Occult breast carcinoma in reduction mammaplasty specimens: 14-year experience

Spectrum of histopathologic findings in risk-reducing bilateral prophylactic mastectomy in patients with and without BRCA mutations

Many germline mutations have been implicated in breast cancer pathogenesis and despite several studies on occult atypical lesions in prophylactic mastectomy specimens from patients with BRCA1/2 mutations, there are very limited data on other genes associated with increased breast cancer risk and the distribution of lesions in patients with hereditary breast cancer. We identified 207 patients who underwent bilateral prophylactic mastectomy due to germline mutations in BRCA1/2, PALB2, CHEK2, ATM, CDH1, PTEN, BARD1, or strong family history between 2015 and 2023. Patients with biopsy-proven past or current invasive breast carcinoma or carcinoma in-situ preoperatively were excluded. In addition to multiple benign lesions, the following atypical lesions were identified: flat epithelial atypia (16.9%), atypical ductal hyperplasia (14.0%), lobular neoplasia (14.0%), ductal carcinoma in-situ (4.3%), invasive ductal carcinoma (0.4%). Both low-grade and high-grade pathway lesions were identified in this cohort, and in a subset of patients, they co-occurred. The frequency of atypical lesions identified in patients with strong family history were comparable to those with proven germline mutation. PTEN immunohistochemistry showed loss of expression in ductal carcinoma in-situ and tubular adenomas in PTEN-mutant patients. Overall, findings from this cohort support the benefit of prophylactic mastectomy in patients with germline mutations and/or strong family history. Additionally, this is the first demonstration that PTEN immunohistochemistry may be helpful in identifying germline mutations in patients with atypical or neoplastic proliferations.

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.

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.

Discussion of Histopathological Findings of 954 Breast Reduction Specimens

Objectives

Breast reduction is a frequently sought procedure by patients and one of the most commonly performed operations by plastic surgeons. Follow-up of histopathological results after reduction mammoplasty is very important. This study aimed to evaluate the histopathological results of patients undergoing bilateral reduction mammoplasty to determine the incidence of breast lesions and risk factors of high-risk breast lesions.

Methods

477 patients who underwent reduction mammoplasty in the plastic surgery department between October 2013 and January 2020 were included in this study. Patients were evaluated according to age, body mass index (BMI), comorbidity factors, tobacco use, family history and histopathological findings.

Results

The mean age of patients was 42.43±12.05 years. Body mass index ranged from 23 to 34.6. As for comorbidity factors, 12 patients had hypertension, five patients had asthma and six patients had diabetes mellitus. Seventeen patients (3.6%) were smokers, and 25 (5.2%) patients had a family history of breast cancer. Among the patients, 2.3% were 20 years and under, 17.1% were between 21 and 30 years old, 21.5% were between 31 and 40 years old, 33.1% were between 41 and 50 years old, 18.2% were between 51 and 60 years old, and 7.5% were 60 years and above. 85.4% of histopathological findings consisted of normal breast tissue and nonproliferative breast lesion breast lesions. The incidences of proliferative breast lesions, atypical hyperplasia and in situ lesions were calculated as 5.7%, 2% and 0.4%, respectively. The mean follow-up period was 3.8±1.6 years.

Conclusion

Although preoperative breast cancer screening methods are used before the reduction mammoplasty, high-risk lesions may be encountered afterwards. One of the biggest advantages of reduction mammoplasty in addition to psychophysiological recovery is breast cancer risk reduction.

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.

The rate of incidental atypical and malignant breast lesions in reduction mammoplasty specimens

AIMS

Reduction mammoplasty (RM) is one of the most common plastic surgeries in the United States. We aimed to demonstrate the rate of incidental atypical and malignant breast lesions (AMBL) found in RM specimens and the impact of the number of submitted tissue sections on the rate of AMBL.

METHODS AND RESULTS

We analysed our database for patients who had undergone reduction mammoplasty between 2000 and 2018. Patients with a history of breast cancer were excluded from the study. All pathology reports were analysed for AMBL (ALH, LCIS, FEA, ADH, DCIS, invasive carcinoma). The grossing protocol was to submit 10 sections from each breast between 2000 and 2013 and six sections between 2014 and 2018. One hundred and sixty-nine of 5208 patients (3.3%) and 216 of 10 340 RM specimens (2.1%) showed at least one AMBL. Nineteen (0.36%) patients had incidental cancer. The median age of patients with AMBL was significantly higher than patients without ABL (aged 59 years versus 45 years). There was no cancer in patients aged <30 years. The age-controlled rate of overall AMBL as well as atypia and cancer only did not decrease by submitting fewer sections during the 2014-18 period compared to the 2010-13 period.

CONCLUSIONS

Decreasing the number of tissue sections from 10 to six did not lead to a significant decrease in the rate of overall AMBL or cancer. Our data suggest that submitting six tissue sections from each breast for patients aged >30 years and two sections from each breast for patients aged <30 years would be sufficient.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Risk-Stratified Comparison of High-Risk Findings in Reduction Mammoplasty

BACKGROUND

Reduction mammoplasty is indicated for symptomatic macromastia or breast asymmetry after contralateral cancer surgery. Previous studies compared the incidence of high-risk lesions in resection specimens between these 2 groups. However, no studies have compared incidental findings in breast reduction specimens based on relative risk of cancer. Our study stratifies lesions by relative risk of malignant progression and compares the frequency of these findings in bilateral versus unilateral reduction mammoplasties.

METHODS

Charts were reviewed from 422 patients undergoing breast reductions by a single surgeon over a 10-year period. Age, procedure, specimen weight, and histologic findings were recorded. Pathologic data were stratified by relative risk of malignant progression and compared between patients with and without cancer histories.

RESULTS

Three hundred five patients underwent bilateral reduction mammoplasty and 117 patients underwent unilateral reduction mammoplasty over the 10-year period. Bilateral patients had a higher incidence of benign lesions (P = 0.02). Both groups had similar incidences of proliferative lesions (P = 0.48). Unilateral patients had a higher incidence of atypia (P = 0.05) and carcinoma in situ (P < 0.01). One unilateral patient had an incidentally found invasive carcinoma.

CONCLUSIONS

Patients undergoing unilateral reduction after oncologic resection have a higher incidence of high-risk lesions compared with those undergoing bilateral reductions for macromastia. Although others have compared incidental findings between these cohorts, no group has compared these incidental findings stratified by risk. Our data underscore the importance of pathologic analysis of reduction specimens for early detection of high-risk lesions and will prove valuable for preoperative counseling before reduction mammoplasty for either of these indications.

Occult disease in reduction mammoplasties and prophylactic mastectomies

The aim of this study was to determine the incidence of occult breast carcinoma and significant breast disease in clinically and radiologically unremarkable breast reduction specimens and prophylactic mastectomies. A retrospective search using specimen type codes was performed in the computerized histopathology archive from April 2007 to April 2016. The pathology results of 505 patients were analyzed (782 specimens). A total of 267 patients underwent simple reduction mammoplasties (10 unilateral), 20 had bilateral prophylactic mastectomies and 218 undertook contralateral symmetrizing or prophylactic mastectomy surgery following a history of breast cancer. Overall, normal (unremarkable) breast tissue was found in 42.6% of patients (n = 215), benign tissue (nonproliferative/proliferative disease without atypia) in 51.1% (n = 258), significant disease (LCIS/proliferative disease with atypia) in 5.5% (n = 28), and malignant disease (invasive/ductal carcinoma in situ) in 0.8% (n = 4). The incidence of significant breast pathology was statistically higher (P value < .0001) in prophylactic mastectomies (12.4%) compared to reduction mammoplasties (2.3%). There was however no significant increase in the incidence of malignancy between prophylactic mastectomies (1.2%) and reduction mammoplasties (0.6%). Even though the clear majority of resected tissue in reduction mammoplasties and prophylactic mastectomies is benign, our findings support the continued need for histological examination of these specimens for occult carcinoma and precursor lesions.

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.

Discussion of preoperative mammography in women undergoing reduction mammaplasty

PURPOSE

Reduction mammaplasty is one of the most common procedures performed by plastic surgeons. Previous studies demonstrated that most plastic surgeons do not require preoperative mammography prior to reduction mammaplasty. The incidental discovery of malignant or high-risk lesions in breast reduction specimens may preclude the possibility of breast-conserving surgery. The purpose of this study was to examine the factors associated with discussion of preoperative mammography with reduction mammaplasty patients.

METHODS

About 638 consecutive patients were identified between January 2000 and December 2010 who underwent reduction mammaplasty. Clinicopathologic and treatment information was collected. Factors associated with discussion of preoperative mammography prior to surgery were compared.

RESULTS

Of 638 patients, the median age was 36 (range 18-77) with 44% ≥40. Approximately half (56.0%) were White and 37.5% were African-American. The use of mammography was discussed in 43.3% of patients and completed in 41.5%. On final pathology, eight patients (1.3%) had high-risk lesions and two (0.3%) demonstrated malignancy (1 DCIS, 1 invasive). Of these 10 patients, two were under the age of 40 and four had preoperative mammograms. Factors associated with mammography discussion were age ≥40, White race, the presence of comorbidities, family history of breast cancer, prior breast surgery, prior breast biopsy, history of breast cancer (all P < 0.0001) and tobacco use (P = 0.04).

CONCLUSIONS

Due to the potential risk of invasive cancer and high-risk lesions in the final surgical specimen, preoperative mammography should be discussed with selected patients by plastic surgeons, particularly those who fall within national screening guidelines.

Pathologic findings in reduction mammoplasty specimens: a surrogate for the population prevalence of breast cancer and high-risk lesions

PURPOSE

Mammoplasty removes random samples of breast tissue from asymptomatic women providing a unique method for evaluating background prevalence of breast pathology in normal population. Our goal was to identify the rate of atypical breast lesions and cancers in women of various ages in the largest mammoplasty cohort reported to date.

METHODS

We analyzed pathologic reports from patients undergoing bilateral mammoplasty, using natural language processing algorithm, verified by human review. Patients with a prior history of breast cancer or atypia were excluded.

RESULTS

A total of 4775 patients were deemed eligible. Median age was 40 (range 13-86) and was higher in patients with any incidental finding compared to patients with normal reports (52 vs. 39 years, p = 0.0001). Pathological findings were detected in 7.06% (337) of procedures. Benign high-risk lesions were found in 299 patients (6.26%). Invasive carcinoma and ductal carcinoma in situ were detected in 15 (0.31%) and 23 (0.48%) patients, respectively. The rate of atypias and cancers increased with age.

CONCLUSION

The overall rate of abnormal findings in asymptomatic patients undergoing mammoplasty was 7.06%, increasing with age. As these results are based on random sample of breast tissue, they likely underestimate the prevalence of abnormal findings in asymptomatic women.

Reviewing the Evidence to Guide Clinical Care: Proliferative Breast Lesions in Breast Reduction Specimens

The number of reduction mammoplasties performed in the United States continues to increase annually. Given the high incidence of breast cancer in women, it is routine practice for breast tissue excised during routine breast reductions procedures to be sent for pathology review. During pathology assessment, occult malignancy and on-occasion proliferative breast lesions of unknown and/or variable malignancy may also be present. We provide a review of commonly diagnosed atypical proliferative breast lesions in breast reduction specimens and a guide to plastic surgeons for further management.

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

CONTEXT

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

OBJECTIVES

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Breast Cancer Detection by Preoperative Imaging in Reduction Mammaplasty Patients: A Single Center Study of 918 Patients

BACKGROUND

The role of preoperative imaging and the usability of different imaging modalities is highly variable and controversial in reduction mammaplasty patients. Our study describes the imaging process in a single center in regard to modality selection, age and timing, and of the association between imaging and histopathological findings in reduction mammaplasty specimens.

METHODS

Nine hundred eighteen women, who underwent reduction mammaplasty during 1.1.2007-31.12.2011, were retrospectively reviewed for demographics, preoperative imaging, further preoperative examinations, and pathology reports.

RESULTS

Preoperative imaging had been conducted for 89.2% (n = 819) of the patients. In 49 (6.0%) patients, suspicious preoperative imaging led to further examinations revealing 2 high-risk lesions (atypical ductal hyperplasia (ADH), lobular carcinoma in situ (LCIS)), and 2 cancers preoperatively. Postoperatively abnormal histopathology specimens were revealed in 88 (10.4%) patients. The incidence of high-risk lesions was 5.5% (n = 47), and the incidence of cancer was 1.2% (n = 10). Preoperative imaging was normal (BI-RADS 1 and BI-RADS 2) in 80.8% of these patients. The sensitivity of the preoperative imaging for cancer detection was 20.0%, and the specificity was 100.0%.

CONCLUSIONS

Preoperative imaging and further examinations do not sufficiently detect malignant or cancer risk-increasing findings. Therefore, histopathological analysis of reduction mammaplasty specimens seems mandatory.

Should we routinely analyze reduction mammaplasty specimens?

BACKGROUND

Reduction mammaplasty is one of the most common plastic surgery procedures. Preoperative imaging and histopathology protocols vary among countries and institutions. We aimed to analyze the incidence of occult breast cancer and high-risk lesions in reduction mammaplasty specimens. We also analyzed whether patients with abnormal histopathology differed from the study population in terms of demographics.

PATIENTS AND METHODS

In total, 918 women who underwent reduction mammaplasty from January 2007 to December 2011 were retrospectively reviewed for demographics, preoperative imaging, further preoperative examinations, pathology reports, and postoperative follow-up.

RESULTS

Abnormal histopathological findings were revealed in 88 (10%) patients with a mean age of 49.5 ± 10.2 years. The incidence of breast cancer was 1.2%, and the incidence of high-risk lesions (atypical ductal and lobular hyperplasia and lobular carcinoma in situ) was 5.5%. Age and specimen weights were significantly higher in patients with abnormal histopathology. Eighty-one percent of patients with abnormal histopathology had normal preoperative imaging revealing two high-risk and two cancer findings. Two patients developed breast cancer in the same breast in which the high-risk lesion was originally detected.

CONCLUSION

Women with abnormal histopathology cannot be sufficiently detected preoperatively. Therefore, histopathological analysis of reduction mammaplasty specimens seems mandatory. Reduction mammaplasty combined with subsequent histopathological examination offers a sufficient chance of detecting cancer and risk-increasing lesions that merits the cost of histopathology.

Assessing Risk and Avoiding Complications in Breast Reduction

Assessing risk and avoiding complications in breast reduction requires a meticulous history, systematic physical examination, management of expectations, and careful consideration and execution of operative technique. Attention should be paid to comorbidities. Shape, symmetry, contours, scar location, skin quality, nipple-areolar complex (NAC) shape, NAC position relative to inframammary fold, and NAC position relative to the volume of the breast should be evaluated. Because complications cannot always be anticipated, informed consent is a vital part of managing expectations. Intraoperative considerations include blood pressure control, limiting tension, delayed healing and tissue loss, and using applied anatomy to avoid malposition and asymmetry.

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.

Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain

INTRODUCTION

Bilateral breast reduction (BBR) is one of the most frequently performed female breast operations. Despite no evidence supporting efficacy of drain usage in BBRs, postoperative insertion is common. Recent high quality evidence demonstrating potential harm from drain use has subsequently challenged this traditional practice. The aim of this study is to assess the current practice patterns of drains usage by Plastic & Reconstructive and Breast Surgeons in UK and Ireland performing BBRs.

METHOD

An 18 question survey was created evaluating various aspects of BBR practice. UK and Irish Plastic & Reconstructive and Breast Surgeons were invited to participate by an email containing a link to a web-based survey. Statistical analysis was performed with student t-test and chi-square test.

RESULTS

Two hundred and eleven responding surgeons were analysed, including 80.1% (171/211) Plastic Surgeons and 18.9% (40/211) Breast Surgeons. Of the responding surgeons, 71.6% (151/211) routinely inserted postoperative drains, for a mean of 1.32 days. Drains were used significantly less by surgeons performing ≥20 BBRs (p = 0.02). With the majority of BBRs performed as an inpatient procedure, there was a trend towards less drain usage in surgeons performing this procedure as an outpatient; however, this was not statistically significant (p = 0.07).

CONCLUSION

Even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilised. In an era of evidence- based medicine, surgeons performing breast reductions must adopt the results from scientific research into their clinical practice.

Adverse Histopathology and Imaging Findings in Reduction Mammaplasty Day-surgery Patients

Background and Aims:

Reduction mammaplasty is a popular procedure in plastic surgery. Occasionally, occult invasive breast carcinoma or findings demonstrating increased risk of breast cancer occur in reduction mammaplasty specimens. The incidences have been studied elsewhere, but in Finland, the data on this subject are lacking. Our aim was to analyze the incidence of occult invasive and in situ carcinoma and benign breast disease causing increased risk of breast cancer in reduction mammaplasty specimens. We also analyzed preoperative mammograms and ultrasound images and compared findings with reduction mammaplasty specimens.

Material and Methods:

We performed a retrospective study of 100 women who underwent reduction mammaplasty during 1 January 2007 to 30 April 2009 in Jorvi Hospital day-surgery unit. Demographic data, findings in preoperative imaging, pathology reports, postoperative follow-up, and retrospective reanalysis of preoperative imaging were recorded.

Results:

Histological abnormality occurred in 14.6% of the patients. In situ carcinoma was diagnosed in 4.5% of the patients, and findings demonstrating increased risk of breast cancer were diagnosed in 13.5% of the patients. More than one lesion demonstrating increased risk of breast cancer was diagnosed in 4.5% of the patients. No invasive carcinoma occurred. Preoperative mammogram was performed for the majority (94.0%) of the patients.

Conclusions:

We detected a considerable amount of findings in reduction mammaplasty specimens with prognostic value with regard to future breast cancer risk. We recommend histological analysis for reduction mammaplasty specimens and focus attention on systematically performed preoperative imaging.

Incidence of occult contralateral carcinomas of the breast following mastoplasty aimed at symmetrization

INTRODUCTION

Breast carcinomas are the most frequent form of cancer in French women. Following a total mastectomy, only an estimated 25% of patients wish to undergo breast reconstruction. After mammary volume reconstitution, the plastic surgeon often attempts to harmonize the two breasts by carrying out contralateral reduction mammaplasty (CRM). In the literature, the incidence of occult contralateral carcinomas incidentally discovered in surgical specimens ranges from 1.12 to 4.5%. The main objective of this study was to evaluate occurrence of carcinoma in the CRM specimens in the framework of a breast reconstruction operation. The secondary objective was to determine the consequences of the incidentally discovered carcinoma in the contralateral breast.

MATERIAL AND METHODS

This was a 6-year, bicentric, retrospective study involving women having undergone breast cancer surgery who later underwent contralateral reduction mammaplasty (CRM), that is to say reconstruction aimed at harmonization of the two breasts.

RESULTS

Three hundred and nineteen patients were included in the study. Mean age during the CRM was 55years (29-79). Mean weight of the surgical specimens was 323grams (12-2500). Incidence of occult carcinomas found in the specimens was 0.94% (3 patients). The mean age for these 3 cases was 58years (47-64). All 3 patients had superior pedicle mammaplasty. One of the patients benefited from monobloc resection with orientation of the surgical specimen. In the other 2 cases, there existed 3 surgical resection specimens; in one case, they were oriented; in the other, they were not. In all 3 cases, the histological findings were unifocal ductal carcinomas in situ (DCIS). Mean tumor size was 5.7mm (3-9). Only the patient having had monobloc resection with orientation of the specimen underwent salvage surgery, which consisted in partial mastectomy, otherwise known as secondary lumpectomy. Adjuvant radiotherapy was administered to all of the patients. After 17months of mean follow-up (12-22), no recurrence was found in any of the three cases.

CONCLUSION

Incidence of occult contralateral breast carcinomas after symmetrization CRM approximates 1%. Our observations are in agreement with the data in the literature. Incidence is greater than in mammaplasty carried out for esthetic or functional reasons; this is probably due to the higher age and the previous breast cancer history of the breast reconstruction population. Monobloc resection and orientation of the surgical specimens with surgeon's knots facilitate precise pinpointing of the occult carcinoma. A secondary lumpectomy may take place when margins of excision are invaded or inadequate.

Infrared microspectroscopy identifies biomolecular changes associated with chronic oxidative stress in mammary epithelium and stroma of breast tissues from healthy young women: implications for latent stages of breast carcinogenesis

Studies of the decades-long latent stages of breast carcinogenesis have been limited to when hyperplastic lesions are already present. Investigations of earlier stages of breast cancer (BC) latency have been stymied by the lack of fiducial biomarkers needed to identify where in histologically normal tissues progression toward a BC might be taking place. Recent evidence suggests that a marker of chronic oxidative stress (OxS), protein adducts of 4-hydroxy-2-nonenal (4HNE), can meet this need. Specifically: (1) 4HNE immunopositive (4HNE+) mammary epithelial (ME) cells were found to be prevalent in normal (reduction mammoplasty) tissues of most women (including many teenagers) studied, representative of those living in the United States' high risk-posing environment and: (2) marked (> 1.5-fold) differences were identified between tissues of healthy young women with many vs. few 4HNE+ ME cells in the relative levels of transcripts for 42 of the 84 OxS-associated genes represented in SABioscience Oxidative-Stress/Oxidative-Defense PCR array. Herein we used synchrotron radiation-based Fourier-transform infrared (SR-FTIR) microspectroscopy to identify molecular changes associated with 4HNE adducts in basal and luminal ME cells in terminal ductal units (TDLU), which are the cells of origin of BC, and associated intralobular and interlobular stroma, known contributors to carcinogenesis. Multivariate analysis-derived wavenumbers differentiated 4HNE+ and 4HNE- cells in each of the anatomical compartments. Specifically, principal component and linear discriminant analyses of mid-infrared spectra obtained from these cells revealed unambiguous, statistically highly significant differences in the "biochemical fingerprint" of 4HNE+ vs. 4HNE- luminal and basal ME cells, as well as between associated intralobular and interlobular stroma. These findings demonstrate further SR-FTIR microspectroscopy's ability to identify molecular changes associated with altered physiological and/or pathophysiological states, in this case with a state of chronic OxS that provides a pro-carcinogenic microenvironment.

[Occult primary MALT lymphoma of the breast diagnosed and treated by reduction mammaplasty. An exceptional case report and review of the literature]

Primary Mucosa-associated Lymphoid Tissue (MALT) lymphoma of the breast is a very rare disease. We report here a case of occult primary MALT lymphoma of the breast diagnosed from a mammaplasty specimen. Primary tumor resection during the mammaplasty surgery was the only treatment of this lymphoma, and there was no recurrence at five years. The clinical and radiologic presentation of primary MALT lymphoma of the breast is similar to epithelial breast carcinoma, and the main diagnostic criteria are microscopic examination and immunohistochemistry. The prognosis of breast primary MALT lymphomas is good after local treatment by surgery and/or radiotherapy, and surgery shouldn't be too aggressive. In this case, no other treatment was indicated after the first surgical procedure. To our knowledge, this is the first case report in the literature of occult primary MALT lymphoma of the breast diagnosed from a mammaplasty specimen. This allows us to highlight the need for systematic microscopic examination of mammaplasty specimens conducted by an experienced pathologist, especially as preoperative examinations are not able to detect all occult breast carcinomas.

Histopathologic findings in breast reduction specimens

Reduction mammaplasty is a commonly performed operation for treatment of breast hypertrophy. It allows examination of specimens from a seemingly healthy population. Although there are many publications reporting the incidence of occult breast carcinomas, only a few studies have specifically examined the incidence of other breast lesions in reduction mammaplasty specimens. The authors conducted a single-centre retrospective chart review examining the incidence of benign and precancerous lesions in breast reduction specimens. Both age and the number of tissue sections were evaluated for the association with important pathologic findings. Of the 95 patients who underwent reduction mammaplasty, eight patients (8.4%) had atypical lesions. Fourteen patients (15%) had proliferative and 54 patients (57%) had non-proliferative breast lesions. No occult invasive breast cancer was identified in the breast reduction specimens. The existence of significant pathologic findings was not associated with age (p = 0.231, student t-test). On the other hand, it was found to be associated with the number of tissue sections (p = 0.046, Mann-Whitney U-test). This study reveals that breast reduction specimens should be analyzed histologically since a considerable amount of patients have breast lesions with increased cancer risk. Therefore, this analysis would guide the management of these patients in the follow-up period.

Incidental atypical proliferative lesions in reduction mammoplasty specimens: analysis of 2498 cases from 2 tertiary women's health centers

Atypical proliferative lesions (APLs) are occasionally found in breast reduction specimens. The aim of the study was to investigate the prevalence of APL in reduction mammoplasty specimens from patients who were treated mainly for macromastia. A retrospective medical record review of pathology records on patients who underwent reduction mammoplasty from 2006 to 2012 generated 2498 cases. The sole exclusion criterion was a history of invasive and/or ductal carcinoma in situ (DCIS). Laterality, specimen weight, number of blocks submitted, and presence of APL were recorded and analyzed. We defined APL as invasive carcinoma, DCIS or lobular carcinoma in situ, atypical ductal (ADH) or lobular hyperplasia, and flat epithelial atypia (FEA). The presence of papillomas, radial scars, and fibroadenomas was also recorded. At least 1 APL was identified in 107 (4.3%) of 2498 reduction mammoplasty specimens including invasive duct carcinoma (n = 2), DCIS (n = 4), ADH/FEA (n = 47), and lobular carcinoma in situ/atypical lobular hyperplasia (n = 54). One hundred four (97%) of the 107 patients underwent bilateral, and 3 (3%) underwent unilateral reductions. In conclusion, the frequency of detection of APLs in patients with no history of breast cancer is low (4.3%). Detection of invasive and DCIS lesions is extraordinarily low at 0.2%. The most common APL is lobular neoplasia (2.2%), whereas ADH and FEA are seen in 1.9%. Our findings provide data on the distribution of these lesions in this setting, as well as some insight into their prevalence in the general population. A protocol for submitting tissues from these specimens is also proposed.

Incidence of occult carcinoma and high-risk lesions in mammaplasty specimens

Objectives. To determine the incidence and type of premalignant or malignant changes in mammaplasty specimens and to determine the incidence of these changes according to age distribution. Methods. Retrospective database review of patients who underwent a reduction mammaplasty between 1999 and 2009 was performed from pathology records at a single institution. Results. 700 patients were identified. Of the 644 patients who had bilateral reductions, 25 (4%) had significant pathologic findings. The likelihood of finding premalignant changes or cancer increased with advancing patient age (0.8 percent for patients <40 years old and 10 percent for patients >60 years old). Of the 56 patients who underwent unilateral mammaplasty, 12 patients (21%) had significant pathologic findings. The incidence of finding premalignant changes or cancer in this population also increased with advancing patient age (0 for patients <40 years old to 25 percent for patients >60 years old). Conclusions. When a unilateral mammaplasty is performed to match a breast reconstructed after cancer surgery, the likelihood of identifying premalignant changes or cancer increases more than fourfold. Therefore, one should consider additional radiologic imaging in the preoperative workup of patients with a history of carcinoma prior to undergoing unilateral mammaplasty.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE IV

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

Identification of mammary epithelial cells subject to chronic oxidative stress in mammary epithelium of young women and teenagers living in USA: implication for breast carcinogenesis

Current knowledge of changes in the mammary epithelium relevant to breast carcinogenesis is limited to when histological changes are already present because of a lack of biomarkers needed to identify where such molecular changes might be ongoing at earlier during the of decades-long latent stages of breast carcinogenesis. Breast reduction tissues from young women and teenagers, representative of USA's high breast cancer incidence population, were studies using immunocytochemistry and targeted PCR arrays in order to learn whether a marker of chronic oxidative-stress [protein adducts of 4-hydroxy-2-nonenal (4HNE)] can identify where molecular changes relevant to carcinogenesis might be taking place prior to any histological changes. 4HNE-immunopositive (4HNE+) mammary epithelial cell-clusters were identified in breast tissue sections from most women and from many teenagers (ages 14-30 y) and, in tissues from women ages 17-27 y with many vs. few 4HNE+ cells, the expression of 30 of 84 oxidative-stress associated genes was decreased and only one was increased > 2-fold. This is in contrast to increased expression of many of these genes known to be elicited by acute oxidative-stress. The findings validate using 4HNE-adducts to identify where molecular changes of potential relevance to carcinogenesis are taking place in histologically normal mammary epithelium and highlight differences between responses to acute vs. chronic oxidative-stress. We posit that the altered gene expression in 4HNE+ tissues reflect adaptive responses to chronic oxidative-stress that enable some cells to evade mechanisms that have evolved to prevent propagation of cells with oxidatively-damaged DNA and to accrue heritable changes needed to establish a cancer.

Cosmetic surgery prior to diagnosis of breast cancer

BACKGROUND

Cosmetic breast surgery is amongst the top five most commonly performed cosmetic surgical procedures. With breast cancer being the most common non-skin malignancy in women, the likelihood that a woman undergoing cosmetic breast surgery may have an occult breast cancer needs to be considered. Most of the available data pertaining to breast cancer diagnosis in the setting of cosmetic surgery are from studies of cosmetic breast surgery populations. We report on the prevalence of breast cancer as an incidental finding during cosmetic breast surgery in the context of women subsequently diagnosed with invasive breast cancer.

METHODS

The Bupa Health Foundation Health and Wellbeing after Breast Cancer Study is a prospective cohort study of 1684 women recruited within 12 months of their first diagnosis with invasive breast cancer. Participants completed an enrolment questionnaire and annual follow-up questionnaires for 5 years.

RESULTS

At the second follow-up, 1.5% of women reported having undergone cosmetic breast surgery prior to being diagnosed with breast cancer, 16 had undergone breast reduction and seven had augmentations. Invasive breast cancer was diagnosed at the time of a cosmetic breast procedure in two women, in both an augmentation and a reduction procedure, which is 8.7% (95% confidence interval 23.5% to +20.9%) of the women in our study reporting a cosmetic breast procedure prior to diagnosis.

CONCLUSIONS

Although prior cosmetic breast surgery was reported by few women, breast cancer was diagnosed in two women during the procedure. Surgeons performing elective breast surgery need to understand and apply consistent, reliable breast cancer screening practices.

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.

The role of oncoplastic therapeutic mammoplasty in breast cancer surgery--a review

BACKGROUND

Reduction mammoplasty is an established technique for symptom relief in women with breast hypertrophy. Therapeutic mammoplasty and radiotherapy may allow cancers to be surgically treated whilst maintaining oncological safety and improving cosmetic outcome. This article aims to review the evidence upon which therapeutic mammoplasty is based and to outline an approach for surgical planning and selection.

METHODS

A systematic PubMed and Medline literature search was carried out. All abstracts were studied and papers that dealt primarily with breast conservation using plastic surgery techniques were reviewed.

RESULTS AND CONCLUSION

Therapeutic mammoplasty is a useful procedure for breast conserving cancer surgery in women with large breasts, conferring a good cosmetic and functional outcome. This article proposes that breast surgeons experienced in oncological surgery can safely resect tumours from all aspects of the breast with a minimal number of variations in standard mammoplasty technique.

The need for breast cancer screening in women undergoing elective breast surgery: an assessment of risk and risk factors for breast cancer in young women

BACKGROUND

Given the 11% lifetime risk of breast cancer and increasing popularity of elective breast surgery, the role of preoperative screening begs further investigation. There are currently no guidelines that indicate which women younger than 40 years of age should be screened preoperatively.

OBJECTIVES

A meta-analysis of studies regarding the odds ratio (OR) and relative risk ratio for breast cancer risk factors in women younger than 40 was completed.

METHODS

Of a total of 240 results in the PubMed database for articles referencing breast cancer risk factors in young women, eight were selected for review. A total of 5381 patients were included in the studies in this meta-analysis; 26 risk factors were identified. A meta-analysis was performed to determine the OR of each specific risk factor, with a 95% confidence interval.

RESULTS

The most significant risk factors were having a sister with breast cancer (OR, 11.66), having a first-degree relative with breast cancer (OR, 2.66), having a mother with breast cancer (OR, 2.31), never having breastfed (OR, 1.77), and having undergone a breast biopsy (OR, 1.66). From these data, the authors developed a clinical questionnaire to estimate the risk of breast cancer in young women. In addition, an algorithm was developed for preoperative breast cancer screening for women of all ages undergoing elective breast procedures.

CONCLUSIONS

For women younger than 40, the preoperative risk assessment involves two steps. First, the possibility of existing breast cancer should be evaluated with a preoperative screening survey. Second, the patient's risk for future development of cancer should be assessed, with a focus on genetic mutations. Women older than 40 years of age should be stratified to receive either a preoperative mammogram or MRI. The clinical questionnaire and preoperative screening algorithm provide an evidence-based guideline on which to base the discussion with patients regarding preoperative breast cancer screening.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Safety and efficacy of contra-lateral breast reduction for women with mammary hypertrophy undergoing mastectomy for breast cancer

Women with mammary hypertrophy undergoing mastectomy for breast cancer suffer disability because of disproportionate asymmetry. The case notes of all women with mammary hypertrophy undergoing mastectomy and immediate contra-lateral reduction mammaplasty for primary breast cancer from February 2001 to December 2008 were reviewed. Thirty-three women were identified of whom twenty-seven underwent inferior pedicle reduction mammaplasty and six inferior dermoglandular pedicle reduction with free nipple graft. The duration of surgery ranged from 75 to 146 (median 110) minutes. Between 475 and 2350 (median 1090) grams of breast tissue was excised from the contra-lateral breast. No immediate or delayed complications were observed and there were no delays in commencing adjuvant therapy. Immediate contra-lateral breast reduction in women with mammary hypertrophy undergoing mastectomy for breast cancer is safe and effective means of reducing the physical, psychological and cosmetic problems associated with unilateral mammary hypertrophy following mastectomy.

The use of oncoplastic reduction techniques to reconstruct partial mastectomy defects in women with ductal carcinoma in situ

The application of oncoplastic techniques to breast conservation therapy (BCT) is thought to improve cosmetic results with some documented oncologic advantages in certain patients. Although present data highlight the oncologic safety of this approach, the role of oncoplastic surgery specific to ductal carcinoma in situ (DCIS) has not been elucidated. In this study, all women in the Emory Healthcare system between January 1991 and June 2006 with biopsy-proven DCIS who underwent lumpectomies combined with simultaneous reduction mammaplasties or mastopexies were identified. Medical records, including office notes, operative and pathology reports were analyzed. Parameters included age, BMI, histologic grade (low, intermediate, high) and type (comedo versus non-comedo) of DCIS, margin status, locoregional recurrence, specimen weight, postoperative complications, and overall outcomes. Pedicle design and contralateral breast pathology were also analyzed. Twenty-eight women were included in the study with an average age of 47. Therapeutic mammaplasty was the definitive procedure for 18 (64%) of these patients. Ten patients (36%) required reoperations: nine for positive margins and one for residual microcalcifications (stereo biopsy DCIS). Overall, seven patients (25%) required completion mastectomy with reconstruction (transverse rectus abdominus myocutaneous flap: n = 3, latissimus flap: n = 4), whereas three patients (11%) underwent re-excisions with confirmation of negative margins. All ten women who required completion mastectomy or re-excisions exhibited either intermediate or high-grade, comedo DCIS. Overall, 50% (6/12) of women diagnosed with high-grade comedo DCIS required completion mastectomy with reconstruction after initial therapeutic mammaplasty. The final positive-margin rate for women diagnosed with intermediate-grade, comedo necrosis was 43% (3/7). The women in this failed group that required reoperations were overall younger (mean: 45.6; median: 43) than those in which oncoplastic surgery was the definitive procedure (mean: 57.8; median: 57). There were no significant differences between the failed and successful groups in terms of biopsy weight (failed: 253 g, successful: 237 g), type of excision (e.g., wire-localized), location of tumor, reduction type (e.g., superior medial), or postoperative complications. There was one case of locoregional recurrence of DCIS 7 months after the initial operation. All 28 patients had no evidence of disease at an average follow-up of 2.7 years. This study suggests that although oncoplastic reduction techniques are a reasonable approach for women with DCIS, stricter patient selection and improved confirmation of negative margins will minimize the need for either re-excisions or completion mastectomy and reconstruction.