Alfredo Carlos Simöes Dornellas de Barros

Induction of experimental mammary carcinogenesis in rats with 7,12-dimethylbenz(a)anthracene

PURPOSE To test an experimental model of chemical mammary carcinogenesis induction in rats. METHODS Twenty young virgin Sprague-Dawley female rats, aged 47 days, received 20 mg of 7,12-dimethylbenz(a)anthracene (DMBA) intragastrically by gavage. Afterwards, at 8 and 13 weeks, their mammary glands were examined. At the end of the experiment, the animals were sacrificed, and the mammary tumors were measured and weighed. Tumor fragments were analyzed using light microscopy. RESULTS Eight weeks after DMBA injection, 16 rats presented at least 1 breast tumor (80%). After 13 weeks, all of them (100%) developed breast carcinomas that were confirmed by histopathological analysis. CONCLUSION This experimental animal model of chemical mammary induced carcinogenesis is feasible and can be used in further experiments on the role of tumorigenic biomodulator substances.

Abruptio placentae following snake bite

A case in which, besides the clinical complications that commonly follow snake biting, abruptio placentae occurred is reported here. None of the factors that are frequently associated with abruptio placentae were present. The laboratory tests performed showed that renal function was impaired and that a dramatic hypercoagulability was present. The relationship of the latter to the abruptio placentae is discussed.

Reassurance in the Treatment of Mastalgia

▪ Abstract: 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. ▪

Gynecomastia: physiopathology, evaluation and treatment

Gynecomastia (GM) is characterized by enlargement of the male breast, caused by glandular proliferation and fat deposition. GM is common and occurs in adolescents, adults and in old age. The aim of this review is to discuss the pathophysiology, etiology, evaluation and therapy of GM. A hormonal imbalance between estrogens and androgens is the key hallmark of GM generation. The etiology of GM is attributable to physiological factors, endocrine tumors or dysfunctions, non-endocrine diseases, drug use or idiopathic causes. Clinical evaluation must address diagnostic confirmation, search for an etiological factor and classify GM into severity grades to guide the treatment. A proposal for tailored therapy is presented. Weight loss, reassurance, pharmacotherapy with tamoxifen and surgical correction are the therapeutic options. For long-standing GM, the best results are generally achieved through surgery, combining liposuction and mammary adenectomy.

Immediate effects of intraoperative evaluation of surgical margins over the treatment of early infiltrating breast carcinoma

Aims and Background Local recurrences in patients submitted to conservative breast treatment for early infiltrating breast carcinomas occur in 5–10% of the cases and are caused mainly by inadequate local resection and remaining residual malignant tissue. The present study was carried out to analyze the effect of intraoperative evaluation of surgical margins and its influence on the immediate surgical management of patients with early breast carcinomas (T1–T2) scheduled to undergo quadrantectomy. Methods A total of 102 cases were studied. After a classical quadrantectomy, intraoperative evaluation of surgical margins was done by means of macroscopic, cytological and histopathologic analysis. The margins of the resected tissue were examined to assure they were clear or to orient a wider resection. Results In 64 cases (62.7%), the extent of the quadrant resection was considered adequate and the margins were clear. In 38 cases (37.3%), surgical margins were considered inadequate. An enlarged quadrantectomy was immediately performed in 33 patients (32.4%) and mastectomies in 5 (4.9%). Conclusions Intraoperative evaluation of surgical margins frequently modifies the surgical management of patients who were initially prepared to be submitted to a quadrantectomy, indicating the need for further resection in the form of an enlarged quadrantectomy or mastectomy.

Bilateral Reduction Mammaplasty for Immediate Breast Conservation Surgery Reconstruction and Intraoperative Radiotherapy: A Preliminary Report

BackgroundBreast conservation surgery and postoperative radiotherapy are widely accepted as the treatment of choice for patients with early breast cancer. Despite its oncologic benefits, the radiotherapy may cause unpredictable outcomes in soft tissues, especially in patients undergoing breast reconstruction. Described recently, intraoperative irradiation (IORT) has been indicated for selected patients as an alternative to radiotherapy with fewer adverse local effects. Clinical use of reduction mammaplasty (RM) techniques in oncologic breast surgery has been described previously. However, no previous studies have mentioned its application after breast conservation surgery and IORT.MethodsThe authors used RM to reconstruct a partial breast tissue defect secondary to breast conservation surgery followed by IORT treatment in a 46-year-old patient with an 11-mm invasive ductal carcinoma between the superior internal quadrants of the right breast.ResultsSatisfactory breast volume and shape were achieved, and no immediate or late complications were observed. After 2 postoperative years, no evidence of fat necrosis, tumor recurrence, or tissue volume loss was observed.ConclusionThe initial data indicate that RM in the setting of breast conservation surgery reconstruction and IORT is feasible. With appropriate patient selection, respecting indications and limitations, RM has its place among the various reconstructive techniques. Additional studies with larger clinical series and longer follow-up periods are necessary to analyze the precise IORT effects in patients submitted to immediate breast conservation surgery reconstruction.

Prognostic effects of local recurrence after conservative treatment for early infiltrating breast carcinoma.

Aim A study was carried out to determine whether local recurrence after quadrantectomy, axillary dissection and radiotherapy (QUART) affects the oncologic prognosis of patients with early infiltrating breast carcinoma. Methods A total of 149 patients were submitted to QUART between 1981 and 1990 and followed by an average period of 120.9 months (range, 16–213). Local recurrence was not observed in 132 cases (group 1) but was detected in 17 patients (group 2). Results In group 1, 39 cases (29.5%) presented distant metastases and 34 (25.8%) evolved to death. In group 2, 10 (51.8%) distant metastases and 9 deaths (52.9%) were verified. The survival curves estimated by the Kaplan-Meier method and analyzed by the logrank test were statistically different for distant metastases-free survival (P = 0.03) and for overall survival (P = 0.01). The relative risk in patients with post-QUART local recurrence for distant metastases was 2.09 and for death 2.34. Conclusions It was concluded that post-QUART local recurrences are a poor prognostic factor in patients with early infiltrating breast carcinoma.

Outcome analysis of patients with early infiltrating breast carcinoma treated by surgery with intraoperative evaluation of surgical margins.

Aim The purpose of this study was to determine the effect of intraoperative evaluation of surgical margins (IESM) on the local recurrence rate, the occurrence of distant metastases and survival in invasive breast carcinoma (T1-2). Methods Two groups of patients were compared: a control group of 149 patients treated by classical quadrantectomy without IESM, and an IESM study group of 102 patients submitted to surgical treatment guided by this procedure. In the IESM group 64 quandrantectomies, 33 enlarged quadrantectomies and five mastectomies were performed. Results In the control group 17 local recurrences (11.4%), 49 distant metastases (39.2%) and 43 deaths (31.5%) occurred; in the IESM group there were no local recurrences, nine distant metastases occurred (8.8%) and three patients died (2%). Adjuvant treatment was the same in both groups. The survival curves were estimated by the Kaplan-Meier method and compared with the log-rank test. The curves were censored at 99 months of follow-up for adequate comparison because the follow-up period was different in the two groups. Significant differences in local recurrence-free survival and distant metastasis-free survival curves (P = 0.001) in favor of the study group were observed. The overall survival curve of the IESM group was also superior, but statistical analysis revealed only a strong tendency without significance (P = 0.06). Conclusion Treatment of early infiltrating breast carcinoma guided by IESM results in a better prognosis.

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/m) 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.

Acurácia do Linfonodo Sentinela em Pacientes com Câncer Inicial da Mama Tratadas com Quimioterapia Neoadjuvante

Objetivo: avaliar a capacidade preditiva do estudo do linfonodo sentinela (LS) em relacao ao estado linfonodal axilar em pacientes com carcinoma invasor inicial de mama submetidas ou nao a quimioterapia neoadjuvante. Metodos: foi realizado estudo prospectivo de 112 pacientes, que foram divididas em dois grupos. O primeiro grupo foi constituido por 70 pacientes que nao receberam quimioterapia previa (Grupo I) e o segundo foi formado por 42 pacientes que foram submetidas a quimioterapia neoadjuvante, com tres ciclos do esquema AC (adriamicina + ciclofosfamida) (Grupo II). A resposta a quimioterapia foi parcial >50% em 21 pacientes, sendo que em tres foi completa, e parcial <50% em 19 pacientes; em duas pacientes houve progressao da doenca. Procedeu-se a injecao peritumoral de dextran marcado com 99mTc. A mesma foi realizada com auxilio de estereotaxia em 29 pacientes com tumores nao palpaveis, sendo 16 do grupo I e 13 do grupo II. Os acumulos radioativos demonstrados por cintilografia orientaram a biopsia do LS axilar, com auxilio de probe portatil. O estudo anatomopatologico dos LS compreendeu inicialmente um unico corte histologico. Os LS livres foram submetidos a cortes seriados a cada 50 mm e corados por HE. Resultados: o LS foi identificado em 108 pacientes. Em tres pacientes do grupo I e em uma do grupo II, nas quais nao se obteve identificacao do LS, as lesoes nao eram palpaveis. A acuracia do metodo na predicao do estado linfonodal axilar foi de 100% no grupo de pacientes que nao receberam quimioterapia neoadjuvante e de 93% naquele em que esta forma de tratamento previo foi utilizada. Essa diferenca se mostrou estatisticamente significante. Conclusoes: o presente trabalho possibilitou-nos concluir que em todas as pacientes que nao receberam tratamento quimioterapico previo o estudo do LS foi eficaz para predizer o estado dos linfonodos da axila. A taxa de resultados falso-negativos no grupo de pacientes submetidas a quimioterapia neoadjuvante parece invalidar o emprego do estudo do LS nas mesmas.