Oncologic safety of immediate autologous fat grafting for reconstruction in breast-conserving surgery.

IMPORTANCE: Autologous fat grafting (AFG), or lipofilling, has been used for immediate reconstruction at the time of breast-conserving surgery in order to achieve a satisfactory cosmetic outcome in patients with breast cancer and an unfavorable tumor-to-breast volume ratio or unfavorable tumor location. However, the oncologic safety of this technique is still unclear. OBJECTIVE: To determine whether AFG performed simultaneously with breast-conserving surgery is associated with differences in local relapse rates and disease-free survival. DESIGN: Matched retrospective cohort study. SETTING: Tertiary referral center. PARTICIPANTS: Patients undergoing breast-conserving surgery with or without AFG between 2004 and 2016 were retrospectively enrolled and matched for age, staging, grade, tumor histology, and tumor immunohistochemical profile. MAIN OUTCOME(S) AND MEASURE(S): The cumulative incidence of locoregional recurrence (LRR) and disease-free survival were the primary end points, while distant recurrence and overall survival were the secondary end points. RESULTS: A total of 320 patients were followed. Cases were matched with controls at a 1:4 ratio. There was no difference in LRR or distant recurrence of breast cancer between the two groups. The annual LRR rate was 0.86% in patients who received immediate AFG vs. 0.7% in patients undergoing breast-conserving surgery alone (p ≥ 0.05). Number of lymph nodes was the sole independent risk factor for local recurrence (p = 0.045). No significant differences in disease-free survival rates were found between the groups. CONCLUSIONS AND RELEVANCE: At a mean follow-up of 5 years, no significant differences in locoregional recurrence rates were found between patients who received immediate AFG and those who underwent breast-conserving surgery alone. These findings corroborate previous research demonstrating the oncological safety of immediate AFG reconstruction, further suggesting that this technique as a safe, effective way to achieve optimal cosmetic outcomes in primary breast cancer surgery without jeopardizing oncologic outcomes.

The Effects of Melatonin on the Descending Pain Inhibitory System and Neural Plasticity Markers in Breast Cancer Patients Receiving Chemotherapy: Randomized, Double-Blinded, Placebo-Controlled Trial.

Background: Adjuvant chemotherapy for breast cancer (ACBC) has been associated with fatigue, pain, depressive symptoms, and disturbed sleep. And, previous studies in non-cancer patients showed that melatonin could improve the descending pain modulatory system (DPMS). We tested the hypothesis that melatonin use before and during the first cycle of ACBC is better than placebo at improving the DPMS function assessed by changes in the 0-10 Numerical Pain Scale (NPS) during the conditioned pain modulating task (CPM-task) (primary outcome). The effects of melatonin were evaluated in the following secondary endpoints: heat pain threshold (HPT), heat pain tolerance (HPTo), and neuroplasticity state assessed by serum brain-derived neurotrophic factor (BDNF), tropomyosin kinase receptor B, and S100B-protein and whether melatonin's effects on pain and neuroplasticity state are due more so to its impact on sleep quality. Methods: Thirty-six women, ages 18 to 75 years old, scheduled for their first cycle of ACBC were randomized to receive 20mg of oral melatonin (n = 18) or placebo (n = 18). The effect of treatment on the outcomes was analyzed by delta (Δ)-values (from pre to treatment end). Results: Multivariate analyses of covariance revealed that melatonin improved the function of the DPMS. The Δ-mean (SD) on the NPS (0-10) during the CPM-task in the placebo group was -1.91 [-1.81 (1.67) vs. -0.1 (1.61)], and in the melatonin group was -3.5 [-0.94 (1.61) vs. -2.29 (1.61)], and the mean difference (md) between treatment groups was 1.59 [(95% CI, 0.50 to 2.68). Melatonin's effect increased the HPTo and HPT while reducing the (Δ)-means of the serum neuroplasticity marker in placebo vs. melatonin. The Δ-BDNF is 1.87 (7.17) vs. -20.44 (17.17), respectively, and the md = 22.31 [(95% CI = 13.40 to 31.22)]; TrKB md = 0.61 [0.46 (0.17) vs. -0.15 (0.18); 95% CI = 0.49 to 0.73)] and S00B-protein md = -8.27[(2.89 (11.18) vs. -11.16 (9.75); 95% CI = -15.38 to -1.16)]. However, melatonin's effect on pain and the neuroplastic state are not due to its effect on sleep quality. Conclusions: These results suggest that oral melatonin, together with the first ACBC counteracts the dysfunction in the inhibitory DPMS and improves pain perception measures. Also, it shows that changes in the neuroplasticity state mediate the impact of melatonin on pain. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03205033.

Breast-Conserving Surgery with Immediate Autologous Fat Grafting Reconstruction: Oncologic Outcomes.

INTRODUCTION: Autologous fat grafting (AFG; lipofilling, lipografting) has been used in delayed breast reconstruction. Recently, it has also been investigated as an alternative for immediate reconstruction in patients submitted to breast-conserving surgery (BCS). Although good aesthetic results have been reported, the oncologic safety of the procedure remains under investigation. This article aims to assess oncologic outcomes of patients submitted to BCS with immediate AFG reconstruction. METHODS: This study consisted of 65 patients undergoing BCS with AFG between January 2010 and January 2017. They were closely followed after surgery for a median period of 40.8 months. Locoregional and systemic recurrences were the primary endpoints of this study. RESULTS: Ten patients developed cancer recurrence (15.4%). The median time for recurrence was 58.9 months. Only two patients presented locoregional recurrence (LRR) (3.07%). Five patients had systemic recurrence (7.69%), and three had both systemic and LRR (4.61%). Median disease-free survival (DFS) was 42.2 months, and overall survival (OV) was 44.3 months. Recurrences were significantly associated with the number of metastatic axillary lymph nodes detected. CONCLUSION: Oncologic outcomes of immediate AFG are similar to the results previously reported in BCS without AFG. Locoregional and systemic recurrences are associated with the presence of axillary metastases. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

TP53 p.Arg337His germline mutation prevalence in Southern Brazil: Further evidence for mutation testing in young breast cancer patients.

Premenopausal breast cancer (BC) is a core tumor of Li-Fraumeni (LFS) and Li-Fraumeni-like (LFL) Syndromes, predisposition disorders caused by germline mutations in TP53 gene. In the Southern and Southeastern regions of Brazil, a specific TP53 germline mutation, c.1010G>A (p.Arg337His), was identified at a population frequency of 0.3%, the highest value ever described for a TP53 germline variation. In Brazilian BC patients, carrier frequency can vary from 0.5% to 8.7%. The current study assessed carrier frequency by genotyping TP53 c.1010G>A in 2 BC groups: 1) 315 patients unselected for age of diagnosis and family history (FH) and 2) 239 patients diagnosed before 46 years and without Chompret criteria for LFS or LFL. One carrier was identified in group 1 (0.3%; CI 95% 0.1-1.76%) and six carriers in group 2 (2.5%; CI 95% 0.93-5.39%). The frequencies differed significantly between groups (p = 0.04). The mutation carrier frequency observed in group 2 could justify mutation testing in BC patients diagnosed before 46 years and without Chompret criteria for LFS or LFL. Further studies in larger samples of BC patients of different ages and regions of the country are necessary to provide more definitive TP53 p.Arg337His carrier frequencies in different scenarios.

Immediate reconstruction with autologous fat grafting: influence in breast cancerregional recurrence.

Objective: to evaluate local and systemic recurrence of breast cancer in patients submitted to autologous fat grafting in the immediate reconstruction after conservative surgery for breast cancer. Methods: this is a historical cohort study comparing 167 patients submitted to conservative surgery without reconstruction (conservative surgery group) with 27 patients submitted to conservative treatment with immediate graft reconstruction, following the Coleman's technique (lipofilling group). All patients had invasive carcinoma and were operated by a single surgeon from 2004 to 2011. The postoperative follow-up time was 36 months. Results: the overall incidence of local recurrence was 2.4%. No patient in the lipofilling group had local recurrence during the study period. For systemic recurrence, the rates obtained were 3.7% (one patient) for the fat grafting group and 1.8% (three patients) for the conservative surgery group without reconstruction. Conclusion: there was no significant difference for local or systemic recurrence in the groups studied. Immediate autologous fat grafting appears to be a safe procedure.

Objtivo: avaliar recorrência local e sistêmica do câncer de mama em pacientes submetidas ao enxerto autólogo de gordura na reconstrução imediata após cirurgia conservadora para o câncer de mama. Métodos: estudo de coorte histórica em que foram comparadas 167 pacientes submetidas à cirurgia conservadora sem reconstrução com 27 pacientes submetidas ao tratamento conservador com reconstrução imediata do enxerto, seguindo técnica de Coleman. Todas as pacientes eram portadoras de carcinoma invasor e foram operadas por um único cirurgião, no período de 2004 a 2011. O tempo de acompanhamento pós-operatório foi 36 meses. Resultados: a incidência global de recidiva local foi 2,4%. Nenhuma paciente do grupo de lipoenxertia apresentou recorrência local durante o período do estudo. Para recorrência sistêmica, as taxas obtidas foram de 3,7% (uma paciente) para o grupo lipoenxertia e 1,8% (três pacientes) para grupo da cirurgia conservadora sem reconstrução. Conclusão: não houve diferença significativa para recorrência local ou sistêmica nos grupos estudados. O enxerto autólogo imediato de gordura parece ser um procedimento seguro.

Immediate reconstruction with autologous fat grafting: influence in breast cancerregional recurrence / Reconstrução imediata com enxerto autólogo de gordura: influência na recorrência local de câncer de mama

ABSTRACT Objective: to evaluate local and systemic recurrence of breast cancer in patients submitted to autologous fat grafting in the immediate reconstruction after conservative surgery for breast cancer. Methods: this is a historical cohort study comparing 167 patients submitted to conservative surgery without reconstruction (conservative surgery group) with 27 patients submitted to conservative treatment with immediate graft reconstruction, following the Coleman's technique (lipofilling group). All patients had invasive carcinoma and were operated by a single surgeon from 2004 to 2011. The postoperative follow-up time was 36 months. Results: the overall incidence of local recurrence was 2.4%. No patient in the lipofilling group had local recurrence during the study period. For systemic recurrence, the rates obtained were 3.7% (one patient) for the fat grafting group and 1.8% (three patients) for the conservative surgery group without reconstruction. Conclusion: there was no significant difference for local or systemic recurrence in the groups studied. Immediate autologous fat grafting appears to be a safe procedure.

RESUMO Objetivo: avaliar recorrência local e sistêmica do câncer de mama em pacientes submetidas ao enxerto autólogo de gordura na reconstrução imediata após cirurgia conservadora para o câncer de mama. Métodos: estudo de coorte histórica em que foram comparadas 167 pacientes submetidas à cirurgia conservadora sem reconstrução com 27 pacientes submetidas ao tratamento conservador com reconstrução imediata do enxerto, seguindo técnica de Coleman. Todas as pacientes eram portadoras de carcinoma invasor e foram operadas por um único cirurgião, no período de 2004 a 2011. O tempo de acompanhamento pós-operatório foi 36 meses. Resultados: a incidência global de recidiva local foi 2,4%. Nenhuma paciente do grupo de lipoenxertia apresentou recorrência local durante o período do estudo. Para recorrência sistêmica, as taxas obtidas foram de 3,7% (uma paciente) para o grupo lipoenxertia e 1,8% (três pacientes) para grupo da cirurgia conservadora sem reconstrução. Conclusão: não houve diferença significativa para recorrência local ou sistêmica nos grupos estudados. O enxerto autólogo imediato de gordura parece ser um procedimento seguro.

CYP3A4*22 is related to increased plasma levels of 4-hydroxytamoxifen and partially compensates for reduced CYP2D6 activation of tamoxifen.

AIM: To evaluate the impact of CYP3A4*22 in the formation of endoxifen (EDF) and hydroxytamoxifen (HTF), under different CYP2D6 genotypic backgrounds. MATERIALS & METHODS: 178 patients were enrolled in the study. CYP2D6 and CYP3A4 genotyping and tamoxifen (TAM) and metabolites quantification were performed. RESULTS: EDF concentrations were lower in poor (2.77 ng ml(-1)) and CYP2D6 intermediate metabolizers (5.84 ng ml(-1)), comparing to functional group (EM-F) (10.67 ng ml(-1), p < 0.001). HTF and TAM levels were respectively 47 and 53% higher in CYP3A4*22 carriers compared with *1/*1 patients in the whole group. Patients with impaired CYP2D6 metabolism and carriers of CYP3A4*22 had EDF levels comparable to CYP2D6 EM-F group (9.06 and 10.67 ng ml(-1), p = 0.247). CONCLUSION: The presence of CYP3A4*22 might compensate the reduction of EDF concentrations related to CYP2D6 inactivity, especially due to increased HTF concentrations.

Immediate Reconstruction with Autologous fat Transfer Following Breast-Conserving Surgery.

This study explores the technical viability of autologous fat grafting for immediate partial breast reconstruction following the primary conservative surgery for breast cancer; restoring volume, shape, and symmetry to the treated breast. We analyze the impact in relation to mammographic follow-up and the subjective degree of satisfaction with esthetic results and although we didn't have any local failure during the observation period; we understand that is too early for any kind of conclusion. From June of 2010 to July of 2011, 20 patients were selected for breast-conserving surgery (BCS) with partial breast reconstruction with autologous fat grafting performed during the same operation by the same medical team. The fat graft was injected in the subcutaneous and intraglandular breast tissue around the resected area. We performed an overcorrection, predicting a resorbing of about 30-50% of the volume grafted. All patients received the literature-based recommendations for breast cancer treatment with complementary radiotherapy. The follow-up period after the completion of radiotherapy ranged from 13 to 29 months. The average volume grafted was 121 cc and it was 2.1 times larger than the resected volume. The esthetic scores were considered very good or good in the majority of cases. Mammograms were taken every 6 months after radiotherapy and only one patient had a mammogram classified as BI-RADS 3, suggesting fat necrosis. The remaining patients were classified as BI-RADS 2. Immediate autologous fat grafting is a promising technique for partial breast reconstruction after BCS. It is associated with high patient and physician satisfaction. It is an alternative for reconstruction of small- and medium-sized breasts. This technique has the advantage that enables the reconstruction of defects in areas difficult to repair, particularly in the upper inner quadrants. It also may reduce the need for major glandular or myocutaneous flaps mobilization.

Ultra-high performance liquid chromatography tandem mass spectrometric method for the determination of tamoxifen, N-desmethyltamoxifen, 4-hydroxytamoxifen and endoxifen in dried blood spots--development, validation and clinical application during breast cancer adjuvant therapy.

A LC-MSMS method for the simultaneous determination of tamoxifen, N-desmethyltamoxifen, 4-hydroxytamoxifen and endoxifen in dried blood spots samples was developed and validated. The method employs an ultrasound-assisted liquid extraction and a reversed phase separation in an Acquity(®) C18 column (150×2.1 mm, 1.7 µm). Mobile phase was a mixture of formic acid 0.1% (v/v) pH 2.7 and acetonitrile (gradient from 60:40 to 50:50, v/v). Total analytical run time was 8 min. Precision assays showed CV % lower than 10.75% and accuracy in the range 94.5 to 110.3%. Mean analytes recoveries from DBS ranged from 40% to 92%. The method was successfully applied to 91 paired clinical DBS and plasma samples. Dried blood spots concentrations were highly correlated to plasma, with rs>0.83 (P<0.01). Median estimated plasma concentrations after hematocrit and partition factor adjustment were: TAM 123.3 ng mL(-1); NDT 267.9 ng mL(-1), EDF 10.0 ng mL(-1) and HTF 1.3 ng mL(-1,) representing in average 98 to 104% of the actually measured concentrations. The DBS method was able to identify 96% of patients with plasma EDF concentrations below the clinical threshold related to better prognosis (5.9 ng mL(-1)). The procedure has adequate analytical performance and can be an efficient tool to optimize adjuvant breast cancer treatment, especially in resource limited settings.

Development, validation and clinical application of a HPLC-FL method for CYP2D6 phenotyping in South Brazilian breast cancer patients.

OBJECTIVE: To develop and validate a method for determination of dextromethorphan (DMT) and dextrorphan (DTP) in plasma samples using HPLC-FL and to apply it to CYP2D6 phenotyping of a population from the South of Brazil. METHODS: Samples were prepared by hydrolysis and liquid-liquid extraction. Analysis was conducted in a reversed phase column, with isocratic elution and fluorescence detection. One hundred and forty patients being treated with tamoxifen were given 30 mg of dextromethorphan and their CYP2D6 phenotypes were determined on the basis of [DMT]/[DTP] metabolic ratios in plasma samples collected after 3h. RESULTS: Total chromatography running time was 12 min. Precision (CV%) was below 9.7% and accuracy was between 92.1 and 106.9%. The lower limits of quantification were 1 ng mL(-1) for DMT and 10 ng mL(-1) for DTP. Mean extraction yield of analytes was 86.6%. Mean age of patients was 55.7 years. Phenotype frequencies were as follows: 7.1% poor metabolizers, 13.6% intermediate metabolizers, 77.1% extensive metabolizers and 2.1 ultra-rapid metabolizers. Metabolic ratios for patients on strong (n=11) and weak (n=16) CYP2D6 activity inhibitors were different from each other and also different from ratios for patients not taking enzyme inhibitors (n=113). CONCLUSIONS: A sensitive method for determination of dextromethorphan and its metabolite in plasma samples was developed and successfully applied, providing evidence of the impact that CYP2D6 inhibitors have on the enzyme's metabolic capacity.

Sexual function and chemotherapy in postmenopausal women with breast cancer.

BACKGROUND: This cross-sectional, nested cohort study assessed Female Sexual Function Index (FSFI) scores in postmenopausal women with breast cancer receiving primary chemotherapy. METHODS: The FSFI questionnaire was administered to 24 postmenopausal women one month after diagnosis of breast cancer (post-diagnosis group) and one month after completion of the first cycle of primary anthracyclin-based chemotherapy (post-chemotherapy group). Scores were compared to those of 24 healthy postmenopausal women seeking routine gynecological care (control group). All patients were sexually active at the time of enrollment. Mean age was 57.29 ± 11.82 years in the breast cancer group and 52.58 ± 7.19 years in the control group. RESULTS: Scores in all domains of the FSFI instrument were significantly lower in the post-diagnosis group than in controls (-41.3%, p < 0.001). A further major reduction in FSFI scores was evident on completion of one cycle of primary chemotherapy (down 46.7% from post-diagnosis scores, p < 0.003), again in all domains. Six patients (25%) ceased all sexual relations, in a significant change from baseline (p < 0.001). After one chemotherapy cycle, a further five patients ceased sexual activity, for a total of 11 (45.8%) participants--a borderline significant difference (p = 0.063). CONCLUSION: The present study shows that female sexual function as assessed by the FSFI declines significantly at two distinct points in time: upon diagnosis of breast cancer and after administration of systemic chemotherapy.

Dosagem plasmática do fator de Von Willebrand e variáveis clínicas como fatores prognósticos no câncer de mama / Plasmatic Von Willebrand factor measurement and clinical variables as prognostic factors of breast cancer

Introdução: O fator Von Willebrand (vW) é uma glicoproteína cujo aumento da concentração sérica está associado ao mecanismo de estimulação do epitélio endotelial facilitando a metástase do câncer de mama.Objetivo: O objetivo deste estudo é avaliar o valor prognóstico do vW no câncer de mama, assim como variáveis clínicas.Métodos: Analisou-se uma coorte de 50 pacientes com câncer de mama (CM) do Serviço de Mastologia do Hospital de Clínicas de Porto Alegre, entre os anos 2002 e 2005, quando se avaliou o vW nestes 50 casos e em 53 controles. Decorridos42 meses da última inclusão, todas pacientes com CM foram chamadas para nova avaliação do vW por imunoturbidimetria. Consideramos valores elevados de vW quando acima de 160%. As pacientes foram analisadas de acordo com faixa etária de até 59 anos ou ≥ 60 anos de idade. O desfecho clínico foi dividido entre bom (sem evidência de doença) e ruim(óbito ou com evidência de doença). Resultados: Obtivemos nova coleta em 41 pacientes que retornaram para revisão. O fator vW isoladamente não apresentou um bom desempenho prognóstico para o seguimento do CM em relação ao desfecho clínico. Presença de linfonodos axilares positivos, índice de massa corporal (IMC) ≥30 kg/m2, menarca ≤11 anos e tamanho tumoral >2 cm foram as variáveis significativas para determinação do prognóstico nesta coorte. Conclusões: Neste estudo o fator de vW não se mostrou útil para determinação de prognóstico no CM, enquanto que o estado axilar e o diâmetro tumoral foram fatores determinantes de sobrevida. Mais estudos são necessários para confirmar se a menarca e o IMC também são fatores prognósticos.

Background: The Von Willebrand factor (vW) is a glycoprotein whose high serum levels are associated with the mechanism of endothelium stimulation promoting metastatic processes. Aim: this study is to assess its prognostic value in breast cancer, as well as other clinic variables. Methods: We evaluated a cohort of 50 patients with breast cancer (BC) who were being treated at the Mastology Department of Hospital de ClМnicas de Porto Alegre from 2002 to 2005. We measured the vW levels of these 50 patients and 53 controls. Forty-two months after the last patient was included in the study, all patients with BC had their vW levels measured by means of immunoturbidimetric assay. vW values above 160% were considered high. The patients were divided into two age groups: 59 years old or younger and 60 years old or older. The clinical outcome was good (no evidence of disease) and poor (death or evidence of disease). Results: Forty-one patients provided new blood samples. Of the nine patients who did not show up for new tests, five died of BC and one died of myocardial infarction with no evidence of BC (excluded from the study). Three patients did not return because they were living in other cities and were free of disease in their last visit. Conclusions: vW factor was not a good predictive factor for BC regarding the outcome suggested; however, the other variables analyzed, such as presence of positive axillary lymph nodes, BMI 930, menarche =11 years old, and tumor size >2 cm, were significant for the prognostic of this cohort. Conclusions: In this study vW as not useful to determine prognosis in breast cancer, while axilary status and tumoral sizewere predictive factors of survival. More studies are necessary to confirm if menarche and BMI are prognostic factors too.

Exame clínico das mamas no Programa de Saúde da Família: experiência no litoral sul do Brasil / Clinical breast exam in the health family program: experience in the south coast of Brazil

Objetivos: Avaliar a prevalência de achados benignos e incidência bruta do câncer de mama napopulação feminina atendida em três postos de saúde associados ao Programa de Saúde da Família(PSF) no município de Xangri-Lá, RS, Brasil. Métodos: A partir de um projeto de extensão daFaculdade de Medicina da Universidade Federal do Rio Grande do Sul, agentes de saúde ligadosao PSF convidaram mulheres com mais de 20 anos de idade a fazerem uma avaliação clínica dasmamas nos postos de saúde do município. Um questionário semi-estruturado foi aplicado e, a partirdas variáveis coletadas e do exame físico, fez-se um banco de dados. Resultados: Foram incluídas728 mulheres atendidas no PSF. As alterações benignas de forma e volume ocorreram em 11,4%, asalterações mamilares em 3,4% e a dor referida como mamária em 7%. A taxa bruta de incidência docâncer de mama foi de 128 por 100 mil mulheres. Conclusões: As alterações mamárias ocorreramem 15% das pacientes, e o câncer de mama pôde ser eficientemente diagnosticado por médico treinadono exame das mamas. Espera-se que, a partir dos resultados deste estudo, mais ações de saúdepossam ser estabelecidas para a prevenção e o controle do câncer de mama na atenção primária.

Objectives: To evaluate the prevalence of benign findings and breast cancer incidence among the femininepopulation examined in all the three public offices (PO) associated to the Health Family Program(PSF) in Xangri-Lá, RS, Brazil. Methods: Taking part in an extension project from the Medical Schoolof the Federal University of Rio Grande do Sul, agents from the PSF invited women older than 20 years ofage to perform a breast clinical evaluation in one of the PO. A semi-structured questionnaire was appliedand a database was created to store information from the collected variables and the physical examination.Results: Seven hundred twenty-eigth patients were included. Abnormal breast shape and volume weredetected in 11.4% of cases, nipple abnormalities in 3.4% and referred breast pain in 7.0%. The gross incidencerate of breast cancer was 128 per 100.000 women. Conclusion: Abnormal-benign examinationswere present in 15% of patients and breast cancer was successfully diagnosed by a physician trained inclinical breast examination. We hope that these results could stimulate new programs for prevention andcontrol of breast cancer, applied to primary attention.

Aconselhamento genético no câncer de mama / Genetic counselling in breast cancer

A descoberta dos genes BRCA1 e BRCA2, em 1994, e o posterior desenvolvimento dos testes genéticos fizeram surgir uma nova área de interesse dentro da Mastologia:o aconselhamento genético (AG). Apresentamos a nossa experiência na organizaçäo, no funcionamento e nos resultados iniciais do primeiro ano do Ambulatório de AG do nosso Serviço. Demonstrou-se que o risco de desenvolver câncer de mama percebido pelas pacientes é muito maior que o risco esperado para a idade e os fatores de risco aos quais estäo expostas, revelando a importância do AG no rebaixamento do nível de ansiedade. Verificou-se, também, que uma vez esclarecidas a respeito das indicaçöes e limitaçöes dos testes genéticos para identificaçäo de mutaçöes associadas à gênese do câncer de mama, a maioria das pacientes perde o interesse por ele. Avaliado o risco, propomos a nossa rotina de conduta baseada em diferentes faixas de magnitude de risco relativo: leve, moderado e severo. Na presente amostra, a totalidade das pacientes optou pelo seguimento rigoroso, näo tendo ocorrido nenhum caso de escolha de quimioprevençäo ou mastectomia profilática

A mama e o climatério / The breast and menopause

A mama sofre importantes transformaçöes involutivas no climatério acompanhadas de um pico de incidência de câncer de mama. A ampla disseminaçäo do uso da terapêutica de reposiçäo hormonal (TRH) nos últimos anos criou um problema clínico no qual se procura avaliar as influências positivas e/ou negativas sobre esse processo involutivo e, sobretudo, sobre o risco de câncer de mama. Com o emprego da TRH, vem se notando a permanência ou o surgimento de micro e macrocistos mamários na pós-menopausa. Observa-se, também, um aumento na densidade do parênquima à radiologia, diminuindo a sensibilidade e a especificidade da mamografia. Os estudos existentes a respeito da conexäo TRH e câncer de mama säo inconclusivos, mas apontam para um risco aumentado nas usuárias de mais 5 anos e do esquema combinado-contínuo. A história familiar e o diagnóstico histológico de hiperplasia atípica näo constituem contra-indicaçäo absoluta para a TRH. Parece haver um consenso de que a TRH sintomática, de curto prazo (1 a 2 anos), näo influi na probabilidade de contrair a doença, nem no aumento de recidivas naquelas que tiveram câncer de mama prévio. Muitas das nossas atuais incertezas suscitadas pelos pequenos estudos retrospectivos das décadas de 70 e 80, continuadas nas meta- análises dos anos 90, seräo resolvidas (ou adiadas?) com resultados da Era dos Mega-Trials, recém-iniciada, o que deverá acontecer entre 2005 e 2007

Relaçäo entre margem cirúrgica e recidica local no tratamento conservador do câncer de mama / Relationship between surgical margin and local recurrence in conservative treatment of breast cancer

Os fatores prognóstico característicos das pacientes e/ou do tumor, assim como as medidas complementares ao tratamento cirúrgico, podem estar associados a um aumento do risco de recidiva local de câncer de mama nas pacientes submetidas a tratamento conservador. A literatura diverge muito quanto à influência desses fatores na taxa de recorrência local; contudo, a importância do comprometimento da margem curúrgica é consenso. Afim de relacionar a extensäo da margem de ressecçäo livre de tumor e a presença de recidiva local, bem como outras características do tumor associadas à recidiva, foi realizada análise retrospectiva de 219 pacientes submetidas a tratamento conservador de câncer de mama. A taxa de recidiva foi de 17,8 por cento. Pacientes com margens de menor risco (livre acima de 0,5cm), radioterapia, boost e idade acima de 45 anos apresentaram menores taxas de recidiva, näo sendo, no entanto, estatisticamente significantes. As demais características histológicas do tumor (tamanho do tumor, grau histológico, invasäo, compromentimento de linfonodos, necrose e receptor estrogênico) näo demonstraram influência. Apenas a ampliaçäo de margem cirúrgica diminui significativamente de recidiva local (p=0,04), o que tem implicaçäo direta na extensäo da margem livre de tumor

Diagnóstico clínico y estadificación / Clinical diagnosis and statistics

El cáncer de mama es la neoplasia maligna de mayor incidencia y mortalidad en el sexo femenino en Brasil, representando 23 por ciento de todos los nuevos casos diagnosticados en el país. Las estimaciones hechas por la División de Información del Instituto Nacional del Cáncer (INCA) y por el Ministerio de la Salud señalaron en 1997, la ocurrencia de 28.310 nuevos casos de cáncer de mama, representando una incidencia de 38,08 casos/100.000 mujeres. Igualmente, en el mismo año, fueron estimados 6.780 óbitos consecuentes del cáncer de mama, equivalente a un porcentaje de mortalidad de 9,13/100.000 mujeres. Las regiones Sur y Sudeste brasileras presentan tasas de incidencia mucho mayores que el promedio nacional, comparables a las de los países de Europa Occidental y Estados Unidos. Las perspectivas de nuevos casos para el año 2000, para las Américas Central del Sur, son de 92.700 carcinomas. Las características de alta incidencia y mortalidad en la población femenina son un desafío para la Salud Pública, una vez que es una enfermedad potencialmente curable desde que tenga un diagnóstico precoz y un tratamiento adecuado. El diagnóstico de cáncer de mama es fundamental en la definición del estadificación, tratamiento y pronóstico. El método patrón de diagnóstico es el histológico, para confirmar datos colectados por la anamnesis, examen físico, métodos de imagen (mamografía y ecografía mamaria) y citología. En los últimos años nuevas técnicas y procedimientos diagnósticos han sido utilizados, permitiendo que tumores no palpables sean detectados, así como casos de tumores "in situ"

Câncer de mama: análise clínico-epidemiológica de 892 casos do Hospital de Clínicas de Porto Alegre / Breast cancer: clinical-epidemiologycal analysis of 892 cases in the Hospital de Clínicas de Porto Alegre

Foi realizado um estudo clínico-epidemiológico retrospectivo de 892 casos com diagnóstico anatomopatológico de câncer de mama no Hospital de Clínicas de Porto Alegre, no período de 1976 a 1990. Destes casos, 887 (99,4 por cento) foram do sexo feminimo. A média de idade foi 54,1 anos, sendo o estádio mais freqüente o IIA. A citologia foi realizada através da punçao aspirativa em 354 casos, sendo positiva para células malignas em 283 (31,7 por cento) casos. A sensibilidade da mamografia foi de 86 por cento. o tipo histológico mais encontrado foi o ca ductal invasor (86,5 por cento).

Abscesso de mama: importância do antibiograma / Breast abscess: the importance of the antibiogram

O abscesso da mama foi avaliado em 32 pacientes que procuraram o Serviço de Ginecolofia e Obstetrícia em 1990 e 1991. A idade média das pacientes era de 27 anos e 78 por cento delas eram puérperas. O Staphylococcus aureus foi o agente etiológico mais encontrado (90,64 por cento). A penicilina (89,6 por cento) e a ampicilina (75,8 por cento) apresentaram alta resistência. A eritromicina (89,6 por cento), a oxacilina (96,5 por cento), a cefalotina (96,5 por cento), a lincomicina (76,5 por cento), a vancomicina (100 por cento) e o sulfametoxazol-trimetoprim (89,6 por cento) apresentaram alta sensibilidade.