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

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Prophylactic mastectomy and occult malignancy: Surgical and imaging considerations

BACKGROUND

Sentinel node biopsy (SLNB) is not routinely recommended for patients undergoing prophylactic mastectomy (PM), yet omission remains a subject of debate among surgeons. A modern patient cohort was examined to determine occult malignancy (OM) incidence within PM specimens to reinforce current recommendations.

METHODS

All PM performed over a 5-year period were retrospectively identified, including women with unilateral breast cancer who underwent synchronous or delayed contralateral PM or women with elevated cancer risk who underwent bilateral PM.

RESULTS

The study population included 772 patients (598 CPM, 174 BPM) with a total of 39 OM identified: 17 invasive cancers (14 CPM, 3 BPM) and 22 DCIS (19 CPM, 3 BPM). Of the 86 patients for whom SLNB was selectively performed, 1 micrometastasis was identified. In the CPM cohort, risk of OM increased with age, presence of LCIS of either breast, or presence of a non-BRCA high-penetrance gene mutation, while preoperative magnetic resonance imaging was associated with lower likelihood of OM.

CONCLUSIONS

Given the low incidence of invasive OM in this updated series, routine SLNB is of low value for patients undergoing PM. For patients with indeterminate radiographic findings, discordant preoperative biopsies, LCIS, or non-BRCA high-penetrance gene mutations, selective SLNB implementation could be considered.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Utility and Outcomes of Pre-Operative Screening Breast MRI for Planned Bilateral Prophylactic Mastectomy in High-Risk Patients

Background: There is a paucity of data and consensus guidelines on the utility of preoperative MRI for planned bilateral prophylactic mastectomy. Objective: To evaluate the utility of breast MRI performed in high-risk patients for the indication of planned bilateral prophylactic mastectomy, with attention to diagnostic performance for breast cancer detection. A secondary aim was to assess the potential impact of breast MRI findings on the decision to perform sentinel lymph node biopsy at the time of prophylactic mastectomy. Methods: A retrospective database review identified MRI examinations performed at an academic medical center from August 2003 to January 2020 for the indication of planned bilateral prophylactic mastectomy. Patient demographics, imaging findings, operative details, and pathology were recorded. BI-RADS 1 and 2 assessments were considered negative examinations, and BI-RADS 3, 4, and 5 were considered positive examinations. Descriptive statistics and performance metrics were calculated. Results: The final cohort included 53 patients (mean age, 45 years). Most (35/53; 66%) studies were baseline examinations. Of the 53 patients, 31 (58%) had a negative MRI, and 22 (42%) a positive MRI. MRI detected two malignancies, both assessed as BI-RADS 4 (one invasive lobular carcinoma and one high-grade DCIS). The patient with invasive lobular cancer underwent sentinel lymph node biopsy at the time of mastectomy, which demonstrated metastasis. Breast MRI had sensitivity of 100.0% and specificity of 60.8% for overall breast cancer detection, and sensitivity of 100.0% and specificity of 59.6% for invasive cancer detection. Conclusion: Preoperative MRI for planned bilateral prophylactic mastectomy detected all cancers, indicating a potential role for MRI in impacting surgical decision making. Clinical Impact: Given the high NPV for cancer, our results suggest that lymph node biopsy may be safely avoided in patients with a negative MRI. This is clinically relevant since sentinel nodes cannot be identified post-mastectomy.