Surgical anatomy of the internal thoracic lymph nodes in fresh human cadavers: basis for sentinel node biopsy.

BACKGROUND: While the optimal management of early breast cancer patients with sentinel lymph node (SLN) involvement mapped in the internal thoracic chain is still debated, biopsy may be performed when surgeons select patients who are most likely to benefit. The aim of this study is to examine anatomical aspects of internal thoracic nodes (ITNs) to orientate SLN biopsy in the parasternal area. METHODS: This study was based on dissections of 29 female cadavers. The parameters analyzed were the number of intercostal spaces (ICSs) containing at least one ITN, mean number of nodes in each ICS, position of the ITNs in relation to the internal thoracic artery (ITA), number of retrocostal spaces (RCSs) containing at least one ITN, and mean number of nodes in each RCS. RESULTS: The ICS that was most likely to have at least one ITN was the third, with 86.2% in the right side and 75.8% in the left side. In the second ICS, the rates were 69.2 and 73.6%, and in the fourth, the rates were 48.1 and 33.3%. In the third ICS, on both sides, the mean number of ITNs was the highest (1.2). A tendency of the nodes to be laterally located in the second ICS and medially located in the downward dissection was observed. Most of the RCSs did not present any nodes. CONCLUSIONS: This study indicates that most of the second and third ICSs presented at least one ITN, and the mean number of nodes in the third space was greater. There is a tendency to find nodes medial to the artery downwards from the second to the fourth ICS. ITNs are generally located in ICSs, and the majority of RCSs did not contain any nodes.

Magnetic resonance imaging-guided occult breast lesion localization and simultaneous sentinel lymph node mapping.

BACKGROUND: Radio-guided occult lesion localization is a valid technique for the diagnosis of suspicious non-palpable lesions. Here we determine the feasibility of pre-operative localization of occult suspect non-palpable breast lesions using radio-guided occult lesion localization, as well as for identifying the sentinel lymph node. METHODS: This is a descriptive study of data collected retrospectively. Pre-operative mapping of 34 breast lesions in 25 patients suspected of being malignant was performed using conventional imaging methods with a magnetic resonance imaging-guided radiopharmaceutical injection. RESULTS: The mean time required to perform the localization was 25 minutes. After resection of the lesions using a gamma probe, malignancy was confirmed in fifteen patients (60.0%), with nine invasive ductal carcinomas, two invasive lobular carcinomas, and four in situ ductal carcinomas The resection was confirmed by the complete removal of the radioactive material. The pathologic results and images were concordant in all but two cases, which were submitted for new magnetic resonance imaging examinations and surgery that confirmed the malignancies. Of the 15 patients with confirmed malignancies, 10 had sentinel lymph node resection. Of these, eight were negative for metastases, one had micro-metastases and one had confirmed metastases. Three patients had full axillary node dissection, with metastases found in only one. No side effects were observed with magnetic resonance-guided radiopharmaceutical injection. CONCLUSIONS: The sentinel node occult lesion localization technique is a simple, reproducible and effective alternative approach to occult lesions compared to other methods, such as mammotomy and the hook-wire localization technique, for mapping suspect breast lesions and identifying lymph node metastasis.

Long-Term Results of Intraoperative Radiation Therapy for Early Breast Cancer Using a Nondedicated Linear Accelerator.

Purpose: To present the long-term results of intraoperative radiation therapy (IORT) for early breast cancer using a nondedicated linear accelerator. Methods and Materials: The eligibility criteria were biopsy-proven invasive carcinoma, age ≥40 years, tumor size ≤3 cm, and N0M0. We excluded multifocal lesions and sentinel lymph node involvement. All patients had previously undergone breast magnetic resonance imaging. Breast-conserving surgery with margins and sentinel lymph node evaluation using frozen sections were performed in all cases. If there were no margins or involved sentinel lymph nodes, the patient was transferred from the operative suite to the linear accelerator room, where IORT was delivered (21 Gy). Results: A total of 209 patients who were followed up for ≥1.5 years from 2004 to 2019 were included. The median age was 60.3 years (range, 40-88.6), and the mean pT was 1.3 cm (range, 0.2-4). There were 90.5% pN0 cases (7.2% of micrometastases and 1.9% of macrometastases). Ninety-seven percent of the cases were margin free. The rate of lymphovascular invasion was 10.6%. Twelve patients were negative for hormonal receptors, and 28 patients were HER2 positive. The median Ki-67 index was 29% (range, 0.1-85). Intrinsic subtype stratification was as follows: luminal A, 62.7% (n = 131); luminal B, 19.1% (n = 40); HER2 enriched 13.4% (n = 28); and triple negative, 4.8% (n = 10). Within the median follow-up of 145 months (range, 12.8-187.1), the 5-year, 10-year, and 15-year overall survival rates were 98%, 94.7%, and 88%, respectively. The 5-year, 10-year, and 15-year disease-free rates were 96.3%, 90%, and 75.6%, respectively. The 15-year local recurrence-free rate was 76%. Fifteen local recurrences (7.2%) occurred throughout the follow-up period. The mean time to local recurrence was 145 months (range, 12.8-187.1). As a first event, 3 cases of lymph node recurrence, 3 cases of distant metastasis, and 2 cancer-related deaths were recorded. Tumor size >1 cm, grade III, and lymphovascular invasion were identified as risk factors. Conclusions: Despite approximately 7% of recurrences, we may infer that IORT may still be a reasonable option for selected cases. However, these patients require a longer follow-up as recurrences may occur after 10 years.

One year follow-up on a randomized study investigating serratus anterior muscle and pectoral nerves type I block to reduced neuropathic pain descriptors after mastectomy.

Breast cancer is the second most common diagnosed type of cancer in women. Chronic neuropathic pain after mastectomy occurs frequently and is a serious health problem. In our previous single-center, prospective, randomized controlled clinical study, we demonstrated that the combination of serratus anterior plane block (SAM) and pectoral nerve block type I (PECS I) with general anesthesia reduced acute postoperative pain. The present report describes a prospective follow-up study of this published study to investigate the development of chronic neuropathic pain 12 months after mastectomy by comparing the use of general anesthesia alone and general anesthesia with SAM + PECS I. Additionally, the use of analgesic medication, quality of life, depressive symptoms, and possible correlations between plasma levels of interleukin (IL)-1 beta, IL-6, and IL-10 collected before and 24 h after surgery as predictors of pain and depression were evaluated. The results showed that the use of SAM + PECS I with general anesthesia reduced numbness, hypoesthesia to touch, the incidence of patients with chronic pain in other body regions and depressive symptoms, however, did not significantly reduce the incidence of chronic neuropathic pain after mastectomy. Additionally, there was no difference in the consumption of analgesic medication and quality of life. Furthermore, no correlation was observed between IL-1 beta, IL-6, and IL-10 levels and pain and depression. The combination of general anesthesia with SAM + PECS I reduced the occurrence of specific neuropathic pain descriptors and depressive symptoms. These results could promote the use of SAM + PECS I blocks for the prevention of specific neuropathic pain symptoms after mastectomy.Registration of clinical trial: The Research Ethics Board of the Hospital Sirio-Libanes/Brazil approved the study (CAAE 48721715.0.0000.5461). This study is registered at Registro Brasileiro de Ensaios Clinicos (ReBEC), and ClinicalTrials.gov, Identifier: NCT02647385.

Association Between GATA3 and Histopathological and Immunohistochemical Parameters in Early-Infiltrating Breast Carcinomas.

Objective: This study evaluated the frequency of GATA-binding protein 3 (GATA3) expression in early breast cancer and its relationship with histopathological and immunohistochemical parameters. Materials and Methods: GATA3 was analysed by immunohistochemistry in histological sections of tumors from 105 female patients, with histological diagnosis of invasive breast carcinoma (BC), at clinical stages I, II and IIIA, who underwent primary surgical treatment. GATA3 nuclear expression was determined as the percentage of positive tumor cells and further categorized as high (positive expression in more than 95% of cells) or non-high (negative or low positive expression in up to 95% of tumor cells). GATA3 expression was analysed according to the patient age, tumor and node pathological stage, histological type, histological and nuclear grade, lymphovascular invasion, and estrogen receptor (ER), progesterone receptor (PR), androgen receptor (AR), human epidermal growth factor 2 (HER2) status, and Ki-67 expression. Results: GATA3 expression was positive in 103 cases (98.1%). High expression was significantly associated with low histological and nuclear grade, positive hormonal receptors, and less proliferative activity based on Ki-67 expression. A prominent feature was that 94.7% of the ER-positive/HER2-negative cases presented high-GATA3 expression, as 94.0% of the tumors showing high-GATA3 were ER-positive. In ER-negative/HER2-positive or ER-negative/HER2- negative, high-GATA3 was present in 25% while 75% were non-high-GATA3 compared with ER-positive/HER2- negative (4.1%) and ER-positive/HER2-positive (20%). Proliferative activity in triple-negative breast cancer tended to be higher among tumors with low-GATA3, irrespective of AR expression. In the group of ER-positive/HER2-negative tumors only three cases were low-GATA3 (85% and 80%), both with high proliferative activity. Conclusion: High GATA3 expression is associated with favorable histopathologic and immunohistochemical BC prognostic factors.

Extended Sentinel Node Biopsy in Breast Cancer Patients who Achieve Complete Nodal Response with Neoadjuvant Chemotherapy.

Neoadjuvant chemotherapy (NAC) can eradicate axillary disease in breast cancer (BC) patients. Sentinel node biopsy (SNB) in patients with positive axilla who accomplish complete clinical response after NAC is a new opportunity for changing paradigms and decreasing the extension and the morbidity of axillary surgery. The aim of this article is to review the limits of SNB in this setting and present the current status of an expanded modification of this technique. False-negative rates (FNRs) of conventional SNB exceed the threshold of 10%, and are not acceptable. The extended SNB (ESNB) entails the removal of at least 3 lymph nodes (LNs) including the sentinel node (SN) mapped by dual tracers and a marked lymph node (LN) that was found previously metastatic. This node by node removal procedure greatly reduces the FNRs of the procedure. Despite that axillary lymph node dissection (ALND) is still the standard of care for patients with involved LNs before NAC, the ESNB is a valid option for selected patients in whom axillary positive disease is converted to negative. When ESNB is negative in such cases (immunohistochemistry included), the omission of ALND seems to be safe.

Nipple-sparing mastectomy for early breast cancer: the importance of intraoperative evaluation of retroareolar margins and intra-nipple duct removal.

BACKGROUND: Nipple-sparing mastectomy (NSM) is increasingly performed for breast cancer (BC) treatment. To ensure local control with this procedure, it is important to obtain clear surgical margins. Here, we aimed to estimate the confidence in intraoperative evaluation of the retroareolar margin (IERM) and the necessity of removing the intra-nipple ducts. METHODS: In this retrospective cohort study, we evaluated 224 BC (infiltrating carcinoma 178, ductal carcinoma in situ 46) patients, who underwent NSM. IERM was determined via cytology and frozen sections. Following gland removal, the intra-nipple ducts were excised and embedded in paraffin for analysis. The retroareolar tissue was also paraffin-embedded and reanalyzed for definitive evaluation of retroareolar margins (DERM). The IERM predictive capacity in relation to DERM and the frequency of intra-nipple duct involvement were estimated. RESULTS: IERM classified the sub-nipple areolar complex area as cancer-free in 219 cases (97.8%). The condition of clear retroareolar margin was confirmed by DERM in 216 cases (98.6%). The IERM accuracy was estimated as 98.6%. Ductal carcinoma in situ was detected in intra-nipple ducts using paraffin sections in 1.8% of the cases, despite clear IERM (4/219). CONCLUSIONS: In conclusion, IERM affords high accuracy and its results are suitable to manage the nipple-areolar complex. Nevertheless, some patients may retain residual disease in the intra-nipple ducts; thus, these ducts should ideally be removed during NSM.

Mammary adenectomy followed by immediate reconstruction for treatment of patients with early-infiltrating breast carcinoma: a cohort study.

BACKGROUND: Use of mammary adenectomy for breast carcinoma treatment remains controversial. OBJECTIVE: This study aimed to verify the oncological safety of mammary adenectomy and immediate breast reconstruction for treating selected patients with infiltrating breast carcinoma and to evaluate patients' satisfaction with the reconstructed breasts. DESIGN AND SETTING: Cohort study conducted among patients treated at Hospital Sírio-Libanês, São Paulo, Brazil. METHODS: This study was based on 152 selected patients (161 operated breasts) with infiltrating breast carcinoma who underwent mammary adenectomy and immediate breast reconstruction. In all patients, the diameter of the largest focus of the tumor was less than 3.0 cm, the imaging tumor-nipple distance was greater than 2.0 cm and the pathological assessment showed clear margins. The cumulative incidence of local recurrence (LR), recurrence-free survival (RFS) and overall survival (OS) curves were estimated using the Kaplan-Meier method. After at least one year of follow-up, 64 patients were asked about their satisfaction with the reconstructed breast(s). RESULTS: At a mean follow-up time of 43.5 months, seven cases of LR (4.4%), four distant metastases (2.6%) and five deaths (3.3%) were recorded. The five-year actuarial LR-free survival, RFS and OS were 97.6%, 98.3% and 98.3%, respectively. No cases of nipple-areolar complex recurrence were reported. Forty-one patients (64%) indicated a high level of satisfaction with the reconstructed breasts. CONCLUSIONS: Mammary adenectomy is a safe and efficacious procedure for selected patients with early-infiltrating breast carcinoma and results in a high rate of patient satisfaction with the reconstructed breasts.

Is it possible to predict underestimation in ductal carcinoma in situ of the breast? Yes, using a simple score!

BACKGROUND: Approximately 30% of patients with an initial diagnosis of ductal carcinoma ductal in situ (DCIS) present stromal invasion in the final surgical specimen. This study aimed to describe the prevalence of upstaging in women with an initial diagnosis of pure DCIS and identify predictive factors of invasion. METHODS: This is a cross-sectional study including patients with an initial unilateral DCIS diagnosed through needle core or vacuum-assisted biopsy. All patients were submitted to surgical excision. Clinical, radiological and histological variables were retrospectively collected from our medical records. RESULTS: A total of 169 biopsies diagnosed with DCIS were included in this study. 53 patients presented upstaging for invasive carcinoma (31.4%). In the univariate analysis the following variables were significantly associated with invasive breast carcinoma (IBC) at final diagnosis: age < 46 years, the presence of a palpable mass, type of biopsy, nuclear grade, and comedonecrosis. The frequency of upstaging did not vary according to the tumor size or menopausal status. In the multivariate analysis, only the type of biopsy and the presence of comedonecrosis remained as independent predictors of invasion. Our score attributed specific points according to the type of biopsy and the presence of comedonecrosis, ranging from 0 to 2.5, showing a very good predictive ability. CONCLUSIONS: We were able to identify that the type of biopsy and comedonecrosis are predictive factors of stromal invasion among women with DCIS. The proposed score has shown a good predictive ability and its utilization in the clinical practice can improve therapeutic planning.

NDRG4 promoter hypermethylation is a mechanistic biomarker associated with metastatic progression in breast cancer patients.

The risk of developing metastatic disease in breast cancer patients is traditionally predictable based on the number of positive axillary lymph nodes, complemented with additional clinicopathological factors. However, since lymph node-negative patients have a 20-30% probability of developing metastatic disease, lymph node information alone is insufficient to accurately assess individual risk. Molecular approaches, such as multigene expression panels, analyze a set of cancer-related genes that more accurately predict the early risk of metastasis and the treatment response. Here, we present N-Myc downstream-regulated gene 4 (NDRG4) epigenetic silencing as a mechanistic biomarker of metastasis in ductal invasive breast tumors. While aberrant NDRG4 DNA hypermethylation is significantly associated with the development of metastatic disease, downregulation of NDRG4 transcription and protein expression is functionally associated with enhanced lymph node adhesion and cell mobility. Here, we show that epigenetic silencing of NDRG4 modulates integrin signaling by assembling ß1-integrins into large punctate clusters at the leading edge of tumor cells to promote an "adhesive switch," decreasing cell adhesion to fibronectin and increasing cell adhesion and migration towards vitronectin, an important component of human lymph nodes. Taken together, our functional and clinical observations suggest that NDRG4 is a potential mechanistic biomarker in breast cancer that is functionally associated with metastatic disease.

Cat scratch disease presenting as axillary lymphadenopathy and a palpable benign mammary nodule mimicking a carcinoma.

We present a case involving a 74-year-old woman with cat scratch disease characterized by an enlarged and hard axillary lymph node as well as a palpable breast nodule mimicking a carcinoma. The lymph node and the breast nodule were excised. The pathologic examinations revealed granulomatous lymphadenitis with gram-negative bacilli and an intraductal papilloma. Antibiotic therapy (azithromycin) was prescribed and the patient's clinical evolution was excellent.

Benefits in radical mastectomy protocol: a randomized trial evaluating the use of regional anesthesia.

Surgery is the first-line treatment for early, localized, or operable breast cancer. Regional anesthesia during mastectomy may offer the prevention of postoperative pain. One potential protocol is the combination of serratus anterior plane block (SAM block) with pectoral nerve block I (PECS I), but the results and potential benefits are limited. Our study compared general anesthesia with or without SAM block + PECS I during radical mastectomy with axillary node dissection and breast reconstruction using evaluations of pain, opioid consumption, side effects and serum levels of interleukin (IL)-1beta, IL-6 and IL-10. This is a prospective, randomized controlled trial. Fifty patients were randomized to general anesthesia only or general anesthesia associated with SAM block + PECS I (25 per group). The association of SAM block + PECS I with general anesthesia reduced intraoperative fentanyl consumption, morphine use and visual analog pain scale scores in the post-anesthetic care unit (PACU) and at 24 h after surgery. In addition, the anesthetic protocol decreased side effects and sedation 24 h after surgery compared to patients who underwent general anesthesia only. IL-6 levels increased after the surgery compared to baseline levels in both groups, and no differences in IL-10 and IL-1 beta levels were observed. Our protocol improved the outcomes of mastectomy, which highlight the importance of improving mastectomy protocols and focusing on the benefits of regional anesthesia.

Reliability of inferior dermoglandular pedicle reduction mammaplasty in reconstruction of partial mastectomy defects: surgical planning and outcome.

The objective of this study is to describe the surgical planning of the inferior dermoglandular pedicle (IDP) technique and its outcome following partial mastectomy reconstruction. A total of 26 patients with breast cancer underwent immediate IDP reconstruction. IDP was indicated to reconstruct superior/central breast defects. Postoperative complications were evaluated and information on esthetic result and satisfaction were collected. About 57.6 percent had tumors measuring 2cm or less (T1). Immediate complications occurred in 34.2 percent with skin necrosis in 11.4 and dehiscence in 7.6 percent. Late complications were observed in 11.4 percent. The cosmetic result was considered to be good or very good in 88.4 percent and the majority of patients were satisfied. All complications were treated by conservative approach. IDP is a reliable technique and should be given consideration in cases of superior/central quadrant reconstruction. The success of the procedure depends on patient selection and careful intra-operative management.

Multidisciplinary international survey of post-operative radiation therapy practices after nipple-sparing or skin-sparing mastectomy.

PURPOSE/OBJECTIVE(S): Skin sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) have entered routine surgical practice for breast cancer, though their oncologic safety has not been established in randomized controlled trials. The aim of this study was to evaluate and compare radiation oncologists' and breast surgeons' opinions concerning the indications of post-operative radiation therapy (PORT) after SSM and NSM. MATERIALS/METHODS: Radiation oncologists and breast surgeons from North America, South America and Europe were invited to contribute in this study. A 22-question survey was used to evaluate their opinions. RESULTS: A total of 550 physicians (298 radiation oncologists and 252 breast surgeons) answered the survey. The majority of responders affirmed that PORT should be performed in early-stage (stages I and II) breast cancer for patients who present with risk factors for relapse after SSM and NSM. They considered age, lymph node involvement, tumor size, extracapsular extension, involved surgical margins, lymphovascular invasion, triple negative receptor status and multicentric presentation as major risk factors. Considering that after SSM and NSM, residual breast tissue can be left behind, the residual tissue considered as acceptable in the context of an oncologic surgery were 1-5 mm for breast surgeons. There is no consensus for the necessity of evaluating residual breast tissue through breast imaging. CONCLUSION: Although the indications of PORT after SSM and NSM vary among practitioners, standard risk factors for relapse are considered as important by radiation oncologists and breast surgeons.

Measuring plasma levels of three microRNAs can improve the accuracy for identification of malignant breast lesions in women with BI-RADS 4 mammography.

A BI-RADS category of 4 from a mammogram indicates suspicious breast lesions, which require core biopsies for diagnosis and have an approximately one third chance of being malignant. Human plasma contains many circulating microRNAs, and variations in their circulating levels have been associated with pathologies, including cancer. Here, we present a novel methodology to identify malignant breast lesions in women with BI-RADS 4 mammography. First, we used the miRNome array and qRT-PCR to define circulating microRNAs that were differentially represented in blood samples from women with breast tumor (BI-RADS 5 or 6) in comparison to controls (BI-RADS 1 or 2). Next, we used qRT-PCR to quantify the level of this circulating microRNAs in patients with mammograms presenting with BI-RADS category 4. Finally, we developed a machine learning method (Artificial Neural Network - ANN) that receives circulating microRNA levels and automatically classifies BI-RADS 4 breast lesions as malignant or benign. We identified a minimum set of three circulating miRNAs (miR-15a, miR-101 and miR-144) with altered levels in patients with breast cancer. These three miRNAs were quantified in plasma from 60 patients presenting biopsy-proven BI-RADS 4 lesions. Finally, we constructed a very efficient ANN that could correctly classify BI-RADS 4 lesions as malignant or benign with approximately 92.5% accuracy, 95% specificity and 88% sensibility. We believe that our strategy of using circulating microRNA and a machine learning method to classify BI-RADS 4 breast lesions is a non-invasive, non-stressful and valuable complementary approach to core biopsy in women with BI-RADS 4 lesions.

Nipple-sparing mastectomy for breast cancer and risk reduction: oncologic or technical problem?

BACKGROUND: We evaluated the risks and benefits of nipple-sparing mastectomy in a multiinstitutional experience in the settings of risk-reducing surgery and breast cancer treatment. STUDY DESIGN: We analyzed data on 123 patients who had undergone nipple-sparing mastectomy with breast reconstruction for prophylaxis (n=55), treatment of breast cancer (n=41), or both (n=27) at four large centers. RESULTS: Median patient age was 45 years (range 22 to 70 years). There were 192 procedures (69 bilateral, 54 unilateral). Forty-four patients had invasive cancer; 20 had ductal carcinoma in situ (DCIS); 4 had phyllodes tumor. In all of these patients, the nipple tissue was cancer free on pathologic review. Median followup was 24.6 months (range 2.0 to 570.4 months). Local recurrence developed in two patients: one had DCIS in the upper-outer quadrant, with 71.8 months of followup; the other's cancer was invasive, in the upper-outer quadrant, with 6 months of followup. Distant metastasis developed in a third patient, who died 50 months after the procedure. Breast cancer developed in two patients after prophylactic mastectomy: one in the upper-outer quadrant at 61.8 months; one in the axillary tail at 24.4 months. No patients had recurrences in the nipple-areolar complex. Necrosis of the nipple was reported in 22 of 192 patients (11%) and it was judged minimal (less than one-third total skin of nipple) in 13 of 22 patients (59%). Overall cosmesis was judged by the patient and surgeon as good to excellent in the majority of patients. Level of satisfaction with cosmetic results was similar between prophylactic and treatment patients. CONCLUSIONS: The risk of local relapse was very low in our series of nipple-sparing mastectomies performed for DCIS or invasive cancer. Nipple-sparing mastectomy in the risk-reducing and breast cancer-treatment settings may be feasible in selected patients and should be the subject of additional prospective clinical trials.

The safe association of intraoperative evaluation of surgical margins and neoadjuvant chemotherapy in breast cancer larger than 3 centimeters.

OBJECTIVES AND BACKGROUND: The objective of the present study was to determine whether neoadjuvant chemotherapy in women with breast cancer larger than 3 cm associated with breast-conserving surgery plus intraoperative evaluation of surgical margins is safe. METHODS: A total of 164 patients with breast cancer larger than 3 cm in diameter were submitted to neoadjuvant chemotherapy between 1992 and 1998 and followed until 2003. We used neoadjuvant chemotherapy in pulses at 21-day intervals with 5-fluorouracil (500 mg/m2), epirubicin (50 mg/m2) and cyclophosphamide (500 mg/m2) (FEC). Initially, 3 cycles of chemotherapy were administered, followed by surgery and 6 additional chemotherhapy cycles. During surgery, an evaluation of the surgical margins was performed. RESULTS: Quadrantectomy was performed in 102 patients (62.2%) and mastectomy in 62 (37.8%). Local recurrence in 8 patients, metastasis in 37, and 21 deaths were observed. The curves of local recurrence for quadrantectomy and mastectomy were similar (P = 0.654 and P = 0.841, respectively), and so were the numbers of local recurrence (P = 0.4438). The curves of disease-free survival for quadrantectomy and mastectomy were different (P = 0.034 and P = 0.033, respectively). However, no statistically significant difference was observed in the number of events (P = 0.1283). A statistically significant difference was observed for the curves (P = 0.001 and P = 0.000) and the number (P = 0.0034) of deaths between patients undergoing quadrantectomy or mastectomy. CONCLUSIONS: Neoadjuvant chemotherapy can reduce surgery complexity and is safe when associated with intraoperative evaluation of the surgical margins, without changing the local recurrence rate, disease-free survival, and overall survival.

Clinic, pathologic and molecular landscapes in ultra-young women with breast cancer in the State of São Paulo: a real-world study

Introduction: Breast cancer (BC) centers are increasingly attending "ultra-young" women (UYW) patients (≤ 30 years), who usually present aggressive tumors and face specific problems. Objectives: We aimed to examine a multicentric casuistic view, addressing clinicopathological and molecular characteristics of BC, as well as therapeutic measures and oncological outcomes. Methods: A retrospective multicentric observational study of UYW with infiltrating BC was carried out. The patients were treated between the period from January 1991 to December 2019. Clinical, epidemiological, morphological, molecular, therapeutic and outcomes data were collected from the charts. Results: A total of 293 patients were followed for a average period of 34.5 months. Nulliparity was referred by 204 women (75.5%), of whom 81 (37.1%) were overweight or obese. Positive family history in first-degree relatives was verified in 25 patients (10.1%). Only 30 patients underwent genetic tests, which revealed inherited pathogenic mutations in 12 of them (37.5%). Thirty-two (32) cases were classified as T1 at diagnosis (10.9%), while "De novo" stage IV was found in 29 patients (9.8%). Mastectomy was performed in 175 women (70.2%), quadrantectomy in 46 women (18.4%), and mammary adenectomies in 28 women (11.2%), of which 149 cases were reported after neoadjuvant chemotherapy (56.0%). A total of 111 patients had at least one positive lymph node (47.4%). The rate of patients with estrogen receptor-negative was 32.7% and the rate of patients with Human Epidermal Growth Factor Receptor 2-positive (HER2-positive) was 25%. The frequency of Luminal A neoplasias was 16.6%, Luminal B/HER2- was 35.9%, Luminal B/HER2+ was 15.1%, HER2 overexpressed was 9.3%, and Basal was 22.9%. Taking into account the outcomes, 173 patients were alive without disease (65.7%); 23 patients were alive with any form of recurrence (8.7%); and 67 patients (25.4%) evolved to BC deaths. Conclusions: It was concluded that UYW with BC are commonly diagnosed at advanced stages, present adverse morphological and molecular parameters, and have unfavorable prognosis.

Sentinel lymph node biopsy in breast cancer after neoadjuvant chemotherapy. A pilot study.

AIMS: Sentinel lymph node biopsy (SLN) seems to represent a reliable method for early breast cancer staging, offering an alternative to complete axillary dissection. METHODS: The identification of sentinel node(s), their localization and the predictive capacity of SLN were analysed in 42 patients who had neoadjuvant chemotherapy for breast cancer. Dextran labelled with (99m)Tc was injected close to the tumor. The radioactive uptake in the axilla was detected by scintigraphic images and by a hand-held probe guided the SLN. RESULTS: One or more sentinel nodes were identified in 41 patients (97.6%). We could accurately predict axillary lymph nodes status in 93% of the cases. CONCLUSIONS: SLN can predict the status of the axilla in patients who have received primary chemotherapy.

Reassurance in the Treatment of Mastalgia.

The purpose of the study was to evaluate the results of the application of a nonpharmacologic treatment based on explanations and reassurance to women with mastalgia. A total of 121 women were studied. They received reassurance and underwent follow up with a questionnaire 2-3 months later. An original methodology to evaluate the efficiency of mastalgia treatment was employed, which consisted of comparing pain parameters of the patients before and after treatment. The authors verified a success rate of 70.2% (n = 85) with reassurance. When evaluating the intensity of the symptom, reassurance was effective in 85.7% of the patients with a mild form of mastalgia, in 70.8% with a moderate form, and in 52.3% with a severe form. It was concluded that reassurance should be the first-line treatment for women with mastalgia. Drug prescriptions are indicated only in patients refractory to this form of management.