Tissue screening after breast reduction
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b630 (Published 11 March 2009) Cite this as: BMJ 2009;338:b630
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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,
Mr. F.D. Skidmore, OBE MA MD FRCS
Consultant Surgeon and Surgical Oncologist
Competing interests:
None declared
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
What about the histopathology view?
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
Competing interests: No competing interests