Antonio Carlos Toshihiro Nisida

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.

Integrated approach to women's health

The objective of this study was to demonstrate the importance of the practical application of the concept of reproductive health in São Paulo, Brazil, from 1991 to 1998 at the Pérola Byington Hospital with a new model of Primary Health Care (PHC) in which 2000 women/day, separated into two groups and over 45 years, was attended by nurses trained to detect the most frequently occurring gynecological problems supervised by doctors, who finalized the visit of each patient. The results demonstrated the advantages and viability of this strategy and also the bad health conditions of the women. Based on the high incidence of different kind of diseases detected, programs were set up for the diagnosis and treatment of gynecological cancer, STD, AIDS, hypertension, diabetes, etc. The results of two of these control programs, cervical cancer and breast cancer, demonstrated a significant increase in the diagnosis of early lesions. An economic study demonstrated an obvious and significant impact of this model not only in saving lives, but also in decreasing financial expenses in health.

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.

Emprego concomitante da localização radioguiada da lesão e do estudo do linfonodo sentinela para o carcinoma invasor de mama não palpável

PURPOSE: to assess the simultaneous approach of radioguided occult lesion localization and sentinel lymph node biopsy in women with breast cancer. METHOD: forty-five patients with nonpalpable breast cancer were enrolled in a prospective study. The employed radiocolloid was 99mTc-labelled dextran. The injection was performed peritumorally under sonographic or stereotactic guidance using a 18 gauge needle. Lymphoscintigraph images for the visualization of both the site of injection and sentinel lymph node were obtained in a conventional gamma-camera, with the ipsilateral arm positioned in a 90o angle. Excision biopsy of the tumor and sentinel lymph node were performed with a gamma-detecting probe. RESULTS: the procedure was always successful in permitting the localization of occult breast lesions. It was necessary to enlarge surgical margins in five cases. Concerning the sentinel lymph node we achieved localization in 93% of the cases. No complications were observed. CONCLUSION: the results seems to demonstrate that a combined radioguided occult lesion localization and sentinel lymph node biopsy using the same radiopharmaceutical represents a useful and practicable strategy in the management of early breast cancer.

Intraoprative pathological monitorization of surgical margins: A new method to reduce local recurrences after conservative treatment for breast cancer

Objectives: Local recurrences after conservative surgical treatment for breast cancer are not uncommon and cause negative influences on oncological prognosis and quality of life of the patients. Aiming to avoid this problem, we have developed a new method: &traoperative pathological monitoring of surgical margins, (IPMSM), in order to assure adequacy of resection. IPMSM is based on radiological, macroscopic, cytological and histological examination of the breast specimens in the operating room. Study Methods: We have evaluated 98 women with 100 tumors with clinical stage I-II breast cancer with indication of conservative surgery. The margins were oriented by the surgeon and inked by the pathologist in different colors to retain orientation. The immediate reexcision was indicated in 40 cases and 6 of these have to be submitted to mastectomy. The indications for additional resections were insufficient margins in 23 cases, EIC in 8, multifocality in 4, proliferative lesion at the margin in 4 and diffuse tumor in 1. Results: These patients were followed by a mean period of 42 months (range 3 to 99 months, 0=22) and we have only 1 recurrence that occured 4.5 months after the primary surgery and was not related to localization of the first tumor. We have compared this result with that from an historical series of 149 cases of breast cancer stages I-II treated by conservative surgery, but not submitted to IPMSM, in which we have observed 14 local recurrences (9.3%) in a mean follow up of 106.6 months (range 16 to 194 months). We have analyzed the results with the control group at the same period of time of the study group and we have observed 6.3% of recurrence (p<O,Ol). Conclusion: The IPMSM proved to be a safe and accurate method to prevent an additional surgery for insufficient margins and can reduce the recurrence rate.