Factors associated with unsatisfactory cosmetic results in oncoplastic surgery.

Introduction: Oncoplastic surgery (OS) has expanded the indications for breast-conserving surgery associated with an adequate aesthetic result. However, few studies have described the factors associated with unsatisfactory cosmetic outcomes from this surgical modality. Materials and methods: This is a cross-sectional prospective study that included patients undergoing breast-conserving surgery (BCS) with or without OS. The patients self-evaluated the cosmetic results of the breasts posttreatment and had them photographed. The photos were analyzed by BCCT.core. Individual and treatment factors (local and systemic) for all patients were evaluated. These factors were dichotomized according to the use of OS and to the cosmetic result (satisfactory and unsatisfactory). Categorical variables were tested for association with surgical outcome using the chi-square test while numerical variables using the Mann-Whitney U test. Variables with p <0,2 were selected for multivariate analysis. Results: Of the 300 patients evaluated, 72 (24,0%) underwent OS. According to the patient self-evaluations, an unsatisfactory cosmetic result from OS was significantly associated with younger age at diagnosis, higher body mass index (BMI) at the time of evaluation, larger tumor size and greater weight of the surgical specimen. According to the BCCT.core, only the laterality of the tumor (left) was significantly associated with an unsatisfactory cosmetic result. In logistic regression, considering OS as a control variable, the risk of an unsatisfactory outcome according to patient self-evaluation was related to the tumor ≥ T2 odds ratio (OR) 1,85 (1,027-3,34) and age at diagnosis < 40 [OR 5,0 (1,84-13,95)]. However, according to the software, the variables were associated with an increased risk of an unsatisfactory outcome were the time interval between surgery and evaluation [OR 1,27 (1,16-1,39)], the presence of lymphedema [OR 2,97 (1,36-6,46)], surgical wound infection [OR 3,6 (1,22-11,16)], tumor location on the left side [OR 3,06 (1,69-5,53)], overweight [OR 2,93 (1,48-5,8)] and obesity [OR 2,52 (1,2-5,31)]. Conclusion: There is no standard methodology for breast cosmesis evaluation, which influences the factors associated with unsatisfactory results. Younger patients and those with increased BMI, left breast cancer and extensive resections tend to present with unsatisfactory cosmetic results when OS is performed.

Sequels associated with breast cancer treatment: what is important to measure in a report

Breast cancer treatment is associated with functional sequelae that limit patients in their daily activities or work, impacting their quality of life. This fact becomes more noticeable in the Public System, the tumors are more advanced, leading to more aggressive treatments. Women with low education generally perform menial activities, playing an important role in family income. After cancer treatment, many are unable to carry out their usual activities, having difficulties with their work activities, requiring rehabilitation. These dysfunctions make it difficult or unfeasible to return to work, limiting family income. Knowledge of the Laws, the main sequelae and evaluation methodologies facilitates a more accurate diagnosis of functional conditions, determining the need for rehabilitation. Social Security provides economic support, but to have access to the benefit, a good report is necessary. This, well directed, helps the social security expert and the patients, who are generally so fragile by the disease and the treatment. In this article we discuss the main functional sequelae, how to evaluate them, and how to make a good report to be sent to an expert (AU)

Evaluation of upper limb lymphoedema and diagnostic accuracy of bioimpedance spectroscopy. A comprehensive validation in a Brazilian population.

Lymphoedema is a complication of breast cancer treatment. Its early diagnosis is related to a good prognosis for lymphoedema treatment. The bioimpedance spectroscopy (BIS) evaluates changes in extracellular fluid. The objective of our study was to evaluate the validity, agreement and accuracy of BIS in the diagnosis of breast cancer-related lymphoedema in a Brazilian population. Methods: This is a prospective, cross-sectional study of a convenience sample of 462 women who underwent surgical treatment for breast cancer (mastectomy or breast-conserving treatment). The validity, agreement and accuracy were performed comparing BIS (lymphoedema index (L-DEX) ≥ 6.5 or 10) with volumetry by water displacement, which is the gold standard for evaluating lymphoedema. Receiver operating characteristic curve was performed. Additionally, other methods like perimetry and indirect volumetry of the upper limbs were compared with water displacement volumetry (direct volumetry), and the BIS were compared with subjective evaluation. Results: Considering L-DEX ≥ 10 the sensitivity of the BIS was 44.1%, specificity 95.4%, positive predictive value (PPV) was 70.7%, negative predictive value (NPV) was 87% and kappa was 0.459. The BIS with L-DEX ≥ 6.5, the sensitivity, specificity, PPV, NPV and kappa were 57%, 88.5%, 55.8%, 89% and 0.452, respectively. Area under curve was 0.724 and a possible cut-off point of L-DEX ≥ 7.35 with sensitivity of 57%, specificity of 90.7% and kappa value = 0.489. Conclusion: Although BIS was significantly associated with the subjective evaluation of lymphoedema, it showed low sensitivity and agreement and moderate correlation when used as a method for diagnosing the condition. Thus, it is not the most valid method for evaluating lymphoedema. In addition, it was not the most accurate method when compared with other objective evaluation tools. Public health resources are scarce and must be used consciously. The knowledge that BIS is not a more accurate method than other, lower-cost instruments allows for better targeting of these resources.

Oncoplastic Surgery in Breast-Conserving Treatment: Patient Profile and Impact on Quality of Life.

BACKGROUND: Breast-conserving treatment (BCT) provides better quality of life (QL) than mastectomy without reconstruction. Oncoplastic surgery (OS) encompasses a series of surgical techniques, increasing the indications for BCT, but few studies have evaluated the impact on QL in patients who undergo BCT with OS. MATERIALS AND METHODS: A prospective, cross-sectional study was conducted in women who underwent BCT. We evaluated the characteristics of patients who underwent BCT with and without OS and the associated QL. QL was assessed through the EORTC QLQ-30, EORTC QLQ-BR23, and Breast Cancer Treatment Outcome Scale (BCTOS) questionnaires. RESULTS: A total of 300 patients underwent BCT, 72 underwent breast OS, and 37 underwent bilateral surgery. Patients who underwent OS were younger (p = 0.004), had a higher level of education (p = 0.01), had a smaller time interval since the end of treatment (p = 0.02), had tumours with greater dimensions (p = 0.003), and were more likely to receive neoadjuvant chemotherapy (p = 0.05). Based on the QL questionnaires, no difference was observed between the groups. Breast symmetry was not associated with high patient satisfaction (p = 0.55). CONCLUSION: Despite the fact that OS was performed in patients with worse tumour conditions and in more demanding patients, OS allowed similar cosmetic results to classical BCT.

Oncoplastic Surgery: Does Patient and Medical Specialty Influences the Evaluation of Cosmetic Results?

BACKGROUND: Oncoplastic surgery (OS) has added plastic surgery concepts and techniques to the breast cancer surgery. However, reports of the impact of OS on cosmesis after breast-conserving surgery (BCS) are limited in the literature. PATIENTS AND METHODS: This cross-sectional prospective study included patients who underwent BCS. The patients self-evaluated the cosmetic outcome of the breasts and had them photographed. The photos were evaluated by BCCT.core software and by 6 breast surgeons (mastologists and plastic surgeons) using the Harvard, Garbay, and Fitoussi scales. Kappa and weighted kappa tests were used to analyze agreement for categorical variables; for continuous variables, the interclass correlation index and the chi-square test to analyze the association between the OS and the symmetrization. RESULTS: A total of 300 patients were evaluated: 228 (76.0%) underwent traditional BCS and 72 (24.0%) underwent OS, and of these, 37 (51.4%) underwent contralateral symmetrization surgery. In the evaluation of the cosmetic result, the correlation between patients and observers (BCCT.core and surgeons) was weak; between the 2 groups of surgeons, the correlation was moderate (Fitoussi scale) and excellent (Garbay scale). Plastic surgeons are more critical for evaluating cosmetic results; they considered it good or excellent in 30.0% whereas patients, mastologists, and BCCT.core results considered it so in 78.8%, 34.0%, and 30.0%, respectively. In terms of cosmesis, OS and symmetrization did not influence the results in this study with long follow-up. CONCLUSION: Patients' self-evaluation reported better cosmesis than surgeons' analyses. Plastic surgeons were the most critical. OS and symmetrization did not influence the results.

Proprioceptive neuromuscular facilitation in the functionality and lymphatic circulation of the upper limb of women undergoing breast cancer treatment.

BACKGROUND: With the increase in survival of women treated for breast cancer, it is necessary to evaluate the effect of therapeutic resources on co-morbidities resulting from the surgical treatment of the disease. The aim of this study was to evaluate the effects of proprioceptive neuromuscular facilitation on the functionality and lymphatic circulation of the upper limb involved in the treatment of breast cancer. METHODS: The study was conducted according to randomized clinical trial design. Thirty-two women at a mean age of 52.20 (±8.32) years, submitted to breast cancer treatment, divided into two groups, control - women submitted to standard breast cancer treatment, and treated group, composed of women who underwent breast cancer treatment and rehabilitation with the proprioceptive neuromuscular facilitation technique. Palmar grip strength with dynamometer and shoulder range of motion with goniometer were evaluated. Lymphatic circulation analysis was performed in a computerized scintillation chamber, before and after therapeutic intervention. FINDINGS: In the results obtained, a significant increase (p < 0.05) of palmar grip strength was observed, a significant increase in range of motion of flexion (p < 0.001), extension (p < 0.0012), abduction (p < 0.0001), external rotation (p < 0.0001), internal rotation (p < 0.0001), and not significant for lymphatic flow (p > 0.05). INTERPRETATION: The results obtained in this study allow us to conclude that proprioceptive neuromuscular facilitation favors an increase in muscle strength, range of motion, but not in lymphatic flow, in women undergoing surgical treatment for breast cancer.

Chemoradiation for cervical cancer treatment portends high risk of pelvic floor dysfunction.

GOAL: To assess the impact of chemoradiation on pelvic floor (PF) muscle function after the treatment of cervical cancer (CC). METHODS: We performed a prospective cohort study of women between the ages of 20 and 70 years old who had a diagnosis of CC. Patients were treated with chemoradiation at the Barretos Cancer Hospital (BCH), between August 2016 and July 2017. We performed three evaluations at different time points after chemoradiation treatment to compare changes in muscle function. Pelvic floor muscle function was assessed through perineometry (PNM) and surface electromyography (EMG) at the following time points: Pretreatment Moment 1 (M1): evaluated before chemoradiation; Moment 2 (M2): at the first follow-up medical visit (usually 3 to 4 months after treatment); and Moment 3 (M3): at the second follow-up medical visit (usually after 6 to 9 months after treatment). Mean vaginal squeeze pressure levels were determined by PNM and muscle electromyographic activity by EMG and the results were evaluated by Generalized Linear Model comparisons. RESULTS: Forty-nine patients were evaluated at M1; 35 at M2; and 32 at M3, so that 32 patients had all three muscle evaluations performed. There was a statistically significant increase in the frequency of women with urgency urinary incontinence at the M2 evaluation time (41.9%), compared to pretreatment M1 (18.6%), p<0.001. The means of the vaginal squeeze pressures reduced through M1 to M3 in the phasic (M1: 17.7 mmHg; M3: 11.27mmHg) and tonic contractions (M1: 10.56 mmHg; M3: 7.52mmHg), p = 0.01 and p = 0.03 respectively. There was no difference in pelvic floor function in the three evaluations M1-M3, measured by EMG. The pelvic floor strength assessed by PMN and their interactions with anthropometric, parity and hormonal status variables, showed that a high body mass index (BMI) significantly influenced decreases in pelvic floor muscle function before and after treatment. CONCLUSION: These results show that chemoradiation causes reduction of muscle function of the pelvic floor, especially in the late phase after the end of treatment. Both the high BMI and urgent urinary incontinence symptoms were related to decreased muscle strength.

Factors associated with return to work in breast cancer survivors treated at the Public Cancer Hospital in Brazil.

PURPOSE: To evaluate the impact of return to work on the quality of life of breast cancer patients and to identify factors related to nonreturn to work. METHODS: An observational, cross-sectional study was performed in breast cancer survivors who had worked before their breast cancer diagnosis. We evaluated factors related to return to work (patient perspective, disease, and work), EORTC quality of life questionnaires (general: EORTC QLQ-C30; and breast cancer-specific: EORTC QLQ-BR23), the Shoulder Pain and Disability Index (SPADI), and the Anxiety and Depression Scale (HADS). Half of the patients underwent a physical therapy examination (shoulder goniometry, hand dynamometry, and limb volume). Univariate and multivariate analysis were performed. RESULTS: We included 304 patients, 163 of whom underwent physiotherapy evaluation. Approximately 54.0% (164) of the patients returned to work after treatment. The women who returned to work presented lower age, higher education levels, higher incomes, and smaller initial tumor size. The women who returned to work had higher scores related to body image and sexual function, lower scores in relation to disability and pain, and lower scores related to anxiety and depression. In the multivariate model to evaluate nonreturn to work, pretreatment variables were age, education level, and clinical staging. Sequelae related to loss of strength increased the risk of nonreturn to work. CONCLUSION: Return to work was influenced by age, education level, previous activity types, axillary treatment, and physical sequelae related to loss of hand strength. Breast cancer treatment decreased the women's work capacity. Return to work improved the patients' quality of life.

Comprehensive Validation Study of Quality-of-Life Questionnaire Using Objective Clinical Measures: Breast Cancer Treatment Outcome Scale (BCTOS), Brazilian Portuguese Version.

INTRODUCTION: When evaluating a quality-of-life questionnaire (QLQ), many validation studies do not correlate quality-of-life scores with objective measurements of complications associated with treatment. PATIENTS AND METHODS: We performed a cross-sectional observational study with 300 patients submitted to breast-conserving therapy. The patients answered the European Organization for Research and Treatment of Cancer (EORTC) QLQs C-30 and BR23, as well as the Brazilian Portuguese version of the Breast Cancer Treatment Outcome Scale (BCTOS) questionnaire. Retest, internal consistency, factorial analysis, convergent/divergent analysis, and Rasch evaluation were performed. All patients underwent physical evaluations to assess lymphedema, handgrip strength, shoulder range of motion, breast cosmesis, and breast pain, and these groups were compared on the basis of BCTOS scores. Receiver operating characteristic curve determined the predictive value of BCTOS scores associated with clinical practice. RESULTS: The internal consistencies of the BCTOS domains ranged from 0.785 to 0.895. Factor analysis grouped according to the original questionnaire. Convergent validation showed differences in the sexual functioning and sexual enjoyment domains of the EORTC BR23. Analysis of known groups found that in most domains, the scores were higher in patients with lymphedema, strength deficit, shoulder range-of-motion alteration, poor breast cosmesis, breast pain, and axillary lymphadenectomy. Using a cutoff of 1.26, lymphedema was associated with the edema domain; using a cutoff of 1.33, Late Effects Normal Tissue Task Force/Subjective, Objective, Management, Analytic pain was associated with the pain domain; and using a cutoff of 2.37, the cosmetic domain was associated with subjective cosmesis. CONCLUSION: The association of objective measurements in a validation study of quality of life qualified the study and allowed us to develop better parameters for comparisons of results of breast-conserving therapy between populations.

Translation and cultural adaptation of the Breast Cancer Treatment Outcome Scale (BCTOS) into Brazilian Portuguese.

BACKGROUND: Breast conservative treatment (BCT) is safe when it is performed in association with radiotherapy. The number of referral for BCT has increased, and it has become an important treatment modality. Patients who undergo BCT present some characteristics that are associated with better quality of life compared with patients who undergo mastectomy without reconstruction. Instruments that measure the quality of life specifically used in cases of BCT are limited. One of these instruments is the Breast Cancer Treatment Outcome Scale (BCTOS), which has not yet been translated into Brazilian Portuguese. It contains 22 questions and four domains (functional, aesthetic, breast sensitivity and oedema). METHODS: We performed the translation and cultural adaptation process using Beaton's and EORTC translations process. In summary, the translation process is based on Portuguese translation, translation summary, reverse translation into English, expert committee, pre-test (10 patients), questionnaire review and test of the final version (6 patients). RESULTS: All 16 patients were submitted to quadrantectomy and mammary radiotherapy. Lymphedema was present in 4, altered strength in 5, and altered shoulder mobility in 6 patients. Considering the questionnaire, the reconciled version determined change in 2 items. Pre-test evaluation showed difficulties in 3 patients, but the questionnaire did not change. Test evaluation showed no problems. CONCLUSION: The translation of BCTOS into Portuguese will help us to evaluate the quality of life in BCT patients evaluating treatment-related sequelae and may be useful for oncoplastic surgery evaluation.

Translation and cultural adaptation of the Breast Cancer Treatment Outcome Scale (BCTOS) into Brazilian Portuguese

SUMMARY BACKGROUND: Breast conservative treatment (BCT) is safe when it is performed in association with radiotherapy. The number of referral for BCT has increased, and it has become an important treatment modality. Patients who undergo BCT present some characteristics that are associated with better quality of life compared with patients who undergo mastectomy without reconstruction. Instruments that measure the quality of life specifically used in cases of BCT are limited. One of these instruments is the Breast Cancer Treatment Outcome Scale (BCTOS), which has not yet been translated into Brazilian Portuguese. It contains 22 questions and four domains (functional, aesthetic, breast sensitivity and oedema). METHODS: We performed the translation and cultural adaptation process using Beaton's and EORTC translations process. In summary, the translation process is based on Portuguese translation, translation summary, reverse translation into English, expert committee, pre-test (10 patients), questionnaire review and test of the final version (6 patients). RESULTS: All 16 patients were submitted to quadrantectomy and mammary radiotherapy. Lymphedema was present in 4, altered strength in 5, and altered shoulder mobility in 6 patients. Considering the questionnaire, the reconciled version determined change in 2 items. Pre-test evaluation showed difficulties in 3 patients, but the questionnaire did not change. Test evaluation showed no problems. CONCLUSION: The translation of BCTOS into Portuguese will help us to evaluate the quality of life in BCT patients evaluating treatment-related sequelae and may be useful for oncoplastic surgery evaluation.

RESUMO INTRODUÇÃO: O tratamento conservador da mama (TCM), desde que associado à radioterapia, é seguro. As indicações inicialmente utilizadas para o TCM se elevaram, sendo importante modalidade de tratamento. Novas modalidades, como a oncoplastia associada ao TCM, tornam-se cada vez mais presentes no cotidiano. Pacientes submetidas ao TCM apresentam alguns parâmetros associados a uma melhor qualidade de vida em relação às pacientes mastectomizadas sem reconstrução. Há limitados instrumentos de qualidade de vida a serem utilizados específicamente no TCM, sendo um deles o Breast Cancer Treatment Outcome Scale (BCTOS), questionário este não traduzido e adaptado para a língua portuguesa/Brasil. O BCTOS contém 22 perguntas e quatro domínios (funcional, estético, sensibilidade mamária e oedema). MÉTODOS: Realizamos a tradução e adaptação cultural utilizando a metodologia proposta por Beaton e pelo EORTC. Em resumo, consiste de tradução para o português, resumo da tradução, tradução reversa para o inglês, comitê de especialistas, pré-teste (dez pacientes), revisão do questionário e teste da versão final (seis pacientes). RESULTADOS: As 16 pacientes foram submetidas a quadrantectomia e radioterapia. Linfedema esteve presente em quatro, alteração da força em cinco e alteração da mobilidade em seis pacientes. Avaliando o questionário, a versão de conciliação modificou dois itens. O pré-teste mostrou dificuldades em três pacientes, mas o questionário não se alterou, fato que não se observou no teste final. CONCLUSÃO: A tradução do BCTOS para o português nos ajudará a avaliar a qualidade de vida em pacientes submetidas a tratamento conservador da mama, avaliando as sequelas relacionadas ao tratamento, podendo ser útil na avaliação da cirurgia oncoplástica.

Pelvic floor muscle training and electrical stimulation as rehabilitation after radical prostatectomy: a randomized controlled trial.

[Purpose] To investigate the effect of electrical stimulation and pelvic floor muscle training on muscle strength, urinary incontinence and erectile function in men with prostate cancer treated by radical prostatectomy. [Subjects and Methods] One hundred twenty-three males were randomized into 3 groups 1 month after RP: (G1, n=40) control; (G2, n=41) guideline: patients were instructed to perform three types of home exercises to strengthen the pelvic floor and (G3, n=42) electrical stimulation: patients in this group were also instructed to perform exercises as group G2, and also received anal electro-stimulation therapy, twice a week for 7 weeks. The primary outcome assessment was based on the measurement of the recovery of pelvic floor muscle strength between groups. Secondary outcomes were: 1 hour Pad Test, ICIQ-SF, IIEF-5 and IPSS. Data were obtained preoperatively and at 1, 3 and 6 months after surgery. [Results] There was no significant difference in the demographic data among groups. Greater urinary leakage and pelvic floor muscle weakness in the first month compared to pre treatment improved after 3 and 6 months postoperative, without difference among groups. [Conclusion] The muscle strength recovery occurs independently of the therapy employed. Pelvic floor exercises or electrical stimulation also did not have an impact on the recovery of urinary continence and erectile function in our study.

Effects of transcutaneous electrical nerve stimulation on chemotherapy-induced peripheral neuropathy symptoms (CIPN): a preliminary case-control study.

[Purpose] The aim of this double-blind, randomized and placebo-controlled study is to investigate the effects of Transcutaneous Electrical Nerve Stimulation for reducing the side effects of Chemotherapy-induced Peripheral Neuropathy in cancer patients undergoing chemotherapy with oxaloplatin or paclitaxel. [Subjects and Methods] Twenty-four patients were randomly allocated into two groups: active or placebo stimulation. All patients were assessed for pain, numbness/tingiling, frequency of symptoms, and quality of life. The transcutaneous Electrical Nerve Stimulation device was applied daily with modulating frequencies ranging between 7 Hz and 65 Hz in distal limb regions during three cycles of chemotherapy (45 days). The other stimulation parameters were: pulse duration of 200 µsec, intensity at the highest tolerable level, and increases in intensity when it diminished. [Results] The data showed no difference between active or placebo groups in terms of pain, numbness/tingling, frequency of symptoms or impact on daily life activities. [Conclusion] These results suggest that Transcutaneous Electrical Nerve Stimulation applied in the frequency variation mode was not proven to be effective to improve the symptoms of Chemotherapy-induced Peripheral Neuropathy during chemotherapy cycles. There was no worsening of symptoms in subsequent cycles of the onset of symptoms of the disease.

Lymphoscintigraphy detecting alterations of upper limb lymphatic flow following early sentinel lymph node biopsy in breast cancer.

PURPOSE: To evaluate early variations in lymphatic circulation of the arm pre- and post-sentinel lymph node biopsy (SLNB) and conservative breast surgery by lymphoscintigraphy (LS). PATIENTS AND METHODS: Between 2005 and 2012, 15 patients underwent LS before and after the SLNB (total=30 studies). The pre-SLNB study was considered the control. Early images within twenty minutes (dynamic and static images) and delayed images within ninety minutes of arms and armpits were acquired using a gamma camera. The LS images before and after the SLNB of each patient were paired and compared to each other, evaluating the site of lymphatic flow (in the early phase) and identifying the number of lymph nodes (in the late phase). These dynamic images were subjected to additional quantitative analysis to assess the lymphatic flow rate using the slope assessed by the angular coefficient of the radioactivity × time curves in areas of interest recorded in the axillary region. The variations of lymphatic flow and the number of lymph nodes in the post-SLNB LS compared to the pre-SLNB LS of each patient were classified as decreased, sustained or increased. The clinical variables analyzed included the period between performing the SLNB and the subsequent LS imaging, age, body mass index, number of removed lymph nodes, type of surgery and whether immediate oncoplastic surgery was performed. RESULTS: The mean age was 54.53±9.03 years (36-73 years), the mean BMI was 27.16±4.16 kg/m2 (19.3-34.42), and the mean number of lymph nodes removed from each patient was 1.6±0.74 (1-3). There was significant difference in the time between surgery and the realization of LS (p=0.002; Mann-Whitney U test), but in an inverse relationship, the higher was the range, the smaller was the lymphatic flow, indicating a gradual reduction of lymphatic flow after surgery (Spearman's p=0.498, with p=0.013). CONCLUSION: Upper limb lymphatic flow gradually decreased after the SLNB and conservative breast surgery in this study, but these results are exploratory because of the small sample size. Further studies are needed to confirm and to investigate more in depth these findings.

Arm lymphoscintigraphy after axillary lymph node dissection or sentinel lymph node biopsy in breast cancer.

PURPOSE: Compare the lymphatic flow in the arm after breast cancer surgery and axillary lymph node dissection (ALND) versus sentinel lymph node biopsy (SLNB) using lymphos-cintigraphy (LS). PATIENTS AND METHODS: A cross-sectional study with 39 women >18 years who underwent surgical treatment for unilateral breast cancer and manipulation of the axillary lymph node chain through either ALND or SLNB, with subsequent comparison of the lymphatic flow of the arm by LS. The variables analyzed were the area reached by the lymphatic flow in the upper limb and the sites and number of lymph nodes identified in the ALND or SLNB groups visualized in the three phases of LS acquisition (immediate dynamic and static images, delayed scan images). For all analyses, the level of significance was set at 5%. RESULTS: There was a significant difference between the ALND and SLNB groups, with predominant visualization of lymphatic flow and/or lymph nodes in the arm and axilla (P=0.01) and extra-axillary lymph nodes (P<0.01) in the ALND group. There was no significant difference in the total number of lymph nodes identified between the two groups. However, there was a significant difference in the distribution of lymph nodes in these groups. The cubital lymph node was more often visualized in the immediate dynamic images in the ALND group (P=0.004), while the axillary lymph nodes were more often identified in the delayed scan images of the SLNB group (P<0.01). The deltopectoral lymph node was only identified in the ALND group, but with no significant difference. CONCLUSION: The lymphatic flow from the axilla was redirected to alternative extra-axillary routes in the ALND group.

Oncology E-Learning for Undergraduate. A Prospective Randomized Controlled Trial.

The e-learning education is a promising method, but there are few prospective randomized publications in oncology. The purpose of this study was to assess the level of retention of information in oncology from undergraduate students of physiotherapy. A prospective, controlled, randomized, crossover study, 72 undergraduate students of physiotherapy, from the second to fourth years, were randomized to perform a course of physiotherapy in oncology (PHO) using traditional classroom or e-learning. Students were offered the same content of the subject. The teacher in the traditional classroom model and the e-learning students used the Articulate® software. The course tackled the main issues related to PHO, and it was divided into six modules, 18 lessons, evaluated by 126 questions. A diagnosis evaluation was performed previous to the course and after every module. The sample consisted of 67 students, allocated in groups A (n = 35) and B (n = 32), and the distribution was homogeneous between the groups. Evaluating the correct answers, we observed a limited score in the pre-test (average grade 44.6 %), which has significant (p < 0.001) improvement in post-test evaluation (average grade 73.9 %). The correct pre-test (p = 0.556) and post-test (p = 0.729) evaluation and the retention of information (p = 0.408) were not different between the two groups. The course in PHO allowed significant acquisition of knowledge to undergraduate students, but the level of information retention was statistically similar between the traditional classroom form and the e-learning, a fact that encourages the use of e-learning in oncology. CLINICAL TRIAL REGISTRATION NUMBER: REBECU1111-1142-1963.

Risk Factors for Arm Lymphedema in a Cohort of Breast Cancer Patients Followed up for 10 Years.

BACKGROUND: The etiology of lymphedema is multifactorial, and definition criteria of lymphedema, its limitation, and follow-up must be considered in studies related to risk factors. The aim of this study is to evaluate risk factors related to arm lymphedema in a cohort study with a long follow-up. PATIENTS AND METHODS: The study was performed in 622 breast cancer patients. The main endpoint reported was the presence of clinical lymphedema reported in medical records. Univariate and multivariate regression analyses were performed to identify factors related to lymphedema. RESULTS: 66.4% of the patients were submitted to mastectomy, 88.4% to level III axillary lymphadenectomy, 34.9% to radiotherapy in the supraclavicular fossa, and 4.3% to axillary radiotherapy. The mean follow-up was 96.7 months. 45 patients (7.2%) developed lymphedema, of which 82.2% had developed lymphedema at 60 months. Univariate regression analysis showed that supraclavicular radiotherapy, adjuvant/palliative chemotherapy, ≥ 15 lymph nodes dissected, and axillary surgery increase the lymphedema rate by 1.87, 2.28, 2.03, and 6.17, respectively. Adjusted multivariate regression analysis showed that the combination of axillary dissection and number of lymph nodes dissected was the main factor related to lymphedema (p = 0.017). CONCLUSION: In the pre-sentinel era, axillary dissection and the number of lymph nodes resected are related to 10-year lymphedema.

Biópsia do linfonodo sentinela para o câncer de mama com anestesia local / Sentinel node biopsy for breast cancer under local anesthesia

Introdução: A técnica da biópsia do linfonodo sentinela (BLS) e considerada padrão-ouro como método preditor do comprometimento axilar para o câncer de mama. Entretanto, a avaliação perioperatória do linfonodo sentinela tem desvantagens. Tentando minimizar as desvantagens, alguns serviços começaram a realizar a pesquisa do linfonodo sentinela sob anestesia local. O objetivo principal deste trabalho prospectivo e demonstrar nossa experiência na pesquisa do linfonodo sentinela, realizada sob anestesia local, e demonstrar a viabilidade deste procedimento. Métodos: Trata-se de um estudo prospectivo que tem como alvo as pacientes matriculadas na Fundação Pio XII - Hospital de Câncer de Barretos, as quais são portadoras de carcinoma da mama. As pacientes foram submetidas à biópsia do linfonodo sentinela sob anestesia local, no período de janeiro a novembro de 2009, conforme protocolo estabelecido. Resultados: No período de janeiro a dezembro de 2009, foram realizados 41 procedimentos da pesquisa de linfonodo sentinela sob anestesia local. Durante o procedimento sob anestesia local, a média dissecada foi de 2,4 (0-5) linfonodos. Em quatro casos, o resultado anatomopatológico dos linfonodos ressecados foi positivo; houve um caso para macrometástases e três restantes para micrometástases. Em todos os pacientes, o procedimento foi realizado sem intercorrências, utilizando-se de doses de anestésicos muito inferiores aos seus níveis tóxicos. Todos os pacientes evoluíram sem qualquer tipo de complicação intra ou pós-operatória. Conclusão: A pesquisa do linfonodo sentinela sob anestesia local e um procedimento factível que traz pouco desconforto para o paciente, devendo ser indicado sempre que possível. Apresenta inúmeras vantagens, comparando-se com a técnica sob anestesia geral.

Introduction: The technique of sentinel lymph node biopsy (SIB) is the gold standard method to predict the axilar status for breast cancer. However, the intraoperative evaluation of the sentinel lymph node has disadvantages. Some services, attempting to minimize these disadvantages, have begun to carry out the sentinel lymph node biopsy under local anesthesia. The aim of this prospective study is to demonstrate our experience in the sentinel lymph node biopsy, which was carried out under local anesthesia, and this procedure's feasibility. Methods: This is a prospective study that targets the patients enrolled in the Hospital de Câncer de Barretos, suffering from breast cancer. The patients underwent sentinel lymph node biopsy under local anesthesia from January to November, 2009, according to the established protocol. Results: From January to December, 2009, 41 research procedures were performed of the sentinel lymph node under local anesthesia. During the procedure under local anesthesia, the dissected average was 2.4 (0-5) lymph nodes. In four cases, the result of the resected pathological lymph nodes was positive; in one case for macrometastases; and the remaining three for micrometastases. In all patients, the procedure was performed uneventfully, using doses of anesthetic below their toxic levels. All patients survived without any complications intra- or postoperatively. Conclusion: The sentinel lymph node biopsy under local anesthesia is a feasible procedure that brings little discomfort to the patient, and should be indicated whenever possible. It has many advantages, when comparing with the technique under general anesthesia.

(99m)Tc-sestamibi scintigraphy used to evaluate tumor response to neoadjuvant chemotherapy in locally advanced breast cancer: A quantitative analysis.

To evaluate the tumor response to neoadjuvant chemotherapy, (99m)Tc-sestamibi breast scintigraphy was proposed as a quantitative method. Fifty-five patients with ductal carcinoma were studied. They underwent breast scintigraphy before and after neoadjuvant chemotherapy, along with clinical assessment and surgical specimen analysis. The regions of interest on the lesion and contralateral breast were identified, and the pixel counts were used to evaluate lesion uptake in relation to background radiation. The ratio of these counts before to after neoadjuvant chemotherapy was assessed. The decrease in uptake rate due to chemotherapy characterized the scintigraphy tumor response. The Kruskal-Wallis test was used to compare the mean scintigraphic tumor response and histological type. Dunn's multiple comparison test was used to detect differences between histological types. The Mann-Whitney test was used to compare means between quantitative and qualitative variables: scintigraphic tumor response vs. clinical response and uptake before chemotherapy vs. scintigraphic tumor response. The Spearman's test was used to correlate the quantitative variables of clinical reduction in tumor size and scintigraphic tumor response. All of the variables compared presented significant differences. The change in (99m)Tc-sestamibi uptake noted on breast scintigraphy, before to after neoadjuvant chemotherapy, may be used as an effective method for evaluating the response to neoadjuvant chemotherapy, since this quantification reflects the biological behavior of the tumor towards the chemotherapy regimen. Furthermore, additional analysis on the uptake rate before chemotherapy may accurately predict treatment response.