Pathological macroscopic evaluation of breast density versus mammographic breast density in breast cancer conserving surgery.

Correlation between imaging and anatomopathological breast density has been superficially explored and is heterogeneous in current medical literature. It is possible that mammographic and pathological findings are divergent. The aim of this study is to evaluate the association between breast density classified by mammography and breast density of pathological macroscopic examination in specimens of breast cancer conservative surgeries. Post-hoc, exploratory analysis of a prospective randomized clinical trial of patients with breast cancer candidates for breast conservative surgery. Breast mammographic density (MD) was analyzed according to ACR BI-RADS® criteria, and pathologic macroscopic evaluation of breast density (PMBD) was estimated by visually calculating the ratio between stromal and fatty tissue. From 412 patients, MD was A in 291 (70,6%), B in 80 (19,4%) B, C in 35 (8,5%), and D in 6 (1,5%). Ninety-nine percent (201/203) of patients classified as A+B in MD were correspondently classified in PMBD. Conversely, only 18.7% (39/209) of patients with MD C+D were classified correspondently in PMBD (p < 0.001). Binary logistic regression showed age (OR 1.06, 1.01-1.12 95% CI, p 0.013) and nulliparity (OR 0.39, 0.17-0.96 95% CI, p 0.039) as predictors of A+B PMBD. Conclusion: Mammographic and pathologic macroscopic breast density showed no association in our study for breast C or D in breast image. The fatty breast was associated with older patients and the nulliparity decreases the chance of fatty breasts nearby 60%.

Clinicopathological characteristics of endometrial carcinomas according to DNA mismatch repair protein status.

DNA mismatch repair protein deficiency (MMRd) in endometrial carcinoma is associated with the risk of Lynch syndrome and response to immune checkpoint inhibitors. It is also related to microsatellite instability and corresponds to a molecular subtype of endometrial tumor with an unclear prognosis. Here, we evaluated the clinicopathological characteristics and prognosis of 312 consecutive endometrial carcinoma cases submitted to complete surgical staging at a single institution. We compared MMRd and mismatch repair protein-proficient (MMRp) tumors and examined the effects of the MMR protein loss type (MLH1/PMS2 vs. MSH2/MSH6) and influence of L1CAM and p53 expression. The median follow-up period was 54.5 (range, 0-120.5) months. No difference was observed between MMRd [n = 166 (37.2%)] and MMRp [n = 196 (62.8%)] cases in terms of age, body mass index, FIGO stage, tumor grade, tumor size, depth of myometrial infiltration, or lymph node metastasis. More MMRd than MMRp tumors had endometrioid histology (87.9% vs. 75.5%) and despite MMRd had more lymphovascular space invasion (LVSI; 27.2% vs. 16.9%), they presented fewer recurrences and no difference in lymph node metastasis and disease-related death. Relative to those with MLH1/MSH6 loss, tumors with MSH2/MSH6 loss were diagnosed at earlier FIGO stages, were smaller, and had less ≥50% myometrial invasion, LVSI and lymph node metastasis. Outcomes, however, did not differ between these groups. L1CAM positivity and mutation-type p53 expression were more common in MMRp than in MMRd tumors and did not differ between the MLH1/PMS2 and MSH2/MSH6 loss groups. In the entire cohort, L1CAM and mutation p53 expression were associated with worse prognosis, but only non-endometrioid histology, FIGO stage III/IV, and deep myometrial infiltration were significant predictors. In the subgroup of endometrioid carcinomas, only FIGO stage III/IV was associated with poor outcomes. The risk of lymph node metastasis was associated with tumor size, non-endometrioid histology, and multifocal LVSI. For MMRd tumors, only tumor size and myometrial invasion depth were predictive of lymph node involvement. In our cohort, MMRd tumors were associated with greater recurrence-free, but not overall, survival. The precise identification of MMRd status, present in a substantial proportion of endometrial cancer cases, is a challenge to be overcome for proper patient management. MMRd status serves as a marker for Lynch syndrome, and a significant number of these tumors are high risk and candidate to immunotherapy.

Validation of the Residual Cancer Burden Index as a prognostic tool in women with locally advanced breast cancer treated with neoadjuvant chemotherapy.

AIMS: To correlate the 'Residual Cancer Burden' (RCB) index with overall survival (OS) and disease-free survival (DFS) in women undergoing neoadjuvant chemotherapy at the Cancer Institute of the State of São Paulo. METHODS: We analysed the medical records of patients with breast cancer who underwent neoadjuvant chemotherapy and breast surgery, from 2011 to December 2017. Variables analysed were age, clinical and pathological staging, molecular subtype, number of recurrences or metastases, number of deaths, value and class of the RCB index. We used the Kaplan-Meier and the log-rank statistics to evaluate the possible association between RCB and OS and DFS. A regression model was used to determine the independent association of the RCB with the outcomes controlling for confounding factors. RESULTS: 347 patients were included in the analysis with a mean age of 49.39 years. Initial clinical staging was T3 in 57.9% of patients and 43.8% of patients had N1 axillary status. Survival analysis showed a statistically significant better prognosis for the RCB 0 (pCR) subgroup compared with RCB 1, 2 and 3 (log rank p=0.01). In a multivariate analysis, only the RCB classification showed a statistically significant correlation with DFS (RCB 1, HR 6.9, CI 1.9 to 25.4, p=0.004; RCB 2, HR 4.2, CI 1.6 to 10.8, p=0.03; and RCB 3, HR 7.6, CI 2.76 to 20.8, p=0.00). CONCLUSION: We demonstrated a positive and significant relationship between the RCB index and the risk of relapse and death.

Association Between GATA3 and Histopathological and Immunohistochemical Parameters in Early-Infiltrating Breast Carcinomas.

Objective: This study evaluated the frequency of GATA-binding protein 3 (GATA3) expression in early breast cancer and its relationship with histopathological and immunohistochemical parameters. Materials and Methods: GATA3 was analysed by immunohistochemistry in histological sections of tumors from 105 female patients, with histological diagnosis of invasive breast carcinoma (BC), at clinical stages I, II and IIIA, who underwent primary surgical treatment. GATA3 nuclear expression was determined as the percentage of positive tumor cells and further categorized as high (positive expression in more than 95% of cells) or non-high (negative or low positive expression in up to 95% of tumor cells). GATA3 expression was analysed according to the patient age, tumor and node pathological stage, histological type, histological and nuclear grade, lymphovascular invasion, and estrogen receptor (ER), progesterone receptor (PR), androgen receptor (AR), human epidermal growth factor 2 (HER2) status, and Ki-67 expression. Results: GATA3 expression was positive in 103 cases (98.1%). High expression was significantly associated with low histological and nuclear grade, positive hormonal receptors, and less proliferative activity based on Ki-67 expression. A prominent feature was that 94.7% of the ER-positive/HER2-negative cases presented high-GATA3 expression, as 94.0% of the tumors showing high-GATA3 were ER-positive. In ER-negative/HER2-positive or ER-negative/HER2- negative, high-GATA3 was present in 25% while 75% were non-high-GATA3 compared with ER-positive/HER2- negative (4.1%) and ER-positive/HER2-positive (20%). Proliferative activity in triple-negative breast cancer tended to be higher among tumors with low-GATA3, irrespective of AR expression. In the group of ER-positive/HER2-negative tumors only three cases were low-GATA3 (85% and 80%), both with high proliferative activity. Conclusion: High GATA3 expression is associated with favorable histopathologic and immunohistochemical BC prognostic factors.

Microablative fractional radiofrequency as a therapeutic option for vulvar lichen sclerosus: a pilot study

OBJECTIVES: To assess the clinical response to and the histomorphometric effects of microablative fractional radiofrequency (MFR) in women with symptomatic vulvar lichen sclerosus (VLS). METHODS: This was a pilot study on the use of MFR for the treatment of VLS. Upon recruitment and at each treatment session, all participants were examined and each of their symptoms were rated on a visual analog scale. After the procedure, the participants completed a satisfaction questionnaire. We compared the morphometric findings of vulvar biopsies performed at enrollment and after the last treatment session. The participants were divided into three groups according to previous treatment with corticosteroids: G1, no previous treatment; G2, treated for up to 5 years; and G3, treated for >5 years. RESULTS: This study included 26 women. After two to three sessions, most participants in all groups became either "asymptomatic" or "much better" than before treatment and were "very satisfied" or "satisfied" with the intervention. Pruritus and burning sensation were the most frequently reported symptoms. Nearly 40% of the participants in all groups reported complete remission of symptoms. The improvement was rated as moderate or higher by 80%, 76%, and 66% of the women in groups 1, 2, and 3, respectively. The improvement of symptoms persisted for 11 months (range, 7-16 months), on average, after the treatment. Type III collagen concentration significantly increased and was associated with important symptom improvement. Tissue trophism and vascularization also increased but did not reach statistical significance, probably because of the small number of cases. CONCLUSIONS: MFR may be an effective and safe treatment for symptomatic VLS.

Nipple-sparing mastectomy for early breast cancer: the importance of intraoperative evaluation of retroareolar margins and intra-nipple duct removal.

BACKGROUND: Nipple-sparing mastectomy (NSM) is increasingly performed for breast cancer (BC) treatment. To ensure local control with this procedure, it is important to obtain clear surgical margins. Here, we aimed to estimate the confidence in intraoperative evaluation of the retroareolar margin (IERM) and the necessity of removing the intra-nipple ducts. METHODS: In this retrospective cohort study, we evaluated 224 BC (infiltrating carcinoma 178, ductal carcinoma in situ 46) patients, who underwent NSM. IERM was determined via cytology and frozen sections. Following gland removal, the intra-nipple ducts were excised and embedded in paraffin for analysis. The retroareolar tissue was also paraffin-embedded and reanalyzed for definitive evaluation of retroareolar margins (DERM). The IERM predictive capacity in relation to DERM and the frequency of intra-nipple duct involvement were estimated. RESULTS: IERM classified the sub-nipple areolar complex area as cancer-free in 219 cases (97.8%). The condition of clear retroareolar margin was confirmed by DERM in 216 cases (98.6%). The IERM accuracy was estimated as 98.6%. Ductal carcinoma in situ was detected in intra-nipple ducts using paraffin sections in 1.8% of the cases, despite clear IERM (4/219). CONCLUSIONS: In conclusion, IERM affords high accuracy and its results are suitable to manage the nipple-areolar complex. Nevertheless, some patients may retain residual disease in the intra-nipple ducts; thus, these ducts should ideally be removed during NSM.

L1 Cell Adhesion Molecule (L1CAM) expression in endometrioid endometrial carcinomas: A possible pre-operative surrogate of lymph vascular space invasion.

BACKGROUND: Risk stratification of endometrial carcinomas is primarily based on surgical staging that requires extensive retroperitoneal lymph node dissection. One of the most powerful predictor of lymph node involvement is the lymph vascular space invasion (LVSI). The objective of this study was to determine the potential of L1 Cell Adhesion Molecule (L1CAM) to predict LVSI and its association with other risk factors in endometrioid endometrial carcinomas. MATERIALS AND METHODS: We studied 47 consecutive patients aged 37-88 (61.34±10.52). Twenty-three patients (48.9%) were submitted to complete surgical staging. Nine patients (19.1%) underwent surgical staging without para-aortic dissection. Seven (14.9%) were submitted to hysterectomy with no lymph node dissection. Eight patients (17.0%) only had the biopsy material for analysis. The 32 patients submitted to lymphadenectomy were staged according to the FIGO system and classified among the risk categories of the ESMO-ESGO-ESTRO guidelines. The following histological characteristics were analyzed: tumor size (mm), depth of myometrial infiltration, presence of microcystic, elongated, and fragmented (MELF) pattern of myoinvasion, and lymph vascular space invasion (LVSI). Immunohistochemical analyses of mismatch repair (MMR) proteins MLH1, MSH2, MSH6, and PMS2, p53, and L1CAM were performed in formalin-fixed paraffin embedded whole tumor tissue sections. RESULTS: LVSI was identified in 26/41 (63,4%) of the cases. L1CAM was positive in 8/47 (17%) cases, all of them positive for LVSI and within the high-risk category of ESMO-ESGO-ESTRO. L1CAM-positive cases were associated with high histological grade and p53 aberrant immunohistochemical profile. Besides, it showed a trend to larger tumors, greater depth of myometrial infiltration, and with a higher frequency of the MELF pattern of myoinvasion. LVSI was also associated with FIGO stage, tumor size, depth of myometrial infiltration, and tumor grade. CONCLUSIONS: L1CAM is highly associated with LVSI and could be used as a pre-operative predictor of lymph node involvement in endometrioid endometrial carcinomas.

Biological activities and phytochemical profile of Passiflora mucronata from the Brazilian restinga

ABSTRACT In general, Passiflora species have been reported for their folk medicinal use as sedative and anti-inflammatory. However, P. caerulea has already been reported to treat pulmonary diseases. Severe pulmonary tuberculosis, generally caused by Mycobacterium tuberculosis strains resistant to multiple drugs, can lead to deleterious inflammation and high mortality, encouraging new approaches in drug discovery. Thus, the aim of this work was to evaluate the Passiflora mucronata Lam., Passifloraceae, potential for tuberculosis treatment. Specifically, related to antimycobacterial activity and anti-inflammatory related effects (based on inhibition of nitric oxide, tumor necrosis factor-alpha production and antioxidant potential), as well as the chemical profile of P. mucronata. High performance liquid chromatography coupled with diode-array ultraviolet and mass spectrometer analyses of crude hydroalcoholic extract and ethyl acetate fraction showed the presence of flavonoids. Ethyl acetate fraction showed to be as antioxidant as Ginkgo biloba standard extract with EC50 of 14.61 ± 1.25 µg/ml. One major flavonoid isolated from ethyl acetate fraction was characterized as isoorientin. The hexane fraction and its main isolated compound, the triterpene β-amyrin, exhibited significant growth inhibitory activity against Mycobacterium bovis BCG (MIC50 1.61 ± 1.43 and 3.93 ± 1.05 µg/ml, respectively). In addition, Passiflora mucronata samples, specially hexane and dichloromethane fractions, as well as pure β-amyrin, showed a dose-related inhibition of lipopolysaccharide (LPS)-induced nitric oxide production. In conclusion, Passiflora mucronata presented relevant biological potential and should be considered for further studies using in vivo pulmonary tuberculosis model.

PRIMARY BREAST LYMPHOMA PRESENTING AS LOCALLY ADVANCED BREAST CANCER: A CASE REPORT / Linfoma primário apresentando-se como um câncer de mama localmente avançado: relato de caso

Hematopoietic diseases can be found in the breast and mimic a mammary neoplasm, such as leukemia and/or lymphoma. Although lymphomas are considered lymph node tumors, 25-40% have extranodal sites. Primary lymphomas of the breast represent 0.1- 0.5% of all breast neoplasms and may have primary or secondary origin. Primary lymphomas normally start in the breast without involvement of other sites. The diagnosis is made through physical and pathological examination. We report a 77-year-old female who had a locally advanced mass in the right breast associated with inflammatory signs and symptoms and with palpable axillary lymph nodes. The imaging tests were non-specific and didn't help the diagnosis. The pathology report revealed a diffuse, B-cell lymphoma infiltrating the breast (lymphoma non-Hodgkin's). Due to the rarity of the case, and the unknown pathogenesis systemic chemotherapy with CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone) regime were performed. The use of rituximab, as well as radiotherapy, remain controversial in the literature, but for some authors the radiotherapy is indicated with a total dose of 30 to 45 GY. Our patient performed radiotherapy of the breast and axilla. Because of total remission of the disease, it was not necessary complementary treatment or breast surgery.

Doenças hematopoiéticas podem ser encontradas na mama e simular uma neoplasia mamária, como leucemia e/ou linfoma. Apesar de os linfomas serem considerados tumores linfonodais, 25-40% acometem sítios extranodais, sendo um deles a mama. Os linfomas primários da mama representam 0,1-0,5% de todas as neoplasias da mama. Podem ter origem primária ou secundária. Os primários normalmente iniciam-se na mama sem acometimento de outros sítios linfonodais. O diagnóstico é feito através do exame físico e anatomopatológico. Relatamos um caso de uma paciente, idosa, de 77 anos, que compareceu em nosso serviço com uma massa progressiva envolvendo toda a mama direita, ulcerada e associada a sinais e sintomas inflamatórios com linfonodos axilares palpáveis. Os exames de imagem foram inespecíficos e não ajudaram no diagnóstico, não tendo sido recomendados para o rastreio dessa neoplasia. O exame anatomopatológico revelou um linfoma de células B difuso infiltrando a mama (linfoma não Hodgkin). Devido à raridade do caso, a etiopatogenia é desconhecida, e o tratamento foi realizado com os esquemas quimioterápicos para linfoma segundo o consenso para linfomas de células B, sendo a base o tratamento com antraciclinas. A paciente realizou seis ciclos de CHOP (ciclofosfamida, doxorrubicina, vincristina e prednisona), com a regressão total da lesão. O uso do rituximabe, bem como a radioterapia, permanecem controversos na literatura, mas a radioterapia é indicada por alguns autores na dose de 30 a 45 GY. Nossa paciente realizou radioterapia da mama e da axila com ausência de remissão da doença, não tendo sido necessário tratamento complementar ou cirurgia da mama.

SPECT-CT-Guided Thoracoscopic Biopsy of Sentinel Lymph Nodes in the Internal Mammary Chain in Patients With Breast Cancer: A Pilot Study.

OBJECTIVE: The objective of this study was to determine the impact of the use of single-photon emission computed tomography fused with computed tomography (SPECT-CT) on thoracoscopic biopsy of sentinel lymph nodes (SLNs) in the internal mammary chain in patients with breast cancer by evaluating resultant changes in staging and their clinical implications. METHODS: Between September 2010 and January 2014, we performed lymphoscintigraphy-assisted thoracoscopic biopsy of the internal mammary chain SLN in 20 patients with breast cancer. Single-photon emission computed tomography fused with computed tomography was also used in 13 of these patients. The sentinel nodes were surgically identified with the aid of a gamma probe. RESULTS: Sentinel lymph nodes were identified surgically in 19 of 20 patients. In the 13 patients in whom SPECT-CT was used, it readily identified SLNs, especially when they were located over an intercostal space. Change of staging occurred in three patients (15%), two of whom accordingly received adjuvant radiotherapy to the internal thoracic chain. CONCLUSIONS: Compared with lymphoscintigraphy alone, the use of SPECT-CT improves localization of the SLN in the internal mammary chain, allowing more accurate planning of each individual's treatment.

Psicanálise e Psicoterapia: o Fator da Sugestão no “ Tratamento Psíquico” / Psychoanalysis and Psychotherapy: Suggestion as a Factor in the “ Psychological Treatment” / Psicoanálisis y psicoterapia: la sugestión como factor en el “ tratamiento psíquico”

Resumo A noção de sugestão participa da fundação do campo psicanalítico e faz parte de seu vocabulário clínico. A rigor, pertence a sua pré-história, pois a história propriamente dita começa quando Freud abandona a hipnose. Em contrapartida, a explicação paulatina do fenômeno sugestivo foi sendo construída no decorrer da própria edificação teórica da disciplina freudiana, em particular depois de estabelecido seu vínculo com os conceitos psicanalíticos de transferência e de identificação. Esse percurso histórico permeado de reflexões imanentes, recorrentes e necessárias sobre o fenômeno, presentes desde o nascimento da psicanálise, tem seu apogeu em 1921, quando Freud, no trabalho sobre a psicologia das massas e análise do eu, chega a sua explicação definitiva. Levando em conta que a sugestão forma com a repetição e a resistência as três modalidades pelas quais se manifesta a transferência, este artigo busca apresentar subsídios para finalmente concluir com proposições sobre as diferenças clínico-epistemológicas fundamentais entre psicanálise e psicoterapia....(AU)

Abstract The notion of suggestion participates in the foundation of the psychoanalytic field and is part of its clinical vocabulary. Strictly speaking, such notion belongs to its prehistory, as the history of psychoanalysis only begins when Freud abandons hypnosis. However, the gradual elucidation of the suggestive phenomenon was built along the theoretical construction of psychoanalysis itself and, in particular, after establishing its link with the psychoanalytic concepts of transference and identification. This historical route (permeated by immanent, recurring and necessary reflections about this phenomenon that are present ever since the birth of psychoanalysis) has its peak in 1921, when Freud, in his work on group psychology and the analysis of ego, reaches its definitive explanation. Taking into account that suggestion forms, along with repetition and resistance, the three aspects through which transference manifests itself, this article seeks to present subsidies to finally conclude with propositions concerning the fundamental clinic-epistemological differences between psychoanalysis and psychotherapy....(AU)

Resumen La noción de sugestión participa en la fundación del campo psicoanalítico y es parte de su vocabulario médico. En sentido estricto, pertenece a su prehistoria, pues la historia comienza propiamente solo cuando Freud abandonó la hipnosis. En cambio, la explicación gradual del fenómeno sugestivo fue construyéndose durante la edificación misma de la disciplina freudiana, sobre todo después de establecer un vínculo con los conceptos psicoanalíticos de transferencia e identificación. Este recorrido histórico impregnado de reflexiones inmanentes, recurrentes y obligatorias sobre este fenómeno, presentes desde el nacimiento del psicoanálisis, tiene su punto álgido en 1921, cuando Freud, en el texto sobre la psicología de las masas y el análisis del yo, alcanza su explicación definitiva. Teniendo en cuenta que la sugestión junto con la repetición y la resistencia, forman las tres modalidades en que se manifiesta la transferencia, este artículo busca subsidios para finalmente concluir con proposiciones sobre las diferencias epistemológicas fundamentales entre la clínica psicoanalítica y la psicoterapia....(AU)

A eficácia das psicoterapias: apontamentos sobre uma cultura da avaliação em relatório francês de saúde / Efficacy of psychotherapy: notes on an evaluation culture in a French health report / Eficacia de las psicoterapias: notas sobre una cultura de evaluación en un informe francés de salud

A crescente expansão das ciências cognitivas na última década tem confrontado a psicanálise como método terapêutico e questionado a respeito de sua eficácia terapêutica. Em 2004, a Direção Geral da Saúde francesa solicitou a um grupo de peritos que realizasse um relatório de avaliação das principais psicoterapias presentes na França e examinasse a eficácia dos tratamentos empreendidos. O objetivo do artigo, resultante de pesquisa teórico-bibliográfica, é apresentar parte desta história recente da psicanálise na França, com a descrição do relatório publicado, analisado e discutido à luz de textos psicanalíticos ou sobre psicanálise. Procuramos explorar seus impasses e algumas questões políticas e econômicas que atravessam a publicação, que concluiu pela ineficácia da psicanálise em relação às demais abordagens avaliadas. As conclusões ressaltam a importância atribuída pela cultura às práticas avaliativas e à busca do completo estado de bem-estar, para em seguida apontar alguns vieses da avaliação da psicanálise pelo método da medicina baseada em evidências e esclarecer as repercussões do relatório na França uma década depois sobre o tratamento do autismo por psicanalistas. (AU)

The growing expansion of cognitive sciences in the last decade has confronted psychoanalysis as a therapeutic method and questioned its therapeutic efficacy. In 2004, the French General Directory of Health demanded a group of experts to conduct an evaluation report on the major psychotherapies practiced in France, and to examine the effectiveness of the treatments undertaken. This article results from a theoretical and bibliographical research and aims to present part of the recent history of psychoanalysis in France, describing the published report, analysing, and discussing it, with the support of psychoanalytic texts or texts about psychoanalysis. We explore the report's impasses as well as some political and economic issues that permeated the publication, which concluded the ineffectiveness of psychoanalysis compared to other approaches evaluated. The findings show the cultural importance given to evaluation practices and to the pursuit of a complete state of well-being. In sequence, they point out some biases in the psychoanalytic evaluation conducted under the evidence-based medicine method and clarify the report's repercussions on the treatment of autism by psychoanalysts in France a decade after. (AU)

La creciente expansión de la ciencia cognitiva en la última década se ha enfrentado el psicoanálisis como método terapéutico y cuestionado su eficacia terapéutica. En 2004, el Director General de la Salud de Francia pidió a un grupo de expertos para llevar a cabo un informe de evaluación de las principales psicoterapias presentes en Francia, y examinar la eficacia de los tratamientos realizados. El propósito del artículo, que resulta de investigación teórica y bibliográfica, es dar a conocer parte de esta historia reciente del psicoanálisis en Francia, describiendo el informe publicado, analizado y discutido a la luz de los textos psicoanalíticos o acerca del psicoanálisis. Exploramos sus impasses y algunas cuestiones políticas y económicas que atraviesan la publicación, la cual señala la falta de efectividad del psicoanálisis en relación con otros enfoques evaluados. Las conclusiones ponen de relieve la importancia otorgada por la cultura a las prácticas de evaluación y a la búsqueda del estado completo de bienestar, a continuación, señalan algunos sesgos de la evaluación del psicoanálisis por el método de la medicina basada en evidencias y aclaran las repercusiones del informe en Francia una década después en el tratamiento del autismo por los psicoanalistas. (AU)

Morphologic, molecular and microenvironment factors associated with stromal invasion in breast ductal carcinoma in situ: Role of myoepithelial cells.

BACKGROUND: Ductal carcinoma in situ is the last step preceding invasive ductal carcinoma in breast carcinogenesis. OBJECTIVE: We investigated the role of myoepithelial cells and epithelium characteristics as predictors of the risk of stromal invasion. METHODS: We selected 236 cases with initial diagnosis of DCIS followed by surgical ressection distributed in groups 1 (without invasion) and 2 (with invasive carcinoma). RESULTS: The risk of stromal invasion after a DCIS diagnosis in biopsy was associated to triple-negative profile and loss of CD10 expression by myoepithelial cells, and inversely associated with CK5/6 expression by neoplastic cells and high expression of Smooth Muscle Myosin Heavy Chain (SMMHC) by myoepithelial cells. CONCLUSIONS: A combination of characteristics of epithelial and myoepithelial cells in DCIS in biopsy specimens is related to the risk of stromal invasion.

O registro imaginário nos antecedentes lacanianos / The imaginary register in the Lacanian background

Antes da introdução do registro simbólico em seu ensino, algo que marcou de forma indelével os primeiros seminários, Lacan deteve-se desde a publicação de sua tese, em 1932, até o memorável Discurso de Roma, em 1953, com as questões relativas à formação do eu em sua dependência da imagem do outro. Na esteira da proposta de uma psicologia concreta, presente na tese, Lacan aborda como fundamentais os conceitos de complexo, imago e identificação, em suas inflexões no complexo de desmame, complexo de Édipo, e principalmente o complexo de intrusão, que foi posteriormente elaborado como o estádio do espelho.

The imaginary register in the Lacanian antecedents. Prior to the introduction of the symbolic register in his teaching, something that left an indelible mark in his first seminars, Lacan focused his research, since the publication of his thesis in 1932 until the memorable Speech of Rome in 1953, on the issues related to the formation of the Ego (moi) in the dependence of the image of the other. In the wake of the proposal for a concrete psychology in his thesis, Lacan discusses the fundamental concepts of complex, imago and identification in their inflections in the weaning complex, the Oedipus complex, and especially the intrusion complex, which later was developed as the mirror stage.

Sobre o jogo do amor e do azar / Considerations on the game of love and chance

Este artigo discute o estatuto conferido ao acaso nos jogos de azar e do encontro amoroso faltoso, tendo como paradigma as descrições de Alexis, personagem principal e, em parte, autobiográfico de Dostoiévski em Um jogador (1866b). A atmosfera de apostas e riscos em todos os níveis da trama permite destacar os aspectos em que se entrecruzam o amor e o jogo como no ditado universal: sorte em um, azar no outro. A aposta na transformação (pelo jogo ou pelo amor) e a repetição são, então, discutidas pela via do desejo de reconhecimento e dos conceitos de narcisismo e ideal do eu. São igualmente exploradas as estratégias da posição masoquista da escravidão voluntária, que exibem o jogador como joguete, objeto ordinário. O texto é finalizado com algumas considerações sobre o autor russo e o texto que Freud (1928) a ele consagrou, Dostoiévski e o parricídio...

This article discusses the role conferred to chance in gambling and wrongful tryst, taking as a basis the descriptions of Alexis, the main character of Dostoyevsky’s partly autobiographical novel, The gambler (1866b). The atmosphere of bets and risks at all levels of the plot makes it possible to highlight aspects where love and gambling intertwine as the well-known saying goes: lucky at cards, unlucky in love. The bet on transformation (by gambling or by love) and the manifest repetition are then discussed via the desire for recognition and the concepts of narcissism and ego ideal. Furthermore, the discussion examines the strategies of the masochistic position of voluntary slavery that reveal the player as a plaything, an ordinary object. The article concludes with some considerations on the russian author and the text that Freud (1928) devoted to him, Dostoyevsky and parricide...

Este artículo discute el estatuto conferido al acaso en los juegos de azar y del encuentro amoroso faltoso, teniendo como paradigma las descripciones de Alexis, personaje principal y en parte autobiográfico de Dostoiévski en Un jugador (1866b). La atmósfera de apuestas y riesgos en todos los niveles de la trama permite destacar los aspectos en que se entrecruzan el amor y el juego como en el dictado universal: suerte en uno, azar en el otro. La apuesta en la transformación (por el juego o por el amor) y la repetición son así discutidas por la vía del deseo de reconocimiento y de los conceptos del narcisismo e ideal del Yo. Son igualmente exploradas las estrategias de la posición masoquista de la esclavitud voluntaria, que exhiben el jugador como juguete, objeto ordinario. El texto se concluye con algunas consideraciones sobre el autor ruso y el texto que Freud (1928) le consagró, Dostoiévski y el parricidio...

Advanced small-cell ovarian carcinoma, hypercalcemic type: a challenging therapeutic entity.

Small-cell ovarian carcinoma (SCOC) is a rare and aggressive neoplasia, predominantly affecting young women who are frequently first diagnosed with advanced stage disease. Platinum-based chemotherapy (ChT) can provide high response rates and rapidly ameliorate symptoms in this scenario. However, progression after chemotherapy usually occurs quickly, leading to high mortality rates. In addition, ChT complications, such as tumor lysis syndrome (TLS) can also occur, jeopardizing the patient's outcome. We present a case of metastatic SCOC in a 47-year-old patient who achieved tumor response after platinum-based chemotherapy and developed TLS, from which she recovered with supportive treatment. After the second ChT cycle, she developed febrile neutropenia and died 8 weeks after the diagnosis of SCOC. Although SCOC is a chemo-sensitive tumor, short-lived responses and frequent chemotherapy complications lead to a dismal prognosis.

Malignant paratesticular mesothelioma.

Mesothelioma of the tunica vaginalis testis (MTVT) is a rare tumor that usually affects patients after the sixth decade of life. Exposure to asbestos is a known risk factor. Enlargement of the scrotal volume is the most common initial clinical manifestation, and about 15% of cases present metastasis at diagnosis. The treatment relies on surgical resection while the role of adjuvant chemotherapy and radiotherapy remains unclear. The prognosis for patients is generally poor, with a lethal outcome in 30% over a 24-month period. The authors report a case of a 62-year-old patient with the diagnosis of MTVT without a history of asbestos exposure. After surgical treatment, metastatic disease ensued. Chemotherapy was initiated, but could not be continued due to marked and fast clinical deterioration. The authors call attention to the difficulty of early diagnosis of MTVT due to a nonspecific clinical picture, the lack of action by the patient when the scrotal enlargement was first noticed, and the lack of tumor markers. Delayed diagnosis is definitely related to unfavorable prognosis.

Fatores morfológicos, moleculares e do microambiente relacionados ao risco de invasão estromal em carcinomas ductais in situ da mama / Morphologic, molecular and microenvironment factors associated with stromal invasion in breast ductal carcinoma in situ

INTRODUÇÃO: O carcinoma ductal in situ da mama é o estágio final antes do carcinoma ductal invasivo (CDI) no processo de carcinogênese mamária. As semelhanças histológicas, moleculares e imunoistoquímicas do epitélio nestas duas lesões tornaram improvável que o epitélio fosse o único responsável pelo processo de invasão estromal. Ao mesmo tempo, foram identificadas importantes alterações nas características do microambiente mamário durante esta transição. As células mioepiteliais, componente do microambiente e cuja rotura determina o diagnóstico histológico do carcinoma invasivo, tem papel direto ou indireto neste processo. A fim de predizer esse risco de invasão, propomos que as características das células mioepiteliais sejam investigadas em conjunto com as características intrínsecas do epitélio neoplásico. OBJETIVOS: Determinar os fatores morfológicos e moleculares das células epiteliais e os marcadores das células mioepiteliais do microambiente em carcinomas ductais in situ da mama relacionados ao risco de invasão estromal. MÉTODOS: Foram selecionados retrospectivamente 236 casos consecutivos com diagnóstico inicial de CDIS seguidos de ressecção cirúrgica na Divisão de Anatomia Patológica da Faculdade de Medicina da Universidade de São Paulo no período de janeiro de 2000 a dezembro de 2009, divididos nos grupos 1 (CDIS puro, 90 casos) e 2 (CDIS associado a carcinoma invasor, 146 casos). Blocos de microarranjos de tecido foram construídos com áreas representativas dos CDIS e CDI que foram, então, classificados nos perfis moleculares de acordo com o seu perfil imunoistoquímico. Os marcadores mioepiteliais (vimentina, AML, calponina, p63, CK5/6, SMMHC, CD10) foram avaliados de acordo com a expressão imunoistoquímica baixa ou alta. RESULTADOS: Os perfis moleculares dos componentes in situ e invasivo da mesma lesão foram semelhantes. Os CDIS de baixo grau histológico, em comparação aos CDIS de alto grau, apresentaram maior número de casos com perfil molecular...

INTRODUCTION: Ductal carcinoma in situ is the last step preceding invasive ductal carcinoma in breast carcinogenesis. Histologic, molecular and immunohistochemistry similarities in epithelium of these components make improbable that epithelial changes are sole responsible for the stromal invasion. At the same time important changes were identified in mammary microenvironment during this transition. Myoepithelial cells, components of microenvironment and which rupture is the histological definition of stromal invasion, have a direct or indirect role in this process. We propose an associated investigation of myoepithelial cells and intrinsic neoplastic epithelium caracteristics in view of predict the risk of stromal invasion. OBJECTIVES: To determinate morphologic and molecular factors of epithelial cells and microenvironment myoepithelial cell markers related to stromal invasion risk in ductal carcinomas in situ of the breast. METHODS: 236 cases with initial diagnosis of DCIS followed by surgical ressection were retrospectively selected from Division of Surgical Pathology, Faculty of Medicine, Sao Paulo University from january 2000 to december 2009, divided in groups 1 (pure DCIS, 90 cases) and 2 (DCIS associated with invasive carcinoma, 146 cases). Tissue microarrays were constructed with selected areas of DCIS and IDC and those were then classificated in molecular subgroups according to its immunohistochemistry profile. Myoepithelial markers (vimentin, smooth muscle actin, calponin, p63, CK5/6, SMMHC, CD10) were avaliated according to its high or low immunohistochemistry expression. RESULTS: Molecular profiles of in situ and invasive components of the same tumor were similar. Low-grade DCIS showed more luminal profiles than highgrade DCIS (143 vs. 18), and less luminal/HER2-positive (6 vs. 11), HER2 (4 vs. 27) and triple-negative (3 vs. 22) profiles. Group 1 DCIS, compared to group 2 DCIS, showed more cases with hormonal receptor expression (84.4% vs. 71.2%)...