Plastic & Reconstructive Surgery:
Original Articles: Breast
Breast Pathology and Reduction Mammaplasty
Pitanguy, Ivo M.D.; Torres, Ernani M.D.; Salgado, Francisco M.D.; Pires Viana, Giovanni André M.D.
Rio de Janeiro, Brazil
From the Department of Plastic Surgery, The Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Institute of Postgraduate Medical Studies, and the Ivo Pitanguy Clinic.
Received for publication August 15, 2003; revised February 25, 2004.
Ivo Pitanguy, M.D., The Ivo Pitanguy Clinic, Rua Dona Mariana, 65, Rio de Janeiro 22280-020, Brazil, firstname.lastname@example.org
Breast cancer is the tumor with the highest prevalence and incidence in women. Reduction mammaplasty is one of the most common procedures performed in Brazil by the plastic surgeon, and it is not uncommon for the surgeon to find a breast tumor during the operation or afterward, when the histopathological report is received. In this study, 2488 patient files were reviewed retrospectively. All patients had undergone reduction mammaplasty at the senior author’s private clinic (the Ivo Pitanguy Clinic) between January of 1957 and December of 2002. Resected breast tissue was examined histopathologically. The objective of this study was to verify the occurrence of breast carcinoma found accidentally postoperatively. The senior author’s team performed all of the operations and the same pathologist performed every histopathological examination. The histopathological test results were divided into two groups: benign lesions and tumors. The highest frequency of breast pathology was benign lesions, and of them, 80.8 percent involved fibrocystic changes and fibroadiposity. The tumor group was subdivided into benign tumors and malignant tumors. Among the benign tumors, fibroadenoma was the one most common, in 2.2 percent. The frequency of malignant tumors was 0.5 percent of all patients. Most of the histopathological lesions were found in patients between 30 and 50 years of age. A reduced number of patients had no lesions (3.7 percent). Lack of a pathological investigation or a cursory or hurried examination of any mammary tissue by the pathologist may overlook important lesions. In the analysis of these statistics, the concept of normal breast tissue was questioned.
The histopathological appearance of normal breast tissue changes depending on the hormonal variations that occur during menstruation, pregnancy, and menopause. These factors must be taken into account in the histopathological analysis of breast tissue.
The mammary gland has been the subject of much research and many publications.1–35 Methods and technologies such as ultrasonography, mammography, and biopsy by needle aspiration allow different experts to diagnose mammary lesions at earlier stages than was once possible.2,4,11,13–16,29
The importance of analyzing any tissue removed during a reduction mammaplasty in both healthy and asymptomatic patients has been emphasized in many publications.1,3,5,6,9,10,12,18,21,26,31–33 This article is a revision and discussion of 2488 consecutive asymptomatic patients who underwent reduction mammaplasty with histopathological examination at the Ivo Pitanguy Clinic from 1957 to 2002.
Patients and Methods
A retrospective study was done of the files of patients who underwent breast reduction at the Ivo Pitanguy Clinic in the period from 1957 to 2002. The histopathological examination was done in 2488 patients. Some patients had two or three diagnoses, resulting in a total of 2588 diagnoses. These patients had no previous symptoms of tumor or any other indications of breast pathology and presented to this service requesting the correction of benign aesthetic breast deformities, mostly breast hypertrophy.
The preoperative investigation routinely performed included radiological examination, ultrasound scanning, or high-resolution or digital mammography. For patients younger than 30 years of age, ultrasound scanning was requested. In patients older than 30 years of age, xeromammography was the routine examination until 1985. In the last 18 years a high-definition mammography (either digital or high-resolution) has been adopted. Preoperative investigation in the earlier cases (181 patients) was done exclusively by clinical examination, which failed to disclose any abnormalities.
This study was divided into three periods in accordance with the radiological examination: first period, no radiological test (181 patients); second period, xeromammography screening (1853 patients); and third period, high-definition mammography (454 patients).
All the surgical procedures were performed by the senior author, using either the Pitanguy technique or the Pitanguy rhomboid (also called the Arié-Pitanguy) procedure. All resected tissue was forwarded to the same pathologist.
In the Pitanguy technique, resection of the breast parenchyma is performed without manipulating breast tissue and without dissociating parenchyma from the skin. This resection is done on the lower pole and, depending on the deformity being treated, it may be in the shape of an inverted keel (when parenchyma is mostly glandular) or straight (when breast tissue is predominantly composed of fatty tissue). Both types of resections form two columns or pillars. When these two pillars are brought together, the nipple-areola complex naturally raises into its new position. All dead space is eliminated with the closure of the pillars. The nipple-areola complex is raised together with the adipose capsule, which is considered the third pedicle.17,19,20,23–25,27
The Pitanguy rhomboid technique is indicated for the treatment of moderate hypertrophy with or without breast ptosis; it leaves only a single vertical scar on the breast. Resection is adapted to the breast shape; it can also be the inverted keel type or flat type. The vertical scar can be decomposed in the shape of an inverted T at the end of the surgery to avoid extending the vertical incision below the mammary sulcus.17,19,20,23–25,27
The breast tissue must be examined very carefully. At the end of the operation, all breast tissue is identified and sent to the pathologist. Several slices no thicker than 0.5 mm are randomly made in the whole specimens. The tissue is cut, imitating the leaves of a book, and is then closely examined, slice by slice, for any areas judged to be conspicuous, hard, or suspicious by appearance or tactile sensation. All suspected areas are then fixed in paraffin and formaldehyde for 24 hours. After this time, each paraffin block is cut and the sections are stained using routine hematoxylin and eosin.18,21,26 In certain cases, when suspicious areas are seen during the visual examination, two or three slices are chosen for microscopic examination. In this way, the pathologist is able to identify small dysplastic lesions, inflammatory lesions, and neoplastic lesions under the microscope.
The mean age of patients operated on at the Ivo Pitanguy Clinic was 34.9 years old (range, 13 to 85 years). The analysis of age range in our population showed that most of the histological lesions were found in patients from 30 to 50 years of age (Table I).
TABLE I Patients Ope...Image Tools
Breast parenchyma was histopathologically normal in 91 of the 2488 women (11 patients in the first period and 80 women in the second period), and 2497 abnormalities in breast tissue were discovered in the remaining 2397 women undergoing reduction mammaplasty. The highest frequency of breast pathology corresponded to benign lesions: fibroadiposity and fibrocystic changes were seen in 80.8 percent of cases (Table II).
TABLE II Frequency o...Image Tools
The tumor group was subdivided into benign tumors and malignant tumors. Among the benign tumors, fibroadenoma was the most common, being found in 2.2 percent of the patients (Table III). Malignant tumors were found in 0.5 percent of the patients. The most common malignant tumor in this series was invasive ductal carcinoma (seven cases, 0.3 percent) (Table IV). It was verified that most of the malignant tumors were in patients ranging in age from 31 to 60 years, mostly over the fifth decade of life (Table I). Among these groups, two cases of cancer were found in the first period (1 percent of cases), five were found in the second period (0.3 percent of cases), and five were found in the third period (0.9 percent of cases) (Table IV). Among these 12 women with an occult malignancy, four of them (33.3 percent) had multiple diagnoses, and in all of them, the benign lesion found was fibrocystic change.
From the analysis of the surgical specimens, a high frequency of breast pathology was found in asymptomatic patients. It is notable that in a total of 2588 histopathological examinations, normal breast parenchyma was found in only 91 patients, corresponding to 3.7 percent of the total. This result and the fact that all the patients were healthy and asymptomatic indicate that the concept of normal breast should be discussed, considering the histopathologic aspect, which depends on multiple factors such as age and hormonal influence. A breast is understood as “normal” when the glandular and ductal elements and the connective tissues do not show morphological changes, with a perfect balance among the different tissues.
Fibroadiposity was usually found in breast tissue with a weight range from a few grams to more than 1 kg of each surgical piece. The fibroadiposity is characterized by the almost nonexistence of glandular elements, a few ducts, fat tissue with prominent hyperplasia, and fiber threads in higher or lower intensity.18,21,25,26,28,30
For this work, dysplasia, also called fibrocystic changes, was considered the group of illnesses that gather all benign alteration or alterations of the breast tissue found under microscopic examinations (e.g., fibrosis, sclerosing adenosis, and cystic disease). The relationship between dysplasia and breast cancer has changed in the last 20 years. It was first believed that breast dysplasia could turn into malignancy. Since the work of Pitanguy and Cavalcanti in 1976,22 Woods in 198334 and Dupont and Page in 1985,7 and Dupont et al. in 1993,8 there has been a change in this concept which significantly reduced the indication of prophylactic subcutaneous mastectomy.
As shown in this study (Table II), 96.5 percent of our statistics had some alterations at the histopathological examination. Accordingly, prophylactic subcutaneous mastectomy must be indicated in a very limited number of cases that must be very well analyzed. This procedure frees the patients from a “castration syndrome,” as it maintains the aesthetic characteristics of the organ without increasing its morbidity.
The tumors found were divided into two groups: benign and malignant. Of the benign tumors, the most frequently found was fibroadenoma. This tumor is histopathologically characterized by two components: a prolific stroma of connective fibrosis and one epithelial element (ductal and acini), so that the connective component predominates. There are two histological types: the pericanalicular, in which the fiber connective tissue is predominant and surrounds the glandular space, and the intracanalicular, in which the fiber tissue invades into the ducts. Both patterns often coexist in the same tumor.18,21,25,26,28,30
Cystosarcoma phyllodes, also called phyllodes tumor or giant fibroadenoma, which is histologically benign, shows the same configuration of the fibroadenoma. It has a hyperplasia cell stroma and may be wrapped, although not completely. In some cases, it can exhibit malignant behavior.18,21,25,26,28,30
The papilloma of the breast is characterized histologically by the proliferation of intraductal epithelium that may show a variable degree of cellular atypia.18,21,25,26,28,30 We consider papilloma to be a lesion of low malignancy, with the following characteristics: a nucleus hyperchromasia with varied sizes of nuclei and signs of early invasion.
Cancer of the female breast is rarely found before the age of 35, occurring with a peak incidence at or after menopause.28,30,35 Curiously, carcinoma is more common in the left breast than in the right, at a ratio of 110:100.30 The malignant tumors were classified as noninvasive or invasive tumors, following the classification adopted from the International Classification of Diseases (ICD-10). The invasive carcinoma subdivisions are given in Table IV.
Ductal carcinoma in situ, also known as intraductal carcinoma, is considered a lesion associated with breast cancer; histopathologically it is characterized by atypical proliferation of the papillar epithelium intraductal.2,7,8,15,28,30 More than 90 percent of breast carcinomas arise within the ducts.28,30
Lobular carcinoma in situ is a histologically unique lesion manifested by proliferation in one or more terminal ducts or ductules (acini). It can be seen in breasts removed for fibrocystic disease in the vicinity of invasive carcinoma or admixed with intraductal carcinoma.2,28,30
It was verified that most of the malignant tumors occurred at patient ages ranging from 31 to 60 years, mostly after the fifth decade of life, which agrees with the data from the literature. One would expect that the percentage of malignancies undetected by operative screening would decrease as screening methods improve; however, the incidence of cancer was 1.0 percent in the first period, 0.3 percent in the second period, and 0.9 percent in the third period. Probably in the last period there was an increase as a result of the smaller population (454 women) in this period as compared with the second, largest, period (1853 patients).
In all cases in which the histopathological test detected a chance of malignancy, the surgery was performed with the aim to cure. In specific cases, patients were directed to a specialist, such as a mastologist, gynecologist, or oncologist.
Breast reduction, according to the Pitanguy technique or the Pitanguy rhomboid (Arié-Pitanguy) technique, permits a comprehensive approach to the breast parenchyma. After removal of the breast tissue, which represents approximately 40 percent of breast volume, the surgeon may proceed to a careful palpation of all other segments, especially the upper external quarter. In doing so, it would be possible to detect any small tumors.
In the retrospective analysis of the histopathological examinations performed on surgical material from reduction mammaplasties at the Ivo Pitanguy Clinic, a high frequency of various pathologies was verified, especially benign ones, and there was a reduced number of patients who had mammary parenchyma without alterations. In the analysis of these statistics, the concept of a normal breast came to our attention, considering that all patients had no previous symptoms or tumor alterations. Lack of a pathological investigation and a cursory or a hurried examination of any mammary tissue by the pathologist may overlook important lesions.
Although a reduction mammaplasty is not a prophylactic measure in the prevention of breast cancer, there is no doubt that it is a unique opportunity to evaluate with great richness of detail a patient’s breast parenchyma, which is especially valuable in women in higher risk groups.
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