Monday, August 17, 2009

Should Excised Mastectomy Scars Be Routinely Sent for Analysis?

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Surgeons are commonly faced with the question of whether or not a surgical specimen should be submitted for histologic analysis. Routine histologic examination of clinically unsuspected mastectomy scars that are excised during secondary corrective surgery is considered good practice, but in this era of cost containment in medicine should it be done? 
Locoregional recurrence of breast cancer following mastectomy occurs mainly in the first 3 to 5 years at an incidence rate of  3 to 7%.    That risk after breast-conserving therapy is 1.5 to 2 % per year, stabilizing around 10 to 20 % at 10 to 15 years. 
The first reference article below involved a retrospective review of 433 patients with a history of breast cancer whose mastectomy or breast-conserving surgery scars (455 scars, 22 pts had bilateral surgery) were excised and sent for histopathologic examination.   This included all their patients who had delayed breast reconstruction between January of 2000 and December of 2006 at the three National Health Service plastic and reconstructive surgery units in the West Midlands, United Kingdom.   Four (o.9% of 455) of the mastectomy scars (only three patients as one had bilateral scar recurrence) were positive for carcinoma recurrence.    None of the patients had any preoperative clinical suspicion of recurrent disease.  Their patients mean interval from primary breast surgery to reconstruction was 46.8 months (range, 2 months to 32 years).
This studies authors concluded:
In keeping with cancer surgery principles and with the potential for improved patient outcome, we recommend routine histologic examination of mastectomy scars at the time of delayed breast reconstruction.

The second reference article had a similar number of patients (424) treated by plastic surgeons of The Netherlands Cancer Institute from January of 1994 through May of 2004.   They sent 728 scars for routine histologic examination, 503 (70 percent) of which were excised within the first 3 postmastectomy years.  None of the patients had any preoperative clinical suspicion of recurrent disease.  Several patients (210 of 424) had multiple scars excised.  No evidence of metastatic or de novo tumor was found in any of the 728 scars, but residual glandular tissue was found in 11 scars. 
This studies authors concluded:
Because we found no evidence of tumor in any of the 728 scars we, more convincingly, support and extend their conclusion that routine submission of clinically unsuspected scars excised at the time of breast reconstruction or scar correction after prophylactic or curative breast surgery did not benefit our patients.

Which is the correct answer?  I honestly don’t know.  For now, I’ll continue to routinely send any postmastectomy scars.

Mastectomy Scars following Breast Reconstruction: Should Routine Histologic Analysis Be Performed?; Plast Reconstr Surg. 123(4):1141-1147, April 2009; Warner, Robert M.; Wallace, David L.; Ferran, Nicholas A.; Erel, Ertan; Park, Alan J.; Prinsloo, Daniel J.; Waters, Ruth
Routine histologic examination of 728 mastectomy scars: Did it benefit our patients?;  Plast Reconstr Surg. 2006;118:1288-1292; Woerdeman LA, Kortmann JB, Hage JJ.
Locoregionally recurrent breast cancer: Incidence, risk factors and survival;  Cancer Treat Rev. 2001;27:67-82; Clemons M, Danson S, Hamilton T, Goss P.

1 comment:

Gizabeth Shyder said...

I personally have only seen one recurrence of breast cancer at a scar site, but it was a clinically suspicious lesion I was called to perform a fine needle aspiration upon.

I was curious if the path literature had looked at this, but no according to pubmed.

I think I would send any tissue near a previous invasive cancer to a pathologist for examination, but I certainly could be biased, being a pathologist.