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Breast Malignancies In Transgender Surgical Patients
Harsh Patel1, Andre Alcon, MD2, Kelsey McClure, MD3, Randy Sherman, MD1, Dhivya Srinivasa, MD1, Esther A. Kim, MD3.
1Cedars-Sinai Medical Center, Los Angeles, CA, USA, 2UCSF Plastic and Reconstructive Surgery, Los Angeles, CA, USA, 3UCSF Plastic and Reconstructive Surgery, San Francisco, CA, USA.

INTRODUCTION
Breast cancer is the most common malignancy in women, with the lifetime risk in the general female population of 12%1. Conversely, males have a lower risk lifetime risks of 0.1%. This is complicated in the transgender population where patientís assigned birth gender differs from their gender identity, often requiring surgical procedures and hormone supplementation to find congruence with their gender identity. We present a retrospective review of specimen pathology in transgender patients undergoing gender-affirming mastectomies (GAS).
METHODS
Retrospective analysis of patients who underwent GAS from August 2014 to November 2018 were included in this study. All surgeries were performed by the senior surgeon. The breast tissue specimens were weighed and analyzed via permanent section. Data was analyzed using STATA (StataCorp).
RESULTS
171 patients underwent bilateral, GAS. The average age at the time of surgery was 30.6 [15-64]. Of the 141 patients that responded, the average time they felt gender incongruence was 4.99 years. 111 (64.9%) self-identified as Caucasian, 12 (7.0%) as black, 2 (1.2%) as Pacific Islander and Native American each, 24 (14.0%) as other, and 7 (4.1%) declined to answer. 149 patients (87.1%) were BRCA negative and 22 (12.9%) patientsí status was unknown. 139 patients (81.3%) had been receiving or had received hormone therapy at the time of surgery, 21 (12.3%) had not received hormone therapy, and 11 (6.4%) declined to answer. Of the patients who received hormone therapy, 62 (44.6%) received up to one year of hormone therapy, 67 received between 1 and 5 years (48.2%), and 10 (7.2%) received greater than 5 year of hormone therapy. 147 patientís breast pathology (294 total samples) were available for study and are summarized in the table below. 83.3% (245 breast samples) had normal findings, 16.0% (47 breast samples) had benign findings, 0.3% (1 breast sample) showed DCIS, 0.3% (1 breast sample) returned with invasive disease. Average mastectomy tissue weight was 463.1g (R: 467.3g and L: 458.7g). Our patient with invasive disease was a 55-year-old transgender male on hormones for two years. Pathology for the right breast was significant for invasive ductal carcinoma, while the contralateral breast tissue was significant for focal atypical ductal hyperplasia.
CONCLUSIONS
In recent years, transgender cancer screening guidelines have been the topic of much research and debate. Largely due to the artificial hormonal milieu in these patients, understanding the incidence of hormone driven malignancies is of utmost importance. There are scant reports and systematic reviews in the literature on the topic, but no consensus guidelines have been established. Our data supports the pursuit of proper guidelines for transgender breast cancer screening post-operatively.
Table 1: Summary of Pathology of Mastectomy Tissue

R BreastL BreastCombined
Benign121/147 (82.3%)124/147 (84.4%)245/294 (83.3%)
Benign (other)24/147 (16.3%)23/147 (15.6%)47/294 (16.0%)
Premalignant1/147 (0.7%)None1/294 (0.3%)
Malignant1/147 (0.7%)None1/294 (0.3%)

1Sonneblick et al. Breast Imaging of Transgender Individuals: A Review. Curr Radiol Rep 2018;6:1. Doi: 10.1007/s40134-018-0260-1


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