Published 10 March 2009, doi:10.1136/bmj.b630
Cite this as: BMJ 2009;338:b630

Analysis

Tissue screening after breast reduction

Mohammed Keshtgar, consultant breast surgeon1, Alireza Hamidian Jahromi, clinical fellow in breast surgery 1, Tim Davidson, consultant breast surgeon1, Paula Escobar, clinical fellow in breast surgery 1, Patrick Mallucci, consultant plastic surgeon 1, Afshin Mosahebi, consultant plastic surgeon 1, Michael Baum, emeritus professor of breast surgery 1

1 University Department of Surgery, Royal Free Hampstead NHS Trust and Royal Free and University College Medical School, London NW3 2QG

Correspondence to: M Keshtgarmo.keshtgar{at}royalfree.nhs.uk

Patients who undergo breast reduction surgery have a low risk of being found to have breast cancer, but they need to be made aware of it—and doctors need to debate whether routine histological examination of tissue specimens is a good idea. We sought the views of Tom Treasure, a surgeon (doi:10.1136/bmj.b759), Jeremy Sugarman, an ethicist (doi:10.1136/bmj.b753), and Tessa Boase, a lay person (10.1136/bmj.b776)

Reduction mammoplasty is one of the most common procedures performed by plastic surgeons all around the world.1 For decades, it has been a common practice to send even normal looking surgical specimens for histopathological analysis because of the possibility of finding asymptomatic breast cancer. A postal questionnaire sent to consultant members of the British Association of Plastic Surgeons in 1994 found that 89% routinely sent breast reduction tissue for histopathology, and 42% of respondents had seen at least one case of breast cancer from these tissues.2

Pathological findings of breast cancer at the time of reduction mammoplasty have been reported.3 In 1960 the incidence of breast carcinoma found after breast reduction surgery was reported to be 0.38%.4 In different series, occult carcinoma has been found in 0.05-1.66% of breast reduction specimens, and the chance of finding such a cancer is affected by thoroughness of preoperative and postoperative examinations.5 Other authors have described in detail the pathological findings in breast reduction specimens but not found breast cancer in their studies.2 6 7 In 27 500 women in Ontario, Canada, who had reduction mammoplasty, 0.06% (95% confidence interval 0.03% to 0.09%) had invasive carcinoma.8 In our institution a retrospective review of a prospectively maintained database of over a five year period found positive histology in 0.8% of 391 patients.

The decrease in detection of occult cancer in breast reduction specimens in recent years has been explained by advances in early detection of cancers, improvement in patient education, a younger group of patients undergoing this surgery, and more thorough preoperative screening of patients.9 10

Case history

A 37 year old woman with no known risk factors for breast cancer underwent bilateral reduction mammoplasty and mastopexy for cosmetic reasons. Recovery was uneventful, but histology of the right breast showed non-comedo small cell type ductal carcinoma in situ with cancer in the lobules. The left breast specimen showed no abnormality.

As the specimens were not oriented the pathologist was unable to be precise about the site of the lesion, but excision was thought to be complete. Follow-up mammograms were done annually, along with physical examination. After her first assessment, microcalcifications were seen in the right breast and interpreted as benign. Three years later new microcalcifications in the midline of the lower right breast were seen; mammotome biopsy showed an area of mixed lobular carcinoma in situ and ductal carcinoma in situ.

A wide local excision was performed, but histology showed that the lesion had not been excised completely. Furthermore, the cosmetic result of this procedure was not satisfactory.

The patient was offered a choice of further excision and radiotherapy or mastectomy and immediate reconstruction, and she chose the latter. The mastectomy with a free flap reconstruction was uneventful, but she will have to undergo further surgery to reconstruct the nipple.

Discussion

Currently, screening for breast cancer by any modality is not recommended in the UK for women under the age of 50—but young women throughout the world are in effect undergoing a "screening" procedure after cosmetic reduction surgery without their informed consent. In this case, a 37 year old woman, as a result of this screening, was found to have pathology of uncertain clinical importance and has undergone years of anxiety and multiple surgical procedures. Furthermore, she cannot be reassured that this surgery has benefited her.

Several authors have reported that part of the clinical difficulty arises because specimens are not oriented during surgery and therefore it is not possible to identify the exact area affected. Intraoperative tailoring, which includes mobilisation of the tissues, will distort the normal architecture of the breast.9 11 12 Thus, the subsequent radiological assessment is not simple, and the surgical decision is often not easy.8

The concern is always to achieve complete clearance of the disease. In the survey from Ontario, even though cancers found after breast reduction were detected in an earlier stage than symptomatic cancers in the same region, patients who had had breast reduction were more likely to have mastectomy (67%) than conservative surgery (52%).8

Either the routine practice of screening the excised breast tissue should be abandoned completely, or women should be given the opportunity of informed consent for an unproved and potentially harmful screening practice.

Cite this as: BMJ 2009;338:b630

Contributors and sources: All senior authors have extensive experience in oncological and aesthetic aspects of breast surgery. Data came from their own patient and from a PubMed search using keywords "breast reduction", "cancer screening", "reduction mammoplasty", "breast cancer", and "ethics".

Funding: None.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Patient consent obtained.

References

  1. Colwell AS, Kukreja J, Breuing KH, Lester S, Orgill DP. Occult breast carcinoma in reduction mammaplasty specimens: 14-year experience. Plast Reconstr Surg 2004;113:1984-8.[Web of Science][Medline]
  2. Titley OG, Armstrong AP, Christie JL, Fatah MF. Pathological findings in breast reduction surgery. Br J Plast Surg 1996;49:447-51.[CrossRef][Web of Science][Medline]
  3. Maliniac JW. Use of pedicle dermofat flap in mammoplasty. Plast Reconstr Surg 1953;12:110-5.[Web of Science]
  4. Snyderman RK, Lizardo JG. Statistical analysis of malignancies found before, during or after routine breast plastic operations. Plast Reconstr Surg Transplant Bull 1960;25:253-6.[CrossRef][Medline]
  5. Hage JJ, Karim RB. Risk of breast cancer among reduction mammoplasty patients and the strategies used by plastic surgeons to detect such cancer. Plast Reconstr Surg 2006;117:727-35.[CrossRef][Web of Science][Medline]
  6. Cruz NI, Guerrero A, Gonzalez CI. Current findings in the pathological evaluation of breast reduction specimens. Bol Asoc Med P R 1989;81:387-9.[Medline]
  7. Strombeck JO. Macromastia in women and its surgical treatment. Acta Chir Scan Suppl 1964;341:1-214.
  8. Tang Cl, Brown MH, Levine R, Sloan M, Chong N, Holowaty E. Breast cancer found at the time of breast reduction. Plast Reconstr Surg 1999;103:1682-6.[CrossRef][Web of Science][Medline]
  9. 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.[Web of Science][Medline]
  10. White RR IV. Incidence of breast carcinoma in patients having reduction mammoplasty. Plast Reconstr Surg 1998;102:1774-5.[CrossRef][Web of Science][Medline]
  11. Van der Torre PM, Butzelaar RM. Breast cancer and reduction mammoplasty: the role of routine pre-operative mammography. Eur J Surg Oncol 1997;23: 341-2.
  12. Dinner MI, Artz JS. Carcinoma of the breast occurring in routine reduction mammoplasty. Plast Reconstr Surg 1989;83:1042-4.[Web of Science][Medline]
(Accepted 19 November 2008)


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