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Heng YJ, Baker GM, Fein-Zachary VJ, Guzman-Arocho YD, Bret-Mounet VC, Massicott ES, Torous VF, Schnitt SJ, Gitin S, Russo P, Tobias AM, Bartlett RA, Varma G, Kontos D, Yaghjyan L, Irwig MS, Potter JE, Wulf GM. Effect of testosterone therapy on breast tissue composition and mammographic breast density in trans masculine individuals. Breast Cancer Res 2024; 26:109. [PMID: 38956693 DOI: 10.1186/s13058-024-01867-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 06/27/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND The effect of gender-affirming testosterone therapy (TT) on breast cancer risk is unclear. This study investigated the association between TT and breast tissue composition and breast tissue density in trans masculine individuals (TMIs). METHODS Of the 444 TMIs who underwent chest-contouring surgeries between 2013 and 2019, breast tissue composition was assessed in 425 TMIs by the pathologists (categories of lobular atrophy and stromal composition) and using our automated deep-learning algorithm (% epithelium, % fibrous stroma, and % fat). Forty-two out of 444 TMIs had mammography prior to surgery and their breast tissue density was read by a radiologist. Mammography digital files, available for 25/42 TMIs, were analyzed using the LIBRA software to obtain percent density, absolute dense area, and absolute non-dense area. Linear regression was used to describe the associations between duration of TT use and breast tissue composition or breast tissue density measures, while adjusting for potential confounders. Analyses stratified by body mass index were also conducted. RESULTS Longer duration of TT use was associated with increasing degrees of lobular atrophy (p < 0.001) but not fibrous content (p = 0.82). Every 6 months of TT was associated with decreasing amounts of epithelium (exp(β) = 0.97, 95% CI 0.95,0.98, adj p = 0.005) and fibrous stroma (exp(β) = 0.99, 95% CI 0.98,1.00, adj p = 0.05), but not fat (exp(β) = 1.01, 95%CI 0.98,1.05, adj p = 0.39). The effect of TT on breast epithelium was attenuated in overweight/obese TMIs (exp(β) = 0.98, 95% CI 0.95,1.01, adj p = 0.14). When comparing TT users versus non-users, TT users had 28% less epithelium (exp(β) = 0.72, 95% CI 0.58,0.90, adj p = 0.003). There was no association between TT and radiologist's breast density assessment (p = 0.58) or LIBRA measurements (p > 0.05). CONCLUSIONS TT decreases breast epithelium, but this effect is attenuated in overweight/obese TMIs. TT has the potential to affect the breast cancer risk of TMIs. Further studies are warranted to elucidate the effect of TT on breast density and breast cancer risk.
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Affiliation(s)
- Yujing J Heng
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Dana 517B, Boston, MA, 02115, USA.
| | - Gabrielle M Baker
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Dana 517B, Boston, MA, 02115, USA
| | - Valerie J Fein-Zachary
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Yaileen D Guzman-Arocho
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Dana 517B, Boston, MA, 02115, USA
| | - Vanessa C Bret-Mounet
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Dana 517B, Boston, MA, 02115, USA
| | - Erica S Massicott
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Dana 517B, Boston, MA, 02115, USA
| | - Vanda F Torous
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Stuart J Schnitt
- Dana-Farber/Brigham and Women's Cancer Center, Dana-Farber Cancer Institute-Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sy Gitin
- The Fenway Institute, Boston, MA, USA
| | | | - Adam M Tobias
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Richard A Bartlett
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Gopal Varma
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Despina Kontos
- Departments of Radiology, Biomedical Informatics, and Biomedical Engineering, Columbia University Irving Medical Center, New York, NY, USA
| | - Lusine Yaghjyan
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
| | - Michael S Irwig
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jennifer E Potter
- The Fenway Institute, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Gerburg M Wulf
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Cortina CS, Purdy A, Brazauskas R, Stachowiak SM, Fodrocy J, Klement KA, Sasor SE, Krucoff KB, Robertson K, Buth J, Lakatos AEB, Petroll AE, Doren EL. The Impact of a Breast Cancer Risk Assessment on the Decision for Gender-Affirming Chest Masculinization Surgery in Transgender and Gender-Diverse Individuals: A Pilot Single-Arm Educational Intervention Trial. Ann Surg Oncol 2024:10.1245/s10434-024-15701-2. [PMID: 38940898 DOI: 10.1245/s10434-024-15701-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 05/21/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Persons assigned female or intersex at birth and identify as transgender and/or gender-diverse (TGD) may undergo gender-affirming chest masculinization surgery (GACMS); however, GACMS is not considered equivalent to risk-reducing mastectomies (RRM). This study aimed to estimate the prevalence of elevated breast cancer (BC) risk in TGD persons, compare self-perceived versus calculated risk, and determine how risk impacts the decision for GACMS versus RRM. METHODS A prospective single-arm pilot educational intervention trial was conducted in individuals assigned female or intersex at birth, age ≥ 18 years, considering GACMS, without a BC history or a known pathogenic variant. BC risk was calculated using the Tyrer-Cuzik (all) and Gail models (age ≥ 35 years). Elevated risk was defined as ≥ 17%. RESULTS Twenty-five (N = 25) participants were enrolled with a median age of 24.0 years (interquartile range, IQR 20.0-30.0 years). All were assigned female sex at birth, most (84%) were Non-Hispanic (NH)-White, 48% identified as transgender and 40% as nonbinary, and 52% had a first- and/or second-degree family member with BC. Thirteen (52%) had elevated risk (prevalence 95% confidence interval (CI) 31.3-72.2%). Median self-perceived risk was 12% versus 17.5% calculated risk (p = 0.60). Of the 13 with elevated risk, 5 (38.5%) underwent/are scheduled to undergo GACMS, 3 (23%) of whom underwent/are undergoing RRM. CONCLUSIONS Over half of the cohort had elevated risk, and most of those who moved forward with surgery chose to undergo RRM. A BC risk assessment should be performed for TGD persons considering GACMS. Future work is needed to examine BC incidence and collect patient-reported outcomes. Trial Registration Number ClinicalTrials.gov (No. NCT06239766).
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Affiliation(s)
- Chandler S Cortina
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA.
| | - Anna Purdy
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ruta Brazauskas
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Samantha M Stachowiak
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jessica Fodrocy
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kristen A Klement
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sarah E Sasor
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kate B Krucoff
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kevin Robertson
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Froedtert and the Medical College of Wisconsin's Inclusion Health Clinic, Milwaukee, WI, USA
| | - Jamie Buth
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Froedtert and the Medical College of Wisconsin's Inclusion Health Clinic, Milwaukee, WI, USA
| | - Annie E B Lakatos
- Froedtert and the Medical College of Wisconsin's Inclusion Health Clinic, Milwaukee, WI, USA
| | - Andrew E Petroll
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Froedtert and the Medical College of Wisconsin's Inclusion Health Clinic, Milwaukee, WI, USA
| | - Erin L Doren
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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LaRosa MX, Chikarmane SA, Yu RN, Grimstad F, Chow JS. Peri-surgical imaging of intersex and gender diverse youths. Pediatr Radiol 2024:10.1007/s00247-024-05900-0. [PMID: 38520560 DOI: 10.1007/s00247-024-05900-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 03/25/2024]
Abstract
This publication provides an overview of current imaging indications and practices for patients undergoing gender-affirming surgery, with an emphasis on the importance of tailored, patient-specific care. Gender-affirming surgeries are performed with personalized approaches at various stages of life for those with intersex traits or differences in sex development (I/DSD) and transgender and gender diverse (TGD) individuals. For I/DSD patients, ultrasound, genitography, or MRI occurs during infancy and puberty to evaluate genital and gonadal anatomy. Facial harmonization involves bony and soft tissue modifications, guided by maxillofacial computerized tomography (CT) with three-dimensional reconstruction. Ultrasound is the main modality in assessing hormone-related and post-surgical changes in the chest. Imaging for genital reconstruction uses cross-sectional images and fluoroscopy to assess neoanatomy and complications.
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Affiliation(s)
- Michelle X LaRosa
- Department of Radiology, Boston Children's Hospital, 300 Longwood Avenue, Main Building, 2nd Floor, Boston, MA, 02115, USA.
| | - Sona A Chikarmane
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Richard N Yu
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - Frances Grimstad
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Jeanne S Chow
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA
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4
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Wahlström E, Audisio RA, Selvaggi G. Aspects to consider regarding breast cancer risk in trans men: A systematic review and risk management approach. PLoS One 2024; 19:e0299333. [PMID: 38451995 PMCID: PMC10919728 DOI: 10.1371/journal.pone.0299333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/07/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND The risk of breast cancer in trans men is currently a poorly understood subject and trans men likely carries a different level of risk from that of cis women. AIM This review aims to review several aspects that affects breast cancer risk in trans men and to apply the Swiss cheese model to highlight these risks. The study takes its cue from a systematic review of all described breast cancer cases in trans men following medical or surgical intervention because of gender dysphoria. METHODS PubMed was systematically searched on the 14th of March 2023 to find all published cases of breast cancer following chest contouring surgery in trans men. Included articles had to involve trans men, the diagnosis of breast cancer had to be preceded by either a medical or surgical intervention related to gender dysphoria, and cases needed to involve invasive breast cancer or ductal carcinoma in situ. Articles were excluded if gender identity in the case subject was unclear and/or a full English version of the report was unavailable. Quality and risk of bias was evaluated using the GRADE protocol. A literature review of specific risk altering aspects in this population followed. The Swiss cheese model was employed to present a risk analysis and to propose ways of managing this risk. RESULTS 28 cases of breast cancer in trans men have been published. The Swiss cheese model identified several weaknesses associated with methods of preventing breast cancer in trans men. CLINICAL IMPLICATIONS This study may highlight the difficulties with managing risk factors concerning breast cancer in trans men to clinicians not encountering this patient group frequently. CONCLUSION This review finds that evidence for most aspects concerning breast cancer in trans men are inadequate, which supports the establishment of a risk-management approach to breast cancer in trans men.
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Affiliation(s)
- Edvin Wahlström
- Department of Plastic Surgery, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Riccardo A. Audisio
- Department of General Surgery, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Gennaro Selvaggi
- Department of Plastic Surgery, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
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Cathcart-Rake EJ, Ruddy KJ, Tevaarwerk AJ, Jatoi A. Breast cancer and gender-affirming hormone therapy for transgender and gender-diverse (TGD) individuals. Maturitas 2024; 181:107913. [PMID: 38262089 PMCID: PMC10872221 DOI: 10.1016/j.maturitas.2024.107913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 12/01/2023] [Accepted: 01/06/2024] [Indexed: 01/25/2024]
Abstract
Transgender and gender-diverse (TGD) individuals are at risk for breast cancer, but are less likely to undergo screening mammograms and appear to suffer poorer cancer-related outcomes than cisgender women. Gender-affirming hormone therapy (GAHT) may be lifesaving for TGD individuals from the perspective of affirming their core identities; however, the effects of GAHT on cancer development, progression, and outcomes are poorly understood.
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Affiliation(s)
| | - Kathryn J Ruddy
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, United States of America
| | - Amye J Tevaarwerk
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, United States of America
| | - Aminah Jatoi
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, United States of America
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Guzmán-Arocho YD, Collins LC. Pragmatic guide to the macroscopic evaluation of breast specimens. J Clin Pathol 2024; 77:204-210. [PMID: 38373781 DOI: 10.1136/jcp-2023-208833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 06/27/2023] [Indexed: 02/21/2024]
Abstract
The pathological assessment of a breast surgical specimen starts with macroscopic evaluation, arguably one of the most critical steps, as only a small percentage of the tissue is examined microscopically. To properly evaluate and select tissue sections from breast specimens, it is essential to correlate radiological findings, prior biopsies, procedures and treatment with the gross findings. Owing to its fatty nature, breast tissue requires special attention for proper fixation to ensure appropriate microscopic evaluation and performance of ancillary studies. In addition, knowledge of the information necessary for patient management will ensure that these data are collected during the macroscopic evaluation, and appropriate sections are taken to obtain the information needed from the microscopic evaluation. Herein, we present a review of the macroscopic evaluation of different breast specimen types, including processing requirements, challenges and recommendations.
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Affiliation(s)
| | - Laura C Collins
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Heng YJ, Baker GM, Fein-Zachary VJ, Guzman-Arocho YD, Bret-Mounet VC, Massicott ES, Gitin S, Russo P, Tobias AM, Bartlett RA, Varma G, Kontos D, Yaghjyan L, Irwig MS, Potter JE, Wulf GM. Effect of testosterone therapy on breast tissue composition and mammographic breast density in trans masculine individuals. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.09.24300987. [PMID: 38260574 PMCID: PMC10802634 DOI: 10.1101/2024.01.09.24300987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Objective Determine the association between TT and breast tissue composition and breast tissue density in trans masculine individuals (TMIs). Design This is a cross-sectional study. Setting TMIs (n=444) underwent chest-contouring surgeries to treat their gender dysphoria between 2013 and 2019 at an urban medical center. Participants Of the 444 TMIs, 425 had pathology images analyzed by our deep-learning algorithm to extract breast tissue composition. A subset of 42/444 TMIs had mammography prior to surgery; mammography files were available for 25/42 TMIs and analyzed using a breast density software, LIBRA. Main Outcomes and Measures The first outcome was the association of duration of TT and breast tissue composition assessed by pathologists (categories of lobular atrophy and stromal composition) or by our algorithm (% epithelium, % fibrous stroma, and % fat). The second outcome is the association of TT and breast density as assessed by a radiologist (categorical variable) or by LIBRA (percent density, absolute dense area, and absolute non-dense area). Results Length of TT was associated with increasing degrees of lobular atrophy ( p <0.001) but not fibrous content ( p =0.821) when assessed by the pathologists. Every six months of TT was associated with decreased amounts of both epithelium (exp(β)=0.97, 95% CI 0.95-0.98, adj p =0.005) and stroma (exp(β)=0.99, 95% CI 0.98-1.00, adj p =0.051), but not fat (exp(β)=1.01, 95%CI 0.98-1.05, p =0.394) in fully adjusted models. There was no association between TT and radiologist's breast density assessment ( p =0.575) or LIBRA measurements ( p >0.05). Conclusions TT decreases breast epithelium and fibrous stroma, thus potentially reducing the breast cancer risk of TMIs. Further studies are warranted to elucidate the effect of TT on breast density and breast cancer risk. Summary Box Very little is known about the effect of gender-affirming testosterone therapy on cancer risks, such as breast cancer.Epidemiological studies had different conclusions about the association between testosterone and breast cancer in cisgender women (positive association) and trans masculine individuals (inverse association).More laboratory-based research are needed to understand the effect of testosterone on breast cancer risk in the understudied trans masculine population.Our study provides quantitative histological evidence to support prior epidemiological reports that testosterone may reduce breast cancer risk in trans masculine individuals.
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Chaum M, Grossi S, Chen J, Hu V, Ray E, Giuliano A, Bose S. Masculinizing hormone therapy effect on breast tissue: Changes in estrogen and androgen receptors in transgender female-to-male mastectomies. Breast 2023; 72:103596. [PMID: 37951051 PMCID: PMC10665694 DOI: 10.1016/j.breast.2023.103596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 10/03/2023] [Accepted: 10/26/2023] [Indexed: 11/13/2023] Open
Abstract
PURPOSE Almost two percent of individuals in the United States identify as gender non-conforming. In the female-to-male (FTM) transgender population, masculinizing hormone therapy with testosterone is commonly prescribed in gender transition. To date, the effects of exogenous androgens on breast tissue and its roles in altering breast cancer risk are poorly understood. This study examines the histopathologic findings in gender affirming mastectomy (GAM) in transgender FTM patients and the effects of exogenous androgens on estrogen receptors (ER) and androgen receptors (AR). METHODS A retrospective review of pathology specimens obtained between 2017 and 2020 was performed comparing androgen exposed breast tissue with breast tissue without androgen exposure. Breast specimens were obtained from patients who underwent FTM GAM with recorded exogenous androgen exposure. Control breast specimens were obtained from reduction mammoplasty (RM) procedures in cisgender women which were aged matched to the GAM cohort, as well as postmenopausal women with benign/prophylactic mastectomy procedures; all controls were without androgen exposure. The histopathologic findings were assessed. Immunohistochemistry for AR and ER was performed and the score interpreted by digital image analysis. RESULTS Androgen-exposed breast tissue revealed dense fibrotic stroma, lobular atrophy, thickened lobular basement membranes, and gynecomastoid changes. Longer duration of androgen exposure resulted in a more pronounced effect. The incidence of atypia or cancer was lower in GAM than RM cohort. ER and AR expression was highest in transgender male breast tissue with intermediate duration of exogenous androgen exposure. CONCLUSION Increased androgen exposure is associated with lobular atrophy and gynecomastoid changes in breast parenchyma. Overall, ER and AR are expressed strongly in lobular epithelium in patients with prolonged androgen exposure. Exogenous testosterone does not appear to increase risk for breast cancer. Additional studies are needed to investigate the mechanism responsible for these changes at a cellular level and its role in cancer development.
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Affiliation(s)
- Manita Chaum
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Sara Grossi
- Saul and Joyce Brandman Breast Center, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States; Department of Surgery, University of California San Diego, San Diego, CA, United States.
| | - Jiaxi Chen
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Vivian Hu
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States; Department of Surgery, University of California San Diego, San Diego, CA, United States
| | - Edward Ray
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Armando Giuliano
- Saul and Joyce Brandman Breast Center, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Shikha Bose
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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Jorns JM, Farooq A, Puzyrenko A, Jarzembowski J, Thike AA, Nasir NDM, Ng CCY, Liu W, Lee JY, Lim AH, Guan P, Teh BT, Tan PH. Giant juvenile fibroadenomas with and without prominent pseudoangiomatous stromal hyperplasia (PASH)-like change: clinicopathological and molecular characteristics. Histopathology 2023; 83:357-365. [PMID: 37140543 DOI: 10.1111/his.14935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/15/2023] [Accepted: 04/17/2023] [Indexed: 05/05/2023]
Abstract
AIMS Juvenile fibroadenomas (JFA) are biphasic fibroepithelial lesions (FEL) usually occurring in adolescent female patients. Giant (G) JFA, like other FEL, may exhibit prominent pseudoangiomatous stromal hyperplasia (PASH)-like change. We sought to determine clinicopathological and molecular characteristics of GJFA with and without PASH. METHODS AND RESULTS Archives were searched for cases of GJFA (1985-2020). All were stained for androgen receptor (AR), beta-catenin, CD34 and progesterone receptor (PR). Cases were sequenced using a custom 16-gene panel - MED12 (exons 1 and 2), TERT promoter (-124C>T and -146Ctable>T), SETD2, KMT2D, RARA (exons 5-9), FLNA, NF1, PIK3CA (exons 10, 11 and 21), EGFR, RB1, BCOR, TP53, PTEN, ERBB4, IGF1R and MAP3K1. Twenty-seven GJFA from 21 female patients aged 10.1-25.2 years were identified. Size ranged from 5.2 to 21 cm. Two patients had multiple, bilateral and later recurrent GJFA. Thirteen (48%) cases showed prominent PASH-like stroma. All were positive for stromal CD34, negative for AR and beta-catenin and one case showed focal PR expression. Sequencing showed MAP3K1 and SETD2 mutations in 17 samples, with KMT2D, TP53 and BCOR aberrations in 10 (45%), 10 (45%) and seven (32%) cases, respectively. Tumours with a PASH-like pattern had higher prevalence of SETD2 (P = 0.004) and TP53 (P = 0.029) mutations, while those without PASH had more RB1 mutations (P = 0.043). MED12 mutation was identified in one case. TERT promoter mutation was observed in four (18%), including two recurrences. CONCLUSIONS Gene mutations along more advanced phases of the proposed FEL pathogenetic pathway in GJFA are unusual, and suggest a mechanism for more aggressive growth in these tumours.
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Affiliation(s)
- Julie M Jorns
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ayesha Farooq
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Andrii Puzyrenko
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jason Jarzembowski
- Department of Pathology, Children's Hospital of Wisconsin, Madison, WI, USA
| | - Aye Aye Thike
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
| | | | | | - Wei Liu
- Laboratory of Cancer Epigenome, National Cancer Centre Singapore, Singapore
| | - Jing Yi Lee
- Laboratory of Cancer Epigenome, National Cancer Centre Singapore, Singapore
| | - Abner Herbert Lim
- Laboratory of Cancer Epigenome, National Cancer Centre Singapore, Singapore
| | - Peiyong Guan
- Laboratory of Cancer Epigenome, National Cancer Centre Singapore, Singapore
- Quantitative Biology and Medicine Programme, Duke-NUS Medical School, Singapore
| | - Bin Tean Teh
- Laboratory of Cancer Epigenome, National Cancer Centre Singapore, Singapore
| | - Puay Hoon Tan
- Luma Medical Centre, Singapore
- KK Women's and Children's Hospital, Singapore
- Department of Anatomy, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Pathology, University of Western Sydney, Sydney, NSW, Australia
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Graziano TA. Meta-ethnography on Chest Dysphoria and Liberating Solutions for Transmasculine Individuals. J Obstet Gynecol Neonatal Nurs 2023; 52:350-363. [PMID: 37302796 DOI: 10.1016/j.jogn.2023.05.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/04/2023] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
OBJECTIVE To describe the experience of chest dysphoria in transmasculine people and the strategies they use to address it. DATA SOURCES AnthroSource, PubMed, CINAHL, PsycInfo, SocIndex, and Google Scholar. STUDY SELECTION I searched for records written in English from 2015 and later in which authors reported qualitative findings related to chest dysphoria. These records included journal articles, dissertations, chapters, and unpublished manuscripts. I excluded records if the authors explored gender dysphoria as a whole or focused on transfeminine individuals. If authors explored gender dysphoria in general but addressed chest dysphoria, I included the record for analysis. DATA EXTRACTION I read and reread each record several times to fully understand the context, methods, and results. With subsequent readings, I maintained a list of key metaphors, phrases, and ideas using index cards. This allowed examination among and within records to explore relationships among key metaphors. DATA SYNTHESIS I identified nine eligible journal articles and used the meta-ethnographic methodology of Noblit and Hare to compare reported experiences of chest dysphoria across records. The three overarching themes I identified were (Dis)Connection to One's Body, Fluctuating Anguish, and Liberating Solutions. I identified eight subthemes within these overarching themes. CONCLUSION Chest dysphoria must be relieved to free patients from distress and to make them feel authentically masculine. Nurses should familiarize themselves with chest dysphoria and the liberating solutions that patients use to address it.
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Baker GM, Bret-Mounet VC, Xu J, Fein-Zachary VJ, Tobias AM, Bartlett RA, Clohessy JG, Vlachos IS, Massicott ES, Wulf GM, Schnitt SJ, Heng YJ. Toker Cell Hyperplasia in the Nipple-Areolar Complex of Transmasculine Individuals. Mod Pathol 2023; 36:100121. [PMID: 36889065 PMCID: PMC10293043 DOI: 10.1016/j.modpat.2023.100121] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/17/2023] [Accepted: 01/20/2023] [Indexed: 02/05/2023]
Abstract
We previously reported breast histopathologic features associated with testosterone therapy in transmasculine chest-contouring surgical specimens. During that study, we observed a high frequency of intraepidermal glands in the nipple-areolar complex (NAC) formed by Toker cells. This study reports Toker cell hyperplasia (TCH)-the presence of clusters of Toker cells consisting of at least 3 contiguous cells and/or glands with lumen formation-in the transmasculine population. Increased numbers of singly dispersed Toker cells were not considered TCH. Among the 444 transmasculine individuals, 82 (18.5%) had a portion of their NAC excised and available for evaluation. We also reviewed the NACs from 55 cisgender women who were aged <50 years old and had full mastectomies. The proportion of transmasculine cases with TCH (20/82; 24.4%) was 1.7-fold higher than cisgender women (8/55; 14.5%) but did not achieve significance (P = .20). However, in cases with TCH, the rate of gland formation is 2.4-fold higher in transmasculine cases, achieving borderline significance (18/82 vs 5/55; P = .06). Among transmasculine individuals, TCH was significantly more likely to be present in those with higher body mass index (P = .03). A subset of 5 transmasculine and 5 cisgender cases were stained for estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), androgen receptor (AR), cytokeratin 7, and Ki67. All 10 cases were cytokeratin 7+ and Ki67-; 9 out of 10 cases were AR+. Toker cells in transmasculine cases demonstrated variable expression of ER, PR, and HER2. For cisgender cases, Toker cells were consistently ER+, PR-, and HER2-. In conclusion, there is a higher rate of TCH in the transmasculine than cisgender population, particularly among transmasculine individuals with high body mass index and taking testosterone. To our knowledge, this is the first study to demonstrate that Toker cells are AR+. Toker cell features display variable ER, PR, and HER2 immunoreactivity. The clinical significance of TCH in the transmasculine population remains to be elucidated.
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Affiliation(s)
- Gabrielle M Baker
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vanessa C Bret-Mounet
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jingxiong Xu
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Valerie J Fein-Zachary
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Adam M Tobias
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Richard A Bartlett
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - John G Clohessy
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ioannis S Vlachos
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Erica S Massicott
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Gerburg M Wulf
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Stuart J Schnitt
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Yujing J Heng
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
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12
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Tomalty D, Giovannetti O, Gaudet D, Clohosey D, Harvey MA, Johnston S, Komisaruk B, Hannan J, Goldstein S, Goldstein I, Adams MA. The prostate in women: an updated histological and immunohistochemical profile of the female periurethral glands and their relationship to an implanted midurethral sling. J Sex Med 2023; 20:612-625. [PMID: 36763941 DOI: 10.1093/jsxmed/qdac046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/11/2022] [Accepted: 12/09/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND There is evidence of glandular tissue in the region of the anterior vaginal wall-female periurethral tissue (AVW-FPT) that has similar morphology and immunohistochemistry to the prostate in men. Surgical injury to this tissue has been suggested as a potential cause of sexual dysfunction following midurethral sling (MUS) procedures. However, the anatomy and embryology of these glands have not been fully resolved. This has led to difficulties in classifying this tissue as a prostate and defining its clinical significance related to MUS procedures. AIM To describe the histological and immunohistochemical characteristics of the female periurethral glands using markers of prostate tissue and innervation and to examine their anatomical relationships to an implanted MUS. METHODS Using gross and fine dissection, the AVW-FPT was dissected from 9 cadavers. Prior to dissection, 2 cadavers underwent simulation of the MUS procedure by a urogynecologist. Samples were paraffin embedded and serially sectioned. Immunohistochemistry was performed using markers of prostate tissue and innervation. OUTCOMES Redundant immunohistochemical localization of markers for prostatic tissue and innervation of the glandular tissue of the AVW-FPT, including the region of MUS implantation. RESULTS Female periurethral glands were immunoreactive for markers of male prostatic tissue, including prostate-specific antigen, androgen receptor, HOXB13, and NKX3.1. Markers of innervation (protein gene product 9.5, choline acetyl transferase, and vasoactive intestinal polypeptide) also localized to certain regions of the glandular tissue and associated blood supply. Surgical simulation of the MUS procedure demonstrated that some periurethral glands are located in close proximity to an implanted sling. CLINICAL TRANSLATION The AVW-FPT contains glandular tissue in the surgical field of MUS implantation. Iatrogenic damage to the female periurethral glands and the associated innervation during surgery could explain the negative impacts on sexual dysfunction reported following MUS procedures. STRENGTHS AND LIMITATIONS This is the first study to characterize the female periurethral glands using markers of prostatic tissue in concert with markers of general and autonomic innervation and characterize their anatomical relationships within the surgical field of MUS implantation. The small sample size is a limitation of this study. CONCLUSION We provide further evidence that the AVW-FPT contains innervated glands that are phenotypically similar to the male prostate and may share a common embryonic origin. The microscopic and immunohistochemical features of the periurethral glands may be indicative of their functional capacity in sexual responses. The location of these glands in the surgical field of MUS procedures underscores the clinical significance of this tissue.
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Affiliation(s)
- Diane Tomalty
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Olivia Giovannetti
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Dionne Gaudet
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Diandra Clohosey
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Marie-Andrée Harvey
- Obstetrics and Gynaecology, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada
| | - Shawna Johnston
- Obstetrics and Gynaecology, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada
| | - Barry Komisaruk
- Department of Psychology, Rutgers University, Newark, NJ 07102, United States
| | - Johanna Hannan
- Department of Physiology, East Carolina University, Greenville, NC 27834, United States
| | - Sue Goldstein
- San Diego Sexual Medicine, San Diego, CA 92120, United States
| | - Irwin Goldstein
- San Diego Sexual Medicine, San Diego, CA 92120, United States
| | - Michael A Adams
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, K7L 3N6, Canada
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13
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Gurrala RR, Kumar T, Yoo A, Mundinger GS, Womac DJ, Lau FH. The Impact of Exogenous Testosterone on Breast Cancer Risk in Transmasculine Individuals. Ann Plast Surg 2023; 90:96-105. [PMID: 36534108 DOI: 10.1097/sap.0000000000003321] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Exogenous testosterone is vital to gender-affirming therapy for transmasculine individuals. Testosterone may be implicated in breast cancer (BCa) because it can activate androgen and estrogen receptors. To further explore this risk, we performed a systematic review to investigate the impact of exogenous testosterone on BCa risk in transmasculine individuals. METHODS We searched PubMed/MEDLINE and Ovid/Embase for clinical and preclinical studies assessing BCa and testosterone therapy and screened 6125 articles independently. We ascertained level of evidence using a modified tool from Cook et al (Chest. 1992;102:305S-311S) and risk of bias using a modified Joanna Briggs Institute's Critical Appraisal Tool. RESULTS Seventy-six studies were included. Epidemiological data suggested that BCa incidence was higher in transmasculine individuals compared with cisgender men but lower compared with cisgender women. Histological studies of transmasculine breast tissue samples also demonstrated a low incidence of precancerous lesions. Interestingly, cases demonstrated that BCa occurred at a younger average age in transmasculine individuals and was predominantly hormone receptor positive. The mechanism for BCa in transmasculine individuals may be related to androgen receptor stimulation or conversion to estradiol. Serum studies reported varied estradiol levels associated with exogenous testosterone. Animal and in vitro studies demonstrated that testosterone was growth inhibitory but may induce proliferation at higher doses or with low estradiol levels. CONCLUSIONS Plastic surgeons play a critical role in providing gender-affirming care for transmasculine patients. The limited studies available suggest that this patient population has decreased risk for BCa when compared with cisgender women; however, any BCa that does occur may have different clinical presentations and underlying mechanisms compared with cisgender women and men. Overall, the limitations for clinical studies and discrepancies among preclinical studies warrant further investigation.
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Affiliation(s)
| | | | - Aran Yoo
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA
| | | | - Daniel J Womac
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA
| | - Frank H Lau
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA
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14
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Heng YJ, Zhang KJ, Valero MG, Baker GM, Fein-Zachary VJ, Irwig MS, Wulf GM. Invasive Ductal Carcinoma of the Breast in a Transgender Man: A Case Report. Case Rep Oncol 2023; 16:811-817. [PMID: 37900827 PMCID: PMC10601725 DOI: 10.1159/000529859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 02/13/2023] [Indexed: 10/31/2023] Open
Abstract
There is limited literature about breast cancer in the transgender population. Very little is known about how gender-affirming hormone therapy affects their breast cancer risk. On the other end, for those diagnosed with breast cancer, there are no clinical guidelines to manage their breast cancer, specifically, how to manage their gender-affirming hormone therapy during breast cancer treatment. Here, we report a 52-year-old transman diagnosed with a grade 2 invasive ductal carcinoma (ER+/PR+/HER2-), and ductal carcinoma in situ (DCIS) of intermediate grade. We discussed his risk factors as well as treatment options.
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Affiliation(s)
- Yujing J. Heng
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kevin J. Zhang
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Monica G. Valero
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Gabrielle M. Baker
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Valerie J. Fein-Zachary
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Michael S. Irwig
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Gerburg M. Wulf
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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15
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Wolters EA, Rabe KE, Siegel L, Butts J, Klein ME. Histopathologic Features of Breast Tissue From Transgender Men and Their Associations With Androgen Therapy. Am J Clin Pathol 2022; 159:43-52. [PMID: 36469057 PMCID: PMC9825198 DOI: 10.1093/ajcp/aqac123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 09/20/2022] [Indexed: 12/10/2022] Open
Abstract
OBJECTIVES To assess the histopathologic features of breast tissue of transgender men (TM) undergoing gender-affirming bilateral mastectomies in relation to androgen therapy (AT). METHODS We reviewed 374 transgender bilateral mastectomy cases from 2017 to 2020. Of these, 314 (84.4%) patients received preoperative AT. We compared these with 127 cases of cisgender females undergoing elective breast reduction. RESULTS Breast specimens from TM on AT, compared with cisgender women, showed a median higher gross percentage of fibrous tissue (P < .001), reduced lobular density (P = .004), higher amount of lobular atrophy (P < .001), and lower incidence of cysts (P < .001), apocrine metaplasia (P < .001), calcifications (P < .001), columnar cell change (P = .002), and atypia (P = .003). Each additional month of AT was associated with a 2% decrease in the odds of having nonapocrine cysts (P = .02), a 5% decrease in the odds of having usual ductal hyperplasia (P = .007), and a 0.14% decrease in median lobular density (95% confidence interval, -0.18 to -0.05). CONCLUSIONS In this study, breast specimens from TM, particularly with a history of AT, had a higher proportion of fibrous tissue, fewer lobules, and a higher degree of lobular atrophy than cisgender females. Rare cases of atypia were not predicted by preoperative imaging or gross findings, supporting routine microscopic evaluation of these specimens.
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Affiliation(s)
- Emily A Wolters
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kimmie E Rabe
- Pathology Department, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Lianne Siegel
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Jessica Butts
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN, USA
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16
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Kelley JT, McMullen-Tabry ER, Skala SL. Reproductive Organ Pathology of Individuals Undergoing Gender-Affirming Surgery. Surg Pathol Clin 2022; 15:421-434. [PMID: 35715169 DOI: 10.1016/j.path.2022.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
As gender-affirming surgeries become more routine, it is increasingly important for pathologists to recognize the expected histologic changes seen in various tissues secondary to gender-affirming hormone therapy. For example, exogenous testosterone-related squamous atrophy or transitional cell metaplasia of the cervix may be confused for high-grade squamous intraepithelial lesion. In addition to distinguishing between benign and dysplastic/malignant features, pathologists should be mindful of the phrasing of their reports and aim to use objective, nongendered language.
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Affiliation(s)
- Justin T Kelley
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Emily R McMullen-Tabry
- Department of Pathology, Grand Traverse Pathology, PLLC, 1105 6th Street, Traverse City, MI 49684, USA
| | - Stephanie L Skala
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA.
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17
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Kim CF, Jou D, Ganor O, Boskey ER, Kozakewich H, Vargas SO. Prostatic metaplasia and pilar differentiation in gender-affirming mastectomy specimens. Mod Pathol 2022; 35:386-395. [PMID: 34689157 DOI: 10.1038/s41379-021-00951-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/30/2021] [Accepted: 10/01/2021] [Indexed: 12/18/2022]
Abstract
With the increasing practice of gender-affirming mastectomy as a therapeutic procedure in the setting of gender dysphoria, there has come a profusion of literature on the pathologic findings within these specimens. Findings reported in over 1500 patients have not included either prostatic metaplasia or pilar metaplasia of breast epithelium. We encountered both of these findings in the course of routine surgical pathology practice and therefore aimed to analyze these index cases together with a retrospective cohort to determine the prevalence, anatomic distribution, pathologic features, and associated clinical findings of prostatic metaplasia and pilar metaplasia in the setting of gender-affirming mastectomy. In addition to the 2 index cases, 20 additional archival gender-affirming mastectomy specimens were studied. Before mastectomies, all but 1 patient received testosterone cypionate, 6/22 patients received norethindrone, and 21/22 practiced breast binding. Prostatic metaplasia, characterized by glandular proliferation along the basal layer of epithelium in breast ducts, and in one case, within lobules, was seen in 18/22 specimens; 4/22 showed pilar metaplasia, consisting of hair shafts located within breast ducts, associated with squamoid metaplasia resembling hair matriceal differentiation. By immunohistochemistry, prostatic metaplasia was positive for PSA in 16/20 cases and positive for NKX3.1 in 15/20 cases. Forty-three reduction mammoplasty control cases showed no pilar metaplasia and no definite prostatic metaplasia, with no PSA and NKX3.1 staining observed. We demonstrate that prostatic metaplasia and pilar metaplasia are strikingly common findings in specimens from female-assigned-at-birth transgender patients undergoing gender-affirming mastectomy. Awareness of these novel entities in the breast is important, to distinguish them from other breast epithelial proliferations and to facilitate accrual of follow-up data for better understanding their natural history.
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Affiliation(s)
- Charlotte F Kim
- Department of Pathology, Boston Children's Hospital, Boston, MA, USA.,Department of Pathology and Immunology, Baylor College of Medicine and Pavilion for Women at Texas Children's Hospital, Houston, TX, USA
| | - David Jou
- Department of Pathology, Boston Children's Hospital, Boston, MA, USA.,Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Oren Ganor
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Elizabeth R Boskey
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Harry Kozakewich
- Department of Pathology, Boston Children's Hospital, Boston, MA, USA
| | - Sara O Vargas
- Department of Pathology, Boston Children's Hospital, Boston, MA, USA.
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18
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Schultz JJ, Naides AI, Bai D, Shulzhenko NO, Keith JD. Pathological Evaluation of Breast Specimens in Transgender Chest Masculinization: Incidental Findings and Effect of Prior Chest Binding and Androgen Therapy in 74 Consecutive Patients. Transgend Health 2022; 6:353-357. [PMID: 34993306 DOI: 10.1089/trgh.2020.0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Jerette J Schultz
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Alexandra I Naides
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Di Bai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Nikita O Shulzhenko
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Jonathan D Keith
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA.,East Coast Advanced Plastic Surgery, Livingston, New Jersey, USA
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19
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Pollack EB, O’Keefe MC. Breast Imaging in Special Populations: Indications and Findings in Pregnant and Lactating, Male, and Transgender Patients. CURRENT BREAST CANCER REPORTS 2021. [DOI: 10.1007/s12609-021-00428-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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20
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Andrews AR, Kakadekar A, Greene DN, Khalifa MA, Santiago V, Schmidt RL. Histologic Findings in Surgical Pathology Specimens From Individuals Taking Masculinizing Hormone Therapy for the Purpose of Gender Transition: A Systematic Scoping Review. Arch Pathol Lab Med 2021; 146:766-779. [PMID: 34559874 DOI: 10.5858/arpa.2020-0774-ra] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Transgender men and transmasculine persons experience a discordance between the female sex they were assigned at birth and their gender. They may choose to take hormone therapy and/or undergo surgery to masculinize the body. Understanding the common (and less common) histologic changes present in patients taking masculinizing hormones will empower pathologists to better serve this unique patient population. OBJECTIVE.— To summarize histologic findings in surgical pathology specimens from persons taking masculinizing hormones as a part of gender transition. DATA SOURCES.— A systematic review of the OVID Medline and PubMed databases was performed to identify all studies describing histologic findings in surgical pathology specimens from transgender men from January 1946 to January 2021. CONCLUSIONS.— Publication in this area has markedly increased in the last 2 decades. However, most of the studies identified were descriptive and case reports describing changes seen in specimens removed as a part of masculinizing surgical procedures. Benign histologic findings include stromal hyalinization and epithelial atrophy in the breast, polycystic ovarian syndrome-like changes in the ovary, and transitional cell metaplasia in the cervix. The most commonly reported neoplastic finding was adenocarcinoma of the breast, with rare cases of ovarian, endometrial, cervical, vaginal, pituitary, pancreatic, and cardiovascular neoplasia also reported. Ongoing research in this area is needed to better characterize the histologic findings in persons taking masculinizing hormones to provide a deeper understanding of the effect of these treatments on different tissues and facilitate better patient management.
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Affiliation(s)
- Alicia R Andrews
- From the Department of Pathology and Laboratory Medicine, University of Saskatchewan, Saskatoon, SK Canada (Andrews, Kakadekar)
| | - Archan Kakadekar
- From the Department of Pathology and Laboratory Medicine, University of Saskatchewan, Saskatoon, SK Canada (Andrews, Kakadekar)
| | - Dina N Greene
- Kaiser Permanente Washington Laboratories, Seattle, Washington (Greene)
| | - Mahmoud A Khalifa
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis (Khalifa, Santiago)
| | - Victor Santiago
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis (Khalifa, Santiago)
| | - Robert L Schmidt
- Department of Pathology, University of Utah, Salt Lake City (Schmidt)
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