Thursday, December 14, 2017

OCMA Blog

OCMA Specialty Spotlight: Should Tissue from Mammoplasty be Examined by the Pathologist?

According to The American Society of Plastic Surgeons, 296,203 breast augmentations and 21,714 breast implant   replacements were performed in 2010. In 2011, after 60 cases of breast implant-associated anaplastic large cell lymphoma  (ALCL) became known to FDA, that agency issued a warning to patients who already had or were considering breast implants.1,2 Breast implant-associated ALCL is a rare type of lymphoma of T-cell lineage with clinical signs and symptoms of swelling, pain, pruritis and/or effusion around the implant.3According to a recent study in M.D. Anderson Cancer Center, patients who present with effusion without a distinct mass have an excellent nprognosis if the breast implant and fibrous capsule are removed. In contrast, patients who present with a distinct mass in the vicinity of the implant may have advanced stage or possibly systemic disease and poorer prognosis.4

One of 500,000 women receiving breast implants is estimated to develop implant-associated ALCL.5However, this frequency may be underestimated for the following reasons. Firstly, there are no standardized recommendations for pathologic examination of tissue excised during cosmetic surgery. The routine submission of tissue from that type of procedure is not typically considered the standard of care and is dictated by the individual and/or institutional policies. Secondly, there are no consensus recommendations for examination of the fibrous capsule surrounding the implant, where the lymphoma would be most commonly detected. According to a survey of 413 institutions in 1999, mostly in the United States, 10.7% had policies that exempted the submission of mammary   implants for pathology examination, and 63% had policies that recommended mammary implants for gross examination only, without distinguishing implants from capsulectomy specimens.6 Being more cognizant of the disease, one can surmise that the detection rate of ALCL will increase as more surgeons send the capsule and breast tissue surrounding the implant to pathology, and as pathologists submit more tissue for microscopic  evaluation.

In view of the above discussion, the following questions merit consideration. Should patients with breast implants have them removed for the fear of a malignancy? A negative response to this question would be appropriate; there is no ground for panic unless the patient experiences pain, swelling, retraction, or effusion around the implant. Should the implant, the surrounding capsule and breast tissue be submitted to pathology for both gross and microscopic examination, even though the likelihood of detecting a malignancy in this type of specimen is quite low? An affirmative response would be appropriate in this situation considering that in addition to ALCL, a very small    number of patients could harbor a clinically undetectable mammary carcinoma. 

Newport Coast Pathology (NCP), Inc. is committed to providing high quality care and exceptional anatomic pathology    services for the patient and the referring physician, respectively. Our pathologists treat every specimen as if it were their own or that of their family member. We strongly believe that the pathologist is an integral member of the team of physicians involved in the patient's care, and that communication between the pathologist and the clinician is essential to serving the needs of the patient. Our pathologists are available for consultation with referring physicians and their staff, any time. 

NCP offers a comprehensive menu of diagnostic tests, including: Histopathology, Histochemistry, Immunohistochemistry, Non-GYN Cytology, Cancer prognostic marker tests by various methods  

Newport Coast Pathology, Inc., was founded in 2010 by Mani Ehteshami, MD, a pathologist who recognized a need for a local laboratory that would provide personalized service. Dr. Ehteshami is certified in anatomic and clinical pathology by the American Board of Pathology, and has 17 years of post-fellowship experience and expertise in surgical pathology and cytopathology, specifically in gastrointestinal, liver, genitourinary and breast pathology. He earned a medical degree from Rosalind Franklin University of Medicine and Sciences in Chicago. Following the completion of his residency in anatomic and clinical pathology at the University of New Mexico School of Medicine in Albuquerque, Dr. Ehteshami was a fellow in oncologic surgical pathology at the University of Texas, M.D. Anderson Cancer Center in Houston, where he was trained by many internationally known academic pathologists including Drs. Kathy Foucar, Elvio Silva, Nelson Ordonez, and Ruth Katz. 

http://newportcoastpath.com/  T: (888) 463-3606 


Prior to relocating to Orange County, Dr. Ehteshami was the Medical Director and co-owner of a highly successful private anatomic pathology laboratory in northern California for 13 years. In addition, he held several key leadership positions including Medical Director of Clinical Laboratories, chair of the Pathology Department and chair of the Cancer Care committee at Shasta Regional Medical Center. He was interviewed by and published in Make [Me] Heal publication:"Checking for Breast Cancer when you Have Breast Implants", April 28, 2011 issue. He has affiliation with the following professional organizations: Fellow of the College of American Pathologists, Fellow of the American Society of Clinical Pathology, Member of the California Society of Pathologists, Member of the California Medical Association, Member of the Orange County Medical Association.

Before earning his medical degree, Dr. Ehteshami volunteered his services to educate and counsel patients with multiple sclerosis, and helped to establish housing for those patients. As the Chairman of the Patient Services Committee, a member of the Medical Advisory Committee, and a member of the Board of Trustees of National Multiple Sclerosis Society in Orange County, he was recognized for his outstanding volunteer service. Dr. Ehteshami is an avid runner who has raced in dozens of full and half marathons in the US and abroad. 


References

1. US Food and Drug Administration. Anaplastic large cell lymphoma (ALCL) in women with breast implants: preliminary FDA findings and analyses. 2011. Available at: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm239995.htm. Accessed June 22, 2011.

2. US Food and Drug Administration. FDA medical device communication: reports of anaplastic large cell lymphoma (ALCL) in women with breast implants. 2011. Available at:  http://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm240000.htm. Accessed January 26, 2011.

3. Keech JA Jr, Creech BJ. Anaplastic T-cell lymphoma in proximity to a saline-filled breast implant. Plast Reconstr Surg. 1997;100:554-555.

4. Anaplastic Large Cell Lymphoma Associated With Breast Implants: A Report of 13 Cases.  Aladily, Tariq N.; Medeiros, L. Jeffrey; Amin, Mitual B.; Haideri, Nisreen; Ye, Dongjiu; Azevedo, Sergio J.; Jorgensen, Jeffrey L.; de Peralta-Venturina, Mariza; Mustafa, Eid B.; Young, Ken H.; You, M. James; Fayad, Luis E.;  Blenc, Ann Marie; Miranda, Roberto N. American Journal of Surgical Pathology. 36(7):1000-1008, July 2012.

5. Kenkel JM. Discussion: anaplastic large cell lymphoma and breast implants: a systematic review. Plast Reconstr Surg. 2011;127:2151-2153.

6. Zarbo RJ, Nakhleh RE. Surgical pathology specimens for gross examination only and exempt from submission: a College of American Pathologists Q-Probes study of current policies in 413 institutions. Arch Pathol Lab Med. 1999;123:133-139.


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