Current clinical practice in the management of phyllodes tumors of the breast: an international cross-sectional study among surgeons and oncologists.

PURPOSE: Phyllodes tumors of the breast are rare fibroepithelial lesions that are classified as benign, borderline or malignant. There is little consensus on best practice for the work-up, management, and follow-up of patients with phyllodes tumors of the breast, and evidence-based guidelines are lacking. METHODS: We conducted a cross-sectional survey of surgeons and oncologists with the aim to describe current clinical practice in the management of phyllodes tumors. The survey was constructed in REDCap and distributed between July 2021 and February 2022 through international collaborators in sixteen countries across four continents. RESULTS: A total of 419 responses were collected and analyzed. The majority of respondents were experienced and worked in a university hospital. Most agreed to recommend a tumor-free excision margin for benign tumors, increasing margins for borderline and malignant tumors. The multidisciplinary team meeting plays a major role in the treatment plan and follow-up. The vast majority did not consider axillary surgery. There were mixed opinions on adjuvant treatment, with a trend towards more liberal regiments in patients with locally advanced tumors. Most respondents preferred a five-year follow-up period for all phyllodes tumor types. CONCLUSIONS: This study shows considerable variation in clinical practice managing phyllodes tumors. This suggests the potential for overtreatment of many patients and the need for education and further research targeting appropriate surgical margins, follow-up time and a multidisciplinary approach. There is a need to develop guidelines that recognize the heterogeneity of phyllodes tumors.

mHealth program for patients with advanced cancer receiving treatment in a public health hospital in Brazil.

OBJECTIVE: Previous studies have suggested the benefit of routine screening for biopsychosocial symptoms among patients with cancer. In recognition of the lack of data from low- and middle-income countries, this study sought to test and determine the effect of a mHealth program to screen biopsychological symptoms among patients with advanced breast or gynecological cancer. METHODS: This was a quasi-experimental pre-post study conducted in a public hospital located in central western Brazil. Patients diagnosed with advanced breast of gynecological cancer who were about to initiate chemotherapy treatment at this institution and had access to Internet by smartphone, computer or tablet were invited to participate. Patients received training on using the app Comfort, a program developed to rate their physical and emotional symptoms during the 6-month of the proposed study. Patients were also asked to complete the EuroQOL 5D (EQ-5D-3L) every month. Mann-Whitney U test was used to determine differences among groups of patients (engaged and non-engaged). RM-ANOVA was used to determine the effect of time on mean visual analog scale (VAS) score. RESULTS: A total of 125 patients were recruited (median age = 46.6 years old, 41.6% married). Mostly, patients possessed lower levels of education and had relatively low monthly incomes. Notably, 67.2% of patients engaged with the Comfort program, and few patients (4%) withdrew due to lack of engagement with the program or issues with internet connection. In general, patients who engaged with the program reported improvement in physical and emotional symptoms (p < 0.01), as well as in their overall quality of life (VAS; p = 0.009), compared with patients who did not engage with the program. CONCLUSIONS: This is the first mHealth program developed in Brazil for patients in a low resource setting. Our findings suggest that Comfort could be an effective resource to assist patients and health care providers track symptoms and improve patients' quality of life.

The Attitudes of Brazilian Breast Surgeons on Axillary Management in Early Breast Cancer-10 Years after the ACOSOG Z0011 Trial First Publication.

PURPOSE: To evaluate the impact of the ACOSOG Z0011 trial on axillary breast cancer surgery management in Brazil following publication of that study (2010) and again in 2020. PATIENTS AND METHODS: A survey of members of the Brazilian Society of Mastology. RESULTS: Of 1627 breast surgeons, 799 (49.1%) completed and returned the questionnaire. For patients with the Z11 inclusion criteria, following detection of a positive sentinel lymph node (SLN), axillary dissection (AD) was recommended by 99.2% of respondents before publication of the study, 47.5% in 2010 and 18.5% in 2020 (p < 0.001). In breast-conserving surgery, if there were micro-metastases, 2.6% would perform AD, 30.3% axillary radiotherapy, and 67.1% no additional axillary treatment, while with macro-metastases, these proportions were 21.3%, 52.2%, and 26.5%, respectively. In cases of mastectomy and of nodal extracapsular extension, 43.4% and 36% of surgeons, respectively, recommended AD. For clinically negative axilla and suspicious findings at ultrasonography, 69% of the surgeons would apply the Z11 approach. Most applied the Z11 criteria in cases of younger patients (83.6%) and triple-negative and/or HER2 positive tumors (74%). AD was significantly more likely to be recommended by surgeons who did not work in academic institutes, who worked in locations other than capital cities, who were not board-certified, and who were ≥ 50 years old. CONCLUSIONS: This survey revealed substantial changes in axillary surgery management in cN0/pathologically positive SLN, particularly following publication of the updated Z11 results and other similar studies. A better education environment and long-term follow-up were factors associated with the incorporation of Z11-related changes in practice.

Management of early-stage triple-negative breast cancer: recommendations of a panel of experts from the Brazilian Society of Mastology.

BACKGROUND: Triple-negative breast cancer (TNBC) is a heterogenous subtype involving different patterns of behavior and clinical course, demanding a complex, individualized sequence of treatment. The knowledge and attitudes of the affiliated members of the Brazilian Society of Mastology regarding TNBC were evaluated and a consensus regarding management and treatment was reached. METHODS: Affiliates completed a survey involving 44 objective questions. In addition, a specialist meeting was held with 27 experts and 3 ad hoc consultants. The panelists completed the survey before and after brainstorming. Answers achieving 70% of agreement were considered consensual. The chi-square test was used to compare answers between panelists and affiliates and the Kappa coefficient to calculate agreement. RESULTS: Consensus among the panelists increased from 26 (59.1%) to 32 questions (72.7%) following brainstorming (p = 0.17), including 7/10 questions on systemic treatment. Among the affiliates, consensus was achieved for 24 questions (54.5%), resulting in moderate agreement (κ = 0.445). Neoadjuvant chemotherapy should be indicated for almost all cases (except cT1a-b N0) and should include platinum agents. When indicated, immunotherapy is part of the standard of care. The panel reaffirmed the concept of no ink on tumor as indicative of adequate margins and the possibility of sentinel lymph node biopsy for cN1 patients who become cN0 following neoadjuvant therapy. Controversies remain on combining immunotherapy with capecitabine/olaparib in pertinent cases. CONCLUSION: Expert consensus was achieved for > 70% of the questions, with moderate agreement between panelists and affiliates. Educational interventions on systemic breast cancer treatment affected decision-making in 60% of the questions.

Resistance Training, Fatigue, Quality of Life, Anxiety in Breast Cancer Survivors.

ABSTRACT: Moraes, RF, Ferreira-Júnior, JB, Marques, VA, Vieira, A, Lira, CAB, Campos, MH, Freitas-Junior, R, Rahal, RMS, Gentil, P, and Vieira, CA. Resistance training, fatigue, quality of life, anxiety in breast cancer survivors. J Strength Cond Res 35(5): 1350-1356, 2021-Resistance training (RT) has shown to be effective in improving fatigue, quality of life (QOL), and anxiety levels among breast cancer survivors (BCS), but there is no consensus as to how this practice should be prescribed for optimal performance. This study analyses the effects of once weekly RT on fatigue, QOL, and anxiety levels among BCS. Randomized controlled trial. Twenty-five BCS (aged 54.6 ± 5.5 years) were randomized into RT or control groups. The RT group performed 8 weeks of RT (once per week). Fatigue was assessed using the Piper Fatigue scale, QOL was assessed using the SF-36, and anxiety was assessed using the STAI State-Trait Anxiety Inventory. Resistance training significantly improved the following subscales of SF-36: aspects of physical functioning (+27%, p = 0.027); physical role functioning (+54%, p = 0.008); emotional role functioning (+42%, p = 0.027); and mental health (+16%, p = 0.032). Furthermore, RT improved fatigue levels (-55%, p = 0.001 for general fatigue) and anxiety (anxiety state, -19%, p = 0.012; anxiety trait, -23%, p = 0.001). Resistance training seemed to be a positive nonpharmacological tool for the reduction of fatigue, anxiety, and for improvement of several aspects of QOL in BCS.

The impact of sociodemographic factors and health insurance coverage in the diagnosis and clinicopathological characteristics of breast cancer in Brazil: AMAZONA III study (GBECAM 0115).

PURPOSE: In Brazil, the available cancer registries are deficient in number and quality and, hence, little information is known regarding sociodemographic, clinicopathological characteristics, treatment patterns, and outcomes of breast cancer (BC) patients. We performed the AMAZONA III/ GBECAM 0115 study and in this analysis, we describe patients' characteristics at diagnosis and their association with health insurance type. METHODS: This is a prospective cohort study developed in 23 sites in Brazil including women with newly diagnosed invasive BC from January 2016 to March 2018. In order to compare healthcare insurance type, we considered patients who were treated under the Brazilian public health system as publicly insured, and women who had private insurance or paid for their treatment as privately insured. RESULTS: A total of 2950 patients were included in the study. Median age at diagnosis was 53.9 years; 63.1% were publicly insured. The majority of patients (68.6%) had stage II-III breast cancer and ductal carcinoma histology (80.9%). The most common breast cancer subtype was luminal A-like (48.0%) followed by luminal B-HER2 positive-like (17.0%) and triple-negative (15.6%). Luminal A was more frequent in private (53.7% vs. 44.2%, p < .0001) than public, whereas Luminal B HER2-positive (19.2% vs. 14.2%, p = 0.0012) and HER2-positive (8.8% vs. 5.1%, p = 0.0009) were more common in patients with public health system coverage. Only 34% of patients were diagnosed by screening exams. Privately insured patients were more frequently diagnosed with stage I disease when compared to publicly insured patients; publicly insured patients had more stage III (33.5% vs. 14.7%; p-value < 0.0001) disease than privately insured ones. Breast cancer was detected by symptoms more frequently in publicly than in privately insured patients (74.2% vs 25.8%, respectively; p-value < 0.0001). CONCLUSIONS: Patients with public health coverage were diagnosed with symptomatic disease, later stages and more aggressive subtypes when compared to privately insured patients.

Management of early breast cancer during the COVID-19 pandemic in Brazil.

PURPOSE: The COVID-19 pandemic has impacted early breast cancer (EBC) treatment worldwide. This study analyzed how Brazilian breast specialists are managing EBC. METHODS: An electronic survey was conducted with members of the Brazilian Society of Breast Cancer Specialists (SBM) between April 30 and May 11, 2020. Bivariate analysis was used to describe changes in how specialists managed EBC at the beginning and during the pandemic, according to breast cancer subtype and oncoplastic surgery. RESULTS: The response rate was 34.4% (503/1462 specialists). Most of the respondents (324; 64.4%) lived in a state capital city, were board-certified as breast specialists (395; 78.5%) and either worked in an academic institute or one associated with breast cancer treatment (390; 77.5%). The best response rate was from the southeast of the country (240; 47.7%) followed by the northeast (128; 25.4%). At the beginning of the pandemic, 43% changed their management approach. As the outbreak progressed, this proportion increased to 69.8% (p < 0.001). The southeast of the country (p = 0.005) and the state capital cities (p < 0.001) were associated with changes at the beginning of the pandemic, while being female (p = 0.001) was associated with changes during the pandemic. For hormone receptor-positive tumors with the best prognosis (Ki-67 < 20%), 47.9% and 17.7% of specialists would recommend neoadjuvant endocrine therapy for postmenopausal and premenopausal women, respectively. For tumors with poorer prognosis (Ki-67 > 30%), 34% and 10.9% would recommend it for postmenopausal and premenopausal women, respectively. Menopausal status significantly affected whether the specialists changed their approach (p < 0.00001). For tumors ≥ 1.0 cm, 42.9% of respondents would recommend neoadjuvant systemic therapy for triple-negative tumors and 39.6% for HER2 + tumors. Overall, 63.4% would recommend immediate total breast reconstruction, while only 3.4% would recommend autologous reconstruction. In breast-conserving surgery, 75% would recommend partial breast reconstruction; however, 54.1% would contraindicate mammoplasty. Furthermore, 84.9% of respondents would not recommend prophylactic mastectomy in cases of BRCA mutation. CONCLUSIONS: Important changes occurred in EBC treatment, particularly for hormone receptor-positive tumors, as the outbreak progressed in each region. Systematic monitoring could assure appropriate breast cancer treatment, mitigating the impact of the pandemic.

Oncoplastic mammaplasty with geometric compensation: Evolution of the technique, outcomes and follow-up in a multicentre retrospective cohort.

BACKGROUND AND OBJECTIVES: To report on the outcomes and evolution of an oncoplastic mammaplasty referred to as geometric compensation mammaplasty. METHODS: Seventy-three patients with malignant tumours were operated on and followed up in five centres in two countries. Preoperative markings were performed using a Wise pattern. The resection of affected skin was geometrically compensated using another area of preserved skin. RESULTS: Mean pathological tumour size was 30.42 ± 21.98 mm. Twenty tumours (30.77%) were locally advanced and 15 (20.55%) were multicentric. Twenty-two patients (34.38%) were submitted to neoadjuvant chemotherapy. Cosmetic results were considered good or excellent in 59 cases (80.82%). Margins were positive in two cases (2.74%). Complications were partial wound dehiscence (n = 11; 15.07%), fat necrosis (n = 9; 12.33%), skin necrosis (n = 5; 6.85%), seromas (n = 5; 6.85%), enlarged scars (n = 7; 9.59%) and infection (n = 2; 2.74%). There were three cases of local recurrence (4.29%), two of bone metastasis (2.86%) and three of metachronous contralateral breast cancer (4.35%). No deaths were recorded within a mean follow-up of 35.33 ± 28.21 months. CONCLUSIONS: The technique allowed breast conservation in situations requiring a large resection of skin in difficult positions, with a high rate of free margins, correction of ptosis, satisfactory symmetry and few complications.

Temporal changes in breast cancer screening coverage provided under the Brazilian National Health Service between 2008 and 2017.

BACKGROUND: In Brazil, 70% of the population depends on the public healthcare system. Since early detection is considered crucial, this study aimed to evaluate temporal changes in breast cancer screening coverage provided under the Brazilian National Health Service (SUS) according to the different regions of the country between 2008 and 2017. METHODS: This ecological study analyzed data on breast cancer screening within the SUS for women aged 50-69 years. Coverage was calculated from the ratio between the number of screening tests conducted and the expected number for the target population. Joinpoint regression analysis was used to calculate annual percent changes (APC) in coverage. RESULTS: Around 19 million mammograms were performed in 50-69-year old women within the SUS between 2008 and 2016. The estimated APC indicates that breast cancer screening coverage increased by 14.5% annually in Brazil between 2008 and 2012 (p < 0.01), with figures stabilizing between 2012 and 2017 as shown by an APC of - 0.4% (p = 0.3). In the five geographic regions of the country, the APC initially increased, then stabilized in the north, northeast and southeast and decreased in the south and Midwest. Of the 26 states, coverage increased in seven and remained stable in six. In the other 13, there was an initial increase followed by stabilization in 11, and a reduction in coverage in two. In the Federal District, coverage remained stable throughout the study period. CONCLUSION: Evaluation of the temporal changes in breast cancer screening coverage provided under the Brazilian National Health Service revealed an initial increase, confirming that public policies were effective, although insufficient to ensure organized screening. There appears to be a lack of uniformity between the different regions and states and this situation is highlighted in the final 5-year period, with the APC reflecting stabilization of breast cancer screening coverage.

Mean glandular dose in digital mamography in women with breast implants.

PURPOSE: Mean Glandular Dose (MGD) is the quantity related to the risk of radiation-induced breast cancer. This study aimed to evaluate the MGD in screening mammography for women with breast implants. METHODS: This retrospective study used data of 2680 mammographies of 335 asymptomatic women with mammary implants examined in a digital direct x-ray unit. Each woman had a total of eight images: four in standard views and four with posterior displacement of the implant (ID). Data on kV, mAs, target/filter combination, compressed breast thickness and MGD were obtained from the DICOM header of the stored images. Quantitative variables were presented through descriptive statistics for median (5th-95th percentiles); and the qualitative variables were presented by numbers and percentages. Mean glandular doses of standard views and ID views were compared and statistical analysis was used to assess the influence of implant position, breast glandularity and thickness on mean glandular doses. RESULTS: Median MGD for standard views were 3.30 (2.60-4.00) mGy for CC and 3.31 (2.70-4.20) mGy for MLO. For ID views, median were 1.20 (0.90-2.20) mGy and 1.40 (0.97-3.74) mGy for CC and MLO views, respectively. Median MGD for the whole examination of women with breast implants was 9.60 (7.92-12.07) mGy, ranging from 6.25 to 21.50 mGy. When comparing MGD median for standard and ID views it was found a statistically significant difference (p < 0.05), with higher doses for the standard views due to the greater compressed breast thickness in these views. It was observed that, in the standard views, MGD decreases with increasing breast thickness due to the manual radiographic techniques used to expose the women. It was also observed that implant position does not affect MGD in breast augmentation mammography. CONCLUSION: Mammography of women with mammary implants gives higher radiation doses when compared with those without implants. For more accurate dose assessment in augmented breast mammography, it is necessary that specific conversion factors for the calculation of MGD based on air kerma at entrance of breasts with implants are made available.

Trends in breast cancer surgery at Brazil's public health system.

BACKGROUND AND OBJECTIVES: To analyze time trend patterns in Breast Cancer (BC) surgeries performed at Brazil's Public Health System, known as SUS from 2008 to 2014. METHODS: Ecological study of time series, based on the database system from SUS. Information on surgical procedures performed for BC treatment was collected. Analysis of the absolute number of surgeries was performed using Poisson Regression through Jointpoint Regression, and the trends were calculated through the annual percentage change (APC), with a confidence interval (CI) of 95%, and statistical significance when P < 0.05. RESULTS: Data analysis from 193.596 breast surgeries revealed a reduced number of simple mastectomies (APC -4.4%; CI -7.4 to -1.4; P < 0.05); stable trends in radical mastectomy with lymphadenectomy (APC -1.0%; CI -2.4 to 0.5; P = 0.1) and breast conserving surgery (APC 0.4%; CI -1.6 to 2.4; P = 0.6). Also, we observed a reduced number of axillary lymphadenectomy dissection (APC -16.8%; CI -26.8 to -5.4; P < 0.05); increased trends in breast reconstruction with implants after 2011 (APC 9.1%; CI 0.1-18.8; P < 0.05) and with flaps after 2012 (APC 61.3%; CI 41.3-84.0; P < 0.05). The overall rate of patients with breast reconstruction increased from 15% in 2008 to 29.2% in 2014. CONCLUSIONS: We found a significant increase in breast reconstruction in public health system in Brazil, and also a reduction in simple mastectomy and axillary lymphadenectomy.

Sociodemographic and clinical factors affecting body image, sexual function and sexual satisfaction in women with breast cancer.

AIMS AND OBJECTIVES: To evaluate the effect of sociodemographic and clinical factors on body image, sexual function and sexual satisfaction in women following breast cancer treatment. BACKGROUND: Women with breast cancer may experience a wide range of symptoms associated with body image and sexuality that can severely affect their quality of life. Therefore, the health care professional's ability to understand the patient's complaints and her sexual history is highly relevant in specialised multidisciplinary care. DESIGN: A cross-sectional survey. METHODS: Seventy-seven participants were included. Body image, sexual function and sexual satisfaction were evaluated using the EORTC QLQ-BR23 questionnaire. Results were shown as means, standard deviations, frequencies and percentages. Cronbach's alpha was calculated. Spearman's correlation test, the chi-square test and multivariate logistic regression were used in the statistical analysis, conducted using the spss statistical software package, version 17.0. RESULTS: Low scores were found in the desire (34·63), frequency (32·03) and sexual satisfaction (45·91) domains, while body image scores were higher (63·57). No strong correlation was found between body image and any of the other domains. Patients without a steady partner experienced more sexual desire (p < 0·04) and more frequent sexual activity (p < 0·01). Sexual activity was also more frequent (p < 0·03) in women with a higher education level and in those using aromatase inhibitors. CONCLUSIONS: Sexual function and satisfaction were affected to a greater extent than body image. No association was found between body image and sexual performance. The effect of marital status and education level on sexual function merits particular attention. RELEVANCE TO CLINICAL PRACTICE: A well-trained multidisciplinary team should be available to evaluate women's need for support and to provide information on the disease, its treatment and its impact on their lives and on their sexuality.

Effect of Ki-67 on Immunohistochemical Classification of Luminal A to Luminal B Subtypes of Breast Carcinoma.

It has recently been proposed to include an immunohistochemical marker of cell proliferation, Ki-67, as an element with which to classify the molecular subtypes of breast cancer. The objective of this study was to evaluate the effect of the introduction of the Ki-67 marker on the molecular classification of breast cancer by immunohistochemistry. This study was performed on 234 cases of invasive ductal carcinoma of the breast submitted to two immunohistochemical classification panels, one including Ki-67 and the other not. The data obtained with the two classifications were correlated with well-established prognostic factors such as histologic grade, the number of lymph nodes affected and tumor size. The molecular classification without Ki-67 identified: 136 cases of luminal A (58.1%), 19 cases of luminal B (8.1%), 27 cases of human epidermal growth-factor receptor 2 overexpressing (11.5%), 27 cases of basal-like (11.5%), and 25 cases of nonbasal-like triple-negative tumors (10.7%). When Ki-67 was included, this situation changed significantly, with the following cases being identified: 72 cases of luminal A (30.8%) and 83 cases of luminal B tumors (35.5%), resulting in a Kappa score of 0.216. Evaluation of correlations between the luminal A and luminal B tumor subtypes and the selected prognostic factors showed a statistically significant difference only when Ki-67 was included and only with respect to histologic grade (p < 0.001). The new classification with Ki-67 significantly altered the prevalence of the luminal A and luminal B subtypes and improved correlation with the histologic grade.

Temporal trends in female breast cancer mortality in Brazil and correlations with social inequalities: ecological time-series study.

BACKGROUND: Breast cancer is the most common cause of death from cancer in women in less developed regions. Therefore, the objective of this study was to provide data on the temporal trends in female breast cancer mortality between 1990 and 2011 and to evaluate its association with the social inequalities present in Brazil. METHODS: Breast cancer mortality data and estimates for the resident population were obtained from the Brazilian National Health Service database for the 1990-2011 period. Age-standardized mortality rates were calculated (20-39, 40-49, 50-69 and ≥70 years) by direct standardization using the 1960 standard world population. Trends were modeled using joinpoint regression model and linear regression. The Social Exclusion Index and the Human Development Index were used to classify the 27 Brazilian states. Pearson's correlation was used to describe the association between the Social Exclusion Index and the Human DeveIopment and the variations in mortality rates in each state. RESULTS: Age-standardized mortality rates in Brazil were found to be stable (annual percent change [APC] = 0.3; 95% CI: -0.1 - 0.7) between 1994 and 2011. Considering the Brazilian states, significant decreases in mortality rates were found in Rio Grande do Sul, Rio de Janeiro and São Paulo. Increases in mortality rates were most notable in the states of Maranhão (APC = 11.2; 95 %CI: 5.8 - 16.9), Piauí (APC = 9.8; 95% CI: 7.6 - 12.1) and Paraíba (APC = 9.3; 95% CI: 6.0 - 12.8). There was a statistically significant correlation between Social Exclusion Index and a change in female breast cancer mortality rates in the Brazilian states between 1990 and 2011 and between Human Development Index and mortality between 2001 and 2011. CONCLUSIONS: Female breast cancer mortality rates are stable in Brazil. Reductions in these rates were found in the more developed states, possibly reflecting better healthcare.

Oncoplastic mammaplasty with geometric compensation--a technique for breast conservation.

OBJECTIVE: To describe a technique of oncoplastic mammaplasty, referred to as geometric compensation, which is suitable for tumors close to the skin in areas not included in the classic preoperative drawings for mammaplasty. MATERIALS AND METHODS: Seventeen patients with malignant tumors were included. Preoperative markings followed the "Wise-pattern" technique. The resection of affected skin was geometrically compensated with another area of preserved skin. RESULTS: The mean age of the patients was 52.88 ± 12.14 years. Mean pathological tumor size was 43.82 ± 31.39 mm. There were 7 (41.18%) locally advanced tumors. Six patients (35.29%) were submitted to neoadjuvant and the remainder to adjuvant chemotherapy. Radiotherapy was indicated in all cases. Fifteen patients (88.24%) received hormone therapy. Ptosis was corrected in all cases. The aesthetic result was rated excellent in seven cases (41.18%), good in 7 (41.18%), and fair in three cases (17.65%). Surgical margins were free. A seroma developed in one case (5.88%), small fat necrosis in three (17.65%), and enlarged scar in one (5.88%). There were no recurrences within 28.24 ± 18.02 months. CONCLUSIONS: The technique allowed breast conservation in situations requiring large resection of affected skin, with free surgical margins, correction of ptosis, satisfactory symmetry, and few complications.

Incidence and risk factors for winged scapula after surgical treatment for breast cancer.

AIMS AND OBJECTIVES: To evaluate the incidence of winged scapula following surgical breast cancer treatment, determine its evolution over time and correlate factors that might influence this incidence. BACKGROUND: Winged scapula is a complication that may occur as a result of exposing the long thoracic nerve during axillary lymphadenectomy for the treatment for breast cancer. There is no consensus in the literature about the incidence of this complication after surgical treatment for breast cancer, and complication rates range from 1·5-74%. DESIGN: This is a prospective cohort study. METHODS: A prospective cohort study was conducted including 57 patients with breast cancer who underwent surgical treatment. Each patient was assessed before and after the surgery, by means of Hoppenfeld manoeuvre. The incidence rate of winged scapula was calculated at four different times. RESULTS: At the preoperative assessment, none of the patients presented with winged scapula, while 16 patients (28·1%) were shown to have this complication after the procedure. The incidence of winged scapula decreased over time. Factors associated with winged scapula were as follows: patients younger than 50 years, clinical stage I and II and no neoadjuvant chemotherapy. Other factors that were evaluated, such as type of surgery, number of lymph nodes compromised and removed, as well as body mass index, were not associated with the risk of winged scapula. CONCLUSIONS: This study demonstrated that the incidence of winged scapula is low and decreased over time. Furthermore, a greater incidence of winged scapula was noted in young women at an initial stage of the disease who had not been treated with neoadjuvant chemotherapy. RELEVANCE TO CLINICAL PRACTICE: The result of this work may have great impact, for demonstrating what risk factors are significantly associated with winged scapula after surgical treatment for breast cancer.

Is my patient an appropriate candidate for sentinel node biopsy? Less axillary surgery, for the right patients. Critical review and grades of recommendation.

INTRODUCTION: While general conclusions of historical trials are widely recognized, the nuances regarding precise indications of Sentinel Node Biopsy (SNB) in breast cancer in complex clinical scenarios often remain a source of debate and require further elucidation. METHODS: Two reviewers (JFB and GNM) independently searched electronic databases for studies including SNB as the main intervention. Filters were applied to retrieve only clinical trials (randomized or experimental non-randomized); non-oncological outcomes were excluded. The selected studies were considered to construct a narrative review focused on inclusion criteria and survival outcomes, followed by recommendations. RESULTS: Fourteen (n = 14) trials were selected, including eleven (n = 11) randomized trials for upfront surgery, and three (n = 3) single-group clinical trials for surgery following neoadjuvant therapy. All trials for upfront surgery provided long-term survival data for SNB, that was equivalent or non-inferior to axillary dissection, in tumors without palpable adenopathy (caution for larger T3 and T4 tumors) - Grade of recommendation: A. In tumors up to 5 cm, complete axillary dissection is not necessary if up to two sentinel nodes are positive for macrometastasis, and radiation therapy is planned - Grade of recommendation: A. If there are more than two sentinel nodes positive for macrometastasis, or a positive node other than the sentinel one, complete axillary dissection is recommended - Grade of recommendation: A. Following neoadjuvant chemotherapy, considering 10% as an acceptable false negative rate, SNB might be offered for cN0 patients who have remained negative, and for cN1 (caution for cN2) patients become clinically negative; complete axillary dissection might not be necessary if at least two sentinel lymph nodes are retrieved, and there is no residual disease - Grade of recommendation: B. CONCLUSION: SNB can be performed in most cases of clinically negative nodes. After neoadjuvant chemotherapy, SNB is feasible and may have acceptable performance for cN0 and cN1 tumors, although prospective survival data is still awaited.