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Reduction mammaplasty specimens and occult breast carcinomas
EJSO (2005) 31, 19–21
www.ejso.com
Reduction mammaplasty specimens and occult breast carcinomas D. Kakagiaa,*, K. Fragiab, A. Grekouc, D. Tsoutsosd a
Department of Surgery, Thraki Medical Center, 1 Komninon Str., 68100 Alex/polis, Greece Department of Pathology, Athens General Hospital ‘G. Gennimatas’, 154 Mesogion Str., 11527 Athens, Greece c ‘Histodiagnostiki’ Pathology Center, 74 Mitropoleos Str., Thessaloniki, Greece d Department of Plastic Reconstructive Surgery, Athens General Hospital ‘G. Gennimatas’, 154 Mesogion Str., 11527 Athens, Greece b
Accepted for publication 29 July 2004 Available online 28 September 2004
KEYWORDS Breast neoplasms; Reduction mammaplasty; Screening mammography
Abstract Aim. The aim of this study was to report the incidence of occult cancer in reduction mammaplasty (RM) specimens. Methods. A retrospective study of 314 women who underwent RM from February 1996 to August 2001. Results. Occult carcinomas were detected in three patients, in two of which the lesions were invasive. Atypical ductal or lobular hyperplasia was found in five cases and other carcinoma risk lesions in four patients. Other benign changes were identified in totally 133 patients. Conclusion. Incidental carcinomas will occasionally be found in RM procedures. q 2004 Elsevier Ltd. All rights reserved.
Introduction Pathologic examination of mammary gland specimens from reduction mammaplasty (RM) procedures reveals important clinical information and allows for detection and evaluation of glandular lesions. The reported incidence of occult breast carcinomas in RM specimens, though low, ranges from
* Corresponding author. Address: 7 P. Kirillou Str., 68100 Alex/polis, Greece. Tel.: C30-25510-23334; fax: C30-2551035601. E-mail address: [email protected] (D. Kakagia).
0.16 to 0.7%.1–5 RM is an increasingly popular operation.6–10 The histopathologic findings in a large series of RM specimens are described in this study.
Patients and methods A retrospective study of 314 reduction mammaplasties performed for cosmetic reasons between February 1996 and August 2001 is reported. Medical notes, theatre records and pathologic findings were reviewed. All patients had had a mammogram 6 weeks to 3 months preoperatively with no evidence
0748-7983/$ - see front matter q 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2004.07.026
20
D. Kakagia et al. Both patients were subsequently elected for modified radical skin-sparing mastectomy, which was performed via the previous RM incision after complete removal of the scar with a 1 cm margin (Fig. 1), as already described by Rudolph and Niedbala.10 Flaps were raised superiorly and inferiorly and mastectomy was followed by immediate submuscular breast reconstruction with implants (in one case bilateral). Skin closure was performed following the ‘inverted T’ pattern. Histologic examination of mastectomy specimens revealed one residual focus of invasive lobular carcinoma of 0.2 cm in diameter in the second patient and one focus in each specimen in the bilateral mastectomy patient of 0.4 and 0.5 cm in diameter. In both patients all axillary nodes were negative. Both patients have been on postoperative follow up for 28 and 32 months, remain well and are free of evident disease.
of cancer. Patients with positive personal and/or family history for breast cancer were excluded from this study. Breast size and degree of ptosis determined the technique of reduction. At the bipedicled lateral pedicle (Strombeck) technique the central and inferior parts of the breast were removed. The site of glandular resection was located at the junction of the upper quadrants and laterally during the inferior pedicle (Tom Robbins) procedure, whereas it was the inferior part of the gland that was mainly resected when the superior pedicle (Pitanguy) technique was performed. Clinically abnormal breast tissue on palpation was marked and excised. All operative specimens were submitted for histopathologic examination.
Results The median age of patients was 43G8 years. The inferior pedicle technique was performed on 101 patients, the superior pedicle on 47 and the lateral pedicle technique on 166 patients. The mean tissue weight removed per breast was 830 g (range 540– 1860). Occult invasive carcinomas were found in two patients and in one patient non-comedo ductal carcinoma in situ (DCIS) was detected. Carcinoma risk lesions were reported in nine patients. Benign lesions and fibrocystic changes were found in 133 patients (Table 1). Well-differentiated invasive lobular carcinomas were found in the pathologic examination of the operative specimens in two patients. In one of them multiple invasive and in situ lobular carcinomas were found bilaterally. In the second patient the lobular carcinomas were also multifocal. All invasive lesions were located centrally and did not exceed 0.7 cm in diameter. Table 1
Discussion Approximately 60% of RM specimens may reveal pathologic changes, including occult carcinomas in 0.16–0.7% of the cases.1–5 Occult carcinomas are observed more frequently (3–5%) in specimens from RM performed for symmetry of the contralateral breast.6 The overall false negative rate of mammography is approximately 7.5%11,12 whereas it is significantly higher (19%) for invasive lobular carcinoma.13 The diagnosis of breast cancer after RM may complicate further cancer management and limit the surgical options.5,14–16 Surgical management of invasive carcinoma incidentally discovered at RM was first reported in 1959 by Snyderman and Lizardo.1 Jansen et al. in 1988 recommended skin-
Histologic findings of specimens from breast reduction procedures and management
Histologic findings
ILC DCIS Atypical hyperplasia Florid ductal hyperplasia Moderate ductal hyperplasia Mild ductal hyperplasia Fibrocystic changes Adenosis Fibroadenoma
Reduction procedure
Patients N
%
2 1 5 1 3 16 94 18 5
0.64 0.32 1.6 0.32 0.95 5.1 29.93 5.73 1.6
LP, SP IP IP (2), LP (3) LP IP (1), LP (2) IP (5), SP(2), LP (9) IP (41), SP(5), LP (48) LP (12), IP (6) IP(3), LP(2)
IP, inferior pedicle technique; LP, bipedicled lateral pedicle technique; SP, superior pedicle technique; IBR, immediate breast reconstruction.
Reduction mammaplasty specimens and occult breast carcinomas
21
required so that the optimal therapeutic option is offered.
References
Figure 1 Pre-operative marking of the area to be removed which includes the scar from the previous breast reduction. Skin-sparing mastectomy is performed via the previous incision after elevation of skin flaps.
sparing mastectomy with resection of previous RM incisions with a 2 cm margin.2 Rudolph and Niedbala in 2003 suggested scar removal with a 1 cm margin.10 Keheler and colleagues in 2003 also recommended skin sparing modified radical mastectomy with scar removal.9 Any dubious lesion encountered during RM should be excised and sent for histology. If extensive dissection has already been performed, then ideally the operation should be completed so that margins of at least 1 cm around the tumour are obtained and properly marked.9 Because of the bulk of the tissue usually removed at RM, despite thorough observation and manual exploration, there may still be occult lesions in the operative specimen, a fact that renders pathologic examination of the removed breast tissue mandatory. In both our cases although the operative specimens were properly marked and the margins would otherwise be considered as safe, residual foci of invasive carcinomas were suspected as the tumours were multifocal. This was actually confirmed by the histologic examination of the mastectomy specimens. In conclusion thorough preoperative clinical examination and mammography can reduce the rate of incidentally discovered cancer during RM procedures. Pathologic examination of RM specimens is imperative as it provides important clinical evidence for diagnosis and possible further management of breast lesions. Close collaboration between breast surgeons, plastic surgeons and oncologists is
1. Snyderman RK, Lizardo JG. Statistical study of malignancy found before, during or after breast plastic operations. Plast Reconstr Surg 1960;25:253–6. 2. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: case reports and a survey of plastic surgeons. Plast Reconstr Surg 1998;101:361–4. 3. Dinner MI, Artz JS. Carcinoma of the breast occurring in routine reduction mammaplasty. Plast Reconstr Surg 1989; 83:1042–4. 4. Ishag MT, Bashinsky DY, Beliaeva IV, Niemann TH, Marsh Jr WL. Pathologic findings in reduction mammaplasty specimens. Am J Clin Pathol 2003;120:377–80. 5. Gottlieb JR, McKinney P, Walkinshaw MD, Sperling RL. Occult breast carcinoma in patients undergoing reduction mammaplasty. Aesthetic Plast Surg 1989;13:279–83. 6. Petit JY, Rietjens M, Contesso G, Bertin F, Gilles R. Contralateral mastoplasty for breast reconstruction: a good opportunity for glandular exploration and occult carcinomas diagnosis. Ann Surg Oncol 1997;4:511–5. 7. Petit JY, Rietjens M, Garusi C, Greuze M, Perry C. Integration of plastic surgery in the course of breast-conserving surgery for cancer to improve cosmetic results and radicality of tumour excision. Recent Results Cancer Res 1998;152: 202–11. 8. Spear SL, Pelletiere CV, Wolfe AJ, Tsangaris TN, Pennanen MF. Experience with reduction mammaplasty combined with breast conservation therapy in the treatment of breast cancer. Plast Reconstr Surg 2003;111:1102–9. 9. Keleher AJ, Langstein HN, Ames FC, et al. Breast cancer in reduction mammaplasty specimens: case reports and guidelines. Breast J 2003;9:120–5. 10. Rudolph R, Niedbala A. Surgical management of the patient with invasive carcinoma discovered at reduction mammoplasty. Am Surg 2003;69:1003–5. 11. Kopans DB. Screening for breast cancer and mortality reduction among women 40–49 years of age. Cancer 1994; 74:311–22. 12. Lopez MJ, Smart CR. Twenty-year-follow up of minimal breast cancer from the Breast Cancer Detection Demonstration Project. Surg Oncol Clin N Am 1997;6:393–401. 13. Krecke KN, Gisvold JJ. Invasive lobular carcinoma of the breast: mammographic findings and the extent of disease at diagnosis in 184 patients. Am J Roentgenol 1993;161: 957–60. 14. Cathcart Sr R, Hagerty RC. Preoperative and postoperative considerations in elective breast operations. Ann Plast Surg 1989;22:533–8. 15. Lanfrey E, Rietjens M, Garusi C, Petit JY. Mammoplasty for symmetry of the contralateral breast and its oncologic value. Ann Chir Plast Esthet 1997;42:160–7. 16. Petit JY, Rietjens M, Contesso G, Bertin F, Gilles R. Contralateral mastoplasty for breast reconstruction: a good opportunity for glandular exploration and occult carcinomas diagnosis. Ann Surg Oncol 1997;4:511–5.
www.ejso.com
Reduction mammaplasty specimens and occult breast carcinomas D. Kakagiaa,*, K. Fragiab, A. Grekouc, D. Tsoutsosd a
Department of Surgery, Thraki Medical Center, 1 Komninon Str., 68100 Alex/polis, Greece Department of Pathology, Athens General Hospital ‘G. Gennimatas’, 154 Mesogion Str., 11527 Athens, Greece c ‘Histodiagnostiki’ Pathology Center, 74 Mitropoleos Str., Thessaloniki, Greece d Department of Plastic Reconstructive Surgery, Athens General Hospital ‘G. Gennimatas’, 154 Mesogion Str., 11527 Athens, Greece b
Accepted for publication 29 July 2004 Available online 28 September 2004
KEYWORDS Breast neoplasms; Reduction mammaplasty; Screening mammography
Abstract Aim. The aim of this study was to report the incidence of occult cancer in reduction mammaplasty (RM) specimens. Methods. A retrospective study of 314 women who underwent RM from February 1996 to August 2001. Results. Occult carcinomas were detected in three patients, in two of which the lesions were invasive. Atypical ductal or lobular hyperplasia was found in five cases and other carcinoma risk lesions in four patients. Other benign changes were identified in totally 133 patients. Conclusion. Incidental carcinomas will occasionally be found in RM procedures. q 2004 Elsevier Ltd. All rights reserved.
Introduction Pathologic examination of mammary gland specimens from reduction mammaplasty (RM) procedures reveals important clinical information and allows for detection and evaluation of glandular lesions. The reported incidence of occult breast carcinomas in RM specimens, though low, ranges from
* Corresponding author. Address: 7 P. Kirillou Str., 68100 Alex/polis, Greece. Tel.: C30-25510-23334; fax: C30-2551035601. E-mail address: [email protected] (D. Kakagia).
0.16 to 0.7%.1–5 RM is an increasingly popular operation.6–10 The histopathologic findings in a large series of RM specimens are described in this study.
Patients and methods A retrospective study of 314 reduction mammaplasties performed for cosmetic reasons between February 1996 and August 2001 is reported. Medical notes, theatre records and pathologic findings were reviewed. All patients had had a mammogram 6 weeks to 3 months preoperatively with no evidence
0748-7983/$ - see front matter q 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2004.07.026
20
D. Kakagia et al. Both patients were subsequently elected for modified radical skin-sparing mastectomy, which was performed via the previous RM incision after complete removal of the scar with a 1 cm margin (Fig. 1), as already described by Rudolph and Niedbala.10 Flaps were raised superiorly and inferiorly and mastectomy was followed by immediate submuscular breast reconstruction with implants (in one case bilateral). Skin closure was performed following the ‘inverted T’ pattern. Histologic examination of mastectomy specimens revealed one residual focus of invasive lobular carcinoma of 0.2 cm in diameter in the second patient and one focus in each specimen in the bilateral mastectomy patient of 0.4 and 0.5 cm in diameter. In both patients all axillary nodes were negative. Both patients have been on postoperative follow up for 28 and 32 months, remain well and are free of evident disease.
of cancer. Patients with positive personal and/or family history for breast cancer were excluded from this study. Breast size and degree of ptosis determined the technique of reduction. At the bipedicled lateral pedicle (Strombeck) technique the central and inferior parts of the breast were removed. The site of glandular resection was located at the junction of the upper quadrants and laterally during the inferior pedicle (Tom Robbins) procedure, whereas it was the inferior part of the gland that was mainly resected when the superior pedicle (Pitanguy) technique was performed. Clinically abnormal breast tissue on palpation was marked and excised. All operative specimens were submitted for histopathologic examination.
Results The median age of patients was 43G8 years. The inferior pedicle technique was performed on 101 patients, the superior pedicle on 47 and the lateral pedicle technique on 166 patients. The mean tissue weight removed per breast was 830 g (range 540– 1860). Occult invasive carcinomas were found in two patients and in one patient non-comedo ductal carcinoma in situ (DCIS) was detected. Carcinoma risk lesions were reported in nine patients. Benign lesions and fibrocystic changes were found in 133 patients (Table 1). Well-differentiated invasive lobular carcinomas were found in the pathologic examination of the operative specimens in two patients. In one of them multiple invasive and in situ lobular carcinomas were found bilaterally. In the second patient the lobular carcinomas were also multifocal. All invasive lesions were located centrally and did not exceed 0.7 cm in diameter. Table 1
Discussion Approximately 60% of RM specimens may reveal pathologic changes, including occult carcinomas in 0.16–0.7% of the cases.1–5 Occult carcinomas are observed more frequently (3–5%) in specimens from RM performed for symmetry of the contralateral breast.6 The overall false negative rate of mammography is approximately 7.5%11,12 whereas it is significantly higher (19%) for invasive lobular carcinoma.13 The diagnosis of breast cancer after RM may complicate further cancer management and limit the surgical options.5,14–16 Surgical management of invasive carcinoma incidentally discovered at RM was first reported in 1959 by Snyderman and Lizardo.1 Jansen et al. in 1988 recommended skin-
Histologic findings of specimens from breast reduction procedures and management
Histologic findings
ILC DCIS Atypical hyperplasia Florid ductal hyperplasia Moderate ductal hyperplasia Mild ductal hyperplasia Fibrocystic changes Adenosis Fibroadenoma
Reduction procedure
Patients N
%
2 1 5 1 3 16 94 18 5
0.64 0.32 1.6 0.32 0.95 5.1 29.93 5.73 1.6
LP, SP IP IP (2), LP (3) LP IP (1), LP (2) IP (5), SP(2), LP (9) IP (41), SP(5), LP (48) LP (12), IP (6) IP(3), LP(2)
IP, inferior pedicle technique; LP, bipedicled lateral pedicle technique; SP, superior pedicle technique; IBR, immediate breast reconstruction.
Reduction mammaplasty specimens and occult breast carcinomas
21
required so that the optimal therapeutic option is offered.
References
Figure 1 Pre-operative marking of the area to be removed which includes the scar from the previous breast reduction. Skin-sparing mastectomy is performed via the previous incision after elevation of skin flaps.
sparing mastectomy with resection of previous RM incisions with a 2 cm margin.2 Rudolph and Niedbala in 2003 suggested scar removal with a 1 cm margin.10 Keheler and colleagues in 2003 also recommended skin sparing modified radical mastectomy with scar removal.9 Any dubious lesion encountered during RM should be excised and sent for histology. If extensive dissection has already been performed, then ideally the operation should be completed so that margins of at least 1 cm around the tumour are obtained and properly marked.9 Because of the bulk of the tissue usually removed at RM, despite thorough observation and manual exploration, there may still be occult lesions in the operative specimen, a fact that renders pathologic examination of the removed breast tissue mandatory. In both our cases although the operative specimens were properly marked and the margins would otherwise be considered as safe, residual foci of invasive carcinomas were suspected as the tumours were multifocal. This was actually confirmed by the histologic examination of the mastectomy specimens. In conclusion thorough preoperative clinical examination and mammography can reduce the rate of incidentally discovered cancer during RM procedures. Pathologic examination of RM specimens is imperative as it provides important clinical evidence for diagnosis and possible further management of breast lesions. Close collaboration between breast surgeons, plastic surgeons and oncologists is
1. Snyderman RK, Lizardo JG. Statistical study of malignancy found before, during or after breast plastic operations. Plast Reconstr Surg 1960;25:253–6. 2. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: case reports and a survey of plastic surgeons. Plast Reconstr Surg 1998;101:361–4. 3. Dinner MI, Artz JS. Carcinoma of the breast occurring in routine reduction mammaplasty. Plast Reconstr Surg 1989; 83:1042–4. 4. Ishag MT, Bashinsky DY, Beliaeva IV, Niemann TH, Marsh Jr WL. Pathologic findings in reduction mammaplasty specimens. Am J Clin Pathol 2003;120:377–80. 5. Gottlieb JR, McKinney P, Walkinshaw MD, Sperling RL. Occult breast carcinoma in patients undergoing reduction mammaplasty. Aesthetic Plast Surg 1989;13:279–83. 6. Petit JY, Rietjens M, Contesso G, Bertin F, Gilles R. Contralateral mastoplasty for breast reconstruction: a good opportunity for glandular exploration and occult carcinomas diagnosis. Ann Surg Oncol 1997;4:511–5. 7. Petit JY, Rietjens M, Garusi C, Greuze M, Perry C. Integration of plastic surgery in the course of breast-conserving surgery for cancer to improve cosmetic results and radicality of tumour excision. Recent Results Cancer Res 1998;152: 202–11. 8. Spear SL, Pelletiere CV, Wolfe AJ, Tsangaris TN, Pennanen MF. Experience with reduction mammaplasty combined with breast conservation therapy in the treatment of breast cancer. Plast Reconstr Surg 2003;111:1102–9. 9. Keleher AJ, Langstein HN, Ames FC, et al. Breast cancer in reduction mammaplasty specimens: case reports and guidelines. Breast J 2003;9:120–5. 10. Rudolph R, Niedbala A. Surgical management of the patient with invasive carcinoma discovered at reduction mammoplasty. Am Surg 2003;69:1003–5. 11. Kopans DB. Screening for breast cancer and mortality reduction among women 40–49 years of age. Cancer 1994; 74:311–22. 12. Lopez MJ, Smart CR. Twenty-year-follow up of minimal breast cancer from the Breast Cancer Detection Demonstration Project. Surg Oncol Clin N Am 1997;6:393–401. 13. Krecke KN, Gisvold JJ. Invasive lobular carcinoma of the breast: mammographic findings and the extent of disease at diagnosis in 184 patients. Am J Roentgenol 1993;161: 957–60. 14. Cathcart Sr R, Hagerty RC. Preoperative and postoperative considerations in elective breast operations. Ann Plast Surg 1989;22:533–8. 15. Lanfrey E, Rietjens M, Garusi C, Petit JY. Mammoplasty for symmetry of the contralateral breast and its oncologic value. Ann Chir Plast Esthet 1997;42:160–7. 16. Petit JY, Rietjens M, Contesso G, Bertin F, Gilles R. Contralateral mastoplasty for breast reconstruction: a good opportunity for glandular exploration and occult carcinomas diagnosis. Ann Surg Oncol 1997;4:511–5.