Occult cancer in specimens of reduction mammaplasty aimed at symmetrization. A multicentric study of 2718 patients

Three-Pedicle Reduction Mammaplasty Technique in the Treatment of Greater Breast Hypertrophy Patients With or Without Breast Cancer: Surgical and Patient-reported outcomes

BACKGROUND

Reduction mammoplasty (RM) is an important procedure in the management of symptomatic greater breast hypertrophy with or without early-stage breast cancer. We aim to introduce a new procedure: the three-pedicle reduction mammaplasty technique.

METHODS

A prospectively maintained database was reviewed, and two prospectively registered clinical studies were included of all breast hypertrophy patients with or without breast cancer who underwent three-pedicle RM with inverted T incision at West China Hospital or the Fourth People's Hospital of Sichuan Province from 2018 to 2022. Patient demographics, patient-reported cosmetic results, quality of life (QoL), surgical outcomes and complications were assessed.

RESULTS

During a median period of 22.5 months, 101 reduction mammaplasties were performed (Mage= 35.80; MBMI= 27.05). Mean reduction weight was 880.9 g ranging from 423-1630 g per breast. The nipple-to-sternal notch distance (N-SN) at post-operation was significantly shorter than preoperatively (left, 34.51 cm; right, 34.69 cm). Major complications and minor complications were 1.9% (1/52 patients) and 13.5% (7/52 patients), respectively. Multivariate logistic regression analyses showed that BMI > 30 was independent risk factors for a complication. Except for sexual and physical well-being at 1-month post-operation, patients gave a higher score on the BREAST-Q (breast satisfaction, physical well-being, psychosocial well-being) after the operation than before the operation (P<0.001).

CONCLUSIONS

The three-pedicle RM technique was demonstrated to be an effective and safe RM procedure for moderate to severe breast hypertrophy patients with or without breast cancer, with the advantages of removing the lesions, reducing hypertrophic breasts and accomplishing mammoplasty.

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   http://www.springer.com/00266.

Routine Pathology Examination of Breast Tissue in Adolescent Reduction Mammaplasty: Not Cost Effective in a 7-Year Review

BACKGROUND

Routine pathology examination of breast tissue in reduction mammaplasty (RM) is performed with aims of detecting incidental malignancy or risk-increasing lesions. In adolescent patients, the reported incidence ranges between 0% to 0.01%, and costs of pathology claims range between $23 and $614 per analysis. We aim to investigate the rate of incidental findings and the cost-effectiveness of routine pathology examination in adolescent RM.

METHODS

A single-center retrospective review of the pathology results for 132 breast specimens from 66 consecutive RM patients was performed. Data collected for analysis included breast cancer risk factors, demographic information, and operative variables.

RESULTS

Zero cases of incidental malignant or risk-increasing lesions were found among the 132 breast specimens from 66 patients aged between 10 and 24 years. Of the 132 specimens, 34 (26%) contained benign fibrocystic disease, which was significantly associated a body mass index greater than 30 kg/m 2 and tissue resection weight greater than 1000 g per breast ( P = 0.003, P = 0.007) respectively.

CONCLUSIONS

Based on the available data, the use of routine specimen analysis costs more than US $150 million for one breast cancer diagnosis during RM in this age group. In our study, zero atypical, precancerous, or cancerous lesions were detected in a 7-year analysis. The results of this study support the current literature, which reports no occurrence of incidental findings in young women and may promote a greater understanding of evidence-based healthcare spending while concomitantly decreasing the strain placed on histopathology services.

Pathological Evaluation of Breast Specimens in Transgender Chest Masculinization: Incidental Findings and Effect of Prior Chest Binding and Androgen Therapy in 74 Consecutive Patients

Background: The rate of masculinizing chest surgery for gender affirmation continues to increase. With a paucity of literature on pathological evaluation of breast specimens in this patient population, there is a need for these data and for protocols on the handling of these specimens. Methods: A retrospective chart review was performed between 2015 and 2020 on all patients who underwent chest masculinization surgery for gender dysphoria by the senior author (J.D.K.). Inclusion criteria were any patient with sex assigned female at birth who underwent removal of breast and/or nipple areolar complex tissue for gender affirmation. Patient demographics were recorded. Bilateral breast tissue was sent for routine pathology in all cases and findings were recorded. A p-value of <0.05 was considered significant. Results: Seventy-four consecutive patients and 148 breast specimen reports were identified from a database and included in the study. The mean age was 26 years (15-49). Thirty-nine patients had a known history of chest wall binding and 60 patients had undergone preoperative androgen therapy. There was no invasive or in situ carcinoma found in any breast tissue specimens. Thirty-four patients had a benign lesion in one or both breast specimens. Atypical lobular hyperplasia was found in one patient's specimen. A history of chest wall binding was not correlated with any benign lesions (p=0.79) or stromal fibrosis (p=0.94). A history of testosterone use was not correlated with any benign lesions (p=0.35) or stromal fibrosis (p=0.20). Conclusions: The prevalence (1.4%) of significant breast pathology and of benign findings (46%) in our study closely correlates with the rates in the literature. We found no correlation between significant breast pathology or benign lesions and a history of chest wall binding or preoperative androgen therapy. We recommend all breast specimens removed during chest masculinization surgery be sent for pathological evaluation.

The Incidence of Occult Malignant and High-Risk Pathologic Findings in Breast Reduction Specimens

BACKGROUND

The goal of this study was to determine the incidence of occult malignancy and high-risk breast pathologic findings in patients who undergo breast reduction procedures.

METHODS

Medical records of consecutive patients who underwent reduction mammaplasty performed by the senior authors (A.L. and G.W.C.) at Emory University Hospital between 1997 and 2018 were reviewed. Data regarding patient demographics, personal or family history of malignancy, operative technique, pathologic findings, and follow-up were extracted. Patients were categorized into two groups, those with and those without breast cancer. Group A patients underwent reduction for symptomatic macromastia, and group B underwent contralateral reduction for unilateral breast cancer treated with oncoplastic partial or total breast cancer reconstruction. Pathologic findings were divided into four groups; normal, benign, high-risk, and malignant.

RESULTS

A total 1014 patients (1419 breast reductions) were included in the study. Comparing groups A and B, mean age was 37.8 ± 16.2 years versus 54.5 ± 11.1 years (p < 0.001), mean body mass index was 34.1 ± 7.6 kg/m2 versus 33.3 ± 7.4 kg/m2 (p = 0.2), and average reduction weight was 875.6 ± 491 g versus 723.7 ± 438 g (p < 0.001). The incidence of high-risk or malignant lesions was 1.8 percent (n = 15) in group A and 8 percent (n = 49) in group B (p < 0.001). On multivariable logistic regression analysis, age and personal history of breast cancer were positive predictors for high-risk and malignant lesions.

CONCLUSIONS

The incidence of abnormal pathologic findings in breast reduction specimens is not uncommon, and occult malignancy or high-risk lesions can be found, especially in patients with contralateral breast cancer. Appropriate specimen orientation, diligence with checking the pathologic findings, and open communication with the pathologist are crucial.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

[Prophylactic mastectomy and occult cancer: a ten-year experience at a cancer center]

INTRODUCTION

Women identified as high-risk for breast cancer may choose between close follow-up and radical mastectomy. Prophylactic mastectomy, as any other surgery, is associated with benefits and harms. The aim of this study was to assess the morbidity associated with prophylactic mastectomy and to evaluate the prevalence of occult cancers.

METHODS

All patients who underwent unilateral or bilateral prophylactic mastectomy between 2007 and 2017 in our institution were eligible for inclusion in this retrospective study. Medical history, type of surgery, occurrence of complication or reoperation and pathological reports were examined in medical charts.

RESULTS

79 women underwent prophylactic mastectomy over the studied period of which 58.2% were contralateral after breast cancer. A genetic mutation was present in 86.1% of cases. Postoperative complications occurred in 43.0% of cases. An additional surgery for medical or esthetic purpose was needed in 72.1% of cases. Occult cancer was found in 11.4% of the pathological reports. Triple negative invasive ductal carcinoma was discovered in two cases (2.5%).

DISCUSSION

Prophylactic mastectomy is the only effective preventive action against breast cancer. Women must be clearly informed of possible complications, high reoperation rate and potential pathological findings. Identifying women most at risk for breast cancer would help to better target those who will benefit most from surgery.

Occult Breast Carcinoma Is More Common in Women Undergoing Breast Reduction after Contralateral Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Occult breast carcinoma is occasionally found in breast reduction specimens. Although its incidence varies widely, there is a trend toward an increased incidence for women with a history of breast cancer. The authors performed a systematic review and meta-analysis of occult carcinoma incidence in breast reduction specimens.

METHODS

The MEDLINE and Embase databases were searched for peer-reviewed studies with no language restrictions for studies that recorded the incidence of occult carcinoma in breast reduction specimens. Cancer incidence per specimen was pooled for women with and without a history of breast cancer.

RESULTS

Forty-two studies were eligible for inclusion, of which 29 were quantitatively analyzed. The pooled incidence of carcinoma was higher within specimens from women with breast cancer (3.4 percent; 95 percent CI, 2.2 to 5.3 percent) than without (0.6 percent; 95 percent CI, 0.4 to 0.8 percent), and this increased likelihood was significant when populations were compared directly (OR, 6.02; 95 percent CI, 3.06 to 11.86; p < 0.0001).

CONCLUSIONS

Women with a history of breast cancer have an increased incidence of occult breast carcinoma within their breast reduction specimens compared with women with no breast cancer history. There is a need for preoperative radiology screening, counseling, and histopathology guidelines to ensure adequate diagnosis and management of these women.

A Review on Cancer of Unknown Primary Origin: The Role of Molecular Biomarkers in the Identification of Unknown Primary Origin

The primary site cannot be found after clinical and pathological evaluation, which are called cancers of unknown primary origin (CUP). CUPs may resemble a specific primary tumor site which shares common clinicopathological characteristics and prognosis. However, it may be present as a distinct disease entity with undifferentiated pathological features. More than 4% of patients are diagnosed as CUP. These patients were diagnosed as malignant tumors by cytology or pathology. And they were usually treated with empirical chemotherapy and associated with a poor prognosis. How to accurately diagnose and treat a cancer of unknown primary origin is a major clinical concern. To address this question, a complex assessment is carried out which includes a complete medical history of the patient, physical examination, complete blood count, urinalysis, serum chemistries, histologic evaluation, chest radiograph, computed tomography, magnetic resonance imaging, and immunohistochemistry (IHC) studies. Molecular diagnostic information reflects that CUP's molecular characteristics are similar to primary tumors with the development of genomics and the expansion of gene sequencing technology. Gene expression profiling is the most commonly used molecular diagnostic method for CUP. In this chapter, we summarize the current diagnostic methods and challenges of CUP, and the clinical value of the molecular-level tumor diagnostic technique.

Incidental breast carcinoma: incidence, management, and outcomes in 4804 bilateral reduction mammoplasties

INTRODUCTION

Bilateral reduction mammoplasty is one of the most common plastic surgery procedures performed in the U.S. This study examines the incidence, management, and prognosis of incidental breast cancer identified in reduction specimens from a large cohort of reduction mammoplasty patients.

METHODS

Breast pathology reports were retrospectively reviewed for evidence of incidental cancers in bilateral reduction mammoplasty specimens from five institutions between 1990 and 2017.

RESULTS

A total of 4804 women met the inclusion criteria of this study; incidental cancer was identified in 45 breasts of 39 (0.8%) patients. Six patients (15%) had bilateral cancer. Overall, the maximum diagnosis by breast was 16 invasive cancers and 29 ductal carcinomas in situs. Thirty-three patients had unilateral cancer, 15 (45.5%) of which had high-risk lesions in the contralateral breast. Twenty-one patients underwent mastectomy (12 bilateral and nine unilateral), residual cancer was found in 10 in 25 (40%) therapeutic mastectomies. Seven patients did not undergo mastectomy received breast radiation. The median follow-up was 92 months. No local recurrences were observed in the patients undergoing mastectomy or radiation. Three of 11 (27%) patients who did not undergo mastectomy or radiation developed a local recurrence. The overall survival rate was 87.2% and disease-free survival was 82.1%.

CONCLUSIONS

Patients undergoing reduction mammoplasty for macromastia have a small but definite risk of incidental breast cancer. The high rate of bilateral cancer, contralateral high-risk lesions, and residual disease at mastectomy mandates thorough pathologic evaluation and careful follow-up of these patients. Mastectomy or breast radiation is recommended for local control given the high likelihood of local recurrence without either.

Is Histological Evaluation of Reduction Mammaplasty Specimens Worthwhile?

BACKGROUND

Reduction mammaplasty (RM) is one of the most common plastic surgery procedures. Despite its cost, the total number of RM procedures continues to increase every year.

OBJECTIVES

The purpose of this study is to review the prevalence of benign and malignant breast lesions among women who live in the Aegean region of Turkey, based on our university hospital's records and to compare our results with those in the literature.

METHODS

Seven hundred and thirty-three consecutive female patients who underwent RM between January 2003 and January 2017 in the Department of Plastic, Reconstructive, and Aesthetic Surgery were included in this study.

RESULTS

One hundred and sixty-five patients (23.4%) had preoperative breast imaging results. According to the Breast Imaging Reporting and Data System (BIRADS), most of these patients had BI-RADS-2 and BIRADS-1 findings (41.21% and 40%, respectively). Fibrocystic changes were the most common lesions (81.3%). Sixty-eight patients (9.6%) had normal breast tissue on the right side and 34 patients (4.8%) had the same on the left side. Five patients (0.71%) had atypical ductal hyperplasia and no atypical lobular carcinoma. Four patients (0.56%) had occult breast cancer and one patient (0.14%) had benign phyllodes tumor.

CONCLUSIONS

RM is a good opportunity to detect proliferative lesions and occult breast cancer. While meeting the patient's aesthetic desires, the plastic surgeon should consider for histopathological evaluation. We suggest that every part of the breast tissue should be sent to pathological examination regardless of the weight of the specimen. Even if health insurance does not cover its cost, patients should be informed about the importance of this process.

LEVEL OF EVIDENCE: 4

Mammography screening: A major issue in medicine

Breast cancer mortality is declining in most high-income countries. The role of mammography screening in these declines is much debated. Screening impacts cancer mortality through decreasing the incidence of number of advanced cancers with poor prognosis, while therapies and patient management impact cancer mortality through decreasing the fatality of cancers. The effectiveness of cancer screening is the ability of a screening method to curb the incidence of advanced cancers in populations. Methods for evaluating cancer screening effectiveness are based on the monitoring of age-adjusted incidence rates of advanced cancers that should decrease after the introduction of screening. Likewise, cancer-specific mortality rates should decline more rapidly in areas with screening than in areas without or with lower levels of screening but where patient management is similar. These two criteria have provided evidence that screening for colorectal and cervical cancer contributes to decreasing the mortality associated with these two cancers. In contrast, screening for neuroblastoma in children was discontinued in the early 2000s because these two criteria were not met. In addition, overdiagnosis - i.e. the detection of non-progressing occult neuroblastoma that would not have been life-threatening during the subject's lifetime - is a major undesirable consequence of screening. Accumulating epidemiological data show that in populations where mammography screening has been widespread for a long time, there has been no or only a modest decline in the incidence of advanced cancers, including that of de novo metastatic (stage IV) cancers at diagnosis. Moreover, breast cancer mortality reductions are similar in areas with early introduction and high penetration of screening and in areas with late introduction and low penetration of screening. Overdiagnosis is commonplace, representing 20% or more of all breast cancers among women invited to screening and 30-50% of screen-detected cancers. Overdiagnosis leads to overtreatment and inflicts considerable physical, psychological and economic harm on many women. Overdiagnosis has also exerted considerable disruptive effects on the interpretation of clinical outcomes expressed in percentages (instead of rates) or as overall survival (instead of mortality rates or stage-specific survival). Rates of radical mastectomies have not decreased following the introduction of screening and keep rising in some countries (e.g. the United States of America (USA)). Hence, the epidemiological picture of mammography screening closely resembles that of screening for neuroblastoma. Reappraisals of Swedish mammography trials demonstrate that the design and statistical analysis of these trials were different from those of all trials on screening for cancers other than breast cancer. We found compelling indications that these trials overestimated reductions in breast cancer mortality associated with screening, in part because of the statistical analyses themselves, in part because of improved therapies and underreporting of breast cancer as the underlying cause of death in screening groups. In this regard, Swedish trials should publish the stage-specific breast cancer mortality rates for the screening and control groups separately. Results of the Greater New York Health Insurance Plan trial are biased because of the underreporting of breast cancer cases and deaths that occurred in women who did not participate in screening. After 17 years of follow-up, the United Kingdom (UK) Age Trial showed no benefit from mammography screening starting at age 39-41. Until around 2005, most proponents of breast screening backed the monitoring of changes in advanced cancer incidence and comparative studies on breast cancer mortality for the evaluation of breast screening effectiveness. However, in an attempt to mitigate the contradictions between results of mammography trials and population data, breast-screening proponents have elected to change the criteria for the evaluation of cancer screening effectiveness, giving precedence to incidence-based mortality (IBM) and case-control studies. But practically all IBM studies on mammography screening have a strong ecological component in their design. The two IBM studies done in Norway that meet all methodological requirements do not document significant reductions in breast cancer mortality associated with mammography screening. Because of their propensity to exaggerate the health benefits of screening, case-control studies may demonstrate that mammography screening could reduce the risk of death from diseases other than breast cancer. Numerous statistical model approaches have been conducted for estimating the contributions of screening and of patient management to reductions in breast cancer mortality. Unverified assumptions are needed for running these models. For instance, many models assume that if screening had not occurred, the majority of screen-detected asymptomatic cancers would have progressed to symptomatic advanced cancers. This assumption is not grounded in evidence because a large proportion of screen-detected breast cancers represent overdiagnosis and hence non-progressing tumours. The accumulation of population data in well-screened populations diminishes the relevance of model approaches. The comparison of the performance of different screening modalities - e.g. mammography, digital mammography, ultrasonography, magnetic resonance imaging (MRI), three-dimensional tomosynthesis (TDT) - concentrates on detection rates, which is the ability of a technique to detect more cancers than other techniques. However, a greater detection rate tells little about the capacity to prevent interval and advanced cancers and could just reflect additional overdiagnosis. Studies based on the incidence of advanced cancers and on the evaluation of overdiagnosis should be conducted before marketing new breast-imaging technologies. Women at high risk of breast cancer (i.e. 30% lifetime risk and more), such as women with BRCA1/2 mutations, require a close breast surveillance. MRI is the preferred imaging method until more radical risk-reduction options are eventually adopted. For women with an intermediate risk of breast cancer (i.e. 10-29% lifetime risk), including women with extremely dense breast at mammography, there is no evidence that more frequent mammography screening or screening with other modalities actually reduces the risk of breast cancer death. A plethora of epidemiological data shows that, since 1985, progress in the management of breast cancer patients has led to marked reductions in stage-specific breast cancer mortality, even for patients with disseminated disease (i.e. stage IV cancer) at diagnosis. In contrast, the epidemiological data point to a marginal contribution of mammography screening in the decline in breast cancer mortality. Moreover, the more effective the treatments, the less favourable are the harm-benefit balance of screening mammography. New, effective methods for breast screening are needed, as well as research on risk-based screening strategies.

The Management of Breast Cancer Detected by Reduction Mammaplasty

The incidence of occult breast cancer detected by reduction mammoplasty is 0.06% to 5.45%. Preoperative screening mammography is indicated in all women 40 years and older and in women age 35 with a positive family or personal history of breast cancer before reduction mammoplasty. Breast MRI is considered in women with dense breasts and those with hereditary breast cancer syndromes. Management of occult breast cancer is impacted by specimens being typically removed in pieces and not oriented before submission to pathology. Total mastectomy is the most common treatment because of the uncertainties regarding margin status and disease extent.