How well are Brazilian mastologists (breast surgeons) trained in breast reconstruction and oncoplastic surgery? A study of the impact of a breast reconstruction and oncoplastic surgery improvement course.

Introduction: The breasts are a female symbol, impacts self-image and self-esteem. Breast reconstructive and oncoplastic surgeries have an important role in minimizing injuries. In Brazil less than a third of public health system (SUS) users have access to immediate reconstructive surgery. The low rate of breast reconstructions has multiple causes and the deficiency in availability and surgeons' technical qualification play a role. In 2010, the Breast Reconstruction and Oncoplastic Surgery Improvement Course was created by professors of the Mastology Department of Santa Casa de São Paulo and State University of Campinas (UNICAMP). The objectives of this study were to evaluate the impact of the techniques learned on patients' management by the surgeons enrolled in the Course, as well as to characterize their profile. Methods: All students enrolled in the Improvement Course between 2010 and 2018 were invited to answer an online questionnaire. Students who did not agree to answer the questionnaire or answered them incompletely were excluded. Results: Total students included: 59. The mean age: 48.9 years, male (72%) with more than 5 years of Mastology practice (82.2%), from all regions of Brazil, 1.7% from the North, 33.9% from the Northeast, 44.1% from the Southeast, and 12% from the South. Most of the students considered they had little or no knowledge of breast reconstruction (74.6%) and 91,5% did not consider they had enough aptitude to perform breast reconstructions after finishing residency. After the Course, 96.6% considered themselves apt to perform such surgeries. Over 90% of the students considered the Course had impacted their practice and changed their surgical strategy view. Before the Course, 84.8% of the students stated that less than half of their patients who were operated on for breast cancer had breast reconstruction, compared to 30.5% after the Course. Conclusion: The Breast Reconstruction and Oncoplastic Surgery Improvement Course studied here positively impacted the mastologists' management of patients. New training centers worldwide can help a lot of women with breast cancer.

Dermoglandular advancement-rotation flap for conservative treatment of breast cancer - description of technique, objective and subjective assessments.

Objective: to describe and evaluate the dermoglandular advancement-rotation flap with no contralateral surgery as a technique for the conservative treatment of breast cancer when skin or a large proportion of gland requires resection. Patients/Methods: 14 patients with breast tumors with a mean size of 4.2 cm and need for skin resection. The resection area is included within an isosceles triangle, with its apex located on the areola, which is the pivot for rotation of a dermoglandular flap released through a lateral extension along that triangle base. Symmetry before and after radiotherapy was objectively assessed by authors using the BCCT.core software, as well as subjectively by three experts and patients themselves using the Harvard scale. Results: Experts considered the breast symmetry results to be excellent/good for 85.7% of patients in the early post-operative period and 78.6% in the late post-operative period. Excellent/good ratings provided by BCCT.core software amounted to 78.6% of cases in the early post-operative period and 92.9% in the late post-operative period. Symmetry was rated as excellent/good by 100% of patients. Conclusion: Dermoglandular advancement-rotation flap technique with no contralateral surgery provides good symmetry when a large proportion of skin or gland requires resection on breast conservative cancer treatment.

Autologous Breast Reconstruction With the Latissimus Dorsi Muscle With Immediate Fat Grafting: Long-term Results and Patient Satisfaction.

OBJECTIVE: The aim of this study was to describe a variation of the breast reconstruction technique with myocutaneous flap of the fat-grafted latissimus dorsi muscle and its outcomes and evaluation of patient satisfaction. METHOD: This prospective cohort study included 18 patients and 19 reconstructed breasts, with 1 bilateral case. There were 7 cases of late reconstruction and 11 cases of immediate reconstruction. The flap was prepared with fat at the time of surgery, which was injected before its preparation. The evaluation of the results regarding shape, volume, and symmetry was performed through a satisfaction scale completed by patients and 2 physicians from 12 to 18 months after reconstruction. RESULTS: On average, 171.31 mL of fat was injected (100-275 mL); the average time of unilateral surgery was 3 hours 42 minutes (3 hours to 4 hours 30 minutes). After a mean follow-up of 26.38 months (13-38 months), we did not observe complications of this new technique. In the evaluation performed by patients regarding the shape, volume, and symmetry, more than 80% rated the outcome as excellent and good, and the evaluations by the medical team were also satisfactory. In the comparative analysis between immediate and late reconstruction, patients who underwent immediate reconstruction were more satisfied. CONCLUSIONS: This reconstruction technique with autologous fat injection was effective, with satisfactory and long-lasting results, and without the requirement for implants to set breast shape and volume.

Interaction between cyclooxygenase-2 and insulin-like growth factor in breast cancer: A new field for prevention and treatment.

The objective of this study was to evaluate the correlation between cyclooxygenase-2 (COX-2) and markers of cell proliferation and apoptosis, including, Bcl-2, Bax, Ki-67 and the type I insulin-like growth factor (IGF) receptor (IGF1-R) in ductal carcinoma in situ (DCIS) and infiltrating ductal carcinoma (IDC), present in the same surgical specimen. A total of 110 cases were evaluated using tissue microarrays. Cases were classified in scores from 0 to 3 according to pre-defined methods. The results showed that the positivity rates were COX-2 in 87% of cases in DCIS and IDC; Bcl-2 in 55% of cases in DCIS and IDC; Bax in 23% of cases in IDC and 19% in DCIS, IGF-1 in 24% of cases in DCIS and IDC; and Ki-67 in 81% of cases in DCIS and IDC. We also observed a positive correlation between the expression of COX-2 and IGF1-R (p=0.045). Our results demonstrate a positive correlation between the expression of COX-2 and IGF1-R in DCIS and IDC, demonstrating that they are involved in breast cancer carcinogenesis. Further studies are required to prove the effectiveness of COX-2 and IGF1-R inhibitors for the prevention and treatment of breast cancer, as well as to explain their mechanism of action.

The interaction between aromatase, metalloproteinase 2,9 and CD44 in breast cancer.

OBJECTIVE: This study intends to verify the expression levels and correlation of aromatase, matrix metalloproteinase 2 (MMP-2), matrix metalloproteinase 9 (MMP-9) and CD44 in ductal carcinoma in situ (DCIS) and infiltrating ductal carcinoma (IDC) when both are found in the same breast. METHODS: One hundred and ten cases were evaluated by tissue microarray (TMA) and immunohistochemically screened with anti-aromatase polyclonal antibodies, anti-MMP-2 monoclonal antibodies, anti-MMP-9 polyclonal antibodies and anti-CD44 monoclonal antibodies. RESULTS: Aromatase was expressed in IDC and DCIS in 63 (57.3%) and 60 (67%) of the cases respectively; MMP-2 was similarly expressed in IDC and DCIS in 15 (13.60%) cases; MMP-9 was positively expressed in IDC and DCIS in 83 (75.50%) and 82 (74.50%) cases, respectively; CD44 was positively expressed in IDC and DCIS in 49 (44.50%) and 48 (42.60%) of the cases, respectively; all of them were highly correlated (p<0,001). The correlation analysis found positive, statistically significant correlation, in IDC between aromatase and MMP-2 (p<0.001) and between aromatase and MMP-9 (p=0.034). Positive correlation between aromatase and MMP-2 (p<0.001) and between MMP-9 and CD44 (p=0.030) were found in DCIS. CONCLUSION: These results allow us to conclude that aromatase through local estrogen synthesis in breast tissue plays an important role in breast carcinogenesis, mainly influencing MMP-2 and MMP-9 which are important participants in tumor cell invasion and dependence of their connection to CD44 for action.

The interaction between aromatase, metalloproteinase 2,9 and cd44 in breast cancer / A interação entre aromatase, metalloproteinase 2, 9 e cd44 no câncer de mama

OBJECTIVE: This study intends to verify the expression levels and correlation of aromatase, matrix metalloproteinase 2 (MMP-2), matrix metalloproteinase 9 (MMP-9) and CD44 in ductal carcinoma in situ (DCIS) and infiltrating ductal carcinoma (IDC) when both are found in the same breast. METHODS: One hundred and ten cases were evaluated by tissue microarray (TMA) and immunohistochemically screened with anti-aromatase polyclonal antibodies, anti-MMP-2 monoclonal antibodies, anti-MMP-9 policlonal antibodies and anti-CD44 monoclonal antibodies. RESULTS: Aromatase was expressed in IDC and DCIS in 63 (57.3 percent) and 60 (67 percent) of the cases respectively; MMP-2 was similarly expressed in IDC and DCIS in 15 (13.60 percent) cases; MMP-9 was positively expressed in IDC and DCIS in 83 (75.50 percent) and 82 (74.50 percent) cases, respectively; CD44 was positively expressed in IDC and DCIS in 49 (44.50 percent) and 48 (42.60 percent) of the cases, respectively; all of them were highly correlated (p<0,001). The correlation analysis found positive, statistically significant correlation, in IDC between aromatase and MMP-2 (p<0.001) and between aromatase and MMP-9 (p=0.034). Positive correlation between aromatase and MMP-2 (p<0.001) and between MMP-9 and CD44 (p=0.030) were found in DCIS. CONCLUSION: These results allow us to conclude that aromatase through local estrogen synthesis in breast tissue plays an important role in breast carcinogenesis, mainly influencing MMP-2 and MMP-9 which are important participants in tumor cell invasion and dependence of their connection to CD44 for action.

OBJETIVO: O objetivo desse estudo é verificar as expressões e correlações da aromatase, metalloproteinase 2 da matriz (MMP2), metalloproteinase 9 da matriz (MMP-9) e CD44 no carcinoma ductal in situ (CDIS) e carcinoma ductal infiltrativo (CDI) quando ambos estão presentes simultaneamente na mesma mama. MÉTODOS: Foram avaliados 110 casos pelo método de tissue microarray (TMA) e através da utilização de anticorpos policlonais antiaromatase, anticorpos monoclonais anti-MMP-2, anticorpos policlonais anti-MMP-9 e anticorpos monoclonais anti-CD44. RESULTADOS: A aromatase estava expressa de forma positiva no CDI e CDIS em 63 (57,3 por cento) e 60 (67 por cento) casos, respectivamente. A expressão de MMP-2 estava expressa de forma positiva em 15 (13,6 por cento) casos tanto no CDI, quanto no CDIS. A expressão da MMP-9 estava expressa de forma positiva em 83 (75,5 por cento) e 82 (74,5 por cento) casos de CDI e CDIS, respectivamente. A expressão de CD44 estava expressa de forma positiva em 49 (44,5 por cento) e 48 (42,6 por cento) casos de CDI e CDIS, respectivamente. Todos eles apresentando alta correlação (p<0,001). Na avaliação de correlação foi encontrada correlação positiva estatisticamente significante no CDI entre aromatase e MMP-2 (p<0,01) e entre aromatase e MMP-9 (p=0,034). Nos casos de CDIS houve correlação positiva estatisticamente significante entre aromatase e MMP-2 (p<0,001) e entre CD44 e MMP-9 (p=0,030). CONCLUSÃO: Após analisarmos os resultados de nosso estudo, podemos concluir que a aromatase, através da síntese de estrogênio local no tecido mamário, desempenha importante papel na carcinogênese mamária, principalmente influenciando a atuação da MMP-2 e da MMP-9, grandes responsáveis pela invasão celular tumoral que, por sua vez, provavelmente dependem de sua ligação a CD44 para poder desempenhar suas funções.

[Proposal for the systematization of the elastographic study of mammary lesions through ultrasound scan]. / Proposta de sistematização do estudo elastográfico de lesões mamárias pela ultrassonografia.

OBJECTIVE: Proposal of systematization for the elastographic study in the ultrasound routine. METHODS: Evaluation was made of 308 patients forwarded to the breast intervention service in the CTC-Genesis from May 1, 2007 to March 1, 2008 to perform percutaneous breast biopsy. Prior to the percutaneous biopsy, an ultrasound study and an elastography were performed. Lesions were primarily analyzed and classified according to the Bi-Rads lexicon criteria by the conventional ultrasound scan (B mode). The elastography was then performed and analyzed in accordance with the systematization proposed by the authors, using images obtained during compression and after decompression of the area of interest. Lesions were classified following the system developed by the authors using a four-point scale, where scores (1) and (2) were considered benign, score (3) probably benign and score (4) suspicion of malignancy. Results obtained by the two methods were compared with the histological results using the areas within the ROC (receiver operator curves) curves. RESULTS: The area within the curve for elastography was of 0.952 with a confidence interval between 0.910 and 0.966, error of 0.023, and of 0.867 with a confidence interval between 0.823 and 0.903, error of 0.0333 for the ultrasound. When the areas were compared, a difference between the curves of 0.026 was observed, which was statistically significant. CONCLUSION: This work shows the systematization of the elastographic study using information obtained during compression and after decompression of the ultrasound scan sample, thus showing that elastography might enhance the assessment of risk of malignancy for lesions characterized by the ultrasound.

[Aromatase expression in invasive and in situ ductal carcinoma present in the same breast]. / Expressão da aromatase em carcinomas de mama ductais invasivo e in situ presentes na mesma mama.

OBJECTIVE: to evaluate the expression of aromatase in simultaneously invasive ductal carcinoma (IDC) and ductal carcinoma in situ (DCIS). METHODS: forty-five surgical samples were obtained from mastectomy and quadrantectomy with simultaneous IDC and DCIS of stage I and II patients. Aromatase was evaluated using antibodies anti-aromatase and the samples classified in accordance with the number and intensity of stained cells. RESULTS: Aromatase was expressed positively in 32(71%) and negatively in 13(29%) of the cases in the IDC. The same results were obtained in the DCIS showing a perfect positive correlation. In the normal epithelium,aromatase was positive in 19(42.2%) and negative in 26 (57.8%) and a positive correlation, statistically significant was obtained when compared with IDC and DCIS(p<0.01). Concerning the normal stroma, positivity was only 7 (15.5%) showing no correlation with aromatase expression. Aromatase was positive in 36(80%) of the tumor stroma and this result was statistically significant as in the IDC and DCIS. Comparing results of aromatase expression with nuclear grade, histological grade, tumor size and age no difference was found. CONCLUSION: our results demonstrated high correlation between aromatase expression in IDC, DCIS, normal epithelium and tumor stroma showing a possible autocrine and paracrine mechanism of this enzyme in breast cancer.

Proposta de sistematização do estudo elastográfico de lesões mamárias pela ultrassonografia / Proposal for the systematization of the elastographic study of mammary lesions through ultrasound scan

OBJETIVO: Propor uma sistematização do estudo elastográfico para emprego na rotina ultrassonográfica. MÉTODOS: Avaliação de 308 pacientes encaminhadas ao serviço de intervenção mamária do CTC-Gênese no período de 1 de maio de 2007 a 1 de março de 2008 para a realização de biópsia mamária percutânea. Antes da realização da biópsia percutânea foi realizado o estudo ultrassonográfico e a elastografia. As lesões foram primeiramente analisadas e classificadas conforme o léxico Bi-Rads pelo ultrassom convencional (modo B). Posteriormente, a elastografia foi realizada e analisada conforme sistematização proposta pelos autores, por meio das imagens obtidas durante a compressão e após a descompressão da área de interesse. As lesões foram classificadas conforme escores criados pelos autores: os escores 1 e 2 foram considerados benignos, o escore 3 como provavelmente benigno e o 4 como suspeito para malignidade. Foram comparados os resultados obtidos entre os dois métodos com os resultados histológicos utilizando as áreas dentro das curvas ROC (curvas operadores dependentes). RESULTADOS: A área dentro da curva para a elastografia foi de 0.952 com intervalo de confidência entre 0.910 e 0.966, erro de 0.023, e de 0.867 com intervalo de confidência entre 0.823 e 0.903, erro de 0.0333, para o ultrassom. Quando comparadas as áreas observou-se diferença entre as curvas de 0.026, estatisticamente significativa. CONCLUSÃO: Este trabalho apresenta uma sistematização do estudo elastográfico utilizando as informações obtidas durante a compressão e após a descompressão da amostra ultrassonográfica, demonstrando que a elastografia pode incrementar a avaliação do risco de malignidade para lesões caracterizadas pelo ultrassom.

OBJECTIVE: Proposal of systematization for the elastographic study in the ultrasound routine. METHODS: Evaluation was made of 308 patients forwarded to the breast intervention service in the CTC-Genesis from May 1, 2007 to March 1, 2008 to perform percutaneous breast biopsy. Prior to the percutaneous biopsy, an ultrasound study and an elastography were performed. Lesions were primarily analyzed and classified according to the Bi-Rads® lexicon criteria by the conventional ultrasound scan (B mode). The elastography was then performed and analyzed in accordance with the systematization proposed by the authors, using images obtained during compression and after decompression of the area of interest. Lesions were classified following the system developed by the authors using a four-point scale, where scores (1) and (2) were considered benign, score (3) probably benign and score (4) suspicion of malignancy. Results obtained by the two methods were compared with the histological results using the areas within the ROC (receiver operator curves) curves. RESULTS: The area within the curve for elastography was of 0.952 with a confidence interval between 0.910 and 0.966, error of 0.023, and of 0.867 with a confidence interval between 0.823 and 0.903, error of 0.0333 for the ultrasound. When the areas were compared, a difference between the curves of 0.026 was observed, which was statistically significant. CONCLUSION: This work shows the systematization of the elastographic study using information obtained during compression and after decompression of the ultrasound scan sample, thus showing that elastography might enhance the assessment of risk of malignancy for lesions characterized by the ultrasound.

Expressão da aromatase em carcinomas de mama ductais invasivo e in situ presentes na mesma mama / Aromatase expression in invasive and in situ ductal carcinoma present in the same breast

OBJETIVO: Avaliar expressão da enzima aromatase nos carcinomas de mama ductais invasivos (CDI), in situ (CDIS), no epitélio e estromas adjacentes. MÉTODOS: Foram avaliados 45 espécimes cirúrgicos provenientes de mastectomias e quadrantectomias com CDI e CDIS concomitantes de pacientes com estadios clínicos I e II. A análise da expressão da enzima aromatase foi realizada por meio de anticorpos policlonais antiaromatase e categorização das amostras de acordo com intensidade e número de células coradas. RESULTADOS: Nos 45 casos de CDI a expressão da aromatase foi positiva em 32 espécimes (71 por cento) e negativa em 13 (29 por cento). Nos casos de CDIS, a positividade foi idêntica à observada no CDI, mostrando correlação positiva. No epitélio normal constatou-se expressão positiva em 19 casos (42,2 por cento) e negativa nos outros 26 (57,8 por cento), mostrando correlação positiva estatisticamente (p<0,01), quando comparada com CDI e CDIS. Na análise do estroma normal a expressão da aromatase foi observada em apenas sete (15,5 por cento) dos 45 casos avaliados, não apresentando correlação com nenhuma variável analisada para expressão da aromatase. A presença da aromatase no estroma tumoral foi positiva em 36 casos (80 por cento) e negativa em 9 (20 por cento), mostrando correlação estatisticamente com a expressão no CDI (p<0,01) e no CDIS (p<0,01). Ao se comparar a expressão da aromatase no CDI, CDIS, epitélio normal e estroma tumoral com os graus nuclear e histológico, tamanho tumoral e idade da paciente, não foram encontradas diferenças estatisticamente significantes. CONCLUSÃO: Os resultados revelaram alta correlação entre expressão da aromatase no CDI, CDIS, epitélio normal e estroma tumoral, sugerindo possível mecanismo de ação autócrina e parácrina desta enzima na gênese do câncer de mama.

OBJECTIVE: to evaluate the expression of aromatase in simultaneously invasive ductal carcinoma (IDC) and ductal carcinoma in situ (DCIS). METHODS: forty-five surgical samples were obtained from mastectomy and quadrantectomy with simultaneous IDC and DCIS of stage I and II patients. Aromatase was evaluated using antibodies anti-aromatase and the samples classified in accordance with the number and intensity of stained cells. RESULTS: Aromatase was expressed positively in 32(71 percent) and negatively in 13(29 percent) of the cases in the IDC. The same results were obtained in the DCIS showing a perfect positive correlation. In the normal epithelium,aromatase was positive in 19(42.2 percent) and negative in 26 (57.8 percent) and a positive correlation, statistically significant was obtained when compared with IDC and DCIS(p<0.01). Concerning the normal stroma, positivity was only 7 (15.5 percent) showing no correlation with aromatase expression. Aromatase was positive in 36(80 percent) of the tumor stroma and this result was statistically significant as in the IDC and DCIS. Comparing results of aromatase expression with nuclear grade, histological grade, tumor size and age no difference was found. CONCLUSION: our results demonstrated high correlation between aromatase expression in IDC, DCIS, normal epithelium and tumor stroma showing a possible autocrine and paracrine mechanism of this enzyme in breast cancer.

Short report: cysticercosis of the breast, a rare imaging finding.

Parasitic infection of the breast is rare, especially in cases of cysticercosis. This disease is acquired by ingestion of tapeworm eggs in contaminated food and water supplies or from hands improperly washed after a bowel movement. Diagnosis is usually made incidentally. We report a patient with cysticercosis of the breast. The patient was a 63-year-old woman who had no clinical manifestations, but cysticercus was observed to cause calcifications detected by mammography. Computed tomography demonstrated brain lesions. A definitive diagnosis of cysticercosis was made by demonstration of characteristic calcified larvae. The definitive diagnosis was confirmed by excisional surgery.

Apresentação das lesões mamárias císticas à ultra-sonografia utilizando a elastografia / Features of cystic breast lesions at ultrasound elastography

OBJETIVO: Demonstrar a apresentação mais freqüente das lesões mamárias císticas utilizando a elastografia e discutir a sua aplicabilidade. MATERIAIS E MÉTODOS: A casuística compôs-se de 150 pacientes encaminhadas para realização de biópsia mamária percutânea com 175 lesões. Foram excluídas as lesões com diagnóstico histológico de lesões sólidas (153 lesões) e incluídas as lesões com características císticas à histologia (22 lesões), incluindo cistos complicados, lesões papilíferas, lesões inflamatórias, hiperplasia de células colunares típica e ectasia ductal. Estas lesões foram classificadas de forma retrospectiva por meio da elastografia, conforme escores criados pelos autores, variando de 1 a 4. RESULTADOS: Das 22 lesões encaminhadas, 13 (59 por cento) correspondiam a cistos, uma (4,6 por cento) a ectasia ductal, duas (9,2 por cento) a lesões inflamatórias, cinco (22,6 por cento) a lesões papilíferas e uma (4,6 por cento) a hiperplasia de células colunares. Foram encontrados 17 escores 2, quatro escores 3, um escore 4 e nenhum escore 1, com especificidade de 95 por cento. CONCLUSÃO: As lesões císticas mamárias têm diferentes apresentações à elastografia, conforme o resultado histológico, sendo este um método útil para a sua diferenciação e de fácil aplicabilidade na clínica diária.

OBJECTIVE: To demonstrate the most frequent features of cystic breast lesions at ultrasound elastography, discussing the applicability of this method. MATERIALS AND METHODS: The present casuistic included 150 patients referred for percutaneous breast biopsy of 175 lesions. Histologically diagnosed solid lesions (153 lesions) were excluded; lesions histologically diagnosed as cystic (22 lesions), including complicated cysts, papillary lesions, inflammatory lesions, typical columnar cell hyperplasia and duct ectasia were retrospectively classified by means of elastography, according to a scoring system developed by the authors, with categories ranging between 1 and 4. RESULTS: Thirteen (59 percent) of the 22 lesions evaluated corresponded to cysts, one (4.6 percent) to duct ectasia, two (9.2 percent) to inflammatory lesions, five (22.6 percent) to papillary lesions, and one (4.6 percent) to columnar cell hyperplasia. The scoring system was applied with the following results: 17 category 2 lesions, four category 3 lesions, one category 4 lesion, and none category 1 lesion, with a 95 percent specificity. CONCLUSION: Different features of cystic breast lesions are demonstrated by elastography according to histological results, representing a useful and easily applicable method for differentiating benign from malignant breast lesions.

Fatores de risco para o câncer de mama / Factors associated with increased risk of breast cancer

Pelo aumento da incidência do câncer de mama, a doença se constitui em um grande fardo para mulheres em todo mundo. Em países industrializados, o câncer de mama é a segunda causa de morte entre as mulheres. A etiologia do câncer de mama não é bem entendida, com fatores de riscos conhecidos explicando apenas pequena parte dos casos. Evidências indicam que exposição a fatores genéticos, ambientais e estilo de vida pode desempenhar importante papel na etiologia dessa doença. O objetivo deste estudo é revisar alguns fatores etiológicos e os mecanismos envolvidos no risco do câncer de mama. Baseado na literatura, há indícios que alguns fatores estão associados ao risco: idade, menarca precoce, menopausa tardia, história familiar, radiação ionizante, contraceptivos orais, terapia hormonal, mutação genética e condições clínicas tais como doença benigna da mama, idade precode da primeira gestação, paridade, amamentação e ingesta aumentada de álcool. Os fatores de risco que modulam o desenvolvimento do câncer de mama são discutidos nesta revisão. Todos esses fatores contribuem para o melhor entendimento do risco de câncer de mama e sugerem que se trata de doença multifatorial.

Ciclooxigenase-2 nos carcinomas ductais de mama invasivos com componente ductal in situ e no epitélio adjacente / Cyclooxygenase-2 in invasive ductal carcinoma with ductal component in situ and in adjacent epithelium

OBJETIVO: avaliar a presença da ciclooxigenase-2 (COX-2) nos carcinomas de mama ductal in situ (CDIS) e ductal invasivo (CDI), no estroma adjacente normal e no epitélio. A correlação entre os níveis de expressão com os graus nuclear e histológico, tamanho do tumor e idade da paciente foi também analisada. MÉTODOS: foram incluídos 47 espécimes cirúrgicos provenientes de mastectomias e quadrantectomias com CDI e CDIS concomitantes, estádios clínicos I e II. Foram utilizados anticorpos policlonais anti-COX-2 para determinar a expressão da enzima. As amostras foram categorizadas em escores de zero a três, de acordo com a intensidade e o número de células coradas. RESULTADOS: COX-2 foi positivamente expressa em CDI, CDIS e epitélio normal em 86,7, 84,4 e 73,3 por cento dos casos, respectivamente. Quanto ao grau nuclear (GN), a expressão da COX-2 foi positiva em 80 por cento dos casos de GN-I; 81,5 e 78,9 por cento de GN-II; e 88,5 e 96,1 por cento de GN-III no CDIS e CDI, respectivamente. A expressão da COX-2 ocorreu em 78,9 por cento dos CDIS com comedonecrose e em 89,3 por cento sem comedonecrose. Quanto ao grau histológico (GH) do CDI, a COX-2 foi positiva em 83,3 por cento de GH-I; 89,9 por cento de GH-II e 80 por cento de GH-III. Em relação ao diâmetro tumoral, COX-2 esteve presente em 86,1 por cento de CDI e 83,3 por cento de CDIS em tumores com >2 cm de diâmetro e 11 por cento em CDI; e CDIS em tumores ≤ 2 cm. A faixa etária ≥ 50 anos apresentou 90 por cento de expressão para CDI e 86,7 por cento para CDIS, e 92,5 por cento de COX-2 para ambos CDI e CDIS em pacientes com idade <50 anos. CONCLUSÕES: nossos resultados demonstram alta correlação entre as expressões da COX-2 nos CDI, CDIS e epitélio normal, o que é consistente com a hipótese de que a superexpressão da COX-2 é um evento precoce na carcinogênese mamária. Não houve diferença quando da análise do grau histológico, presença de comedonecrose, grupo etário e tamanho do tumor.

PURPOSE: to evaluate the expression of cyclooxygenase-2 (COX-2) in ductal carcinoma in situ (DCIS), invasive ductal carcinoma (IDC), adjacent normal stroma, and epithelium. The correlation of expression levels with nuclear grade, histological grade, presence or absence of comedonecrosis, tumor size, and patient age was also analyzed. METHODS: forty-seven surgical samples obtained from mastectomy and quadrantectomy with simultaneous DCIS and IDC, stages I and II were included. Anti-COX-2 polyclonal antibodies were used to determine enzyme expression. Samples were classified from zero to three, in accordance with number and intensity of stained cells. RESULTS: COX-2 was positively expressed in IDC, DCIS, and normal epithelium in 86.7, 84.4, and 73.3 percent of the cases, respectively. Concerning nuclear grade (NG), COX-2 expression was positive in 80 percent of cases of NG-I; in 81.5 and 78.9 percent of NG II, and in 88.5 and 96.1 percent of NG III in DCIS and IDC, respectively. COX-2 expression occurred in 78.9 percent of DCIS with comedonecrosis and in 89.3 percent without comedonecrosis. As to histological grade (HG) of IDC, COX-2 was positive in 83.3 percent of HG-I; 89.9 percent of HG-II and 80 percent of HG-III. Concerning tumor diameter, COX-2 was present in 86.1 percent of IDC cases and in 83.3 percent of DCIS larger than 2 cm and in 11 percent of IDC and DCIS tumors ≤2 cm. The age range ≥50 years presented 90 percent expression for IDC and 86.7 percent for DCIS, and the expression was 92.5 percent for both IDC and DCIS in patients <50 years. CONCLUSIONS: our results demonstrated high correlation between COX-2 expression in IDC, DCIS and in the normal epithelium, which is consistent with the hypothesis that COX-2 over expression is an early event in breast carcinogenesis. There was no significant correlation between COX-2 expression in IDC and DCIS and nuclear grade, histological grade, presence of comedonecrosis, age...

Valores preditivos das categorias 3, 4 e 5 do sistema BI-RADS em lesões mamárias nodulares não-palpáveis avaliadas por mamografia, ultra-sonografia e ressonância magnética / Predictive values of bi-rads categories 3, 4 and 5 in non-palpable breast masses evaluated by mammography, ultrasound and magnetic resonance imaging

OBJETIVO: Avaliar os valores preditivos positivo e negativo das categorias 3, 4 e 5 do sistema BI-RADS™ em lesões mamárias nodulares não-palpáveis avaliadas por mamografia, ultra-sonografia e ressonância magnética. MATERIAIS E MÉTODOS: Vinte e nove pacientes com achados mamográficos de lesões mamárias nodulares não-palpáveis, das classes 3, 4 e 5 do BI-RADS, que realizaram exames complementares de ultra-sonografia e ressonância magnética, além de biópsia excisional. Realizaram-se 30 biópsias e correlacionaram-se as lesões e suas respectivas classificações de 3 a 5 do BI-RADS com os resultados histopatológicos. O cálculo dos valores preditivos foi feito utilizando-se equações matemáticas específicas. RESULTADOS: O valor preditivo negativo da categoria 3 pela análise mamográfica foi de 69,23 por cento, pela análise ultra-sonográfica foi de 70,58 por cento e pela análise por ressonância magnética foi de 100 por cento. O valor preditivo positivo da categoria 4 pela análise mamográfica foi de 63,63 por cento, pela análise ultra-sonográfica foi de 50 por cento e pela análise por ressonância magnética foi de 30,76 por cento. O valor preditivo positivo da categoria 5 foi de 100 por cento pelas análises mamográfica e ultra-sonográfica e de 92,85 por cento pela análise por ressonância magnética. CONCLUSÃO: O valor preditivo negativo da categoria 3 foi elevado na análise pela ressonância magnética e os valores preditivos positivos foram moderados na categoria 4 e elevados na categoria 5 pelos três métodos.

OBJECTIVE: To evaluate the predictive value of BI-RADS™ categories 3, 4 and 5 in non-palpable breast masses assessed by mammography, ultrasound and magnetic resonance imaging MATERIALS AND METHODS: Twenty-nine patients with BI-RADS categories 3, 4 and 5 nonpalpable breast masses identified by mammograms were submitted to complementary ultrasound and magnetic resonance imaging studies, besides excisional biopsy. In total, 30 biopsies were performed. The lesions as well as their respective BI-RADS classification into 3, 4 and 5 were correlated with the histopathological results. The predictive values calculation was made by means of specific mathematical equations. RESULTS: Negative predictive values for category 3 were: mammography, 69.23 percent; ultrasound, 70.58 percent; and magnetic resonance imaging, 100 percent. Positive predictive values for category 4 were: mammography, 63.63 percent; ultrasound, 50 percent; and magnetic resonance imaging, 30.76 percent. For category 5, positive predictive values were: mammography and ultrasound, 100 percent; and magnetic resonance imaging, 92.85 percent. CONCLUSION: For category 3, the negative predictive value of magnetic resonance imaging was high, and for categories 4 and 5, the positive predictive values of the three modalities were moderate.

Quimioprevenção do câncer de mama / Current status of breast cancer chemoprevention

Quimioprevenção é definida como o uso de agentes químicos naturais ou sintéticos para reverter, suprimir ou prevenir a progressão carcinogênica para carcinoma invasor. Os fármacos que agem como agentes quimiopreventivos contra o câncer de mama são divididos em dois grupos principais: os que previnem cânceres de mama receptor de estrogênio (RE) positivos, como os moduladores seletivos do receptor de estrogênio (SERM), inibidores de aromatase, agonistas de GnRH e fitoestrogênios; e os fármacos que previnem os cânceres RE-negativos, como os inibidores da ciclooxigenase-2 (COX-2), retinóides, as estatinas, os inibidores do receptor tirosina quinase, o anticorpo monoclonal contra HER-2 e os inbidores da telomerase. Resultados do estudo conduzido pelo NSABP que comparou o tamoxifeno com o raloxifeno (STAR), avaliando a eficácia na redução de risco, assim como a toxicidade desses dois SERMs em uma população similar e de alto risco para câncer de mama, demonstrou que o raloxifeno é tão efetivo quanto o tamoxifeno na redução de risco de câncer de mama invasor (p=0,83) e apresentou menor risco de eventos tromboembólicos e catarata; todavia, exibiu maior risco de carcinoma não invasor, porém sem significância estatística. Baseado nos dados promissores que revelaram diminuição de risco de câncer de mama contralateral em estudos de adjuvância, alguns inibidores de aromatase, incluindo o letrozol, anastrazol e exemestane, estão sendo incorporados em investigações para avaliar sua eficácia como agentes preventivos de alto risco em mulheres. Os inibidores de COX-2 demonstraram sua eficácia na prevenção do câncer de mama em estudos caso-controle e coorte, sendo necessários estudos aleatórios para atestar sua eficácia. O resultado positivo de alguns ensaios clínicos na prevenção do câncer de mama em populações de alto risco sugere que a quimioprevenção é uma estratégia racional e atraente.

Chemoprevention is defined as the use of natural or synthetic chemical agents to reverse, suppress or prevent carcinogenic progression of invasive cancer. Drugs that act as chemoprevention agents for breast cancer are divided into two major groups: drugs that prevent Estrogen Receptor (ER) - positive breast cancers [selective estrogen receptor modulators (SERM), aromatase inhibitors GnKH agonists and phytoestrogens] and drugs that prevent ER - negative breast cancers [cyclooxygenase-2 (COX-2) inhibitors, retinoids, statins, receptor tyrosine, kinase inhibitors, monoclonal antibody against HER-2 and telomerase inhibitors]. Results from the NSABP Study of Tamoxifen and Raloxifene (STAR), which compared the risk-reducing efficacy as well as toxicity of these two SERMs in a similar high-risk for breast cancer population, showed that Raloxifene is as effective as Tamoxifen in reducing the risk of non-invasive breast cancer (p=.83). It has a statistically significant lower risk of thromboembolic events and cataracts, however a non- statistically significant higher risk of noninvasive breast cancer. Based on promising data involving reduction of contralateral breast cancer risk in adjuvant studies, several aromatase inhibitors, including letrozole, anastrozole and exemestane, are being included in trials to evaluate their efficacy in breast cancer prevention in both case-control and cohort studies As such randomized studies to confirm this efficacy are needed. Positive results of several recent clinical trials for preventing breast cancer in high-risk populations suggest that chemoprevention is a rational and attractive strategy.

[Current status of breast cancer chemoprevention]. / Quimioprevenção do câncer de mama.

Chemoprevention is defined as the use of natural or synthetic chemical agents to reverse, suppress or prevent carcinogenic progression of invasive cancer. Drugs that act as chemoprevention agents for breast cancer are divided into two major groups: drugs that prevent Estrogen Receptor (ER)-positive breast cancers [selective estrogen receptor modulators (SERM), aromatase inhibitors GnKH agonists and phytoestrogens] and drugs that prevent ER-negative breast cancers [cyclooxygenase-2 (COX-2) inhibitors, retinoids, statins, receptor tyrosine, kinase inhibitors, monoclonal antibody against HER-2 and telomerase inhibitors]. Results from the NSABP Study of Tamoxifen and Raloxifene (STAR), which compared the risk-reducing efficacy as well as toxicity of these two SERMs in a similar high-risk for breast cancer population, showed that Raloxifene is as effective as Tamoxifen in reducing the risk of non-invasive breast cancer (p=.83). It has a statistically significant lower risk of thromboembolic events and cataracts, however a non- statistically significant higher risk of noninvasive breast cancer. Based on promising data involving reduction of contralateral breast cancer risk in adjuvant studies, several aromatase inhibitors, including letrozole, anastrozole and exemestane, are being included in trials to evaluate their efficacy in breast cancer prevention in both case-control and cohort studies As such randomized studies to confirm this efficacy are needed. Positive results of several recent clinical trials for preventing breast cancer in high-risk populations suggest that chemoprevention is a rational and attractive strategy.

Quantificação dos linfonodos axilares obtidos em cirurgias para câncer na mama e sua correlação com dados terapêuticos e variáveis epidemiológicas / Quantitation of axillary lymph nodes obtained during surgical treatment of patients with breast cancer and its correlation with therapeutic results and epidemiologic variables

A dissecção axilar completa apresenta elevada morbidade, o que coloca em questão a necessidade de extensos procedimentos cirúrgicos de rotina na axila. Para tumores mamários em estádios iniciais pode-se realizar apenas o estudo do linfonodo sentinela. Nos demais estádios faz-se a dissecção completa dos linfonodos axilares, sendo considerada adequada uma amostragem que contenha dez ou mais desses linfonodos. Este estudo retrospectivo quantifica os linfonodos axilares e correlaciona esse número com dados terapêuticos e variáveis epidemiológicas, verificando a influência desses fatores no número de linfonodos axilares dissecados em cem pacientes com diagnóstico de carcinoma ductal infiltrante na mama submetidos a tratamento cirúrgico com esvaziamento axilar homolateral no Departamento de Obstetrícia e Ginecologia da Santa Casa de São Paulo durante o ano de 2002. Concluiu-se que não há relação entre o número de linfonodos axilares, dissecados ou comprometidos pela neoplasia maligna na mama e faixa etária, grupo étnico, profissão, tempo decorrido para o diagnóstico da doença, cirurgião responsável pelo esvaziamento axilar e estadiamento da doença. Existe relação entre a quantidade de linfonodos axilares dissecados e a de comprometidos pelo carcinoma na mama: para cada dez linfonodos axilares dissecados encontramos um linfonodo comprometido pela neoplasia na mama.

Relação da angiogênese no carcinoma ductal primário da mama e a existência ou superveniência de metástases nos linfonodos axilares / Relationship of angiogenesis in the primary carcinoma of the breast and the existence or supervenience of metastasis in the axillary lymph nodes

O diagnóstico preciso do estádio evolutivo do câncer de mama é crítico antes do tratamento e das decisões de conduta. O prognóstico da paciente pode, então, ser estimado com base em vários fatores, entre os quais o estado dos linfonodos axilares e a angiogênese do tumor primário. Angiogênese é o processo que permite a formação de novos vasos provenientes da rede vascular preexistente. É mecanismo complexo, que conduz a um fenótipo angiogênico parcialmente conhecido, envolvendo alterações bioquímicas, moleculares, genéticas e celulares. Tendo em vista as discrepâncias existentes na literatura quanto ao valor dos marcadores dos antígenos das células endoteliais no carcinoma primário da mama e a inexistência de trabalhos nacionais sobre o assunto, neste estudo avaliou-se o papel dos anticorpos para o CD34 e o fator de crescimento vascular endotelial(VEGF) na identificação da angiogênese do carcinoma primário da mama, com vistas e possibilidades da existência de metástases dos linfonodos axilares. Foram estudadas 62 pacientes com carcinoma ductal invasivo primário da mama submetidas a tratamento cirúrgico radical ou conservador e linfonodectomia axilar. Pesquisaram-se as expressões dos marcadores angiogênicos CD34 e VEGF relacionados com variáveis clínicas e laboratoriais, com ênfase nos linfonodos axilares. Os resultados obtidos não permitiram inferir a existência de metástases nos linfonodos axilares antes da operação

Emprego da técnica de alta freqüência na mastectomia radical para redução da drenagem pósðoperatória / The use of electrosurgery in radical mastectomy reducing postoperative drainage

Este estudo teve como propósito verificar se a utilização de cirurgia com bisturi de alta freqüência apresenta eficácia para reduzir a quantidade de material líquido drenado após a realização de mastectomia radical. A cirurgia de alta freqüência foi empregada em 15 mastectomias realizadas no tratamento de câncer mamário nos estádios clínicos II e III. O grupoðcontrole consistiu em 15 portadoras de câncer mamário, nos mesmos estádios clínicos, que foram submetidas à mastectomia radical pela técnica convencional. A análise estatística dos resultados revelou que o volume total drenado foi significatimente menor no grupo de estudo