Are there clinical and subclinical/pathological forms of Paget's disease of the breast?

Introduction: Breast disease management has changed over recent decades, related to molecular subtype, oncoplastic surgery and targeted therapies. Nevertheless, literature on Paget's disease of the breast (PDB), initially described as a clinical entity and now considered a multifocal/multicentric disease. Methods: PDB was classified as clinical in the presence of areolar abnormalities and as subclinical/pathological in all other cases. Clinical and prognostic data were evaluated and compared between the different presentation forms. Statistics comprised descriptive analysis, inter-group comparison (chi-square and Mann-Whitney tests) and overall and cancer-specific survival rates (Kaplan-Meier method and the log-rank test). Results: Of 85 patients included in this series, PDB was clinical in 58.8%. Overall, 27.1% had stage 0 and 92.9% had multifocal/multicentric disease. Most patients (83.5%) had the HER2 or luminal HER2 molecular subtype. Patients with clinical PDB had a higher rate of in situ disease (p=0.028) and were more likely to undergo breast-conserving surgery (p<0.001). Most of the 43 patients with HER2 invasive disease received anti-HER therapy. Mean follow-up time was 71.2 ± 43.3 months. Cancer-specific actuarial survival at 60 and 120 months was 92.3% and 83.1%, respectively. Survival was unaffected by the clinical form of PDB (p=0.275), anti-HER therapy (p=0.509) or oncoplastic surgery (p=0.821). Conversely, clinical stage affected survival significantly (p ≤ 0.001). Conclusion: PDB is a rare condition associated with multifocality/multicentricity and HER2 overexpression. Cases of clinical disease and those of subclinical/pathological disease differ significantly. Further studies are required to evaluate the clinical/areolar disease and the impact of advances in breast disease management on PDB.

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.

Breast reconstruction for locally advanced breast cancer previously submitted to mastectomy and an ipsilateral thoracoabdominal dermofat (ITADE) flap.

Thoracoabdominal (TA) flaps are a good option for primary closure of small and medium defects after mastectomy for locally advanced breast tumours. Although they have a higher rate of necrosis than myocutaneous flaps, they can be easily performed by breast surgeons. Few studies on this procedure have been reported, and we have been unable to identify any prior publications reporting breast reconstruction with TA flaps.

Oncoplastic surgery for Paget's disease of the breast.

Introduction: Paget's disease of the breast (PDB) is a rare nipple entity associated with multifocality. Due to its location, resection of the entire nipple-areolar complex is necessary. Historically central quadrantectomy and mastectomy have the surgical treatments of choice. The feasibility of oncoplastic breast surgery (OBS) for PDB is unknown. Methods: This was a retrospective study performed in a Brazilian oncological hospital. We evaluated the factors related to the performance of OBS in PDB. In addition, the impact of OBS on local recurrence and survival was analysed. Comparisons were made between groups using the chi-square test, Mann-Whitney U test, and Kaplan-Meier method. To assess the impact factor of the variables on the performance of OBS, logistic regression was performed. Results: Eighty-five patients were evaluated. OBS was performed in 69.4% (n=59), and of these, 16 (27.2%) were symmetrized with contralateral surgery. Mastectomy without reconstruction was performed in 28.3% of the patients. The primary procedure performed was mastectomy with reconstruction (n=38; 44.7%), and the preferential technique for immediate reconstruction was skin-sparing mastectomy with prosthesis; for late reconstruction, the preferred technique was using the latissimus dorsi. Breast conserving-surgery was performed in 27.0% (n=23), primarily using the plug-flap technique (OBS). Age was associated with the use of OBS; as patients aged 40-49 exhibited a higher rate of OBS (p = 0.002; odds ratio 3.22). OBS did not influence local recurrence (p=1.000), overall survival (p=0.185), or cancer-specific survival (p=0.418). Conclusion: OBS improves options related to surgical treatment in PDB without affecting local recurrence or survival rates.

Genetic Ancestry of 1127 Brazilian Breast Cancer Patients and Its Correlation With Molecular Subtype and Geographic Region.

PURPOSE: Breast cancer molecular subtypes show significant differences in different ethnic groups in the United States, but no study has evaluated genetic ancestry in breast cancer in Brazilian women. METHODS: Breast cancer patients from distinct parts of Brazil were evaluated. Molecular subtypes were determined by immunohistochemistry. Genetic ancestry was evaluated using a panel of 46 AIMs (ancestry informative markers), which classified genetic ancestry as European, African, Asian, and Amerindian. PCR products were subjected to capillary electrophoresis and analyzed using GeneMapper 4.0 software. Ancestry was evaluated with Structure v.2.3.3 software. Ancestry was tested for correlations with geographic region and molecular subtype. The chi-square test and ANOVA with Bonferroni adjustment were applied. RESULTS: Genetic ancestry and clinical data were evaluated in 1127 patients. Higher rates of self-reported white ethnicity, European ancestry, and HER-2- luminal tumors were identified in the South region, which may influence age at diagnosis and result in a higher rate of early tumors. Conversely, higher rates of African ancestry in the North and Northeast regions, self-reported nonwhite ethnicity, HER-2+ tumors, and triple-negative tumors were noted. Triple-negative and HER-2+ tumors were associated with higher advanced and metastatic disease rates at diagnosis, with triple-negative tumors being more frequent in young women. CONCLUSION: Differences in genetic ancestry, self-reported ethnicity, and molecular subtype were found between Brazilian demographic regions. Knowledge of these features may contribute to a better understanding of age at diagnosis and the molecular distribution of breast cancer in Brazil.

Extreme oncoplasty: past, present and future.

Breast surgery has evolved from mastectomy to breast-conserving surgery (BCS). Breast oncoplastic surgery later emerged with the inclusion and development of techniques used in plastic surgery for breast neoplasms. Recently, a new paradigm has been considered for mastectomy candidates with large multifocal and multicentric tumours, designated extreme oncoplasty (EO), which has allowed new techniques to be applied to tumours that would have been ineligible for BCS before. There are few publications and no uniform descriptions grouping all the technical possibilities and new indications together. We performed this a review with the objective of evaluating the indications and surgeries performed in the EO context, representing a new perspective for BCS. We observed new indications as extensive microcalcifications, locally advanced breast carcinoma with partial response to chemotherapy, small to moderate-sized non-ptotic central tumours and extreme ptosis. Small breasts are able for EO since the presence of ptosis. New surgeries are reported as disguised geometric compensation, perforators flaps, local/regional flaps, latissimus dorsi miniflap and partial breast amputation. It is important to decrease barriers to oncoplastic surgery if we want to increase the use of EO and BCS rates.

HPV-positive cervical squamous cell carcinoma metastasis to the breast, mimicking primary tumor.

INTRODUCTION: Metastatic disease to the breast is a rare condition, with contralateral breast metastasis being the most common primary site. CASE PRESENTATION: We present the case of a patient who underwent treatment for an HPV positive squamous cell carcinoma (SCC) of the cervix who, during follow-up, complained of a nodule in her left breast. Anatomopathological results indicating squamous carcinoma, which was not able to be differentiated from breast metaplastic carcinoma. Resection of the lesion was carried out, confirming carcinoma with squamous cell differentiation with negativity for GCDFP-15, mammaglobin, p63 and SOX10, but with positivity for p16 and for high risk HPV, confirming a single metastatic lesion of cervical carcinoma. DISCUSSION/CONCLUSION: In the presence of SCC in the breast, the differential diagnosis may consider the presence of primary lesion, metaplastic carcinoma with squamous cell differentiation or metastatic disease. The use of markers such as p63, SOX10 and p16, may help for a definitive diagnosis.

Use of Double Myocutaneous Flap after Extended Resection of Locally Advanced Ulcerated Breast Carcinoma.

Locally advanced ulcerated breast neoplasm is a condition that frequently occurs in developing countries. Generally, it is centrally localized and submitted to neoadjuvant therapy; thereafter, upon disappearance of the ulceration, it is submitted to radical mastectomy. Presence of axillary infiltration and ulceration with incomplete response makes it necessary for the use of surgical flaps for skin closure. We report a case in which primary reconstructive surgical procedure and skin closure was necessary, where we used double myocutaneous flaps-the latissimus dorsi and VRAM (vertical rectus abdominis myocutaneous) flap. We discussed treatment of the ulcerated lesions, possible surgical solutions, and the conditions associated with the use of double flaps. For primary closure of extensive areas, double myocutaneous flaps can be used as a solution in cases where skin grafts or surgical microsurgical flaps are not able to serve as a surgical solution. Myocutaneous flaps are associated with lower rates of complication, allowing for rapid recovery without increasing the time necessary before the next adjuvant therapy.

Does breast oncoplastic surgery improve quality of life?

Breast Oncoplastic Surgery (OS) has established itself as a safe procedure associated with the treatment of breast cancer, but the term is broad, encompassing procedures associated with breast-conserving surgeries (BCS), conservative mastectomies and fat grafting. Surgeons believe that OS is associated with an increase in quality of life (QOL), but the diversity of QOL questionnaires and therapeutic modalities makes it difficult to assess from the patient's perspective. To answer this question, we performed a search for systematic reviews on QOL associated with different COM procedures, and in their absence, we selected case-control studies, discussing the main results. We observed that: (1) Patients undergoing BCS or breast reconstruction have improved QoL compared to those undergoing mastectomy; (2) In patients undergoing BCS, OS has not yet shown an improvement in QOL, a fact possibly influenced by patient selection bias; (3) In patients undergoing mastectomy with reconstruction, the QoL results are superior when the reconstruction is performed with autologous flaps and when the areola is preserved; (4) Prepectoral implants improves QOL in relation to subpectoral implant-based breast reconstruction; (5) ADM do not improves QOL; (6) In patients undergoing prophylactic mastectomy, satisfaction is high with the indication, but the patient must be informed about the potential complications associated with the procedure; (7) Satisfaction is high after performing fat grafting. It is observed that, in general, OS increases QOL, and when evaluating the procedures, any preservation or repair, or the use of autologous tissues, increases QOL, justifying OS.

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.

Sentinel Lymph Node Biopsy in T3 and T4b Breast Cancer Patients: Analysis in a Tertiary Cancer Hospital and Systematic Literature Review.

INTRODUCTION: Breast cancer represents the most common type of cancer among women in the world. The presence and extent of axillary lymph node involvement represent an important prognostic factor. Sentinel lymph node biopsy (SLNB) is currently accepted for T1 and T2 with negative axillae (N0); however, many patients with T3-T4b tumors with N0 are often submitted to unnecessarily axillary lymph node dissection. MATERIALS AND METHODS: This is a retrospective, observational study of patients treated for breast cancer between 2008 and 2015, with T3/T4b tumors and N0, who underwent SLNB. A systematic review of the literature was also carried out in 5 bases. RESULTS: We analyzed 73 patients, and SLNB was negative for macrometastasis in 60.3% of the cases. With a mean follow-up of 45 months, no ipsilateral axillary local recurrence was observed. In the systematic review, only 7 articles presented data for analysis. Grouping these studies with the present series, the rate of N0 was 32.1% for T3 and 61.0% for T4b; grouping all studies (T3 and T4b n = 431) the rate was 32.5%. CONCLUSIONS: SLNB in T3/T4b tumors is a feasible and safe procedure from the oncological point of view, as it has not been associated with ipsilateral axillary relapse.

Modified External Oblique Myocutaneous Flap for Repair of Postmastectomy Defects in Locally Advanced Breast Tumors: A Cohort Series Associated with a Systematic Review of Literature.

BACKGROUND: Locally advanced breast tumors (LABT) are situations of difficult resolution in clinical practice. External oblique myocutaneous flap (EOMF) is an option, but there are few studies in the literature on its use. METHODS: This was a retrospective, cohort institutional study of patients with LABT who were undergoing mastectomy combined with the use of modified-EOMF (M-EOMF). Preoperative indications and conditions, factors associated with surgery, time to radiotherapy, local recurrence, and survival were assessed. A systematic review of the literature also was performed to evaluate the use of EOMF. RESULTS: Over the 10-year period, 17 patients underwent M-EOMF closure. The mean duration of surgery was 251 min, and extensive skin area was resected (mean 468 ± 260 cm2). Four patients developed local recurrence. The actuarial survival at 36 months was 48.3%. Using PRISMA statement, among 115 articles evaluated from 3 databases, 8 articles were selected, in which 146 patients underwent EOMF. EOMF are associated with low postoperative complications with 8.9% skin necrosis. The M-EOMF allowed the resection of larger areas than other flaps described in the literature but is associated with skin necrosis. CONCLUSIONS: M-EOMF has the advantages of not requiring a change in the patient's position for the closure of large areas. It is thus an acceptable option for chest wall reconstruction in tumors at the limit of resectability.

IS THERE A SAFE TUMOR SIZE FOR IDENTIFICATION OF BREAST CARCINOMA WITHOUT AXILLARY NODE METASTASIS? / Há um tamanho seguro para a identificação do carcinoma mamário sem metástase linfonodal?

Objective: To evaluate the rate of absence of axillary pathological involvement in patients with clinically negative axilla, submitted to axillary lymphadenectomy (AL). Method: Retrospective longitudinal study, which clinically evaluated patients without axillary metastasis (cN0), who underwent oncologic treatment from 1998 to 2001. Patients were selected at clinical stage I to III. The axillary pathological impairment ratio was correlated with tumor size and clinical stage T and TNM. We also evaluated the locoregional and axillary (local) recurrences. Results: 519 clinically cN0 patients were selected. All were submitted to AL, with a mean of 18 lymph nodes dissected and 3.2 compromised. The axillary metastatic rate was 47.2%. Tumor size and clinical stage were associated with the presence of axillary lymph node metastasis (p<0.001). The axillary involvement was of 78.6% for tumors between 6.1 to 8 cm, and of 100% for tumors larger than 8.1 cm. Forty patients were T4- TNM, where the impairment rate was 57.5%. The specific survival at 120 months was 71.1%, with locoregional recurrence rate of 6.9% (n=36) and local rate of 0.4% (n=2). Conclusion: In patients submitted to axillary lymphadenectomy, the axillary recurrence was extremely low. There are patients with tumors greater than 5 cm, smaller than 8 cm, and selected T4-TNM without metastasis in axilla. Further studies are necessary to evaluate sentinel lymph node dissection in this selected group, but it is unacceptable for tumors larger than 8.1 cm

Objetivo: Avaliar a taxa de ausência de comprometimento anatomopatológico axilar em pacientes com axila clinicamente negativa, submetidas à linfadenectomia axilar (LA). Método: Estudo retrospectivo longitudinal que avaliou pacientes clinicamente com ausência de metástase axilar (N0), submetidas a tratamento oncológico no período de 1998 a 2001. Selecionaram-se pacientes no estádio clínico de I a III. Avaliou-se a relação entre a taxa de comprometimento anatomopatológico axilar, o tamanho do tumor e o estádio clínico T e TNM. Avaliou-se também o risco de recidiva locorregional (RLR) e de recidiva local axilar (RLA). Resultados: 519 pacientes clinicamente N0 foram selecionadas. Todas foram submetidas à LA, com o número médio de 18 linfonodos dissecados e 3,2 comprometidos. A taxa de doença metastática axilar foi de 47,2%. O tamanho do tumor e o estádio clínico estiveram associados à presença de metástase linfonodal axilar (p<0.001). Tumores de 6,1 a 8 cm apresentaram 78,6% de comprometimento, e em tumores maiores que 8,1 cm essa taxa foi de 100%. Quarenta pacientes eram T4-TNM, nos quais a taxa de comprometimento foi de 57,5%. A sobrevida específica aos 120 meses foi de 71,1%, a taxa de RLR foi de 6,9% (n=36) e a RLA de 0,4% (n=2). Conclusão: Em pacientes submetidas à linfadenectomia axilar, a taxa de recorrência axilar foi extremamente baixa. Há pacientes com tumores maiores que 5 cm e menores que 8 cm, T4-TNM, em que a axila se mostrou sem doença metastática axilar. Fazem-se necessários mais estudos prospectivos para avaliar a dissecção do linfonodo sentinela em casos selecionados de tumores T3 e T4 clínico, sendo a dissecção inaceitável para tumores com tamanho superior a 8,1 cm.

Unsuspected Stewart-Treves syndrome clinically mimicked by apparent bullous erysipelas and a systematic review of dermatological presentations of the classical Stewart-Treves syndrome.

BACKGROUND: Stewart Treves-Syndrome (STS) was first characterized as angiosarcoma in the homolateral limb of a patient with breast cancer and lymphedema. Now, other conditions represent STS. It's a rare condition. The diagnosis is easier in the presence of single or multiple purple nodules. Even though other dermatological aspects have been reported, no study has grouped its characteristics. AIM: Evaluate the dermatological characteristics of classical STS (c-STS). METHODS AND RESULTS: We report a patient with chronic lymphedema with a history of recurrent erysipelas that rapidly developed multiple papules in the superior limb. It was initially diagnosed as bullous erysipelas, but unsatisfactory evolution led to biopsy, which demonstrated an unsuspected epithelioid angiosarcoma. We have also performed a review of dermatologic aspects of c-STS using PubMed and Lilacs databases. PICTOS methodology and PRISMA flow chart were considered. The main dermatological aspects associated with c-CTS were summarized. Using a systematic evaluation from 109 articles, 29 were selected and 44 patients were described to whom we added one case. The mean time with lymphedema was 10 years. Of the patients analyzed, 97.2% were female; 95.6% were submitted to radical mastectomy; 81.2% presented with multiple lesions, 67.4% of the lesions were reported as nodules or tumors, 53.4% were purple, 33.4% were associated with an ecchymotic halo, and 33.4% were ulcerated lesions. CONCLUSION: When evaluating patients with chronic lymphedema with new dermatological abnormalities, clinical suspicion, or unfavorable evolution, the knowledge of clinical signs is important for diagnosis, and a biopsy must be considered. Papules associated with erythematous-wine color and bluish hematoma aspect must raise clinical suspicion.

ITADE flap after mastectomy for locally advanced breast cancer: A good choice for mid-sized defects of the chest wall, based on a systematic review of thoracoabdominal flaps.

BACKGROUND: Locally advanced breast cancer (LABC) is still a common problem in developing countries. Extensive resections are aimed at local control and improving quality of life. Dermofat flaps are an option for medium-sized defects. OBJECTIVES: Evaluate the results of a new thoracoabdominal flap (TAF). METHODS: We describe and evaluate an ipsilateral, thoracoabdominal horizontal, dermofat (ITADE) flap performed in patients submitted to mastectomy and immediate reconstruction. A systematic review of the flaps used in this situation was performed. RESULTS: A total of 23 patients underwent the ITADE flap. The average flap size was 360 cm2 . One (4.3%) patient presented extensive loss of the flap. In the literature review, we observed 354 patients with 159 TAFs. We added our cases to the evaluation. A significant reduction in the risk of necrosis using myocutaneous flaps versus TAFs was observed (P < 0.001). Comparing other TAFs and ITADE flaps, considering all necrosis, a significant difference was apparent (P = 0.02), which disappeared when evaluating only larger necrosis (P = 0.13). Multivariate analysis showed that the resected area was the best variable related to the presence of necrosis. CONCLUSIONS: ITADE allows extensive coverage areas, an early start of adjuvant treatment and it can be performed without requiring a reconstructive team.