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.

PAGET'S DISEASE IN A MALE PATIENT: CASE REPORT / Doença de Paget do mamilo em paciente masculino: relato de caso

Paget's disease is a rare entity that accounts for 1 to 3% of breast tumors. Occurrence in male patients is even less common. Literature has reported only 24 cases in the last 20 years. We described the case of a 62-year-old male patient that sought medical care due to erosion and eczema on left nipple. After skin biopsy, the clinical suspicion of Paget's disease was confirmed by histological and immunohistochemical studies, which enabled the proper surgical and oncological treatment

A Doença de Paget do mamilo é uma entidade rara, representando 1 a 3% dos carcinomas de mama. Sua presença em pacientes masculinos é ainda menos comum, com apenas 24 casos na literatura nos últimos 20 anos. Em nosso relato de caso, descrevemos um paciente masculino de 62 anos que procurou atendimento por erosão e eczema no mamilo esquerdo. Após biópsia de pele, a histologia e o estudo imuno-histoquímico confirmaram a suspeita clínica de Doença de Paget do mamilo, possibilitando o tratamento cirúrgico-oncológico adequado.

Non-Hodgkin lymphoma in breast: case report / Linfoma não Hodgkin da mama: relato de caso

e primary breast lymphoma is a rare tumor, accounting for up to 0.5% of breast cancers. Most primary breast lymphoma is presented as non-Hodgkin lymphoma, the B-cells lymphoma is the most common, and Burkitt lymphoma is the most aggressive. We report the case of a 24-year-old female patient, with global, progressive and rapid increase of the right breast during 30 days with reaction to insect bite and progressive weight loss, fatigue, fever and nocturne sweating. An echo-guided core biopsy was held with injury and showed an atypical lymphoid proliferation, suggestive of high-grade non-Hodgkin lymphoma. Immunohistochemistry confirmed non-Hodgkin lymphoma, B immunophenotype, Burkitt type. Also, the diagnosis of HIV infec- tion was performed during hospitalization. Patient started with multidrug chemotherapy scheme and antiretroviral therapy. Burkitt lymphoma is an exceptionally aggressive subtype and can a ect the central nervous system and gastrointestinal tract, and treatment consists of chemothe- rapy with multiple agents as soon as possible. Radiotherapy has no function in the Burkitt type cases, even in case of only local disease.

O linfoma primário de mama é um tumor raro que corresponde a cerca de 0,5% de todos os cânceres de mama. A maioria dos linfomas primários de mama apresenta-se como linfoma não Hodgkin, sendo o mais comum o de células B e o mais agressivo o linfoma de Burkitt. Relatamos o caso de uma paciente feminina, 24 anos, com aumento global, progressivo e rápido da mama direita observado num período de 30 dias, acompanhado de progressiva perda de peso, fadiga, febre e sudorese noturna. Foi realizada biópsia guiada por agulhamento, que identi cou proliferação linfoide atípica, sugestiva de linfoma não Hodgkin de alto grau. A avaliação imuno-histoquímica con rmou o diagnóstico de linfoma não Hodgkin, imunofenótipo B, do tipo Burkitt. O diagnóstico de infecção pelo HIV também foi feito durante a hospitalização. Foi iniciado tratamento com esquema quimioterápico de múltiplas drogas e terapia antirretroviral. O linfoma de Burkitt é um subtipo bastante agressivo e pode afetar o sistema nervoso central e o trato gastrointestinal, e o tratamento consiste em quimioterapia com múltiplos agentes, devendo ser iniciado o mais brevemente possível. A radioterapia não tem papel no tratamento do linfoma de Burkitt, mesmo nos casos de doença localizada.

A phase III, randomized, non-inferiority study comparing the efficacy and safety of biosimilar filgrastim versus originator filgrastim for chemotherapy-induced neutropenia in breast cancer patients.

OBJECTIVES:: To compare the efficacy and safety of two filgrastim formulations for controlling chemotherapy-induced neutropenia and to evaluate the non-inferiority of the test drug relative to the originator. METHODS:: This phase III non-inferiority study had a randomized, multicenter, and open-label design. The patients were randomized at a ratio of 1:1 with a follow-up period of 6 weeks for each patient. In both study arms, filgrastim was administered subcutaneously at a daily dose of 5 mg/kg body weight. The primary endpoint was the rate of grade 4 neutropenia in the first treatment cycle. The secondary endpoints were the duration of grade 4 neutropenia, the generation of anti-filgrastim antibodies, and the rates of adverse events, laboratory abnormalities, febrile neutropenia, and neutropenia of any grade. RESULTS:: The primary efficacy analysis demonstrated the non-inferiority of the test drug compared with the originator drug; the upper limit of the 90% confidence interval (CI) for the rate of neutropenia between the two groups (12.61%) was lower than the established margin of non-inferiority. The two treatments were similar with respect to the secondary endpoints and safety. CONCLUSION:: The efficacy and safety profile of the test drug were similar to those of the originator product based on the rate of grade 4 neutropenia in the first treatment cycle. This study supports Anvisa's approval of the first biosimilar drug manufactured by the Brazilian industry (Fiprima¯).

A phase III, randomized, non-inferiority study comparing the efficacy and safety of biosimilar filgrastim versus originator filgrastim for chemotherapy-induced neutropenia in breast cancer patients

OBJECTIVES: To compare the efficacy and safety of two filgrastim formulations for controlling chemotherapy-induced neutropenia and to evaluate the non-inferiority of the test drug relative to the originator. METHODS: This phase III non-inferiority study had a randomized, multicenter, and open-label design. The patients were randomized at a ratio of 1:1 with a follow-up period of 6 weeks for each patient. In both study arms, filgrastim was administered subcutaneously at a daily dose of 5 mg/kg body weight. The primary endpoint was the rate of grade 4 neutropenia in the first treatment cycle. The secondary endpoints were the duration of grade 4 neutropenia, the generation of anti-filgrastim antibodies, and the rates of adverse events, laboratory abnormalities, febrile neutropenia, and neutropenia of any grade. RESULTS: The primary efficacy analysis demonstrated the non-inferiority of the test drug compared with the originator drug; the upper limit of the 90% confidence interval (CI) for the rate of neutropenia between the two groups (12.61%) was lower than the established margin of non-inferiority. The two treatments were similar with respect to the secondary endpoints and safety. CONCLUSION: The efficacy and safety profile of the test drug were similar to those of the originator product based on the rate of grade 4 neutropenia in the first treatment cycle. This study supports Anvisa’s approval of the first biosimilar drug manufactured by the Brazilian industry (Fiprima¯).

Uma nova plataforma terapêutica para o câncer de mama: a evoluçãodo tratamento sistêmico neoadjuvante / A new therapeutic platform for treating breast cancer: the evolution of systemic neoadjuvant treatment

O tratamento neoadjuvante do câncer de mama consiste no uso de diferentes modalidades terapêuticas prévias à remoção cirúrgica da doença. Tem sido aceito como uma opção para pacientes com doença não metastática, porque pode converter tumores inoperáveis em operáveis e aumentar os índices de cirurgias conservadoras, com os mesmos resultados oncológicos em longo prazo do tratamento adjuvante. A estratégia neoadjuvante está sendo cada vez mais aceita como uma plataforma de pesquisa, em que os efeitos biológicos dos agentes antitumorais podem ser avaliados, os biomarcadores preditivos e os prognósticos podem ser identificados e o desenvolvimento de terapias-alvo pode ser acelerado. Desfechos alternativos que podem predizer resultado clínico em longo prazo e estão disponíveis precocemente, como a resposta patológica completa, oferecem oportunidades únicas para a imediata avaliação dos agentes antitumorais. Além disso, esforços para determinar o perfil molecular da doença residual pós-tratamento neoadjuvante podem levar a uma terapia personalizada do câncer de mama em pacientes com doença de alto risco em estágio inicial.

Neoadjuvant therapy of breast cancer is related to the use of different treatment modalities prior to surgical removal of the disease. It has been accepted as an option for patients with nonmetastatic disease, because it renders inoperable tumors operable and increases the rates of breast-conserving surgery, while achieving the same long-term clinical outcomes as the adjuvant setting. The neoadjuvant strategy is being increasingly accepted as a research platform, where the biologic effects of anticancer agents can be evaluated, prognostic and predictive biomarkers can be identified, and the development of targeted agents can be accelerated. Surrogate endpoints that can predict long-term clinical outcome and are evaluable early on, such as the pathologic complete response, offer unique opportunities for prompt assessment of anticancer agents. Moreover, efforts for molecular profiling of the post-neoadjuvant residual disease may lead to a personalized therapy for breast cancer patients with early-stage high-risk disease.

Efficacy and safety of neoadjuvant pertuzumab and trastuzumab in women with locally advanced, inflammatory, or early HER2-positive breast cancer (NeoSphere): a randomised multicentre, open-label, phase 2 trial.

BACKGROUND: Studies with pertuzumab, a novel anti-HER2 antibody, show improved efficacy when combined with the established HER2-directed antibody trastuzumab in breast cancer therapy. We investigated the combination of pertuzumab or trastuzumab, or both, with docetaxel and the combination of pertuzumab and trastuzumab without chemotherapy in the neoadjuvant setting. METHODS: In this multicentre, open-label, phase 2 study, treatment-naive women with HER2-positive breast cancer were randomly assigned (1:1:1:1) centrally and stratified by operable, locally advanced, and inflammatory breast cancer, and by hormone receptor expression to receive four neoadjuvant cycles of: trastuzumab (8 mg/kg loading dose, followed by 6 mg/kg every 3 weeks) plus docetaxel (75 mg/m(2), escalating, if tolerated, to 100 mg/m(2) every 3 weeks; group A) or pertuzumab (loading dose 840 mg, followed by 420 mg every 3 weeks) and trastuzumab plus docetaxel (group B) or pertuzumab and trastuzumab (group C) or pertuzumab plus docetaxel (group D). The primary endpoint, examined in the intention-to-treat population, was pathological complete response in the breast. Neither patients nor investigators were masked to treatment. This study is registered with ClinicalTrials.gov, number NCT00545688. FINDINGS: Of 417 eligible patients, 107 were randomly assigned to group A, 107 to group B, 107 to group C, and 96 to group D. Patients given pertuzumab and trastuzumab plus docetaxel (group B) had a significantly improved pathological complete response rate (49 of 107 patients; 45·8% [95% CI 36·1-55·7]) compared with those given trastuzumab plus docetaxel (group A; 31 of 107; 29·0% [20·6-38·5]; p=0·0141). 23 of 96 (24·0% [15·8-33·7]) women given pertuzumab plus docetaxel (group D) had a pathological complete response, as did 18 of 107 (16·8% [10·3-25·3]) given pertuzumab and trastuzumab (group C). The most common adverse events of grade 3 or higher were neutropenia (61 of 107 women in group A, 48 of 107 in group B, one of 108 in group C, and 52 of 94 in group D), febrile neutropenia (eight, nine, none, and seven, respectively), and leucopenia (13, five, none, and seven, respectively). The number of serious adverse events was similar in groups A, B, and D (15-20 serious adverse events per group in 10-17% of patients) but lower in group C (four serious adverse events in 4% of patients). INTERPRETATION: Patients given pertuzumab and trastuzumab plus docetaxel (group B) had a significantly improved pathological complete response rate compared with those given trastuzumab plus docetaxel, without substantial differences in tolerability. Pertuzumab and trastuzumab without chemotherapy eradicated tumours in a proportion of women and showed a favourable safety profile. These findings justify further exploration in adjuvant trials and support the neoadjuvant approach for accelerating drug assessment in early breast cancer. FUNDING: F Hoffmann-La Roche.

Recidiva locorregional: importância da margem cirúrgica livre e dos subtipos moleculares do câncer de mama / Locoregional recurrence: the importance of free surgical margins and molecular subtypes of breast cancer

Índices de sobrevida equivalentes observados entre a cirurgia conservadora de mama e a mastectomia tornaram a primeira o tratamento padrão para muitas mulheres com câncer de mama, sendo preferível à mastectomia pelo benefício estético da preservação da mama. A cirurgia conservadora complementada pela radioterapia apresenta altos níveis de controle local da doença. O tamanho da margem tumoral adequado é assunto de interesse em razão da tendência de menor radicalidade cirúrgica, com manutenção de segurança oncológica. É importante, também, em relação à mastectomia, devido à possibilidade de preservação da pele e do complexo aréolo-mandibular, o que pode significar menos margens livres. Diversos estudos sugerem que uma excisão adequada, com margens livres de tumor, é necessária para obter um controle local ótimo. Entretanto, o próprio conceito do que seja margem livre é controverso, além de ser altamente questionável se o aumento do tamanho dessa margem resulta na diminuição do risco de recidiva local. Ressecções mais amplas são associadas a menor recorrência local, mas os dados disponíveis sugerem que o aumento de milímetros da margem livre não resulta em uma diminuição proporcional no risco de recidiva. Atualmente, considera-se adequado o tratamento cirúrgico que obtenha margem cirúrgica negativa, independentemente de seu tamanho. Diversos fatores patológicos, clínicos e de diferentes tratamentos também têm sido associados a um aumento do risco de recorrência local, entre eles a dose de radioterapia, definição do que é margem positiva e negativa, a extensão do envolvimento da margem, a presença de componente intraductal extenso, o tempo de acompanhamento dos pacientes, a influência do tratamento sistêmico adjuvante e, com grande interesse atualmente, os subtipos moleculares genéticos do câncer de mama - luminal A, luminal B, Her-2 positivo e triplo-negativo. A identificação de fatores de risco para recorrência local entre pacientes com margens negativas é....

The effect of neoadjuvant chemotherapy on hormone receptor status, HER2/neu and prolactin in breast cancer.

AIMS AND BACKGROUND: Histological and immunohistochemical findings may vary in cases of breast cancer. Possible changes in tumor markers between biopsies performed before and after neoadjuvant chemotherapy are controversial and pose a challenge when a clinical decision is needed. The objectives of the present study were: (i) to compare the immunohistochemical expression of estrogen, progesterone and prolactin receptors and HER-2/neu in breast cancer before and after neoadjuvant chemotherapy; and (ii) to correlate the expression of these tumor markers with partial tumor response to neoadjuvant chemotherapy. METHODS AND STUDY DESIGN: Immunohistochemical staining for breast tumor markers was performed in 90 cases of breast cancer. Statistical analysis was carried out using Fisher's exact test, McNemar's test, Spearman's correlation and the Kappa index with linear weighting (k). RESULTS: Agreement between markers before and after neoadjuvant chemotherapy was fair to moderate (k = 0.37-0.51). The immunohistochemical expression of HER-2/neu and prolactin receptors showed a significant, albeit weak correlation before and after neoadjuvant chemotherapy (HER-2/neu, rho = 0.34; P = 0.0009; k = 0.35 [95% CI, 0.19-0.51]). Prolactin status changed in 28/90 cases (P = 0.001; McNemar's test), whereas no changes were found in estrogen or progesterone receptors. No association was found between tumor marker expression and tumor response. CONCLUSIONS: It seems prudent to reevaluate immunohistochemical markers such as HER-2/neu after neoadjuvant chemotherapy, since the findings will guide the strategy for implementation of adjuvant systemic treatment. No correlation was found between the tumor markers analyzed in the present study and partial tumor response to neoadjuvant chemotherapy.

Neoadjuvância sistêmica / Systemic neoadjuvance

A neoadjuvância sistêmica é a aplicação de terapia antineoplásica como primeiro tratamento em pacientes sem evidência de metástases e com intenção plena de controle da doença. É tambem chamada de primária, pré-operatória, perioperatória, basal ou de indução. Cada vez mais pacientes estão sendo tratados com quimioterapia (QT), hormonioterapia (HT) e imunoterapia (IT) antes do tratamento cirúrgico e em estágios mais precoces da doença. A chamada Estratégia de Tratamento Multidisciplinar consiste no tratamento sistêmico primário ou adjuvante associada ao tratamento locorregional, através da cirurgia e radioterapia (RT). O tratamento do câncer de mama, em especial o localmente avançado, é baseado nesse planejamento, e a QT com antracíclicos e taxanos ocupa o papel central. Entretanto, a utilização de dados histológicos e marcadores imuno-histoquimicos relacionados a biologia molecular e a expressão genética tumoral conduzem a individualização do tratamento, que consiste na obtenção do máximo de informações disponíveis sobre o tumor para oferecer o tratamento mais adequado para cada paciente. Em relação à IT, ou terapia alvo, muitos ensaios clínicos tem mostrado bons índices de resposta em pacientes HER 2 positivo com esquemas quimioterapicos contendo Trastuzumab. Outras drogas anti-HER 2 também tem sido testadas. A HT neoadjuvante como tratamento único pode ser uma opção adequada em pós-menopáusicas com receptores hormonais (RH) positivo, e os inibidores da aromatase (IA) são a opção de escolha. As principais vantagens do tratamento sistêmico primario consistem na melhora das condições cirúrgicas, uma melhor avaliação do potencial de resposta tumoral a terapia sistêmica e uma possivel melhora da sobrevida.

Systemic neoadjuvant therapy is the first line treatment in patients without evidence of metastasis and with a good control of the disease. It is also named as primary, preoperative, perioperative, basal or induction. Chemotherapy (CT), hormone therapy (HT) and immunotherapy (IT) have been increasingly used before the surgical treatment and in early stages of the disease. The so-called Multidisciplinary Treatment Strategy consists in a primary or adjuvant systemic treatment associated to locoregional treatment through surgery and radiotherapy (RT). Breast cancer treatment, specially the locally advanced, is mainly based on this planning, and CT with anthracyclics and taxanes has the central role. Nevertheless, histologic data and tumor markers, related to molecular biology and tumor genetic expression, have been used to individualize the treatment for breast cancer, by obtaining the maximum available information about the tumor in order to offer the proper treatment for each patient. There are many clinical trials with IT, or target therapy, demonstrating good response rates in patients HER 2positive who used chemotherapy with Trastuzumab. Other anti-HER 2 drugs have been tested. The neoadjuvant HT as single agent can be used as an option in post-menopausal women with positive hormone receptor, and aromatase inhibitors are the drug of choice. The main advantages of primary systemic treatment are better surgical conditions, better evaluation of the potential of the tumor to respond to systemic therapy and, consequently, a better survival rate.

[Cox-2 and CD105 expression in breast cancer and disease-free survival]. / Expressão da cox-2 e CD105 no câncer de mama e sobrevida livre de doença.

OBJECTIVE: To verify the expression of CD105 in primary breast cancer, and the expression of cyclooxygenase-2 in primary breast cancer and in the respective axillary lymph nodes. METHODS: Seventy two women from 18 to 80 years of age, with a diagnosis of Ductal Infiltrative Breast Cancer, stage II, histological type non special, with their respective axillary lymph nodes were submitted to surgical treatment at the "Hospital Nossa Senhora da Conceição" between 2001 and 2002. Immunohistochemical analyses of CD 105 in the primary breast cancer and of COX 2 in the local axillary lymph node were compared for local recurrence. RESULTS: Of the 72 patients with primary tumors, 40 had positive axillary lymph nodes, while 32 were negative. For each primary tumor, only one lymph node was analyzed. . Fifteen patients had local recurrence after 26 months (CI 95% 24-28). Presence of COX-2 in the primary tumors was verified in 52 cases, and presence of CD105 in 34 cases. These independent prognostic factors were not correlated to local recurrence (P= 0.203 e P=0.145, respectively). The period free of local recurrence for patients with positive expression of COX-2 in axillary lymph nodes (with metastasis or not) was of 19 months, while patients with negative expression had a 28.3 months long period free of local recurrence. CONCLUSION: The positive expression of COX-2 in axillary lymph nodes (either positive or negative) seems to be an independent prognostic factor for local recurrence.

Expressão da cox-2 e CD105 no câncer de mama e sobrevida livre de doença / Cox-2 and CD105 expression in breast cancer and disease-free survival

OBJETIVOS: Correlacionar a presença de recidiva local de câncer de mama com a expressão de CD105 em carcinomas primários de mama, e a expressão da ciclooxigenase-2 nos carcinomas primários de mama e nos respectivos linfonodos axilares. MÉTODOS: Estudo com uma coorte histórica de 72 mulheres entre 29 e 67 anos com diagnóstico de carcinoma ductal infiltrante de mama, estadio II, tipo histológico não especial com seus linfonodos axilares respectivos, que tiveram diagnóstico e tratamento cirúrgico no Hospital Nossa Senhora da Conceição, no período de 2001 a 2002. Análise imunoistoquímica do CD105 e COX-2 no tumor primário, da COX-2 nos linfonodos axilares e da recidiva local. RESULTADOS: Das 72 mulheres analisadas com tumores primários, 40 tinham linfonodos axilares positivos e 32 eram negativos; para cada tumor primário, foi escolhido apenas um linfonodo axilar. O grau histológico dos tumores foi I (n=4), II (n=41) e III (n=27). Quinze pacientes apresentaram recidiva local em um período médio de 26 meses (IC 95 por cento 24-28). A presença da COX-2 nos tumores primários foi verificada em 52 casos, e a presença de CD105 em 34 casos, mas não foram considerados fatores prognósticos independentes para recidiva (p=0,203 e p=0,145, respectivamente). A sobrevida para pacientes com expressão da COX-2 em linfonodos axilares (metastáticos ou não metastáticos) foi de 19 meses, contra 28,3 meses para pacientes COX-2 negativa (p<0,0001). CONCLUSÃO: A expressão positiva da COX-2 em linfonodos axilares (positivos ou não) parece ser um fator prognóstico independente para sobrevida livre de doença.

Expression of alpha 1 and beta 3 integrins subunits in the endometrium of patients with tubal phimosis or hydrosalpinx.

OBJECTIVE: To determine the expression of alpha1 and beta3 integrin subunit on the endometrium of infertile patients with hydrosalpinx and infertile patients with tubal phimosis. DESIGN: Case-control study. SETTING: Tertiary medical center. PATIENT(S): Infertile patients with radiologic or laparoscopic diagnosis of hydrosalpinx (n = 11) or tubal phimosis (n = 12) as the only cause of infertility, and fertile controls (n = 17). INTERVENTION(S): Immunohistochemical analysis of alpha1 and beta3 integrin subunits was performed on endometrial biopsies obtained during the implantation window. MAIN OUTCOME MEASURE(S): Histologic score (HSCORE) on luminal and glandular endometrium of the patients with hydrosalpinx or tubal phimosis and the normal fertile controls. RESULT(S): The median (+/-SEM) HSCORE for beta3 subunit expression in endometrial glands was 0.39 +/- 0.23 and 0.42 +/- 0.18 for tubal phimosis and hydrosalpinx, respectively, and 1.74 +/- 0.26 for fertile controls. The median HSCORE for beta3 subunit expression in luminal epithelium for tubal phimosis, hydrosalpinx, and fertile controls was 0.07 +/- 0.06, 0.21 +/- 0.18, and 1.03 +/- 0.31, respectively. No statistical difference was observed on the expression of alpha1 integrin subunit expression between the three groups. CONCLUSION(S): The endometrial expression of beta3 integrin subunit is reduced in the presence of tubal phimosis or hydrosalpinx, during the window of implantation.

Reassessing tumor markers in local recurrences of breast cancer: a new insight.

BACKGROUND: It is believed that a local recurrence of a primitive breast cancer has the same prognostic factor profile as its primary breast cancer tumor. MATERIAL/METHODS: We compared the immunohistochemical expressions of the tumor suppressor protein p53, estrogen receptor (ER), c-erbB2, and E-cadherin in 57 primary invasive breast cancers and in their respective LRs. The McNemar test and the kappa index were used for statistical analysis. RESULTS: In 30 patients (52.6%) the expression of at least one of these markers was different between the primary and locally recurrent tumors. No significant difference was observed between variations in the positive and negative expressions in the primary tumor and local recurrence in cerbB2 (kappa = 0.86), E-cadherin (kappa = 0.55), and p53 (kappa = 0.7). However, the ER presented a low kappa index (kappa = 0.26, p > 0.05). CONCLUSIONS: ER expression should be reviewed in local recurrent breast cancer. This relevant change in ER expression is likely to change the current clinical practice in breast cancer evaluation and treatment.

Estenose vaginal pós-traumatismo pélvico: relato de caso / Vaginal estenosis as sequelae of a traumatic pelvic injury: case report

A case of perineal neoformation (colagenic fibrosis) after trauma with probable vaginal laceration by pelvic bony fragments at the moment of the accident, is related. An important narrowing of the vaginal lumen and functional incapacicty of the organ were followed to the trauma. The authors performed a conventional surgery by with space, plus osteotomy of the pubic branch of left iliac bone, that had undergone a thick protuberance to the left lateral wall of the vagina