Breast Palpation at Time of Breast Implant Excision May Find Cancer

DALLAS--Breast implant excision or exchange offers a unique cancer screeningopportunity in breasts frequently difficult to check manually or radiologically,William Shaw, MD, said at the American Society of Plastic and ReconstructiveSurgeons annual meeting.

Dr. Shaw, professor and chief of the plastic surgery division, UCLAMedical School, recommends routine intraopera-tive bimanual parenchymalpalpation to detect breast cancer.

In a retrospective study, Dr. Shaw and his colleague Geoffrey Fenner,MD, found that palpation revealed suspicious areas requiring frozen sectionbiopsy in 50 of 330 patients undergoing implant removal since 1989.

Because parenchymal scar, pericapsu-lar fibrosis, and silicone mastitisprevented palpable demarcation from surrounding "normal" tissue,biopsy samples were submitted for permanent section, and three positivecancer cases were found. All three patients eventually underwent mastectomyas a result of residual cancer on permanent section or a diagnosis of invasivelobular carcinoma.

Palpating for breast cancer during surgery is important because breastimplant and explant patients can have radio-opaque implants, pericapsularfibrosis, and/or silicone granulomas, Dr. Shaw said. For instance, thethree positive cases, viewed in retrospect, all had subop-timal, compressedmammographic series notable for extensive postsurgical fibrosis. In manypatients, he added, immobile skin incisions, contracture, and parenchymalirregularity complicated any external physical examination.

In general, multiple implant exchanges, silicone injections, implantrupture, and distorting cutaneous scars particularly complicate or obscurewhat Dr. Shaw called "even the most astute or compulsive physicaland radiographic evaluation." Such an evaluation might include supplementary,individualized, or non-conventional annual mammography techniques suchas xeroradiography, ultrasound, and displacement views.

In an interview, Jack Fisher, MD, professor of plastic surgery, Universityof California, San Diego, Medical School, told Oncology News Internationalthat he places more faith in the reliability of mammography, calling it"the first line of defense"--but only if the woman gets a fullseries done by a radiologist skilled in the special techniques requiredfor women with breast implants. "You can't just get a 'shopping centermammogram'," he said.

Linda Waters, MD, clinical assistant professor of plastic surgery, StanfordUniversity Medical School, believes, like Dr. Shaw, that mammographic qualityin women with implants is limited. Therefore, she said in an interview,both external and internal palpation of the breast and implant capsuleshould 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 biopsiesdifficult to read.