Fat grafting to the breast & Mammograms

Currently, one of the big controversies in Plastic Surgery is the topic of fat grafting to the breast, either for post-cancer reconstruction or cosmetic purposes. For years, there have been concerns about the changes that can occur if the injected fat doesn't take in the new location, creating scar tissue. The worry is, of course, that the lump of scar tissue in the breast can look and feel like a breast cancer. Certain scar tissue patterns, on a mammogram, can look just like a breast cancer, and require a biopsy to sort out.

So, any science (rare) as opposed to opinion (frequent) on this topic is welcome news.

At the recent IFATS meeting in Dallas, Dr. Peter Rubin and his team from the University of Pittsburgh presented an interesting review of mammograms following fat grafting to the breast versus mammograms after a standard breast reduction.

They looked at one of the most well-documented series of fat grafting patients, those of Dr. Yoshimura in Japan, who performed breast enhancement with fat grafts which were "turbo-charged" with additional stem cells from the Cytori Celution 800 machine. These 27 patients all had pre-op and 1 year post-op mammograms. These 27 were matched with one year post-surgical mammograms from 23 age-matched women who had undergoing breast reduction surgery.

Then, 8 University of Pittsburgh radiologists with experience in mammography
reviewed each of the 50 post-surgical mammograms without knowing the procedure that had been previously performed, and their comments were tabulated.

Results: Differences in abnormality rates were about the same between the two groups for the findings of oil cysts, benign calcifications and calcifications warranting a biopsy. Scarring and masses requiring biopsy were actually more common in the breast reduction group.

Based on this review, Dr. Rubin, who is a well-respected plastic surgeon and stem-cell researcher, felt that lipoaugmentation of the breast, when performed with Dr. Yoshimura's specific method, had mammographic results that were equal or better than the results after reduction mammaplasty, which is a well-accepted procedure.

Currently, Cytori is still waiting for FDA approval of their Cellution machine. Only surgeons who are using this machine can duplicate Dr. Yoshimura's technique. For all the other methods of fat grafting out there, questions about mammography still remain unanswered.

New Government Mammography guidelines spark debate

This week, an influential government panel known as the U.S. Preventive Services Task Force (USPSTF), whose recommendations influences coverage of screening tests by Medicare and many insurance companies, has come out with new guidelines for mammography, particularly when testing should start, and how often it should be performed. Their article is published in the latest issue of Annals of Internal Medicine (link to article).

These new USPSTF guidelines are sure to spark a hot debate, as the panel claims that:

1) women don't really get a "significant" benefit from mammography until after age 50, rather than age 40, which is the current standard.

2) the mammograms are only needed every second year, not every year, thereafter, which is a change from the current standard.

The American Cancer Society (ACS) and National Cancer Institute (NCI) have already issued statements saying that they don't agree with these looser recommendations, pointing out that breast cancer is a significant issue for women in their forties, and that screening with mammography saves lives - about 1 life saved for every 1900 people screened in the 40-50 age range. (Click here for detailed ACS analysis.) The ACS and NCI fear that, with less screening, that the benefits of early diagnosis and treatment will be lost. The USPSTF panel, on the other hand, feels that the benefit of putting most women through mammograms in their 40's is small, and doesn't outweigh the extra biopsies and drawbacks of additional radiation.

I also wonder if Medicare and insurance companies will use the new USPSTF report as an excuse to reduce the coverage of mammography. Patients may tend to "slack off", and put off getting a mammogram.

I'll be reviewing the original article in detail on my own - but for now, I will continue to follow the ACS and NCI current standards, and recommend that women start mammography at age 40, unless they are in the "high risk" group, in which case it should start even earlier, not later.

Looking for breast cancer with MRI's

A patient asked me the other day about whether MRI scans could be used instead of mammograms, as a more high-tech way to screen for breast cancer. By happenstance, there is a major review article on breast cancer imaging and treatment in the latest issue of the Journal of the American College of Surgeons.

Here are the consensus recommendations of their blue-ribbon panel of experts:

Mammograms, whether standard or digital, are still the recommended method for screening for breast cancer in the general population. If you have an "average" level of breast cancer risk, start getting them at age 40.

The use of MRI as a screening tool is supported by a number of clinical trials, but only for those patients who are at high risk of breast cancer. Appropriate candidates for MRI include:
- women who have a breast cancer risk greater than 20-25%, based on predictive models;
- women who are positive for the BRCA1 or BRCA2 gene, or who are first degree relatives of someone who is positive;
- individuals with previous radiation therapy to the chest between ages 10 - 30;
- women with certain uncommon syndromes with an increased risk of breast cancer.

MRI is also useful for evaluating a newly diagnosed breast cancer, evaluating the opposite breast, for planning treatment or evaluating response to treatment.