Preoperative breast cancer screening before chest masculinization surgery.

[PURPOSE] Detecting malignancy before gender-affirming chest masculinization surgery (GACMS) can alter surgical planning and prevent reoperation, yet a lack of standardized preoperative breast imaging guidelines has resulted in inconsistent, surgeon-dependent practices and potential missed diagnoses. Limited data evaluating the efficacy of pre-GACMS imaging further contributes to this gap. This study aimed to characterize patterns, indications, and outcomes of preoperative breast imaging before GACMS, and to assess the impact of preoperative imaging on cancer detection, surgical decision-making, and timing to surgery.

[METHODS] A single-institution, retrospective review of adults who underwent GACMS between January 2017-September 2024 was conducted. Descriptive statistics summarize preoperative imaging frequency, indications, modalities, outcomes, and postoperative pathology. Alterations in surgical management based on preoperative versus postoperative cancer detection, as well as an institution-wide screening algorithm, are described.

[RESULTS] Of 368 patients, 91.8% (n = 338) were under 40 (mean 27.2, range 18-63). Preoperative breast imaging was recommended in 11.7% (n = 43) and performed in 11.1% (n = 41). Modalities included screening mammography (70.7%, n = 29), diagnostic mammography (29.3%, n = 12), MRI (9.8%, n = 4), and ultrasound (7.3%, n = 3). Indications included age (41.9%, n = 18), family history (30.2%, n = 13), physical exam finding (23.3%, n = 10), and BRCA2 mutation (2.3%, n = 1). Imaging revealed irregular findings in 17.1% (n = 7), with malignancy confirmed in 2 patients (4.9% of imaged; 0.5% overall). One patient who did not receive preoperative imaging was found to have invasive ductal carcinoma on postoperative pathology, resulting in 0.8% (n = 3) overall breast cancer diagnoses perioperatively. Preoperative detection altered surgical planning. Median time to surgery did not significantly differ between imaged and non-imaged patients (3.1 vs. 3.7 months, p = 0.2).

[CONCLUSION] Preoperative breast cancer imaging before GACMS identified malignancies that significantly influenced surgical planning, preventing additional procedures postoperatively. Implementing a decision-making algorithm could guide and standardize breast imaging before GACMS.