Routine Histologic Examination of 728 Mastectomy Scars: Did It Benefit Our Patients?

Histologic Examination of Mastectomy Scars during Breast Reconstruction: A Systematic Review

Background

Breast reconstruction is a standard procedure in postmastectomy plastic surgery. The necessity of routine histological examinations for mastectomy scars during delayed reconstruction remains a topic of debate. We evaluated the need for histological examination of scars during delayed breast reconstruction.

Methods

We conducted a systematic review using PubMed, TDnet, and Cochrane Central in August 2023. Inclusion criteria involved delayed breast reconstruction with histological scar analysis and malignancy reporting. Exclusion criteria encompassed noncancerous breast diseases, prophylactic mastectomies, articles lacking relevant information, case reports, technique descriptions, and reviews. We independently assessed articles. Differences in recurrence rates were determined using a Z-test for proportions. A linear regression model explored the relationship between reconstruction timing and pathological results. The number needed to treat was calculated based on the literature. The Wilcoxon test was used to compare mean reconstruction times and postreconstruction follow-up between groups.

Results

Our analysis covered 11 retrospective observational studies published between 2003 and 2018, including 3754 mastectomy scars. The malignancy recurrence rate was 0.19%, consistent with previous reports, with a number needed to treat of 144.93-188.68 patients. The timing of breast reconstruction postmastectomy averaged 19.9 months, without statistically significant association between reconstruction timing and recurrence rates. Postreconstruction follow-up periods ranged from 60 to 87 months. The postreconstruction adverse outcomes ratio was 2.21%.

Conclusions

Assessing the necessity of histological examination in breast reconstruction is complex. Based on the literature and this study, we do not recommend routine histological examination of mastectomy scars during delayed reconstruction. A selective approach based on risk factors may be beneficial, warranting further research.

Palpable Lumps after Mastectomy: Radiologic-Pathologic Review of Benign and Malignant Masses

Patients who have undergone mastectomy, with or without reconstruction, are not universally screened with mammography or US. Therefore, clinical breast examination by the physician and patient-detected palpable abnormalities are crucial for detecting breast cancer or recurrence. Diagnostic US is the first-line modality for evaluation of postmastectomy palpable masses, with occasional adjunct use of diagnostic mammography for confirming certain benign masses. In the setting of a negative initial imaging evaluation with continued clinical concern, diagnostic MRI may aid in improving sensitivity. Knowledge of the typical multimodality imaging appearances and locations of malignant palpable abnormalities-such as invasive carcinoma recurrence, cancer in residual breast tissue, radiation-induced sarcoma, and metastatic disease-is crucial in diagnosis and treatment of these entities. In addition, familiarity with the range of benign palpable postmastectomy processes-including fat necrosis, fat graft, seroma, granuloma, neuroma, fibrosis, and infection-may help avoid unnecessary biopsies and reassure patients. The authors review common and rare benign and malignant palpable masses in mastectomy patients, describe multimodality diagnostic imaging evaluation of each entity, review radiologic and pathologic correlation, and acquaint the radiologist with management when these findings are encountered. ^©RSNA, 2021.

Use of Routine Pathologic Evaluation of Nonmalignant Lesions in Hand Surgery: A National Study

BACKGROUND

Most lesions of the upper extremity are common and benign, and many have questioned the need for routine pathologic evaluation of these specimens. The authors aim to examine the national use of routine pathologic examination of nonmalignant hand lesions to help guide health care policy and practice patterns.

METHODS

The authors used a national level MarketScan database to form a cohort of adult patients who underwent excision of nonmalignant upper extremity lesions. The authors calculated the rate of submission for each surgical procedure and separately for each diagnosis. The authors also investigated demographic and clinical characteristics associated with the submission of surgical specimens using a multivariable logistic regression model. The authors calculated the total cost of routine pathologic evaluation.

RESULTS

The final study cohort included 222,947 patients and 182,962 specimens from 153,518 cases. The mean rate of submission was 69 percent. Older age, Northeast region, and high comorbidity scores showed significant correlation with the odds of having a specimen submitted for pathologic evaluation. Excision of primary wrist ganglion was the most performed procedure, and benign lesions larger than 4.0 cm were most frequently submitted for pathologic evaluation. The mean cost of routine pathologic examination was $133 per specimen, and the annual expenditure was $5 million.

CONCLUSIONS

The routine pathologic examination of benign hand lesions is used frequently but provides limited clinical benefit at a cost. To increase efficiency and improve quality of care, surgeons should be aware of the low value of routine pathologic evaluation and be more selective for cases for which diagnostic testing will change management.

Recurrent breast cancer in the subpectoral space after implant reconstruction

Breast reconstruction after mastectomy is most commonly performed with a prosthetic implant placed beneath the pectoralis major. Recurrence may rarely be identified in the subpectoral space where the implant was placed. We report a case of recurrent breast cancer after implant-based reconstruction with isolated subpectoral recurrence discovered 5 years later during secondary revision of her reconstructed breast.

Is routine histological examination of mastectomy scars justified? An analysis of 619 scars

BACKGROUND

The increasing incidence of breast cancer is paralleled by an increasing demand for post-mastectomy breast reconstruction. At the time of breast reconstruction routine submission of mastectomy scars has been considered appropriate clinical practice to ensure that no residual cancer exists. However, this practice has been challenged by some and has become the topic of controversy. In a retrospective analysis we wished to assess whether routine submission of mastectomy scars altered treatment.

METHODS

Utilizing the Stanford Translational Research Integrated Database Environment (STRIDE) all patients who underwent implant-based breast reconstruction with routine histological analysis of mastectomy scars were identified. The following parameters were retrieved and analyzed: age, cancer histology, cancer stage (according to the American Joint Committee on Cancer staging system), receptor status (estrogen receptor [ER], progesterone receptor [PR], Her2neu), time interval between mastectomy and reconstruction, and scar histology.

RESULTS

A total of 442 patients with a mean age of 45.9 years (range, 22-73 years) were included in the study. Mastectomy with subsequent reconstruction was performed for in-situ disease and invasive cancer in 83 and 359 patients, respectively. A total of 619 clinically unremarkable mastectomy scars were sent for histological analysis, with the most common finding being unremarkable scar tissue (i.e. collagen fibers). Of note, no specimen revealed the presence of carcinoma.

CONCLUSION

According to published reports routine histological examination of mastectomy scars may detect early local recurrence. However, we were not able to detect this benefit in our patient population. As such, particularly in the current health-care climate the cost-effectiveness of this practice deserves further attention. A more selective use of histological analysis of mastectomy scars in patients with tumors that display poor prognostic indicators may be a more reasonable utilization of resources.

Mastectomy scars following breast reconstruction: should routine histologic analysis be performed?

BACKGROUND

There is some debate in the recent literature regarding the routine submission of mastectomy scars for histologic analysis when performing delayed breast reconstructions. The aim of this study was to review the relevant publications and evaluate the practice of routine histologic examination of mastectomy scars.

METHODS

The authors conducted a retrospective review, across three regional plastic and reconstructive surgery units, of 433 patients who had 455 scars routinely sent for histologic examination following delayed breast reconstruction between January of 2000 and December of 2006. Patients with clinical evidence of recurrent carcinoma were excluded.

RESULTS

Data from 433 patients revealed an average age at reconstruction of 49.9 years (range, 25 to 77 years). The mean interval from primary breast surgery to reconstruction was 3.9 years (range, 2 months to 32 years), and the average length of patient follow-up, from primary surgery, was 6.4 years (range, 1 to 40 years). The majority of the initial operations were carried out for invasive carcinoma (89 percent). Four mastectomy scars in three patients were positive for carcinoma recurrence.

CONCLUSIONS

The publications related to the practice of routine histologic analysis of mastectomy scars provide conflicting conclusions. As a proportion of patients may benefit from the early detection and treatment of locoregional recurrence, the authors suggest that the routine submission of mastectomy scars will allow for the earlier detection of soft-tissue recurrences that may affect long-term outcome. In keeping with cancer surgery principles, the authors recommend routine histologic examination of mastectomy scars following delayed breast reconstruction.