DALLAS--Breast implant excision or exchange offers a unique cancer screening
opportunity in breasts frequently difficult to check manually or radiologically,
William Shaw, MD, said at the American Society of Plastic and Reconstructive
Surgeons annual meeting.
Dr. Shaw, professor and chief of the plastic surgery division, UCLA
Medical School, recommends routine intraopera-tive bimanual parenchymal
palpation to detect breast cancer.
In a retrospective study, Dr. Shaw and his colleague Geoffrey Fenner,
MD, found that palpation revealed suspicious areas requiring frozen section
biopsy in 50 of 330 patients undergoing implant removal since 1989.
Because parenchymal scar, pericapsu-lar fibrosis, and silicone mastitis
prevented palpable demarcation from surrounding "normal" tissue,
biopsy samples were submitted for permanent section, and three positive
cancer cases were found. All three patients eventually underwent mastectomy
as a result of residual cancer on permanent section or a diagnosis of invasive
Palpating for breast cancer during surgery is important because breast
implant and explant patients can have radio-opaque implants, pericapsular
fibrosis, and/or silicone granulomas, Dr. Shaw said. For instance, the
three positive cases, viewed in retrospect, all had subop-timal, compressed
mammographic series notable for extensive postsurgical fibrosis. In many
patients, he added, immobile skin incisions, contracture, and parenchymal
irregularity complicated any external physical examination.
In general, multiple implant exchanges, silicone injections, implant
rupture, and distorting cutaneous scars particularly complicate or obscure
what Dr. Shaw called "even the most astute or compulsive physical
and radiographic evaluation." Such an evaluation might include supplementary,
individualized, or non-conventional annual mammography techniques such
as xeroradiography, ultrasound, and displacement views.
In an interview, Jack Fisher, MD, professor of plastic surgery, University
of California, San Diego, Medical School, told Oncology News International
that he places more faith in the reliability of mammography, calling it
"the first line of defense"--but only if the woman gets a full
series done by a radiologist skilled in the special techniques required
for women with breast implants. "You can't just get a 'shopping center
mammogram'," he said.
Linda Waters, MD, clinical assistant professor of plastic surgery, Stanford
University Medical School, believes, like Dr. Shaw, that mammographic quality
in women with implants is limited. Therefore, she said in an interview,
both external and internal palpation of the breast and implant capsule
should be performed at the time of implant removal or exchange.
It is best to send the suspicious breast tissue for permanent sectioning,
Dr. Waters said, since surgical pathologists can find frozen section biopsies
difficult to read.