In Reply

In Reply.—We appreciate the opportunity to respond to the letter referencing our study of reduction mammoplasty (RMP) specimens and how they are managed in the pathology laboratory. The authors of the letter make excellent points regarding breast cancer screening and overdiagnosis including the potential to overtreat indolent lesions in the breast. However, one of our objectives was to answer the question: “What should a pathology laboratory do once a breast reduction specimen has been received?” Pathologic evaluation of RMP specimens differs from institution to institution. The possible options for evaluation range from gross evaluation only to thorough and complete histopathologic evaluation analogous to a cancer-directed surgery specimen. Our prospective study was designed to answer the question of how best to evaluate RMP specimens on this continuum; the goal of the study was not to perform microscopic screening or to find as many cancers as possible, but rather to suggest a standard protocol for evaluating RMP specimens that would take into account patient age and underlying risk so as to find abnormalities that might be clinically important. While we recommended increased tissue sampling in older patients, our study also suggested that no microscopic examination of RMP specimens is necessary in younger patients or of skin samples from clinically and grossly normal overlying skin.

Multiple studies have reported the significance of atypical hyperplasia (AH) in the risk of subsequent breast cancer.¹  Studies have also shown that prophylactic hormonal treatment is associated with a decrease in breast cancer rates in patients with a history of AH.²  Our study shows that some patients undergoing RMP harbor AH, which provides important information to risk-stratify these patients for potential preventive measures. At our institution, patients with low-grade ductal carcinoma in situ, lobular carcinoma in situ, atypical ductal hyperplasia, or atypical lobular hyperplasia in RMP specimens were offered “high-risk” screening and in some cases, prophylactic hormonal treatment.

The authors of the letter state that, “There is little doubt that sampling 25 sections would detect more cancer”; our study evaluated a maximum of 11 breast sections (in 6 tissue cassettes) from each RMP specimen, thus we cannot comment on the effects of even more tissue sections for microscopic evaluation. However, our data showed that there is a progressively diminishing return with more sampling (see Table 3 of our article). What was not adequately emphasized in our article discussion is that the most important component of an RMP specimen evaluation is gross sectioning and examination for any obvious and concerning lesions in the breast.

Answers to the increasingly important and more complex questions of “overdiagnosis” are outside the scope of our study. We have done our best in this prospective study to establish a guideline approach to evaluating RMP specimens and we hope that other pathology laboratories will find our data useful as they consider their own policies and procedures.