Commentary: The Incidence of Malignant and High-Risk Pathology Findings in Postreduction Mammaplasty Patients

The paper by Hoffman et al looks at a very specific question and delivers a very clear description of the possibility of malignancy in breast reduction surgery. ¹ It is a useful reminder that breast cancer needs to be in the back of any surgeon's mind when they are doing this procedure. The prospect of finding a malignancy in a breast reduction specimen is horrific. Localizing the tumor after resection can be extremely difficult and can often mean the next step is mastectomy versus lumpectomy.

The authors were able to show a similar rate of malignant and high-risk pathologies to those reported in the literature both in Canada and in other countries. The study also corroborated known risk factors such as age and BMI with an increased risk of abnormal pathology.

One of the strengths of the study is that they were able to include all the pathology results for breast reductions at their center over a long period of time. The absence of excluded cases is valuable in verifying a true rate of high-risk pathologies given the low incidence of these cases. However, as the authors allude to, it does not capture a large number of patients given the number of years covered. In this study, there were only a total of 39 cases a year shared by 5 surgeons.

The authors touch on the debate over the age to start screening and whether this should start at 40 or 50 for patients without a significant past or family history of breast cancer. Age for mammogram screening in Canada by province varies from 40 to 45 and 50 years of age. Both false positive and false negative screening results need to be considered. The question about breast cancer screening before the age of 50 is raised by the authors due to the relative lack of ominous pathology in this study in patients under that age. To take a position against screening in that age group, a much larger number of cases would need to be evaluated to provide enough power to support that claim.

This article does discuss the possibility of uncertain tumor location and the possible treatment implications if cancer is detected in such a case. This could lead to a full mastectomy instead of lumpectomy and radiation if positive margins are present. This is an incredibly difficult issue. They suggest en bloc resection and orienting sutures to help place the tumor anatomically, but this is often not possible when trying to achieve symmetry on the table by shaving off parts to gain better symmetry.

Overall, this is a good reminder of the possibility of breast cancer in breast reduction specimens and that this should be part of the surgical discussion and planning. Patients should be encouraged to have routine screening prior to breast reduction surgery.

Conflict of Interest

The authors declare that there is no conflict of interest.