Risk-Stratified Analysis of High-Risk Pathologic Findings in Female to Male Transgender Patients Undergoing Gender-Affirming Chest Masculinization Surgery
Madeleine K. Bruce, BA1, Walter J. Joseph, MD1, Lorelei Grunwaldt, MD2, Vu T. Nguyen, MD1, Carolyn De La Cruz, MD1
1Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; 2Private Practice, Pittsburgh, PA
Background: Chest masculinization surgeries are one of the most common gender-affirming procedures performed. There is a need for better understanding of the risk of breast cancer and post-surgical screening in female to male (FtM) individuals. This study aimed to evaluate the incidence of high-risk pathologic findings in FtM transgender patients undergoing gender-affirming chest reconstructive surgery.
Methods: Medical records were reviewed from all FtM transgender patients undergoing gender-affirming chest reconstructive surgery from January 2010-February 2021 by three plastic surgeons at the University of Pittsburgh Medical Center (UPMC) Magee Women's Hospital and Children’s Hospital of Pittsburgh. RR of malignant progression was used to stratify pathologic data (Table 1). Subsequent management of atypical, in situ, and invasive pathology were also recorded.
Results: A total of 318 patients were included in this study; the average age at surgery was 24.6 ± 8.1 years. The mean specimen weight was 574.0 ± 416.8 grams. Eighty-six patients (27%) had a family history of breast and/or ovarian cancer. Overall, 21 patients (6.6%) had some increased risk of breast cancer: 17 (5.3%) had proliferative lesions, mean age 38.2±12.4 years; 2 had atypical ductal hyperplasia (ADH), ages 33.4 and 38.3 years; and 2 had invasive ductal carcinoma (IDC). One patient with ADH had documented follow up at the high-risk breast cancer clinic; risk reducing medication or further surgery was not recommended. One patient with IDC (40.6 years at time of surgery) underwent preoperative breast MRI at request of the plastic surgeon due to extensive personal and family history of cancer, and prior to mastectomy, was diagnosed with IDC upon ultrasound-guided biopsy. Following mastectomy, the patient underwent chemotherapy and radiation therapy, and unfortunately the cancer progressed and is now metastatic. The other patient, aged 35.4 years at time of surgery, had an incidental finding of IDC on pathology, they did not have a history of breast biopsy or family history of cancer. Following mastectomy, the patient underwent genetic testing and ultrasound of the axilla both of which were negative. This patient is currently on tamoxifen, with plans to continue for 5 years.
Conclusion: In this study we found a 1.2% incidence of high-risk pathologic findings in FtM transgender patients undergoing gender-affirming chest reconstructive surgery. Evidence based guidelines for breast cancer screening for patients who have undergone gender-affirming chest masculinization surgery are needed.
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