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 lobular carcinoma.
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.