised to specific areas of the breast. Understanding the functional importance of genomic instability in early carcinogenesis has important implications for improvement of diagnostic and treatment strategies.

Prophylactic mastectomy for the prevention of breast cancer

BACKGROUND

Breast cancer is the most common cancer and the second most common cause of cancer-related death among North American and Western European women. Recent progress in understanding the genetic basis of breast cancer, along with rising incidence rates, have resulted in increased interest in prophylactic mastectomy as a method of preventing breast cancer, particularly in those with familial susceptibility.

OBJECTIVES

The primary objective was to determine whether prophylactic mastectomy reduces death from any cause in women who have never had breast cancer and in women who have a history of breast cancer in one breast. The secondary objective was to examine the effect of prophylactic mastectomy on other endpoints including breast cancer incidence, breast cancer mortality, disease-free survival, physical morbidity, and psychosocial outcomes.

SEARCH STRATEGY

Electronic searches were performed in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Cancerlit, and the Science Citation Index.

SELECTION CRITERIA

Inclusion criteria were studies in English of any design type including randomized or nonrandomized controlled trials, cohort studies, case-control studies, and case series with at least ten participants. Participants included women at risk for breast cancer in at least one breast. Interventions included all types of mastectomy performed for the purpose of preventing breast cancer, including subcutaneous mastectomy, total or simple mastectomy, modified radical mastectomy, and radical mastectomy.

DATA COLLECTION AND ANALYSIS

Information on patients, interventions, methods, and results were extracted by at least two independent reviewers. Methodological quality was assessed based on how well each study minimized potential selection bias, performance bias, detection bias, and attrition bias. Data for each study were summarized descriptively; quantitative meta-analysis was not feasible due to heterogeneity of study designs and insufficient reporting. Data were analyzed separately for bilateral prophylactic mastectomy (BPM) and contralateral prophylactic mastectomy (CPM).

MAIN RESULTS

Twenty-three studies, including more than 4,000 patients, met inclusion criteria. No randomized or nonrandomized controlled trials were found. Most studies were either case series or cohort studies. All studies had methodological limitations, with the most common source of potential bias being systematic differences between the intervention and comparison groups that could potentially be associated with a particular outcome. Thirteen studies assessed the effectiveness of BPM. No study assessed all-cause mortality after BPM. All studies reporting on incidence of breast cancer and disease-specific mortality reported reductions after BPM. Nine studies assessed psychosocial measures; most reported high levels of satisfaction with the decision to have prophylactic mastectomy (PM) but more variable satisfaction with cosmetic results. Only one study assessed satisfaction with the psychological support provided by healthcare personnel during risk counseling and showed that more women were dissatisfied than satisfied with the support they received in the healthcare setting. Worry over breast cancer was significantly reduced after BPM when compared both to baseline worry levels and to the groups who opted for surveillance rather than BPM. Three studies reported body image/feelings of femininity outcomes, and all reported that a substantial minority (about 20%) reported BPM had adverse effects on those domains. Six studies assessed contralateral prophylactic mastectomy. Studies consistently reported reductions in contralateral incidence of breast cancer but were inconsistent about improvements in disease-specific survival. Only one study attempted to control for multiple differences between intervention groups, and this study showed no overall survival advantage for CPM at 15 years. Two case series were exclusively focused on adverse events from prophylactic mastectomy with reconstruction, and both reported rates of unanticipated re-operations from 30% to 49%.

REVIEWERS' CONCLUSIONS

While published observational studies demonstrated that BPM was effective in reducing both the incidence of, and death from, breast cancer, more rigorous prospective studies (ideally randomized trials) are needed. The studies need to be of sufficient duration and make better attempts to control for selection biases to arrive at better estimates of risk reduction. The state of the science is far from exact in predicting who will get or who will die from breast cancer. By one estimate, most of the women deemed high risk by family history (but not necessarily BRCA 1 or 2 mutation carriers) who underwent these procedures would not have died from breast cancer, even without prophylactic surgery. Therefore, women need to understand that this procedure should be considered only among those at very high risk of the disease. For women who had already been diagnosed with a primary tumor, the data were particularly lacking for indications for contralateral prophylactic mastectomy. While it appeared that contralateral mastectomy may reduce the incidence of cancer in the contralateral breast, there was insufficient evidence about whether, and for whom, CPM actually improved survival. Physical morbidity is not uncommon following PM, and many women underwent unanticipated re-operations (usually due to problems with reconstruction); however, these data need to be updated to reflect changes in surgical procedures and reconstruction. Regarding psychosocial outcomes, women generally reported satisfaction with their decisions to have PM but reported satisfaction less consistently for cosmetic outcomes, with diminished satisfaction often due to surgical complications. Therefore, physical morbidity and post-operative surgical complications were areas that should be considered when deciding about PM. With regard to emotional well-being, most women recovered well postoperatively, reporting reduced cancer worry and showing reduced psychological morbidity from their baseline measures; exceptions also have been noted. Of the psychosocial outcomes measured, body image and feelings of femininity were the most adversely affected.

Breast Reduction Surgery and Breast Cancer Risk: Does Reduction Mammaplasty Have a Role in Primary Prevention Strategies for Women at High Risk of Breast Cancer?

Prophylactic bilateral mastectomy has been demonstrated to reduce breast cancer incidence in women with a high inherited susceptibility to breast cancer. For the majority of high-risk women, however, bilateral prophylactic mastectomy is not an acceptable option for primary prevention of breast cancer. Several epidemiological follow-up studies have indicated that there may be a substantial reduction in breast cancer risk among women who have undergone breast reduction surgery. The authors reviewed the evidence from these studies, with emphasis on the problems inherent in interpreting the results of nonexperimental studies of elective medical procedures. Although such observational studies cannot demonstrate definitively that reduction mammaplasty reduces the risk of breast cancer, the evidence from these studies is sufficiently strong to warrant the evaluation of breast reduction surgery as an option for primary prevention in clinical studies of women at increased risk of breast cancer. The availability of a more acceptable surgical option for primary prevention of breast cancer could increase the number of women willing to choose risk reduction surgery and thus may result in an overall reduction in breast cancer mortality among high-risk women.

Stage of breast cancer at diagnosis among women with cosmetic breast implants

Concern has been raised about the potential delay in breast cancer diagnosis in the augmented breast. We linked a cohort of 2955 women, who received cosmetic breast implants in Denmark during the period 1973-1997 with the Danish Cancer Registry and the Danish Breast Cancer Cooperative Group register. We identified 23 incident cases of invasive breast cancer diagnosed subsequent to breast implantation. We randomly selected 11 controls for each case from the Danish Breast Cancer Cooperative Group's register, and obtained detailed information on all study subjects about surgery, histopathology and stage of breast cancer at diagnosis, intended adjuvant treatment according to trial protocols and overall survival. We found that women with breast implants on average were diagnosed with breast cancer at the same stage as controls. Significantly more women with breast implants had tumour cells in the surgical margins according to the Danish Breast Cancer Cooperative Group's data. There was no significant difference in overall survival between the two groups after an average of 6.4 years of follow-up. Based on this limited number of women with breast cancer subsequent to breast augmentation, breast implants do not appear to delay the diagnosis of breast cancer, and no evidence of impaired survival after breast cancer diagnosis in augmented women was found.

Atypical lobular hyperplasia as a unilateral predictor of breast cancer risk: a retrospective cohort study

BACKGROUND

Clinical decisions about atypical lobular hyperplasia are based on the belief that later invasive breast-cancer risk is equal in both breasts. We aimed to show laterality and subsequent risk implications of invasive breast cancer in women with atypical lobular hyperplasia.

METHODS

We did a retrospective cohort study of 252 women who had undergone 261 benign surgical biopsies that showed atypical lobular hyperplasia from 1950 to 1985, as part of the Nashville Breast Studies. Primary outcomes were development of invasive breast cancer and laterality of cancer compared with side of the biopsied breast.

FINDINGS

50 (20%) of 252 women treated by biopsy only developed invasive breast cancer. Relative risk of breast cancer in women with atypical lobular hyperplasia was 3.1 (95% CI 2.3-4.3, p<0.0001). Of these 50 women, the breast with invasive cancer was the same breast diagnosed with atypical lobular hyperplasia (ipsilateral) in 34 (68%) and the contralateral breast in 12 (24%). The ratio of ipsilateral/ contralateral cancers for atypical lobular hyperplasia without other atypical lesions was 17/5. For six women with atypical lobular hyperplasia plus atypical ductal hyperplasia, the ratio was 1/1.

INTERPRETATION

Invasive carcinoma after atypical lobular hyperplasia is about three times more likely to arise in the breast diagnosed with atypical lobular hyperplasia than in the opposite breast without these initial findings. Our findings suggest a model of premalignancy for atypical lobular hyperplasia intermediate between a local precursor and a generalised risk for both breasts. See Commentary page 96