Approach to Management Using Evidence Based Medicine: Proliferative Breast Lesions Among Reduction Mammoplasty Specimens

Background: Given the reported lifetime estimate of 1 in 8 women becoming diagnosed with breast carcinoma, it is standard perioperative practice for excised tissue obtained from routine reduction mammoplasty procedures to be sent to pathology for review. (1) On average, an estimated 0.2-1.1% (2) of all specimens reviewed is diagnosed with occult malignancy. On occasion, atypical proliferative lesion of variable malignancy potential is also reported, which may become an area of concern given the management of such lesions is often unclear to plastic surgeons due to a paucity of information in the plastic surgery literature. Hence, we aimed to provide a review of commonly diagnosed atypical proliferative lesions identified in routine reduction mammoplasty specimens and the best supporting evidence for their subsequent management.

Methods: Retrospective literature review using keywords reduction mammoplasty, atypical proliferative lesions and management strategies were used to compile the best evidence supporting the index topic. A total of 400 publications were reviewed with 30 of these publications selected to incorporate in this review.  

Results: Commonly encountered atypical proliferative lesions among reduction mammoplasty specimens include pseudoangiomatous stromal hyperplasia (PASH), atypical lobular hyperplasia (ALH), atypical ductal hyperplasia (ADH) and flat epithelial atypia (FEA).  PASH and FEA with no concomitant atypical lesions confers no subsequent risk of malignancy and routine standard of care is often recommended. (3-4) ADH and ALH confer a four-fivefold increase risk of subsequent carcinoma. Current management strategies recommend referral to a breast program, biannual clinical exam, yearly mammography with breast MRI, genetic testing for BRCA mutation and chemoprevention in high risk individuals. (5)

Conclusion: Our review suggests important findings by underscoring the most frequently encountered atypical proliferative lesions among routine reduction mammoplasty specimens as well as highlighting the best evidence supporting management strategies.