Greater breast cancer detection results from examining tissues after reduction mammaplasty

BURLINGTON, VT. — The examination of tissues removed during reduction mammaplasty may lead to a higher detection of breast carcinoma, according to a recent study. More frequent and thorough tissue specimen screening may increase the detection of occult breast cancer, which appears to be of particular benefit in patients over 40 years of age.

Reduction mammaplasty is a common procedure, with more than 100,000 such surgeries performed yearly in the United States alone. However, no standard pathology assessment of tissues currently exists. According to one expert, a consensus is needed, as the reported incidence of occult breast cancer remains a gray area, with incidences ranging from 0.06 percent to 4.6 percent in patients with and without a prior history of breast cancer, respectively.

"Whether reduction mammaplasty is done for cosmetic or reconstructive reasons, all breast tissue specimens should be sent for pathology," says Susan E. MacLennan, M.D., associate professor of surgery, department of plastic and reconstructive surgery, University of Vermont College of Medicine, Burlington, Vt. "The current reported incidence of occult breast cancer is vague, and we need to improve our screening efficiency of breast carcinoma above and beyond standard mammograms, which can frequently come up false negative. This could be achieved by more frequent testing of breast tissue during reduction mammaplasty."

Results showed that cancerous or pre-cancerous cells were found in 12.4 percent of patients, a figure significantly higher than that seen in the literature. Carcinoma was present in 4 percent of all cases, including two invasive, three ductal carcinoma in situ and three lobular carcinoma in situ, and all cases were in patients over 50 years of age.

Additionally, the age of the patient was found to be significantly associated with pathologic findings, as the rate of cancer was 6.2 percent in women 40 years or older and 7.9 percent in women 50 years or older. None of the lesions were identified on preoperative mammograms.

"These findings impact a large group of women when extrapolated to over 100,000 reduction mammaplasty procedures performed each year in the U.S. The 12.4 percent rate of significant pathologic findings translates to more than 12,000 patients annually who would potentially benefit from altered clinical management," Dr. MacLennan says.

CURRENT LIMITATIONS Many institutions can require histologic breast tissue sampling consisting of three breast sections and one skin section. This screening protocol can prove to be an insufficient pathological assessment and may explain the occasionally "missed" pathologic finding, begging the question as to whether enough breast tissue is being screened for occult cancers. Increasing the sample size per breast can possibly help to avoid missing such an important and potentially life-saving diagnosis.

According to Dr. MacLennan, most similar studies in the literature do not account for atypias. However, atypical lobular and ductal hyperplasia confer a relative risk of breast cancer (approximately 4.4 percent) — therefore, patients with these pathologic findings should be put in a higher-risk group and undergo more intense screening.

Though the results of the study do not demonstrate statistical power and define precisely how many sections of breast tissue should be sampled, the data clearly indicates that increased tissue sampling in breast reduction patients does lead to increased detection of pathologic findings in women over 40 years of age, and especially in those over 50 years of age.

"We feel that a fairly cursory pathologic exam is likely adequate in younger patients. However, for women over 40, their tissue should probably be examined more than it presently is in some institutions. In these higher-risk patients, I think it is important for the surgeon to discuss with the pathologist how sampling is done," Dr. MacLennan says.

According to Dr. MacLennan, women over 40 should continue to have a yearly screening mammogram, barring those patients with a positive personal or family history or other extenuating circumstances. Getting additional mammograms over and above what the American Cancer Society recommends on screening is probably not necessary.

"We hope that a definite recommendation in regards to how much tissue should be sampled will come soon, as a missed diagnosis can have catastrophic repercussions. Meanwhile, our institution will likely soon move to change the current pathologic assessment of these specimens and increase the sampling of specimens," Dr. MacLennan says.

DISCLOSURES:
Dr. MacLennan reports no relevant financial interests.