Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Needless convolutions
- peter j mahaffey (11 March 2009)
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Pre-operative assessment
- Louise Gaunt (12 March 2009)
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Screening for breast reduction
- Adhip Mandal (13 March 2009)
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Tissue screening after breast reduction: Need for Guidance
- Reza Nassab, Nathan Hamnett, Michael Barrett, Sanjiv Dhital, Ali Juma (17 March 2009)
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DCIS is clinically important
- Anthony J Maxwell, Jane L. Ooi and J. Mark Pearson (23 March 2009)
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Tissue Screening after Breast Reduction
- David Skidmore, OBE (30 March 2009)
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"Hard cases make bad law"
- Jeremy Wood (1 April 2009)
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Medico legal aspects
- Atul Khanna (6 April 2009)
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What about the histopathology view?
- Anthony G Douglas-Jones, Murali Varma (3 June 2009)
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peter j mahaffey, consultant plastic surgeon bedford hospital mk42 9dj
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This paper has 7 authors and a further 3 have been recruited to comment. Everyone seems to tying themselves in knots in a self-imposed dilemma which is practical and does not merit being elevated into the nebulous and often self-indulgent world of ethics. The operation of breast reduction is not a cosmetic one, at least certainly not when NHS resources are expended on it, and its unfortunate that at least 2 of the commentators are not well enough informed to appreciate that the benefits are intended to be functional. Moreover, outcome studies show that the results rate higher in quality and patient satisfaction outcomes (QUALYS)than a whole host of apparently meritorious general surgical procedures. As the original 7 authors state, breast tissue has always been sent for histology. The figures they quote show that this intercepts a breast cancer for every 250 operations. Most plastic surgeons will, when briefing a patient about the procedure, inform her that the tissue is routinely sent for analysis. What woman would refuse? And what surgeon would wantonly discard the tissue? Only Treasure, in his commentary, identifies the real issue, namely one of evidence. What we do not know is the long-term fate of that group of patients who were unexpectedly found to have a tumour, and whether it varies from a control group of women with breast cancer. We also need to address the issue that if tissue is to be analysed, then it needs to be sent to the histologist in a form which enables the most useful reporting of the results. That should be self-evident with any pathology specimen. Finally, its simply not true for the lay commentator to suggest that the patient whose case history forms the basis of the article went through years of possibly un-necessary misery. The pattern of her treatment really doesn't depart from that which might have been offered for any patient found to have this diagnosis. The question which we clinicians, who like to think we take a scientific approach to medicine, must ask is whether we really do the patient good by the interventions we offer. We must ALWAYS be asking ourselves this question. I, for example, shudder with horror and embarrassment, to recall all the gastrectomies and vagotomies I performed during my general surgical training, only for a wonderfully determined Australian gastroenterologist (Barry Marshall) to show subsequently that gastric ulceration is infective in origin.That should be a lesson to us all. Competing interests: None declared |
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Louise Gaunt, Consultant radiologist Princess Elizabeth Hospital, Guernsey GY4 6UU
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As a radiologist specialising in breast imaging, I am surprised there is no mention of pre-operative mammography. I know the patient considered in the article was aged 37, and there are some doubts about the accuracy of mammography in younger women, but I feel it is appropriate to consider mammography prior to breast reduction surgery, to assist in the potential identification of unsuspected malignancy. With the increasing use of digital techniques the radiation dose to the patient is less than previously, and due to the ability to manipulate the digital image there is the potential for greater diagnostic accuracy. I acknowledge that not all cancers will be identified, but I would encourage all surgeons planning breast reduction surgery to consider pre-operative imaging. From personal experience through my practice I know many centres in Europe routinely request mammography prior to surgery and I feel it is something we should consider in UK. I also agree there needs to full explanation to the patient of the implications of histological examination of the excised tissue - the detection of unsuspected cancer is a recognised consequence of breast reduction surgery and therefore needs to form part of the informed consent process Competing interests: None declared |
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Adhip Mandal, Clinical Research Fellow, Breast Surgery Colchester Hospital University NHS Foundation Trust, CO4 5JL
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All breast reduction specimens should undergo pathological screening for occult cancer as all women are at risk of breast cancer. In the event that a specimen is not examined and does actually have malignant tissue, means an opportunity to diagnose an early cancer is missed with possible disasterous consequences in the future. The surgical procedure for reduction mammoplasty is not effected in anyway with the intent for tissue biopsy. The women should be counselled prior to surgery with the possibility of diagnosis of cancer in the specimen and need for further surgery or treatment. Early diagnosis of breast cancer has advantages in terms of cure and long term prognosis and every oppertunity to maximise results should be seized. Competing interests: None declared |
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Reza Nassab, Specialty Registrar in Plastic Surgery Countess of Chester, Nathan Hamnett, Michael Barrett, Sanjiv Dhital, Ali Juma
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The recent article by Keshtgar et al. raises some interesting issues regarding histological examination of breast tissue following breast reduction surgery.[1] We have recently reviewed our breast reduction cases over a 5 year period. During this period, 202 patients underwent routine bilateral breast reduction surgery for mammary hypertrophy. The mean age of our patients was 36.6 years (range 16-74 years). Histologically, in the 404 breast specimens, 10 fibroadenomas and 2 ductal carcinomas in situ (DCIS) were identified. The two patients with DCIS had no risk factors and were under 55 years of age. Our incidental rate of DCIS was 0.99%, similar to previously published studies (0.05-1.66%).[1-4] Higher rates of incidental breast carcinoma were found in studies that included those with previous breast cancer diagnoses and post reconstruction procedures.[4] In 2005, 45957 new cases of breast cancer were diagnosed in the United Kingdom. Only about 2000 of these were in those under 39 years of age.[5] Patients over 50 years will be part of the national routine breast screening programme, and these patients should have undergone a mammogram prior to surgery. Those at high risk of developing breast cancer should also be appropriately screened prior to surgery. The dilemma arises in those under 50 years of age with no risk factors where reduction surgery is most commonly performed. Titley et al. suggested in patients less than 30 years specimens are sent only if risk factors for breast cancer are present and specimens sent in all those over 40 years.[6] The costs relating to the emotional distress of the patient, histological analysis, and subsequent sequelae must be considered. At present there is no consensus regarding this issue and national guidance would be appropriate. References 1. Keshtgar M, Jahromi AH, Davidson T, Escobar P, Mallucci P, Mosahebi A, Baum M. Tissue screening after breast reduction. BMJ 2009;338:b630 2. Dotto J, Kluk M, Geramizadeh B, Tavassoli FA. Frequency of clinically occult intraepithelial and invasive neoplasia in reeduction mammoplasty specimens: A study of 516 cases. Int J Surg Pathol. 2008;16;25-30 3. Hage JJ, Karim R. 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 4. Colwell AS, Kukreja J, Brueing KH, Lester S, Orgill DP. Occult breast carcinoma in reduction mamaplasty specimens: 14-year experience. Plast Reconstr Surg. 2004;113:1984-8 5. Cancer Research UK. UK Breast Cancer incidence statistics. http://info.cancerresearchuk.org/cancerstats/types/breast/incidence/. 6. Titley OG, Armstrong AP, Christie JL, Fatah MF.Pathological findings in breast reduction surgery. Br J Plast Surg 1996;49:447-51. Competing interests: None declared |
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Anthony J Maxwell, Consultant Radiologist Royal Bolton Hospital, BL4 0JR, Jane L. Ooi and J. Mark Pearson
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We read with interest the debate on whether the tissue excised from women undergoing breast reduction should be submitted for histological examination. In our view, failure to do so would be negligent unless the woman has specifically requested that this not be performed. We do agree that the woman should be informed pre-operatively that the tissue will be examined. It is the practice in our unit to perform pre-operative mammography on all women aged 35 or over who are to undergo breast reduction, in order to avoid the situation described in the case report. Whilst not all cases of malignancy are detectable on mammography, it is likely that the diagnosis would have been established prior to surgery in the case described. The authors state that ‘screening for breast cancer by any modality is not recommended in the UK for women under the age of 50’. In fact, the NHS Breast Screening Programme is in the process of expanding to invite women from the age of 47. Furthermore, they state that ductal carcinoma in situ (DCIS) in a 37-year old is of ‘uncertain clinical importance’ and that 'she cannot be reassured that this surgery has benefited her'. Whilst some cases of DCIS, notably low grade disease in older women, may not progress to invasive disease in the patient’s lifetime, there is little doubt that invasive disease will develop in most women with untreated DCIS within a few years [1], with consequent risk to life. Reference 1. Maxwell AJ, Hanson IM, Sutton CJ, Fitzgerald J, Pearson JM. A study of breast cancers detected in the incident round of the UK NHS Breast Screening Programme: the importance of early detection and treatment of ductal carcinoma in situ. The Breast 2001;10:392-8. Competing interests: None declared |
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David Skidmore, OBE, Consultant Surgeon and Surgical Oncologist Wellington Hospital, London, NW8 9LE
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Dear Sir, The article by Keshtkar and colleagues (BMJ, 21 March 2009) covers two separate issues. The first covers the approximate 1% incidence of occult breast cancer in histological examination of tissue resulting from reduction mammoplasty. As both your lay contributor, Tessa Bowes, and Dr. Sugarman have indicated there can be no justification for not warning a potential patient in advance of this small but significant risk consequent upon undertaking a voluntary cosmetic procedure. Recent High Court cases concerning both a neurosurgeon (Afshar) and a cardiac surgeon (Yacoub) who in the eyes of the Court failed to indicate to a patient and a child’s parent certain risks of the order of 1% in connection with a proposed procedure would appear to make it abundantly clear that based on case law any surgeon who had not raised the possibility of occult carcinoma being identified as a consequence of a reduction mammoplasty could expect to be censured. The second issue in the article reflects Professor Michael Baum’s well known and honorable stand on the matter of the virtues of screening when the natural history of the identified neoplastic process is neither known or understood. In this connection, I recollect the case of a 43 year old patient who had undergone bilateral reduction mammoplasty at the age of 39. Breast changes that occurred were put down to late consequences of the cosmetic procedure by others, but my biopsy revealed advanced invasive lobular carcinoma from which she died. This lady was deprived of the chance of knowing that a tumour was present at the time of her reduction procedure since no histopathology examination was performed. My belief is, therefore, clear. First that the patient should be made aware of this eventuality and second that resected tissue should be sent for histopathology with a request form on which a diagrammatic map indicates the quadrant or other definable anatomical landmarks from which the tissue has been taken. It is evident that in undergoing a reduction mammoplasty the patient is effectively submitting to a random biopsy as a corollary of the operative procedure. If in the unfortunate circumstances of the case reported by the authors of the published paper a malignant process is identified the patient and her family can be provided with a range of strategies to deal with the tumour. This is analogous to the identification of an unsuspected neuro- endocrine tumour in an appendix specimen or small squamous cell carcinoma in an adult circumcision ostensibly carried out for xeroderma obliterans in a diabetic. No scientific clinician can reject information being laid in front of him by a histopathologist even though this may precipitate a clinical quandary for surgeon and patient alike. Yours faithfully,
Competing interests: None declared |
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Jeremy Wood, Consultant Breast Surgeon London and Hertfordshire
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I cannot share the soul searching of Keshtgar and colleagues that the case of DCIS found after breast reduction surgery appears to have provoked. That this is a difficult case with an unfortunate outcome is undoubtably true, however 'hard cases make bad law' and it does not appear to warrant wholescale changes in practice. They have emphasized some uncertainties in the natural history of DCIS, but omit to mention that a significant number of cases of DCIS progress to invasive breast cancer. This progression has been directly observed and is well described. The suggestion that this may not occur is more of an inference from somewhat conflicting data obtained from different sources and is, I would suggest, insufficiently robust to change practice. An alternative view of this case is that the discovery of DCIS may have prevented her from developing breast cancer and this interpretation is as valid as the authors. The issue of informed consent prior to breast reduction surgery is raised; perhaps it should include advice that it may lead to difficulties with breast imaging and may make breast conservation surgery for breast cancer more difficult? As there has been some debate in these columns as well as the media about the potential for the overtreatment of some lesions found at breast screening, perhaps the time has come to revaluate the possible role of a more conservative approach to their management, which in turn might produce more up to date data as to their natural history. The Association of Breast Surgeons at BASO and the Sloane Project are in an excellent position to initiate this. Competing interests: None declared |
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Atul Khanna, Consultant Plastic Surgeon Sandwell General Hospital, West Bromwich, West Midlands B71 4HJ
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Dear Sir/Madam Re: Tissue screening after breast reduction I read the article Tissue screening after breast reduction with contributions from a lay person, ethicist and a surgeon with interest. I am surprised that, given the environment we practice in, the editorial board did not request a medico-legal perspective as well. The article found a positive histology of cancer in 0.8% in 391 patients ( 3 patients) in a retrospective review of a prospectively maintained database over a 5 year period. They go on to state that after 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 procedure. Assuming that the workload of the unit remains the same and from here on specimens after routine breast reduction surgery are not sent for histological assessment it is not inconceivable to expect that over the next 5 years, 3 patients having had breast reduction surgery may present to the unit with advanced breast cancer that could have been treated more promptly if the specimen had been assessed after surgery. A patient after a breast reduction procedure who subsequently develops advanced breast cancer may be interested to know whether her eventual outcome and survival may have been different if the specimen had been sent for histological assessment and based on the assessment earlier treatment had been initiated. Although the authors feel that the practice is unproved and a potentially harmful screening procedure it is accepted practice by a responsible body of medical opinion and the cost of the assessment is incorporated in the overall price for the surgery both in the NHS and private sector in the UK. It is unlikely that a responsible body of surgeons performing breast reduction surgery will stop requesting histological assessment of these specimens given that although the overall percentage risk to the patient stopping this practice is small the risk to the patient affected by this change in practice can be significant. I, for one, will continue to request histological assessment of specimens following breast reduction surgery but will take into account the issues of informed consent that the authors have raised in their article. 1. Keshtgar M, Hamidian Jahromi A, Davidson T, Escobar P, Malluci P, Mosahebi A, et al. Tissue screening after breast reduction, BMJ 2009; 3 Competing interests: None declared |
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Anthony G Douglas-Jones, Consultant Histopathologist University Hospital of Wales, Heath Park, Cardiff, CF144XN, Murali Varma
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We read with interest the article appearing in the BMJ on 21/3/09 in which Mohammed Keshtgar and colleagues discuss the implications of histopathological examination of breast tissue excised during breast reduction surgery. (1) We were surprised that no histopathology opinion had been sought, although the views of a surgeon, an ethicist and a lay person were included. Extensive references are made to pathological examination providing evidence that the chance of finding occult malignancy is very small but some important aspects of the pathology have been overlooked. The authors discuss the value of pathologic examination (“tissue screening”) after breast reduction. Mammographic screening involves radiological examination of the entire breast. For “tissue screening” exclusion of malignancy would involve examining all the tissue histologically since most DCIS is not visible on gross examination. However given the available resources, it would be impractical submit all tissue from breast reduction specimens for histological examination as this would entail many tens of tissue blocks from each case. Moreover, even if the entire specimen was submitted, only about 0.15% (one 4 µ section from each 3-4mm tissue block) would be actually examined under the microscope. In the commentaries, it has been suggested that the specimen should be orientated as this “would seem to need little extra work”. However, reduction specimens are often received in multiple pieces each of which would need to be orientated. Retaining this orientation by painting each piece with multiple colours would significantly increase the workload of the pathologist. Moreover, even if this is meticulously done, assessment of margins would remain imprecise unless each piece is submitted separately with information describing the precise relative spatial relationship of all the pieces recorded by the surgeon and retained during pathological blocking and examination. To achieve screening the test has to be fit for purpose and pre operative mammography (or post operative specimen radiography) are far more practical and cost effective ways of excluding occult malignancy in patients undergoing reduction mammoplasty. The Royal College of Pathologists are trying to reduce histopathology workload and have identified this type of specimen as being of “limited clinical value” and there have been serious suggestions that it should not be submitted for pathological examination.(2) The scenario under discussion (finding unexpected incidental cancer in specimens removed for another purpose) is not unique. Incidental low volume prostate cancer may be found in transurethral resections of the prostate where excess prostatic tissue is removed to relieve urinary retention and routinely submitted for histopathological examination. The likelihood of finding cancer is much higher than in breast reduction specimens and the ethical issues in this clinical setting would be similar to those discussed in the paper and commentaries However, it is unclear whether these patients are warned that unexpected prostate cancer may be diagnosed in these specimens. The authors are correct when they state that women undergoing reduction mammoplasty need to be informed pre-operatively that there is a small chance of discovery of unsuspected malignancy, but it cannot in any sense be presented as screening. An alternative approach which they hint at and which would be supported by the Royal College of Pathologists is that this tissue should not be submitted for histological examination unless there is a specific radiological or clinical indication for doing so. 1. Keshtgar M, Hamidian Jahromi A, Davidson T, Escobar P, Mallucci P, Mosahebi A, Baum M. BMJ 2009;338:691 2. Royal College of Pathologists. Histopathology of limited or no clinical value. RCPath publication 2nd edition, December 2005. London: Royal College of Pathologists. Competing interests: None declared |
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