A Case for Sending Mastectomy Scars for Routine Histopathology

Abstract

Sir: We read with interest the article by Woerderman et al.1 in which they conclude that routine histologic analysis of mastectomy scars did not benefit their patients. Recently, similar articles have been published in plastic surgery journals and presented at scientific meetings2–5 in which this routine practice has been questioned more or less on the grounds of the costs involved. At least one unit in the United Kingdom has abandoned its routine practice of analyzing mastectomy scars after an audit of 19 scars.3 We recently operated on a patient and routine histologic analysis of the scar showed recurrent cancer. We would like to share our experience with and thoughts on this issue. We performed a delayed total autologous left breast reconstruction on a 58-year-old woman using an extended latissimus dorsi flap. Fifteen years earlier, she had undergone wide local excision, axillary clearance, and radiotherapy for breast cancer. Three years later she was found to have a recurrence in the scar and underwent mastectomy and chemotherapy. At the time of reconstruction, she had a horizontal mastectomy scar (Fig. 1) with slight radiotherapy damage to the skin. There was no palpable abnormality in the scar, chest wall, or axilla. During the procedure, she was found to have what appeared to be dense scar tissue in the medial part of the mastectomy scar and under the superior skin flap. The scar and additional specimens from under the flap were sent for routine histologic analysis and were reported to contain a focus of well-differentiated adenocarcinoma (Fig. 2).Fig. 1.: Preoperative view of the patient.Fig. 2.: Low-power view of the mastectomy scar showing a focus of well-differentiated adenocarcinoma (hematoxylin and eosin stain).The patient was reassessed by the breast multidisciplinary team. A staging computed tomography scan showed no evidence of any disease in the chest or abdomen; a baseline magnetic resonance imaging scan was obtained for monitoring purposes. It was thought that tamoxifen may have been keeping her in clinical remission despite the asymptomatic relapse, and the patient was advised to continue taking tamoxifen. It was agreed that aromatase inhibitors would be reserved for either a planned switch or to treat progressive disease. Further surgery was not advocated. She remains under regular review by the multidisciplinary team. In their article, the authors themselves recognize that early detection of local recurrence is very important, and undoubtedly such detection in mastectomy scars could potentially benefit the patient with an early intervention, as reported by Zambacos et al.6 They reported a similar case in which the patient was incidentally found to have a recurrence based on routine histologic analysis of the scar. Their patient received further adjuvant chemotherapy. Very few such cases are known,2,6–8 but it is likely that many more have simply gone unreported. Although it is impossible to say whether or not in the long run such patients would benefit from early detection of asymptomatic recurrence, the potential for benefit does exist. It is equally unclear whether any systemic therapy for locoregional recurrence could increase the overall survival rate. Although we agree with the authors that the pick-up rate of recurrence is extremely low, unless it is proven beyond a doubt that such findings offer no benefit to the patient, we believe that the scars should be routinely subjected to histological analysis and that patients should be offered further treatment as appropriate. We do not support discontinuing this practice merely to cut costs. Manish Sinha, M.R.C.S.Ed., Sp.R. Saurabh Gupta, M.R.C.S., S.H.O. Fiona J. Hogg, F.R.C.S.(Plast.) Institute Canniesburn Plastic Surgery Unit Glasgow Royal Infirmary Glasgow, United Kingdom