This case involves a 31 year-old-female with a family history of breast cancer who was suspected to have a marker for developing breast cancer in the future. A biopsy of her left breast showed atypical ductal hyperplasia (ADH), a retroareolar, and a ductal carcinoma in situ (DCIS). Clips were placed on both. The patient then subsequently underwent a NAC skin-sparing mastectomy with a deep inferior epigastric perforator (DIEP) reconstruction. Two years later, the patient felt a palpable mass in her left breast and underwent an MRI and mammogram. The imaging revealed a retroareolar solid mass containing a ribbon-shaped clip. The subsequent biopsy showed DCIS.
Question(s) For Expert Witness
- 1. How often do you perform mastectomies?
- 2. What are the criteria for offering a woman a NAC skin-sparing mastectomy?
- 3. What care should be taken that all biopsy clips are removed with the mastectomy specimen?
Expert Witness Response E-061928
I am a fellowship-trained breast surgical oncologist. I specialize in breast surgery and breast care for both benign and malignant disease. I am a member of the NCCN breast cancer treatment guidelines panel. I perform mastectomies on a regular basis, with and without reconstruction. A woman can be offered a nipple-sparing mastectomy assuming her cancer isn’t immediately behind the nipple and areola and assuming there isn’t any nipple change or nipple discharge. Beyond that, breast size and shape and cancer stage also impact eligibility. All biopsy clips are usually removed based on overall anatomy. The surgeon knows where the borders of the breast are and where the clips are located. There isn’t typically any imaging done of the tissue removed or of the patient postoperatively to verify clip removal. I have seen this complication but it is rare. One colleague had this experience with cancer located in the far upper outer breast. Another had this experience with cancer located in the far inner breast.